drRumi

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i've seen this done differently by different attendings...what's your intubating ramp technique for intubating the fatties?
 

Hawaiian Bruin

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Blankets cheaper IMO- just make sure the auditory meatus ends up approximately at the level of the sternum. And like JPP said in his latest pearl, a little reverse T-Berg (or just back up on the bed) is your friend for the fluffy patient.
 

SleepIsGood

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In residency I used blankets, but since the advent of the Glidescope, I've never had to ramp anyone yet.
i do both....doesnt hurt. for whatever reason if you cant get a view with the Gscope, in my opinion one doesnt want to come out and 'reposition', lift the patient (heavy) and then try shoving blankets under him/her.

I do it from the get go.
 

rsgillmd

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i've seen this done differently by different attendings...what's your intubating ramp technique for intubating the fatties?
Where I trained we had the Troop pillow. I loved it. But I still occasionally supplemented the Troop pillow with sheets/blankets to get my ideal position.

We don't have the Troop pillow here, so I use a bunch of sheets/blankets and usually a shoulder roll. But in the end, as others have said, the goal is to align the ear with the sternal notch as closely as possible.

I've lost count of the number of times I bailed out others in various situations just by adjusting position. I'm an average laryngoscopist. I don't have the super lifting strength that Jet probably has. So for me positioning is key from the start to helping make the first attempt my only attempt.
 

rsgillmd

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i do both....doesnt hurt. for whatever reason if you cant get a view with the Gscope, in my opinion one doesnt want to come out and 'reposition', lift the patient (heavy) and then try shoving blankets under him/her.

I do it from the get go.
:thumbup::thumbup:
 

SleepIsGood

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Noyac

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I don't do any of this crap. I'm pretty sure the ramps are useless. THe most I do is rev tberg.

So what are you trying to accomplish with a ramp?
 

SleepIsGood

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I don't do any of this crap. I'm pretty sure the ramps are useless. THe most I do is rev tberg.

So what are you trying to accomplish with a ramp?
'align the axises'
 

periopdoc

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IMHO the ramp is no different from sitting the patient up by "breaking the bed." Reverse-T with good head positioning is superior to both. Bending the patient at the waist decreases FRC by pushing the abdominal contents upward into the thorax and I have never understood how bending at the waist effects the alignment of mouth, pharynx, and trachea. Perhaps I am just too dimensionally challenged to see it.

- pod
 

Dejavu

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We do a fair number of obese people (I'm sorry, but it is demeaning to call a pt a "fatty", unprofessional IMHO).

We frequently ramp the pt.

To us, ramping means to place enough bath blankets in such a way as to get the ear lobe level with the sternum. We believe it assists. I seem to remember literature evidence to support ramping as making the intubation easier, but I don't have the references on hand. Maybe I hallucinated the existence of such data.

Can you intubate without a ramp, probably, especially if you have some experience, but in a relatively well known teaching institution/clinic, in a small SE Minnesota town, we ramp frequently.
 

Jay K

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i do both....doesn't hurt.
I do it from the get go.
Certainly true and I also frequently did the same in residency, however I offer that perhaps if you go private, you may begin to pare down certain prep or other activities which you no longer find necessary (as remarked by many other private folks in this thread) and may increase your overall efficiency. You may find you intubate obese patients just fine without ramping or perform other procedures without other prep. You'll figure what's worth your time and what's not and still deliver a safe and effective anesthetic. Unlike a colleague in a well known Minnesota "Clinic," who probably doesn't have to turn over their own rooms, setup "stuff" and has people to give them coffee, bathroom and lunch breaks, you may find in private those extra saved minutes allow you to choke down a hurried lunch or take a piss. Since he's teaching residents and has someone available to prep the room, it "saves" him time in optimizing intubating conditions, rather than having the resident struggle.

Cheers.
 

inmyslumber

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http://media.gatewaync.com/wsj/images/2009/08/28/sleep.jpg

This isnt it, but theres something that looks like these 'troop pillows' that you see on those "SKY MALL" mags. Apparently you can open it up and place it on tray tables and use it to sleep on. :laugh:

Those troop things i be are real cheap :cool: blankets man, blankets.
I believe SleepIsGood refers to the following http://www.skymall.com/shopping/detail.htm?pid=96981577&c=

I laughed out loud when I saw this in the SkyMall catalog on my last flight. Wish I had seen it in person!
 

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Certainly true and I also frequently did the same in residency, however I offer that perhaps if you go private, you may begin to pare down certain prep or other activities which you no longer find necessary
This made me think of one of my buddies who finished last year and is now in PP. He sticks the subclavian from the head of the bed because he says it takes too long to walk around to the side. :laugh:
 

bigeyedfish

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We do a fair number of patients with what is known here as CBP, or chronic biscuit poisoning.

I have a few staff that make me ramp with a mountain of blankets, and no matter how many you put they'll always put one more.

Others are adamant about not ramping. I don't really find one way easier but I notice I have to use a little different technique with the laryngoscope. With the patient ramped way up the handle of the blade is almost parallel with the floor.

What about blade choice and ramping? In my experience the mac users tend to be rampers and miller users tend to be non-rampers.
 

