Intubation expertise

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joooul

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How many intubations ( Dl ) did it took for you to have 90%+ success rate on the first pass?

I'm currently on anesthesia rotation and I feel that I may be the worst resident they ever had, after approximately ~20 attempts, at best I'm able to get 30% of the tubes. I'm constantly trying to seek feedback and try to modify/improve technique in some way, though now I started to think that I may be don't have what it takes to become truly proficient at this procedure.
 
First, there was always at least one resident that was worse than you. I guarantee it.
The number varies depending on the person. But let's just throw out a number of 100 using the same blade as your current goal to become 90%+.

A lot of the failures come from the emotional stress you put on yourself, especially since a lot of stress are put on the new trainees about not damaging teeth and lips and then the crucial nature of oxygenating your patient. I want to stress that teeth are usually pretty sturdy, lips heal really well, and you have at least 6-7 mins with good pre-oxygenation.

Once you get about 30+, you'll start to notice the difference between failure and success is sometimes literally a few centimeters of positioning. Anyone has the capacity to correct that in the 6-7 mins. Even if the monitors start beeping, you still have plenty of time. Do not panic (easier said than done).

After you get about 50+, you'll realize that you're literally trying to line up the mouth and the glottic opening so you can but a tube in a hole about 2 times its size. You can do it!


Some other tips:
Bend the stylet the way you want. Not how you're taught, bending it the way that's most natural to you. you can go for style(t) points after your master the basic intubation.

Ramps out of towels are not a sign of weakness, they help you line up the two orifices in a way that lets you worry about other things as you're learning to intubate.

Hope this helps.

Edit:
One more thing, realize that the mandible is mobile. You can PUSH the mandible down as far as you can and it's not cheating.
 
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I did a pediatrics residency and somehow got the idea in my mind to apply for an anesthesia residency on the way to pediatric critical care. As a peds intern I got to do a month of peds anesthesia and didn't get a single successful intubation (n=10-15). As a third year pediatric resident I did a month of adult anesthesia to "get ready" for the next residency. I thought I made a huge mistake- again struggled with tubes to the point I became viscerally nervous about doing them. Same thing with the first few weeks of anesthesia residency- super depressing to hear about all of your colleagues nailing their tubes and you continue to struggle with yours.

Then one day it just clicked. If you practice enough at any skill, you become better. And now I absolutely love airway management- it's one of my favorite parts of anesthesia. I'm not perfect, and I often have to troubleshoot and work my way down my algorithms, but I have not felt nervous or uncomfortable in the way I used to for over a year now.

For me, several things helped in the very beginning. The first was really truly studying airway anatomy- where does the hard palate end, and the soft palate begin? What are the arytenoids? Where is the vallecula? Once I truly understood airway anatomy, I could describe it to my attending as I was looking and enable them to help guide me. Video laryngoscopes can help with this as well, and there are some like the CMAC or McGrath that allow you to use them as DLs and then only use the video functionality to help if you need it. The second was entering the right side of the mouth at an almost ridiculous extent to really and truly sweep the tongue to the left and well out of the way. Pulling a bunch of soft tissue mass off and above your field of vision is very helpful to orient yourself as to what you are looking at.
 
A few things:

1). You learn more from things going poorly than things going well. Early struggles will likely lead to better skill acquisition and a healthy respect for the airway.

2). You learn from deliberate practice. If you plainly go through intubation 1,000 times, you will be competent and probably fairly good, but not an expert. What will make you an expert isn’t explicitly a number, but the number in concert with focused practice. It’s not enough to simply go through the motions.

3). Although I can’t quote you the paper, the numbers I (vaguely) remember is that the average trainee achieves something like 80-90% success at around 25-35; 95% at something like 100. Then there’s another plateau at something like 250-1000 where you hit 98-99%. I’m an EM/CCM attending with probably somewhere around 300-400 intubations to my name who had a fairly robust training in airway from med school through fellowship - also worked with a lot of anesthesiologists along the way. I feel like those numbers were reasonably accurate for my personal development. My first couple dozen I had relatively low success and, when I couldnt get it, someone else could intubate fairly easily without significant manipulation. Then there was a stage of me being able to get almost all and, when I failed, adjustments could be made to improve the conditions or a different technique could be employed successfully. I think now the number of airways I can’t secure are vanishingly rare and are usually technically very challenging. We also live in a somewhat different time with so many airway tools and adjuncts as well as benign induction meds. I admit, however, that I’m probably more likely to pull the trigger on a FOI than some of my peers.
 
