Is ramping blasé?

[epidural man]

First my background....

I work at an institution where we have people trained from all over as staff, and we have residents. We have journal clubs, try to remain academic, work hard to practice within the confines of an academic standard of care and published guidelines, and previous years annually we have our airway course where Dr Benumof would lecture on all the malpractice cases he was asked to be an expert witness for all the people who died from botched airway stuff. Needless to say, it has had an effect on me.

But, I understand the nuance of academic practices vs private practice.

So here is my question:

I recently did a shift at a small, rural private practice hospital. It was my first week there so I am new - no one knows me - I don't know the system, etc.

Anyway, these patients are huge - just really really fat (I'm not used to this....).

So as I've been taught, and have consistently used, I build an excellent ramp for my big patients with their fat necks and very narrow and arched palettes. Anyway, the nurse and the tech looked at me like I had two heads. I asked, "am I doing it wrong?" And they said "no one else ever builds a ramp."

I was surprised by this. I understood that ramps make your view better, helps you ventilate, makes the experience easier. Am I wrong? Have I been mislead? I wish I could have looked with and without a ramp at these airways - that would have been a cool experiment.

Anyway, a ramp is easy and I can't understand why someone WOULDN"T do it - unless they have experience to show it doesn't help.

Thoughts?

I am happy to be the anesthesiologist that "needs" a ramp - and great if you are the guy that can intubate anybody, anytime, anywhere and I am weak because I am not you. I just would hate to end up in one of Dr Benemof's stories.

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[chocomorsel]

First my background....

I work at an institution where we have people trained from all over as staff, and we have residents. We have journal clubs, try to remain academic, work hard to practice within the confines of an academic standard of care and published guidelines, and previous years annually we have our airway course where Dr Benumof would lecture on all the malpractice cases he was asked to be an expert witness for all the people who died from botched airway stuff. Needless to say, it has had an effect on me.

But, I understand the nuance of academic practices vs private practice.

So here is my question:

I recently did a shift at a small, rural private practice hospital. It was my first week there so I am new - no one knows me - I don't know the system, etc.

Anyway, these patients are huge - just really really fat (I'm not used to this....).

So as I've been taught, and have consistently used, I build an excellent ramp for my big patients with their fat necks and very narrow and arched palettes. Anyway, the nurse and the tech looked at me like I had two heads. I asked, "am I doing it wrong?" And they said "no one else ever builds a ramp."

I was surprised by this. I understood that ramps make your view better, helps you ventilate, makes the experience easier. Am I wrong? Have I been mislead? I wish I could have looked with and without a ramp at these airways - that would have been a cool experiment.

Anyway, a ramp is easy and I can't understand why someone WOULDN"T do it - unless they have experience to show it doesn't help.

Thoughts?

I am happy to be the anesthesiologist that "needs" a ramp - and great if you are the guy that can intubate anybody, anytime, anywhere and I am weak because I am not you. I just would hate to end up in one of Dr Benemof's stories.

You are doing what’s right for the patient. I suspect that in little hospitals, some bad **** happens that they just call part of the course.
I build ramps for my fatties. Like the ones with BMIs in mid 40s and above. I don’t care who looks at me crazy. And I tip their heads up if the ramp isn’t good enough.
You don’t want to be the one written about is a good thought.

How come you don’t have fat patients in your current full time job?

 

[secretasianman]

Yes if I am concerned I fashion a blanket ramp. Maybe you are at a small location with people set in their ways. “That’s how we’ve always done it.” It’s actually good that you even question this, means you have an internal check, as we all should in this profession. Or in life.

 

[GassYous]

Ramped a lot of patients in residency. In pp, haven't ramped a single one but I would if I saw a scary airway. I occasionally raise the head of the OR bed 30 degrees for intubation and extubation because I think it helps with closing capacity and atelectasis, especially for the fatties.

If I were working in a new place where I'm unfamiliar with the people and the layout, I would continue to do what I'm used to doing.

