Percentage of goosing intubations?

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.
ToKingdomCome said:
What do you think your percentage is with DL? I’m sure with VL it’s < 1%
Click to expand...
I'd say definitely <5% but likely <1%. Can't even remember the last time it happened. I'll DL everyone but I also have a low threshold to switch to glidescope if I put the blade in and can't see diddly.

And so far it's 0% with VL.
 
Last edited:
The last tube I goosed was during active cpr on a covid positive pt who was spewing up blood with every chest compression. That was like a year ago or so, otherwise, I haven't had one since like intern year.
 
abolt18 said:
I'd say definitely <5% but likely <1%. Can't even remember the last time it happened. I'll DL everyone but I also have a low threshold to switch to glidescope if I put the blade in and can't see diddly.

And so far it's 0% with VL.
Click to expand...

We have VLs in every room. If I can't see anything with a DL I'll just change to a VL to avoid traumatizing their airway. Because of this I can't remember the last time I tubed the esophagus.

I can't say I DL everyone though. If the patient looks like a difficult intubation from the get-go I'll start with VL. I used to try to DL these patients as well, but I realized: 1) normally my instincts are correct when it comes to difficult intubations so I may as well increase my chance of success on the first attempt, 2) I was DLing difficult airways only as a way of making myself feel like I had a huge **** and not because it was good for patient care. As long as the tube goes in smoothly with no trauma to the airway, I don't care about the method of laryngoscopy.
 
I goosed a 2.5kg premie last week, but I could barely see epiglottis and was told to just push and pray. I knew I was there so it didn't last long. Very senior pedi anesthesiologist took over and it made him sweat a little bit too, so all good. But I honestly can't remember the last time I was in the goose. Counting that one have definitely done it less than 8 or so times in all of residency.

One time I purposefully goosed an 8.5 tube in the ascitic liver failure patient I was intubating in the transplant ICU that just had endless vomit. Tubed the goose, inflated the cuff and had the ICU nurse put her thumb over the tube to give me 10 vomit-free seconds to suction him out enough to secure the airway. That wasn't a good outcome.
 
vector2 said:
A lot of your partners do the same? How does the cost work out for your group?
Click to expand...


Fair question. Maybe 1/4 of us. I haven’t considered or know the cost. Our MACs, millers, and FOBs are all disposable single use too. Maybe a disposable glidescope costs 2x a disposable MAC4? I just prefer to use superior technology that is the least traumatic with the highest success rate in my own hands. That’s why I use US for every single Aline too.
 
nimbus said:
Fair question. Maybe 1/4 of us. I haven’t considered or know the cost. Our MACs, millers, and FOBs are all disposable single use too. Maybe a disposable glidescope costs 2x a disposable MAC4? I just prefer to use superior technology that is the least traumatic with the highest success rate in my own hands. That’s why I use US for every single Aline too.
Click to expand...
You sure the Ultrasound isn't for the extra +1 unit?😎
 
2Fast2Des said:
You sure the Ultrasound isn't for the extra +1 unit?😎
Click to expand...


For a long time and until very recently my group didn’t give us credit for using US for alines because we weren’t sure what proportion of payors actually pay for it. I was using it for alines long before that.
 
McGarth. Probably 3000 for the scope. 15 for the blade.

Glide, depends on the agreement you have with them. Scope is “free”. Blade, probably 30-50. Also the stylet, the FOB, 100-150.

All add up. Lots of Benjamins.
 
IMGASMD said:
McGarth. Probably 3000 for the scope. 15 for the blade.

Glide, depends on the agreement you have with them. Scope is “free”. Blade, probably 30-50. Also the stylet, the FOB, 100-150.

All add up. Lots of Benjamins.
Click to expand...

I prefer to use the regular malleable stylette with the glidescope and put my own bend on it.
 
nimbus said:
I don’t even try DL any more. 100% VL so 0% in the goose.
Click to expand...

