Mac or miller?

[RxBoy]

I currently rotating in anesthesia and I've done about 8 intubations this month with a mac. only 2 completely successful by myself, 3 with assistance, 2 failed, and 1 horribly failed (you know you horribly failed when you vent and the person abdomen rises while the surgeons look at you in disgust).

I've never ventured with the Miller but I noticed every CRNA uses one. Most cases I have to set out a mac because they don't even carry them in the OR. Should I try to use a miller or just stick with trying to perfect techinique with a mac?

Lastly, how hard is it to break teeth? Thats my #1 fear when I am intubating and I think thats why I fail sometimes. I noticed when other people do intubations they press the blade against the teeth for some of the harder airways, meanwhile I avoid the blade even touching the teeth.

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[coprolalia]

I've never ventured with the Miller but I noticed every CRNA uses one.

Mac, Miller, Wis, Glidescope, Bullard, Shikani... at this point, I can intubate just about anyone if they hand me a spatula and a straw from McDonald's.

To "always" use something speaks more to fetish than it does to skill. There's nothing special about any particular blade. Each requires a different technique. The Miller blade is no easier (or harder) than any other blade, but (in my humble opinion) you are far more likely to do damage to the hypopharynx and teeth or have an unecessarily difficult intubation with a Miller, especially if you try it on the wrong patient.

Keep practicing. No one expects you to intubate successfully as a med student. It takes time, patience, and developing the right feel. And, 8 intubations just isn't enough to get comfortable. Stick with one blade for now and learn to master it.

-copro

 

[climbingdocs]

So I am doing my first anesthesia rotation as well. Did 11 intubations all with Mac, one failure (it didn't help that I had 4 orthopods, circulator, attending, and resident standing around the patient, all staring at me!) I think if patient is positioned right, it goes easier. Flex neck, hyperextend head. Is that right Copro?

 

[militarymd]

I recommend the one that is clean.

 

[me454555]

Positioning is more important than choice of blade at this point in your career. Do the little things right and you will have much more success

 

[RxBoy]

I totally agree with you guys. My main concern was learning how to vent correctly and proper airway management because that's probably the only thing that be very useful during intern year. I was just trying to get as much as I can out of this rotation. Thanks for the tips.

 

[dfk]

So I am doing my first anesthesia rotation as well. Did 11 intubations all with Mac, one failure (it didn't help that I had 4 orthopods, circulator, attending, and resident standing around the patient, all staring at me!) I think if patient is positioned right, it goes easier. Flex neck, hyperextend head. Is that right Copro?

neck flexion would make it more difficult IMO.
consider sniffing position.

 

[dfk]

I currently rotating in anesthesia and I've done about 8 intubations this month with a mac. only 2 completely successful by myself, 3 with assistance, 2 failed, and 1 horribly failed (you know you horribly failed when you vent and the person abdomen rises while the surgeons look at you in disgust).

I've never ventured with the Miller but I noticed every CRNA uses one. Most cases I have to set out a mac because they don't even carry them in the OR. Should I try to use a miller or just stick with trying to perfect techinique with a mac?

Lastly, how hard is it to break teeth? Thats my #1 fear when I am intubating and I think thats why I fail sometimes. I noticed when other people do intubations they press the blade against the teeth for some of the harder airways, meanwhile I avoid the blade even touching the teeth.

not hard at all

 

[CerebralEdema]

Mac, Miller, Wis, Glidescope, Bullard, Shikani... at this point, I can intubate just about anyone if they hand me a spatula and a straw from McDonald's.

To "always" use something speaks more to fetish than it does to skill. There's nothing special about any particular blade. Each requires a different technique. The Miller blade is no easier (or harder) than any other blade, but (in my humble opinion) you are far more likely to do damage to the hypopharynx and teeth or have an unecessarily difficult intubation with a Miller, especially if you try it on the wrong patient.

Keep practicing. No one expects you to intubate successfully as a med student. It takes time, patience, and developing the right feel. And, 8 intubations just isn't enough to get comfortable. Stick with one blade for now and learn to master it.

-copro

Completely agree. Practice makes perfect. Try everything that you possible can from glidescopes to Mac to millers to WisHips to phillips to bullards, to using your fingers and doing it blind. The more practice you get with different techniques the better you'll become, and in the process you'll gain an appreciation for each technique and develop your own preferences.