 

[FiO2@21]

Lately I’ve been using the OR table to ramp the patients. Some attendings are on board, some prefer to use linens.

I lower the bed all the way down and then get the back up 30ish degrees. And then +/- towel roll.

I use this position for preO2ing as well.

Maybe that’s what people are doing instead of traditional building with all the towels and blankets?

 

[dhb]

I like to ramp with blankets under the shoulders and head when needed but i'm not surprised many people don't do this.

 

[leaverus]

I've never done it in over 10years of practice. Maybe it's overconfidence that glidescope has changed things up a bit, who knows. Anyway, I don't judge you for it - if it works for you don't change.

 

[deleted162650]

How come you don’t have fat patients in your current full time job?

He’s in the .mil

 

[deleted162650]

+1 for using the table to ramp patients. You achieve the exact same positioning by elevating the HOB and using a firm pillow or couple of towels/blankets under the head. Making a full on blanket ramp is unnecessary and silly (and I also trained under Benumof).

 

[deleted697535]

well the key to it is who is doing the preox, who is pushing the drugs, who is intubating and what does the aw look like.

most obese people are easy to bvm and intubate.

the problem comes when youre with a junior resident who doesnt preox right or pushes the drugs at the wrong time etc

id imagine in a slick moving pp without any of those novice type issues and a glidescope right there then you dont really need to ramp.

 

[anesthesiadoc]

Ever wonder why surgeons are always so particular about table position? I think it's because they learn early the importance of good ergonomics. It's puzzling to me how often anesthesiologists are willing to "settle" for a poor angle in what may be the most dangerous maneuver being performed on their patients that day (both with intubation AND extubation).
Ramping is a great idea. Even if you're planning on video laryngoscopy, it's an easier pass with good positioning.
It drives me crazy when I ask what the airway plan is for our obese patients and the first words I hear are "glide scope."
With good positioning I find a number of patients suddenly seem "skinny from the neck up."

As an aside, I LOVE the Troop pillow.

Manometers, PEEP Valves, Silicone Masks & Filters - Mercury Medical

www.mercurymed.com

Excellent positioning every time, no fussing making the correct angle with blankets (which sometimes shift as the patient is being positioned on the ramp, and you don't have to fish the blankets out from under the patient when you're done (the Troop is comparatively much easier to remove/pull out from under the patient after airway is secure). That's IF the surgeon needs the ramp out after your airway is secure. I've found there are a number of operations where the surgeon's don't care/notice if I leave the troop pillow in for the duration of the surgery. Also puts me in a better position for extubation (in case of the rare need to re-intubate).

 

[coffeebythelake]

HOB up to sniffing position shown to have same effect as putting a bunch of blankets to ramp.

Laryngoscopy and tracheal intubation in the head-elevated position in obese patients: a randomized, controlled, equivalence trial - PubMed

Before induction of anesthesia, obese patients can be positioned with their head elevated above their shoulders on the operating table, on a ramp created by placing blankets under their upper body or by reconfiguring the OR table. For the purpose of direct laryngoscopy and tracheal intubation...

pubmed.ncbi.nlm.nih.gov

 

[ethilo]

I'd say since YOU are the one intubating the patient at that moment and no one else is, you decide what you think is the safest way to do it. I've had multiple times now where the patient was labeled a difficult airway in their chart, I ramp them, and it's so easy a med student could do it. Good ramping often makes these chipshot airways. There's no sense in any degree of struggling if you don't have to. ESPECIALLY when it comes to an airway.

 

[epidural man]

How come you don’t have fat patients in your current full time job?

We do sometimes. Just not every patient which seemed to be the case at this place.

 

[abolt18]

We have a significant amount of patients w BMI >50. Don't even bat an eye until we're breaking 60.

IMO putting the back up on the bed and either a shoulder roll or the head of the table returned to horizontal give me the same benefit as a ramp, but I luckily don't have to mess with pulling out the ramp. As noted above, setting yourself up for success is something you will never regret.