Jay K

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This made me think of one of my buddies who finished last year and is now in PP. He sticks the subclavian from the head of the bed because he says it takes too long to walk around to the side. :laugh:
Right? :laugh: Where does it say you gotta do a subclavian from the side? I say, more power if he can do it from the head of the bed - totally saves you from walking around the anesthesia machine and back... Now if I can figure how to do the radial A-line from the head of the bed... Prior to my current place of employment, you'd have to start the peds IV and mask as well, so they'd just pull the kid's hand over his head to you and you'd mask w/ left hand, and stick w/ right hand - thank goodness they'd connect up the IV at least. Now that I think about it, I could totally do it - I'd just have the patient's hand taped up by his head in position w/ the armrest going upwards (sorta like they were holding their right hand up swearing in a court of law). I'm gonna try it on my next cardiac case... induce/intubate, then A-line at head of bed, then central line - will save me from walking back and forth. Nice...

I think back to all the stupid things my attendings made me do for no reason at all... Like the attending who refused to let me do my ultrasound-guided nerve block with my other hand because I wasn't technically ambidextrous... What?!?! I can't guide a needle w/ my non-dominant hand because the positioning is better for this particular case? Crazy...
 

Sergio99

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I don't use the ramp and I haven't used a miller blade in years with the exception of peds.
Hello,

Why on earth would you use a Miller blade for peds? I don't use the Miller blade for anything. In 35 years I never had a case where the Miller blade made things any easier, whether peds or adults. But of course, I have colleagues that swear for the Miller and never use a Mac. I guess it is a matter of habit. I have done thousands of peds, and I always had a full set of Miller blades, all sizes, in case I needed to use them. Many times I decided to start using the Miller and used it exclusively for several weeks at a time, but always came back to the Mac.

Regarding ramping, I never ramp anyone either. I see my colleagues ramping their patients and having to climb on several footsteps in order to reach the patient. I find it ridiculous. Maybe I am too old-fashioned or too unteachable. If I need to align the axes, I just pull the laryngoscope up and lift the head off the table, or lower the headpiece to hyperextend the head, because sometimes the alignment is achieved by flexing the head and sometimes by extending it, and not always it can be predicted which one will be more effective. I prefer to have the possibility to do both. If you ramp the patient, when you want to flex or extend the head, it becomes a major enterprise.

Greetings
 

Noyac

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Hello,

Why on earth would you use a Miller blade for peds? I don't use the Miller blade for anything. In 35 years I never had a case where the Miller blade made things any easier, whether peds or adults. But of course, I have colleagues that swear for the Miller and never use a Mac. I guess it is a matter of habit. I have done thousands of peds, and I always had a full set of Miller blades, all sizes, in case I needed to use them. Many times I decided to start using the Miller and used it exclusively for several weeks at a time, but always came back to the Mac.

Regarding ramping, I never ramp anyone either. I see my colleagues ramping their patients and having to climb on several footsteps in order to reach the patient. I find it ridiculous. Maybe I am too old-fashioned or too unteachable. If I need to align the axes, I just pull the laryngoscope up and lift the head off the table, or lower the headpiece to hyperextend the head, because sometimes the alignment is achieved by flexing the head and sometimes by extending it, and not always it can be predicted which one will be more effective. I prefer to have the possibility to do both. If you ramp the patient, when you want to flex or extend the head, it becomes a major enterprise.

Greetings
Well on the kiddo's a MAC is fine but on the little tikes I use a mil. I use the biggest miller I can safely get in their mouth also. And I use it like a MAC (in the vallecula) first and if I can't see anything good then I move to the classic miller approach (lift the epiglottis). This is just how I was trained.

I like the comment on lowering the headpiece of the OR table. I do this from time to time when I can't see everything I want to see. Much better than a ramp.
 

Sergio99

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How young do your peds cases go to? I haven't found an adequate substitute for a Mil 0 or 1 or WhisHipple 1.5 in a MAC blade. I'm a little skeptical that you intubate anybody under the age of 18mo's - no offense.
Hello,

The majority of the infants we did used to be between 3 months and a year old, but we had some that were 3 weeks old.

I am not saying the Miller blade was bad; I only said that it didn't give me an added advantage over the Macintosh.

[As an aside, just because of this conversation I decided to start using the Miller blade again and I just intubated a case with a Miller 2 without a stylet: a 50 year old adult. It all went well.]

Greetings.
 

jetproppilot

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I don't do any of this crap. I'm pretty sure the ramps are useless. THe most I do is rev tberg.
HAHAHAHAHAHAHAHAHAHAHAHAHA

Uhhhhhhhh, our professional snowboarder colleague is once again RIGHT.

Dude I think I dribbled a little from laughing so hard.

P.S. See Jetpearl Number 4.
 

jetproppilot

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I think back to all the stupid things my attendings made me do for no reason at all... Like the attending who refused to let me do my ultrasound-guided nerve block with my other hand because I wasn't technically ambidextrous... What?!?! I can't guide a needle w/ my non-dominant hand because the positioning is better for this particular case? Crazy...
Hence my fight against The Establishment.:smuggrin:

In an effort to save residents from a buncha useless s h it.