And in regards to positioning "sniffing" position is usually your best option but sometimes the straight line, straight blade (No head pillow) ENT style technique works great for anterior airways with short necks. Or better yet, just skip the blade and use a FOB. - CE

 

[urge]

Stick to the mac for now. It's easier to have tongue control with it compared to the miller. After you get good with it, use the miller until you are comfortable with both. Using the "clean one" is your goal. Each has it's advantages. And yes, ALL CRNAs USE MILLER. I always wondered why. There's got to be someone telling them it's better than the mac.

 

[Monty Python]

I currently rotating in anesthesia and I've done about 8 intubations this month with a mac. only 2 completely successful by myself, 3 with assistance, 2 failed, and 1 horribly failed (you know you horribly failed when you vent and the person abdomen rises while the surgeons look at you in disgust).

I've never ventured with the Miller but I noticed every CRNA uses one. Most cases I have to set out a mac because they don't even carry them in the OR. Should I try to use a miller or just stick with trying to perfect techinique with a mac?

Lastly, how hard is it to break teeth? Thats my #1 fear when I am intubating and I think thats why I fail sometimes. I noticed when other people do intubations they press the blade against the teeth for some of the harder airways, meanwhile I avoid the blade even touching the teeth.

One thing which is helpful (at least to me) is to raise the OR table so that the pt's forehead is about even with the lower part of your sternum. While this usually evokes sarcastic remarks from others in the room, I've found a high success rate with this particular positioning.

This, along with other handy tips, is noted about halfway down on this how-to guide (complete with video):

http://www.healthsystem.virginia.edu/internet/anesthesiology-elective/airway/intubation.cfm

Learning to intubate is like learning to start IVs or ride a bike. At first you're all thumbs, completely clumsy, falling off the bike and skinning your knees. One day it all just clicks into place, and from then on it's usually a piece of cake.

Having been associated with students the vast majority of my career, I've found the Mac blade easier for newbies, and I think it has a lower incidence rate of dental trauma. Probably out of laziness I've stuck with a Mac 3 for just about everything. I'll also reach for a Miller 3 if I have a difficult airway - again don't ask me why, I just seem to have a higher success rate that way.

Intubation is 98% art, a little skill, and 2% science.

 

[Noyac]

One thing which is helpful (at least to me) is to raise the OR table so that the pt's forehead is about even with the lower part of your sternum. While this usually evokes sarcastic remarks from others in the room, I've found a high success rate with this particular positioning.

Or you could pull up your seat in the OR and intubate while sitting down. This should turn those sarcastic remarks into oohs and ahhs.

 

[lfesiam]

I currently rotating in anesthesia and I've done about 8 intubations this month with a mac. only 2 completely successful by myself, 3 with assistance, 2 failed, and 1 horribly failed (you know you horribly failed when you vent and the person abdomen rises while the surgeons look at you in disgust).

I've never ventured with the Miller but I noticed every CRNA uses one. Most cases I have to set out a mac because they don't even carry them in the OR. Should I try to use a miller or just stick with trying to perfect techinique with a mac?

Lastly, how hard is it to break teeth? Thats my #1 fear when I am intubating and I think thats why I fail sometimes. I noticed when other people do intubations they press the blade against the teeth for some of the harder airways, meanwhile I avoid the blade even touching the teeth.

hello OP, MS4 here, was in your shoes. For me, MAC is better in adults w/ fat tongues, and Miller in Kids. I've done about 80 successful intubations. Was hard at first but knowing/visualizing the anatomy of the vocal cord in relation to everything, really helped. Technqiues like scissors (using thumb& 1st finger to open the mouth), sniff position, stabilizing the head with a donut or your belly, insert the blade on the right side of the mouth then sweep the tongue over slightly rotating the blade) AVOID TEETH AT ALL COST. Haven't chip one yet, they cost about $10,000 a piece from what I was told....

Good OR rooms to practice intubations are the Pediatric ORL cases i.e. tubes! Ask your attending before hand...most of the time they won't tube (LMAs/mask) but if you ask, they'll probably let you...turn over rate at 15-30 minutes per case. You'll probably get to intubate 7-11 times per day. If you chip teeth in kids....at least they are not permanent, the bugger will get a new one (if you get them at the right age). Another good room for intubation practice are the short scope cases in Pediatric GI.

A good clip of the vocal cord. (Air-Q with Air-Vu stylet)
[YOUTUBE]http://www.youtube.com/watch?v=WgQYmXnx0qU[/YOUTUBE]

 

[Monty Python]

Or you could pull up your seat in the OR and intubate while sitting down. This should turn those sarcastic remarks into oohs and ahhs.

The few times I've tried that (sitting on a 4-wheeled stool with no back) I found the stool trying to roll out from underneath me at precisely the wrong time. I guess my center of gravity wasn't properly aligned with everything else going on.