It’s funny how users are now upvoting your comment. Take a look at this thread I created several years back and the responses I got:

forums.studentdoctor.net

Will video laryngoscopes become standard of care? Should they?

Read a recent article regarding ultrasound-guided central lines leading to lower complications, and it got me thinking: 1) why the hell are people still studying this since it seems so obvious to me what the results will be, and 2) will I be thinking the same thing about video laryngoscopy in 20...
forums.studentdoctor.net forums.studentdoctor.net
 
Urzuz said:
We have VLs in every room. If I can't see anything with a DL I'll just change to a VL to avoid traumatizing their airway. Because of this I can't remember the last time I tubed the esophagus.

I can't say I DL everyone though. If the patient looks like a difficult intubation from the get-go I'll start with VL. I used to try to DL these patients as well, but I realized: 1) normally my instincts are correct when it comes to difficult intubations so I may as well increase my chance of success on the first attempt, 2) I was DLing difficult airways only as a way of making myself feel like I had a huge **** and not because it was good for patient care. As long as the tube goes in smoothly with no trauma to the airway, I don't care about the method of laryngoscopy.
Click to expand...
very true, but not every hospital has enough for all 730 starts if everyone had this philosophy. one day...

and what do you do on the floor during emergency intubations or with young kids if you never use DL?

i think it still behooves us to maintain DL skills without glidescope and to make DL our first attempt the vast majority of the time
 
  • Like
Reactions: jwk
IMGASMD said:
McGarth. Probably 3000 for the scope. 15 for the blade.

Glide, depends on the agreement you have with them. Scope is “free”. Blade, probably 30-50. Also the stylet, the FOB, 100-150.

All add up. Lots of Benjamins.
Click to expand...

We have a McGrath in every OR, and it’s the default for all of us MDs, as well as our CRNAs for both safety and efficiency.

But man, if it really is $15 for each of those plastic slip-on blades, that’s really wasteful and I’ll change my practice, perhaps to the Glidescope slip-one if cheaper.

I’ll check with our techs but I was under the impression they were each about $2-3 for the McGrath.
 
JoelJoel84 said:
We have a McGrath in every OR, and it’s the default for all of us MDs, as well as our CRNAs for both safety and efficiency.

But man, if it really is $15 for each of those plastic slip-on blades, that’s really wasteful and I’ll change my practice, perhaps to the Glidescope slip-one if cheaper.

I’ll check with our techs but I was under the impression they were each about $2-3 for the McGrath.
Click to expand...

www.tigermedical.com

Blades for McGRATH MAC Video Laryngoscope - Size 3, X-Blade - 10/bx

Empower physicians with top-quality office furniture, diagnostic equipment, and essential supplies. We specialize in creating efficient, comfortable, and functional medical spaces for doctors, so they can provide the best care for their patients.
www.tigermedical.com www.tigermedical.com

Holy crap

30 dollars each

I DL everyone with no teeth because no chance of dental damage but I feel like I'd rather waste the plastic and the money than pay for a scratched up incisor
 
Urzuz said:
It’s funny how users are now upvoting your comment. Take a look at this thread I created several years back and the responses I got:

forums.studentdoctor.net

Will video laryngoscopes become standard of care? Should they?

Read a recent article regarding ultrasound-guided central lines leading to lower complications, and it got me thinking: 1) why the hell are people still studying this since it seems so obvious to me what the results will be, and 2) will I be thinking the same thing about video laryngoscopy in 20...
forums.studentdoctor.net forums.studentdoctor.net
Click to expand...
I think when we're talking about an experienced anesthesiologist like @nimbus who's been around the block a few times, no one really cares what he uses to intubate. He doesn't have to prove anything to anyone by arbitrarily DL'ing first before switching to something. I haven't been out as long as him but I also don't think I have anything to prove considering I've intubated patients with a Miller 2 multiple times a day for years as a resident, and even now as staff 4 yrs out I still have to rescue a CRNA or resident every couple weeks using DL or VL.