 

[chocomorsel]

We do sometimes. Just not every patient which seemed to be the case at this place.

That’s the case in most everywhere in America. It’s amazing to me how people are ok with being so damn fat. And I am not even talking about BMIs in the 30s.
And it’s completely normal and normalized.

When I complain about being cold, everyones answer is “you need to put some meat on your bones”.
No, I am a healthy weight. Y’all are just used to normalizing obesity.
One of our cardiac surgeons looks like he has a BMI in the 40s. I don’t get it. Saw him drinking three sodas at lunch. But they were “diet” and the small ones.

 

[secretasianman]

Is this at balboa? Did some med school rotations there.. nice and chill..

 

[drmwvr]

Interesting question...haven't thought about it in a long while but ramp building is dogma for a lot of folks.

 

[anaesthetic]

.

 

[26B]

I routinely ramp patients over BMI 40-45, and it seems to make a difference in terms of improving laryngoscopy view in my experience. Did a few weeks of Bariatric surgery cases a while back and only used the Glidescope a couple of times.

 

[triggermaster]

You are doing what’s right for the patient. I suspect that in little hospitals, some bad **** happens that they just call part of the course.
I build ramps for my fatties. Like the ones with BMIs in mid 40s and above. I don’t care who looks at me crazy. And I tip their heads up if the ramp isn’t good enough.
You don’t want to be the one written about is a good thought.

How come you don’t have fat patients in your current full time job?

par for the course

 

[kidthor]

Ever wonder why surgeons are always so particular about table position? I think it's because they learn early the importance of good ergonomics. It's puzzling to me how often anesthesiologists are willing to "settle" for a poor angle in what may be the most dangerous maneuver being performed on their patients that day (both with intubation AND extubation).

This is spot on. I am shocked that anesthesiologists do too many procedures with absurd ergonomics and setup. Intubating with a horrible patient head position and with the intubator crouched into the patient's face, putting in a central line while placing the kit on a trash bin or the patient's chest, putting in art lines under the drapes. Or extubating with the HOB turned 180 degrees away...

Take some pride in your work and make everything right. Don't cut corners!!!

 

[chocomorsel]

par for the course

Sounds like some stuff a Caucasian with a golf club memebership would say. I am neither. Thanks for the correction.
Will never be using that again.

 

[Southpaw]

There's nothing that all of those blankets (which you then have to take out right after the intubation) do for you that proper bed positioning won't.

 

[dhb]

There's nothing that all of those blankets (which you then have to take out right after the intubation) do for you that proper bed positioning won't.

I don't know, i roll a blanket that i put under the shouders and lift the head to allow for exposure of the neck. How do you do that by just moving the table?

 

[Radetzky]

Not to derail from the content of the thread but do you mean passé rather than blasé?

 

[chocomorsel]

Not to derail from the content of the thread but do you mean passé rather than blasé?

Oh Gosh, you too?

 

[Justice4all]

I use the OR bed (Reverse T) to assist with blankets to supplement.
Safety first!

 

[Southpaw]

I don't know, i roll a blanket that i put under the shouders and lift the head to allow for exposure of the neck. How do you do that by just moving the table?

there’s a picture earlier in the thread that describes what I do. It also includes the blanket under the shoulders. I believe everyone should do what works for them. Back of the bed up to get the chest weight off the lungs and isolating the airway for what it truly is (as opposed to adding chest weight to it, making things more difficult) has always worked for me.

 

[triggermaster]

Not to derail from the content of the thread but do you mean passé rather than blasé?

Yes

 

[Beeftenderloin]

This is spot on. I am shocked that anesthesiologists do too many procedures with absurd ergonomics and setup. Intubating with a horrible patient head position and with the intubator crouched into the patient's face, putting in a central line while placing the kit on a trash bin or the patient's chest, putting in art lines under the drapes. Or extubating with the HOB turned 180 degrees away...

Take some pride in your work and make everything right. Don't cut corners!!!