For the past several years I've gone without sitting down - in fact I'll push the anesthesia stool into a corner or into the hall. I found it just getting in my way. Without a stool I can move between head of the bed, anesthesia machine, and supply cart quicker and without getting the stool tangled up with my feet. More importantly, by standing throughout the case (well, I might sit on the machine a little) it's easier to remain focused on the case. I find sitting makes me more prone to zoning out.

 

[Mista Suprane]

One thing which is helpful (at least to me) is to raise the OR table so that the pt's forehead is about even with the lower part of your sternum. While this usually evokes sarcastic remarks from others in the room, I've found a high success rate with this particular positioning.

in my brief career (i'm a CA-1), i've had at least 5 different attendings tell me that this is the best position to intubate from. i have found in the 30 or so intubations i have done so far this year, that it is much more comfortable, and helps your back by putting the airway in a position so that you don't have to hunch over to see the cords.

seems as though those making sarcastic remarks in the OR don't know what they're talking about.

 

[Noyac]

The few times I've tried that (sitting on a 4-wheeled stool with no back) I found the stool trying to roll out from underneath me at precisely the wrong time. I guess my center of gravity wasn't properly aligned with everything else going on.

For the past several years I've gone without sitting down - in fact I'll push the anesthesia stool into a corner or into the hall. I found it just getting in my way. Without a stool I can move between head of the bed, anesthesia machine, and supply cart quicker and without getting the stool tangled up with my feet. More importantly, by standing throughout the case (well, I might sit on the machine a little) it's easier to remain focused on the case. I find sitting makes me more prone to zoning out.

You have a stool without a back. How do you manage?
You should come sit in our OR for a change. You'd be soooo happy.
http://tucson.craigslist.org/fuo/799745253.html

 

[Noyac]

in my brief career (i'm a CA-1), i've had at least 5 different attendings tell me that this is the best position to intubate from. i have found in the 30 or so intubations i have done so far this year, that it is much more comfortable, and helps your back by putting the airway in a position so that you don't have to hunch over to see the cords.

seems as though those making sarcastic remarks in the OR don't know what they're talking about.

By the time you get the table up to the level you need, I've got the pt asleep and intubated all from my sharper image message chair.

 

[Planktonmd]

You have a stool without a back. How do you manage?
You should come sit in our OR for a change. You'd be soooo happy.
http://tucson.craigslist.org/fuo/799745253.html

Wow!
Are you serious??

 

[Planktonmd]

Noy, Can you order a Beer at your OR?

 

[core0]

You have a stool without a back. How do you manage?
You should come sit in our OR for a change. You'd be soooo happy.
http://tucson.craigslist.org/fuo/799745253.html

Is that the medical grade version?

 

[Noyac]

Wow!
Are you serious??

Yeah I'm serious.

The surgeons hate us. Message chairs and fleeces for the OR with our names on them,
Dr. Noyac
Chief Anesthesiologist
Hospital Name

Now anyone interested in interviewing for our one position?

 

[coprolalia]

Yeah I'm serious.

The surgeons hate us. Message chairs and fleeces for the OR with our names on them,
Dr. Noyac
Chief Anesthesiologist
Hospital Name

Now anyone interested in interviewing for our one position?

What's a "Message" chair? Is it wired to the internet or something? I know what a massage chair is.



-copro

 

[Noyac]

What's a "Message" chair? Is it wired to the internet or something? I know what a massage chair is.



-copro

BTW its a joke. We have some nice OR recliners but they don't message, I mean massage.

 

[loveumms]

See if your program has any 'denta safe' tooth guards. These are small padded stickies that go onto the blade. Here is an example: http://www.metropolitanmedical.com/prod/DenInt_1.htm

I always put them on when I let the medical student intubate. It makes it a little harder to get the blade into the mouth however, it really decreases the chance of chipping a tooth. When learning, you often are focused on so many other things that you don't even realize you are hitting the teeth. I will sometimes use them when I expect the intubation will be difficult.

A quick google search reveals that they are somewhat effective and I've never had a chipped tooth on my watch.

 

[jetproppilot]

Heres a nice thread from the ER forum.

Nice posts.....I think mine answers alotta your questions.

http://forums.studentdoctor.net/showthread.php?t=537909&highlight=

 

[Ender]

One thing which is helpful (at least to me) is to raise the OR table so that the pt's forehead is about even with the lower part of your sternum. While this usually evokes sarcastic remarks from others in the room, I've found a high success rate with this particular positioning.