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You won't really realize it has happened but there is a point where it will just click and it varies for each person. One day you will have trouble intubating and you'll reflect on it and notice that it has been a long time since that happened to you. That is when you suddenly figure out it clicked months ago and you never noticed.
 
The key is to adjust! dont have a good view? move the blade around. maybe it needs to go deeper, maybe less deep. tilt the head back more. then just lift, ask for some BURP, it makes it way easier if you have weak arms like i do.
another important thing for beginners is to really scissor open that mouth. give yourself room to put in the blade. if you are barely opening the mouth, chances are your blade wont be in the ideal position
 
I was definitely worse than you. I was 3 months before I could get an lma to sit. Probably 4months to get to 50:50 on intubation...

Who gives a sh1t. It was time well spent learning what you're doing wrong and how to fix it. I could intubate a galloping horse with a spoon now. You will too... Keep the faith...

I always wonder about the ppl that seem too good too soon... They might be bluffers
 
Newtwo said:
I was definitely worse than you. I was 3 months before I could get an lma to sit. Probably 4months to get to 50:50 on intubation...

Who gives a sh1t. It was time well spent learning what you're doing wrong and how to fix it. I could intubate a galloping horse with a spoon now. You will too... Keep the faith...

I always wonder about the ppl that seem too good too soon... They might be bluffers
Click to expand...

Can you intubate a gravid fire ant though
 
Malaysiamoji Yes GIF by Maxis
 
Honestly, good advice all around. I like to stress the stylet part. I realize that everyone’s brains work different and different shapes just make more sense in certain people’s brains. I like my stylet a certain way, but I have a very specific reason why I like it. But, I can also see why certain people like it the other way.
 
joooul said:
Apologies for the necrobump; now I'm working as a CCM attending. This indeed clicked later on, but the DL skill is rapidly deteriorating, thanks to VL/Bipap/HFNC. Thank you for all your replies!
Click to expand...
Way to circle back! Gives trainees perspective. What seems like a huge deal at the time is but a speed bump in retrospect. If you don’t mind me asking, what are your biggest stressors now as CCM attending? Clinical or otherwise…
 
coffeebythelake said:
I dont think I've ever done that before. Is this a common thing?
Click to expand...
I know people who do this, or even vaseline on the lower lip, but I've never picked up the practice.

As mentioned by others in this thread, it's not so much about how many times, but how many it takes you before you notice patterns of success and patterns of failure. Good positioning is most of the battle, really.
 
ranvier said:
Way to circle back! Gives trainees perspective. What seems like a huge deal at the time is but a speed bump in retrospect. If you don’t mind me asking, what are your biggest stressors now as CCM attending? Clinical or otherwise…
Click to expand...
As a fellow, the biggest stressors were clinical, and I was constantly obsessed about being up-to-date and correct in clinical management; somehow, the interaction with the families or other clinicians hasn't been much of a problem.

As an attending, things changed; the clinical part is the most enjoyable part of the day. However, once in a while, interaction with certain family members will drain you dry. It's not even stressful per se, but if you happen to have enough of those on a given week, it's hard to remain sane. Also, working with other clinicians became a little bit more interesting. In academia, it was enough to just say that a patient is too stable for ICU and nobody would care. Currently, I work at a ~ 400-bed hospital, and before you can decline the patient, you have to make everybody happy with your decision. Additionally, we sometimes get blamed for most esoteric/unheard-of things by other specialties ( primarily CT surg, gen surg, and interventional cards ).

Despite all of these minuses, I would still do critical care; the majority of days I truly enjoy, and these minuses I can easily tolerate.
 
joooul said:
How many intubations ( Dl ) did it took for you to have 90%+ success rate on the first pass?

I'm currently on anesthesia rotation and I feel that I may be the worst resident they ever had, after approximately ~20 attempts, at best I'm able to get 30% of the tubes. I'm constantly trying to seek feedback and try to modify/improve technique in some way, though now I started to think that I may be don't have what it takes to become truly proficient at this procedure.
Click to expand...
First off, stop calling them "tubes" because you sound like a re_tard. Everyone starts off like this, everyone freaks out and thinks they'll never become an anesthesiologist, everyone does. Have a beer and relax, kid.
 
coffeebythelake said:
I dont think I've ever done that before. Is this a common thing?
Click to expand...
Not that common. But people lube stylets, ETTs, and LMAs, so I just use the little bit of residual lube on the lips.

Patients lips are often dry and cracked from being npo. So even gently pressure can crack them if they aren't already. Also it's just a nice thing to do.
 
You know, I used to give pretty good advice.

Man, my life would be so good if my biggest worry each day is putting a tube in.
 
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