I tend to disagree with this. I think it’s downright essential in our line of work to be able to do a lot of the procedures we do routinely in awkward positions. I’ve intubated in lateral, placed arterial lines and central lines under drapes, ultrasound placed in awkward locations, crouching, craning my neck, IVs with non dominant hand.

I’m not saying it happens often, but every once in a while there are situations that call for it.

Don’t get me wrong though, these morbidly obese folks should have their position optimized prior to manipulating their airway whenever possible. I routinely ramp them up an/or put the back up or bed in a little reverse T.

 

[kidthor]

I tend to disagree with this. I think it’s downright essential in our line of work to be able to do a lot of the procedures we do routinely in awkward positions. I’ve intubated in lateral, placed arterial lines and central lines under drapes, ultrasound placed in awkward locations, crouching, craning my neck, IVs with non dominant hand.

I’m not saying it happens often, but every once in a while there are situations that call for it.

Don’t get me wrong though, these morbidly obese folks should have their position optimized prior to manipulating their airway whenever possible. I routinely ramp them up an/or put the back up or bed in a little reverse T.

Yes sometimes this comes up. But it's too often due to poor preparation or some weird form of laziness.

It's one thing to place an under-the-drapes line because of something truly unexpected or emergent. It's another to allow people to drape over you and turn up the Cardi B while you place lines and now can't monitor the patient- because you're weak and they think your work is unimportant. (not you specifically, rather the royal you)

 

[Arch Guillotti]

I think it’s downright essential in our line of work to be able to do a lot of the procedures we do routinely in awkward positions.

Of course. But unless its a real emergency I am going to make things as comfortable for me as possible.

 

[coffeebythelake]

I tend to disagree with this. I think it’s downright essential in our line of work to be able to do a lot of the procedures we do routinely in awkward positions. I’ve intubated in lateral, placed arterial lines and central lines under drapes, ultrasound placed in awkward locations, crouching, craning my neck, IVs with non dominant hand.

I’m not saying it happens often, but every once in a while there are situations that call for it.

Don’t get me wrong though, these morbidly obese folks should have their position optimized prior to manipulating their airway whenever possible. I routinely ramp them up an/or put the back up or bed in a little reverse T.

So you are going to "practice" on elective cases by doing things in an awkward non-ergonomic way? I would rather save myself from having back pain.

 

[chocomorsel]

Yes sometimes this comes up. But it's too often due to poor preparation or some weird form of laziness.

It's one thing to place an under-the-drapes line because of something truly unexpected or emergent. It's another to allow people to drape over you and turn up the Cardi B while you place lines and now can't monitor the patient- because you're weak and they think your work is unimportant. (not you specifically, rather the royal you)

Oh God. CardiB is a thing. A huge thing. Like top of the pop charts huge. And she’s a stripper. And behaves like one in her videos. Nasty as hell.
This world is going to hell in a hand basket.
Anyway, back on topic now. I had to just comment.

 

[coffeebythelake]

Yes sometimes this comes up. But it's too often due to poor preparation or some weird form of laziness.

It's one thing to place an under-the-drapes line because of something truly unexpected or emergent. It's another to allow people to drape over you and turn up the Cardi B while you place lines and now can't monitor the patient- because you're weak and they think your work is unimportant. (not you specifically, rather the royal you)

Oh that **** doesn't fly where I work. When a clueless surgeon decides they want to shave the patient and start jossling the patient around before we even put in the tube, I ****ing call them out and yell at them.

 

[Beeftenderloin]

So you are going to "practice" on elective cases by doing things in an awkward non-ergonomic way? I would rather save myself from having back pain.

Anything that looks like it will be/could be remotely challenging and is not emergent, by all means, set up ergonomically take your time, do it right. But yea, if I don’t anticipate difficulty I’m probably not going to pull up a chair, have something to rest my elbows on and have the ultrasound directly across from me for the art line.

 

[coffeebythelake]

Anything that looks like it will be/could be remotely challenging and is not emergent, by all means, set up ergonomically take your time, do it right. But yea, if I don’t anticipate difficulty I’m probably not going to pull up a chair, have something to rest my elbows on and have the ultrasound directly across from me for the art line.