That is just strange to me that you would get rude remarks by using proper technique and positioning. Raising the table to the correct hight is one of the first things they teach us about intubation. I have forgotten to do it a couple of times (very awkward to intubate that low), and I have gotten hammered for it by attendings on both occations.

I have been using only a miller for the last few days. It is alot of fun to try different things. I am still getting used to it. I find that it gives you a better view once you have the proper depth.

Ender

 

[jetproppilot]

That is just strange to me that you would get rude remarks by using proper technique and positioning. Raising the table to the correct hight is one of the first things they teach us about intubation. I have forgotten to do it a couple of times (very awkward to intubate that low), and I have gotten hammered for it by attendings on both occations.



Ender

How about LOWERING THE TABLE TO THE CORRECT HEIGHT? I LOWER THE TABLE 'TIL IT BOTTOMS OUT FOR DIFFICULT INTUBATIONS so I can get down on one knee....gives me the most stable, strongest stance FOR ME, enabling me to give just that little bit more wrist movement with the Miller 2.....lifts the epiglottis just-that-little-bit-more....

I'm not posting this in an antagonistic fashion.

I'm posting this in a LEARNING fashion.

Ender, you are in the LEARNING portion of your career.

But realize for every attending that raises the bed, theres one that wants to LOWER the bed.

I'm glad you're BEING TAUGHT which means said anesthesia attending is engaging you and including you... which is the most important thing.

But let me respectfully say something that'll hopefully impact your career at some point.....earlier than later hopefully....

theres probably twenty or thirty CORRECT ways to perform the action that your current attending is telling you to do via the ONLY WAY, PER CURRENT ATTENDING........maybe your current attending is insecure, maybe he only feels comfortable with the table at a current height...

I can tell you

the tube usually goes in at whatever height the laryngoscopist selects..HIGH OR LOW....

BUT ITS UP TO YOU to determine what your optimum height of the table is for laryngoscopy.....

YOUR ATTENDING TOLD YOU THERES A SPECIFIC HEIGHT.

THATS TRUE......BUT ITS NOT ALWAYS THE SAME.

For some, its at the height you describe.

For me,

ITS LOW. ALL THE WAY TO THE BOTTOM.



HIGH OR LOW?

You pick.

I'll push the remote-buttons for ya.

 

[coprolalia]

Fiberoptic intubation you definitely want the table as low as it will go.

I sit for kiddies. Pull up the stool, get real close to them, and "plinko" in the tube goes.

-copro

 

[Ender]

How about LOWERING THE TABLE TO THE CORRECT HEIGHT? I LOWER THE TABLE 'TIL IT BOTTOMS OUT FOR DIFFICULT INTUBATIONS so I can get down on one knee....gives me the most stable, strongest stance FOR ME, enabling me to give just that little bit more wrist movement with the Miller 2.....lifts the epiglottis just-that-little-bit-more....

I'm not posting this in an antagonistic fashion.

I'm posting this in a LEARNING fashion.

Ender, you are in the LEARNING portion of your career.

But realize for every attending that raises the bed, theres one that wants to LOWER the bed.

I'm glad you're BEING TAUGHT which means said anesthesia attending is engaging you and including you... which is the most important thing.

But let me respectfully say something that'll hopefully impact your career at some point.....earlier than later hopefully....

theres probably twenty or thirty CORRECT ways to perform the action that your current attending is telling you to do via the ONLY WAY, PER CURRENT ATTENDING........maybe your current attending is insecure, maybe he only feels comfortable with the table at a current height...

I can tell you

the tube usually goes in at whatever height the laryngoscopist selects..HIGH OR LOW....

BUT ITS UP TO YOU to determine what your optimum height of the table is for laryngoscopy.....

YOUR ATTENDING TOLD YOU THERES A SPECIFIC HEIGHT.

THATS TRUE......BUT ITS NOT ALWAYS THE SAME.

For some, its at the height you describe.

For me,

ITS LOW. ALL THE WAY TO THE BOTTOM.



HIGH OR LOW?

You pick.

I'll push the remote-buttons for ya.

Thanks. I guess I never thought of kneeling for an intubation, or sitting for that matter. Mostly because no one here does that. Probably has more to do with the tables than anything (or they never tried it). If I dropped the table and tried to intubate on one knee I think I would see...the bottom of the table. Jet, Not all of us are 6'2" 215 lbs

On a serious note, thanks for the tip. I will have to try it once I get a little more comfortable with my intubations in general and I can find a table that will go down far enough (maybe offsite). And of course if I can get the attending to go along with it. Maybe I will have to kneel down on one of the steps the short surgeons use.