The more interesting question is what to do with trainees now that so many institutions, including mine, have a McGrath in every room. I have a CA-2 on his first cardiac month and he wanted to use a McGrath routinely for intubation in pump cases. My first instinct was that this request was ridiculous, but when I thought about it more......1. I know he's at an appropriate level with DL from seeing him in other cases 2. he's actually slightly faster with VL, 2. the stimulation is less and the hemodynamics are better with the plastic vs metal blade. So I said OK.

Anyone think this is a bad way to go with a resident?
 
@vector2 no I think it's a good way to go. I make all non anesthesiology residents intubate with vl. No wondering what they see and time to acceptable proficiency is faster
 
vector2 said:
I think when we're talking about an experienced anesthesiologist like @nimbus who's been around the block a few times, no one really cares what he uses to intubate. He doesn't have to prove anything to anyone by arbitrarily DL'ing first before switching to something. I haven't been out as long as him but I also don't think I have anything to prove considering I've intubated patients with a Miller 2 multiple times a day for years as a resident, and even now as staff 4 yrs out I still have to rescue a CRNA or resident every couple weeks using DL or VL.

The more interesting question is what to do with trainees now that so many institutions, including mine, have a McGrath in every room. I have a CA-2 on his first cardiac month and he wanted to use a McGrath routinely for intubation in pump cases. My first instinct was that this request was ridiculous, but when I thought about it more......1. I know he's at an appropriate level with DL from seeing him in other cases 2. he's actually slightly faster with VL, 2. the stimulation is less and the hemodynamics are better with the plastic vs metal blade. So I said OK.

Anyone think this is a bad way to go with a resident?
Click to expand...
I'm only over a year out. I established my chops early on rescuing CRNAs with the exact same blade they used. Now if I have to rescue I just ask for the glide. If it's not in the room I take a quick look with DL while waiting on it.

I think the approach of letting a senior resident have more control over how he administers the anesthetic is smart. Maybe throw a curve ball at him once in a while to make sure he's not getting too comfortable.

Edit:. Like @nimbus I also like using the regular malleable stylette. I've done it successfully time and time again but it still apparently freaks people out. Which annoys me because it's just another sign that people can't challenge dogma.
 
Last edited:
There aren't enough VL's or U/S machines at my place to use on every patient every time.
 
Urzuz said:
It’s funny how users are now upvoting your comment. Take a look at this thread I created several years back and the responses I got:

forums.studentdoctor.net

Will video laryngoscopes become standard of care? Should they?

Read a recent article regarding ultrasound-guided central lines leading to lower complications, and it got me thinking: 1) why the hell are people still studying this since it seems so obvious to me what the results will be, and 2) will I be thinking the same thing about video laryngoscopy in 20...
forums.studentdoctor.net forums.studentdoctor.net
Click to expand...
I don’t disagree with some of the sentiment though. I’m early in my career and we have easy access to VL in every OR where I work, but I find when teaching residents, that people VL skills are way higher if they learned how to DL well first.
 
I think that it's just like anything else though, where if you don't use it you lose it. As a CA2 I made it a point to DL as much as humanly possible and that resulted in an almost 3 month streak without using a glidescope. When I had an unanticipated difficult airway and had to reach for the glidescope I felt pretty rusty with it. For the same reason I switch between mac and miller blades often even though I prefer a straight blade.
 
I learned to do nerve blocks with landmarks and a nerve stim, but use ultrasound 100% of the time now. Ultrasound is ubiquitous, and undeniably faster (with fewer needle passes, and fewer failed/marginal blocks) than landmark/stim. Even people who were SLICK with landmark/stim now use ultrasound, because it's so much easier, and faster. No increase in cost of disposables. Easy choice.

I learned to place central lines by landmarks and a finder needle, but use ultrasound 100% of the time now. Ultrasound is ubiquitous, and at least for IJ lines using ultrasound is undeniably the standard of care now. Easy choice. Still no disposables to speak of, beyond a probe cover.