Or you could just raise the OR table up and do it standing position. Takes a few seconds. Without wasting time finding a chair. Without an elbow rest. I rarely use ultrasound (and be honest, if you're not anticipating difficulty why would you need one?)

I'm 6'2". I don't need to strain my back bending down. Even when I do that the table is still ok height for others to place foley etc

 

[Beeftenderloin]

Or you could just raise the OR table up and do it standing position. Takes a few seconds. Without wasting time finding a chair. Without an elbow rest. I rarely use ultrasound (and be honest, if you're not anticipating difficulty why would you need one?)

I'm 6'2". I don't need to strain my back bending down. Even when I do that the table is still ok height for others to place foley etc

I was being hyperbolic. I don’t think I’ve ever used a chair, though some of my colleagues do. I usually just raise the table and stand.

 

[epidural man]

Not to derail from the content of the thread but do you mean passé rather than blasé?

Either works actually.

Blasé -= unconcerned or apathetic

Passé =. Outmoded, behind the times.

I was going more for “unconcerned”

 

[Arch Guillotti]

Oh that **** doesn't fly where I work. When a clueless surgeon decides they want to shave the patient and start jossling the patient around before we even put in the tube, I ****ing call them out and yell at them.

You must get along with them great if you have to yell at them.

 

[coffeebythelake]

You must get along with them great if you have to yell at them.

Fortunately a rare occurrence.. but when you are trying to intubate a challengjng big fatty and it is like hitting a moving target because they decide that is the perfect time to jostle thr patient around.. then yes I yell and they snap out of their tunnel vision/ zombie haze.

 

[triggermaster]

Either works actually.

Blasé -= unconcerned or apathetic

Passé =. Outmoded, behind the times.

I was going more for “unconcerned”

No you meant passé. ’Is building a ramp blasé’ makes no sense. If anything building a ramp would be overly concerned not blasé. Passé on the other hand fits your question perfectly.

I don’t think we need to constantly correct each other’s grammar or anything but if I were using a word or phrase incorrectly I’d prefer to be called out on it once, learn from it, and move on.

(Sorry for the continued)

 

[deleted162650]

From geography to grammar - we cover it all here in the SDN Anesthesia forum.

 

[deleted162650]

 

[kidthor]

Exactly.

 

[epidural man]

No you meant passé. ’Is building a ramp blasé’ makes no sense. If anything building a ramp would be overly concerned not blasé. Passé on the other hand fits your question perfectly.

I don’t think we need to constantly correct each other’s grammar or anything but if I were using a word or phrase incorrectly I’d prefer to be called out on it once, learn from it, and move on.

(Sorry for the continued)

okay. I wanted to ask if people were unconcerned about building a ramp. Could you gvie me an example, using the word blasé, in a sentence on how I should have used it?

Thanks for help.

 

[deleted162650]

okay. I wanted to ask if people were unconcerned about building a ramp. Could you gvie me an example, using the word blasé, in a sentence on how I should have used it?

Thanks for help.

Did you not watch the music video???

 

[MirrorTodd]

Everybody here seems very blase about using a ramp. Why are they?

Thats the best I got.

 

[abolt18]

Fortunately a rare occurrence.. but when you are trying to intubate a challengjng big fatty and it is like hitting a moving target because they decide that is the perfect time to jostle thr patient around.. then yes I yell and they snap out of their tunnel vision/ zombie haze.

Just the other day, a surgeon literally started removing the pulse-ox from my patient after we induced anesthesia, were masking while waiting for roc to kick in, and had obviously not yet intubated.

I sat and watched at first just assuming maybe he was unsticking it a bit so it would be easier to remove and switch to the other arm after we intubated, but no he legit started pulling it off until I said somewhat aggressively "Dr. ****, Can you leave that pulse-ox on until we have secured this airway please?"

He looked up at me totally confused at first. Seriously ridiculous.