I would love to learn every technique that I can. I am a strong believer in avoiding "one technique anesthesia." There are attendings here that use the same anesthetic on everyone. They always discuss the patient's risks and medical issues that may effect the anesthetic, but very few actually change their "standard plan" to fit the patient. Then there are some that will ask you question's like "Which of the relaxants have you not yet used?" Then they will not only tailor the anesthetic to the patient, but also make sure you try something you have never done before. That is how I want to be. It kind of reminds me of your "Residents are you trying different anesthetics?" thread.

As always, thanks for the advice Jet.

Ender

PS wow it really makes me feel like a poser, using different size fonts!

 

[Ender]

Completely agree. Practice makes perfect. Try everything that you possible can from glidescopes to Mac to millers to WisHips to phillips to bullards, to using your fingers and doing it blind. The more practice you get with different techniques the better you'll become, and in the process you'll gain an appreciation for each technique and develop your own preferences.

And in regards to positioning "sniffing" position is usually your best option but sometimes the straight line, straight blade (No head pillow) ENT style technique works great for anterior airways with short necks. Or better yet, just skip the blade and use a FOB. - CE

At first I thought you were joking about using your fingers, but I found out that there is an attending here that only uses his fingers for most intubations. He reaches in and feels for the epiglottus and then intubates. That is crazy! I would love to learn that technique some time.

What is an FOB?

Ender

 

[loveumms]

This is a silly question ... maybe I've never acutally thought about it.

When using ones fingers for intubation is there ever a possibility that you initiate the gag reflex? If you push the epiglotis the opposite way by accident, it is possible to induce vomiting? Or do the anesthetics blunt this reflex?

 

[coprolalia]

What is an FOB?

A "f**king OB" resident. In that, as many of you already know, if it ain't the vagina, they don't know what the f*** to do with it. Always use an FOB as the absolute last resort.



-copro

P.S. FiberOptic Bronchoscope

 

[Ender]

A "f**king OB" resident. In that, as many of you already know, if it ain't the vagina, they don't know what the f*** to do with it. Always use an FOB as the absolute last resort.



-copro

P.S. FiberOptic Bronchoscope

Thanks.

 

[lfesiam]

At first I thought you were joking about using your fingers, but I found out that there is an attending here that only uses his fingers for most intubations. He reaches in and feels for the epiglottus and then intubates. That is crazy! I would love to learn that technique some time.

What is an FOB?

Ender

Free On Board. I'm a FOB. Snuck on the boat and bypassed immigration.

anyhow..that is crazy dude, intubating with only fingers?

ps: sneak (verb) Its origins are shrouded in mystery ... From the beginning, and still in standard British English, the past tense and past participle forms are sneaked. Just as mysteriously, in a little more than a century, a new past tense form, snuck, has crept and then rushed out of dialectal use in America, first into the areas of use that lexicographers label jocular or uneducated, and more recently, has reached the point where it is a virtual rival of sneaked in many parts of the English-speaking world. But not in Britain, where it is unmistakably taken to be a jocular or non-standard form.

 

[Monty Python]

At first I thought you were joking about using your fingers, but I found out that there is an attending here that only uses his fingers for most intubations. He reaches in and feels for the epiglottus and then intubates.

The military is teaching that in Prehospital Trauma Life Support.

Insert your index and third finger shaped like a V into the mouth, with your knuckles facing cranially, and your palm facing caudad. Feel for the epiglottis, open the V, put one finger on each side of the epiglottis, and use that as a guide for the ETT which you're blindly inserting. You might also feel the arytenoids posteriorly. If needed you can also exert a little upwards force on the palate with your fingers to open up the oropharyngeal space.

Try it on an intubatable mannequin.

 

[dfk]

i have heard many say line up to the base of the xiphoid..
personally, i don't follow it.
i tend to go about a handful off inches below that..

it's much easier to visualize from afar than other..

i think it's all in how you exercise it.

in the end,
be successful and you shall prosper.

 

[Ender]

i have heard many say line up to the base of the xiphoid..
personally, i don't follow it.
i tend to go about a handful off inches below that..

it's much easier to visualize from afar than other..

i think it's all in how you exercise it.

in the end,
be successful and you shall prosper.

...And if you are not successful you shall not prosper...this reminds me of the "Sphinx" character on the movie "Mystery Men." He would say things like, "If you do not learn to master your anger, your anger shall be your master." I love that movie, it is hilarious. In my opinion it's one of Ben Stiller's best.

Ender