I learned to intubate people with direct laryngoscopy ... now, if an airway doesn't look like it'll be easy, I'll just go straight to VL. But VL isn't ubiquitous, most places I work don't have one in every OR. Also, the cost of consumables isn't trivial. VL is certainly not standard of care now, but it might be some day. For an airway that you know will be easy, it seems, well, wasteful 🙂, to waste the disposable components. Can you be gentler and cause less postop throat discomfort with VL? Maybe, sometimes. But good, experienced direct laryngoscopists won't lift hard to see a grade 1 view, they'll lift gently to see a grade 3 or 4 view, and just put the tube where they know it goes. It only takes 5 or 10 seconds. I don't see a compelling argument now to use VL for most airways. That may change one day when VL is in every room and the cost per airway is comparable to DL.
 
There was a thread in the EM sub a few months ago. They sort of touch upon how to train their residents. I don’t remember what I’ve said there…. Probably nothing good. But we do it so much more frequent than they ever will. I think most of them settled with some sort of hybrid approach. Use VL blade as DL blade, so the attending can “see” what they see….. But their proficiency is on a different level than us, and I am sure being “judged” on a different level than us.

@nimbus I just tell my techs, I am new and not sure what’s going on, I need all the help I can get….
 
IMGASMD said:
There was a thread in the EM sub a few months ago. They sort of touch upon how to train their residents. I don’t remember what I’ve said there…. Probably nothing good. But we do it so much more frequent than they ever will. I think most of them settled with some sort of hybrid approach. Use VL blade as DL blade, so the attending can “see” what they see….. But their proficiency is on a different level than us, and I am sure being “judged” on a different level than us.

@nimbus I just tell my techs, I am new and not sure what’s going on, I need all the help I can get….
Click to expand...
Watching them is cringe inducing. They make navigating the vl to the right position look like a difficult thing.
 
ToKingdomCome said:
What do you think your percentage is with DL? I’m sure with VL it’s < 1%
Click to expand...
Once novices are taken out of the pictures I doubt the decrease in "tubing the goose" is statistically less with video versus direct laryngoscopy. We all should have a bougie immediately available and know how to use it properly. A video laryngoscope should be available nearby as well as a difficult airway cart.
 
I like to DL all and only have VL available if I am worried. I am worried about deteriorating my skillset but probably should switch. +1 on extra costs, but it is hard to keep caring when you see so many other areas that are wasteful on supplies that costs 10x more.
 
BobLoblaw78 said:
I like to DL all and only have VL available if I am worried. I am worried about deteriorating my skillset but probably should switch. +1 on extra costs, but it is hard to keep caring when you see so many other areas that are wasteful on supplies that costs 10x more.
Click to expand...

I saw a nurse open something in a total room that cost $1000 and they didn't even use it
 
GassYous said:
I saw a nurse open something in a total room that cost $1000 and they didn't even use it
Click to expand...
I had a surgeon open a 20k nerve stimulator kit just to get a small screwdriver out. At the same time the hospital was aggressively haggling with us over about $100 or so a day worth of an anesthesia stipend. Not kidding.
 
kidthor said:
I had a surgeon open a 20k nerve stimulator kit just to get a small screwdriver out. At the same time the hospital was aggressively haggling with us over about $100 or so a day worth of an anesthesia stipend. Not kidding.
Click to expand...

The hot topic for my last few places, is still, Suggmadex…….

For something, eventually, they should be able to recoup from patient/insurance. It’s still a talking point against the department……
 
You must log in or register to reply here.

Similar threads

T
Awake Intubation
2
Replies
52
Views
5K
amyl
A
P
Remaining intubated post op
Replies
20
Views
2K
zizzer
Z
S
Anesthesia letter of recommendation
Replies
6
Views
1K
AKMD_1984
A
A
Egd and intubation?
Replies
16
Views
2K
Silo004
Silo004
Guillemot
The Dilemma of Gastric POCUS
2
Replies
93
Views
4K
Radetzky
R
Top