Recent intubation experiences

[Inertia123]

---

Members don't see this ad.

Current PGY-1 on Anesthesia rotation. I have been lucky to work with nice anesthesiologists and CRNAs during the rotation and have gotten to intubate about 30 patients in two weeks. Probably from a combination of luck, easy airways and developing skill, my hit rate has been ~95%. I had 2 cases today that did not go as smoothly as possible and I'm not sure why. The first one was a tall young man who needed a NIMS tube placed (basically a larger diameter tube with electrodes used for monitoring nerve function during thyroid cases). Got a grade 1 view but as I was placing the tube, I completely lost my view with the epiglottis flopping down over the glottic inlet. I regained the view but was having a hard time getting the tube anterior to the arytenoids. My only guess is that maybe I should have used a mac-4 rather than a mac-3. The second case was a middle aged woman. Again, grade 1 view, but as I was trying to pass the tube I was not able to get anterior enough and the tube kept bending posteriorly away from the cords. Thinking back on it I maybe could have used more tongue sweep Both of these I was able to get after some struggling but not without inflicting some airway trauma - which I was not happy about. Also, if these cases were ED RSI cases they would have surely been taken from me long before the point I succeeded in these cases. Weirdly enough, I had a 3rd case with a known difficult airway who I intubated with the glidescope with almost no difficulty at all.

I dunno - I guess it's scary to me to have a streak of about 25 very smooth and uneventful intubations and then come up against 2 that I had difficulty with in the same day. It's also scary to me that I was able to get a grade-1 view in <15 seconds in each case but then had such difficulty placing the actual tube especially since I have placed tubes with a lot more ease in people who I have had lesser quality views.

Thoughts???

 

[Tiger26]

Welcome to emergency medicine--you can have a run of great saves and then have difficulty sleeping after losing your mojo on 1 or 2 in a row

Strikes and gutters, ups and downs

 

[Cerberus]

Welcome to emergency medicine--you can have a run of great saves and then have difficulty sleeping after losing your mojo on 1 or 2 in a row

Strikes and gutters, ups and downs

True true. I haven't missed a tube since my second attempt of intern year... I know that luck only holds so long (which is why I approach every airway like it is a potential disaster).

 

[namethatsmell]

I regained the view but was having a hard time getting the tube anterior to the arytenoids. My only guess is that maybe I should have used a mac-4 rather than a mac-3.

Regardless of blade size, it never hurts asking for slight downward pressure on the neck in these situations. It can often turn an "anterior" airway into just another airway.

I dunno - I guess it's scary to me to have a streak of about 25 very smooth and uneventful intubations and then come up against 2 that I had difficulty with in the same day. It's also scary to me that I was able to get a grade-1 view in <15 seconds in each case but then had such difficulty placing the actual tube especially since I have placed tubes with a lot more ease in people who I have had lesser quality views.

Thoughts???

Yeah, there's nothing like unexpected curveballs (procedural or otherwise) to get in your head...as a fellow intern this has happened not infrequently to me this year. If this is your first time count thyself lucky. At this point I just try to learn from it and then file it under the "controlled chaos" aspect of our field. The funny thing is that while I can objectively look back and see that the vast majority are not an "at fault" situation (outside of happening to be working that day)...they still cause me to lose sleep. Maybe it gets better as our experience/career progresses?

 

[Groove]

Current PGY-1 on Anesthesia rotation. I have been lucky to work with nice anesthesiologists and CRNAs during the rotation and have gotten to intubate about 30 patients in two weeks. Probably from a combination of luck, easy airways and developing skill, my hit rate has been ~95%. I had 2 cases today that did not go as smoothly as possible and I'm not sure why. The first one was a tall young man who needed a NIMS tube placed (basically a larger diameter tube with electrodes used for monitoring nerve function during thyroid cases). Got a grade 1 view but as I was placing the tube, I completely lost my view with the epiglottis flopping down over the glottic inlet. I regained the view but was having a hard time getting the tube anterior to the arytenoids. My only guess is that maybe I should have used a mac-4 rather than a mac-3. The second case was a middle aged woman. Again, grade 1 view, but as I was trying to pass the tube I was not able to get anterior enough and the tube kept bending posteriorly away from the cords. Thinking back on it I maybe could have used more tongue sweep Both of these I was able to get after some struggling but not without inflicting some airway trauma - which I was not happy about. Also, if these cases were ED RSI cases they would have surely been taken from me long before the point I succeeded in these cases. Weirdly enough, I had a 3rd case with a known difficult airway who I intubated with the glidescope with almost no difficulty at all.

I dunno - I guess it's scary to me to have a streak of about 25 very smooth and uneventful intubations and then come up against 2 that I had difficulty with in the same day. It's also scary to me that I was able to get a grade-1 view in <15 seconds in each case but then had such difficulty placing the actual tube especially since I have placed tubes with a lot more ease in people who I have had lesser quality views.

Thoughts???

Like most things... practice makes perfect. Always respect the potential for unexpected catastrophe with any emergent airway. I intubate regularly and ALWAYS have an LMA and a gum elastic bougie within reach. I can't remember the last time I had to open them, but the airways that bite you the hardest are always the ones that you least expect.

 

[RustedFox]

Duuude... youre in an OR, in a controlled environment, with plenty of backup, and you miss a tube... ?

Besssst miss, ever.

Last tube I missed, I was in blood, vomit, and all sorts of laryngopharyngeal edema - and my RT bailed my ass out because he had spent lots of time dicking around with the glidescope that day.


The more you think you know, the more you find out that you don't know.

 

[EctopicFetus]

Always prepare mentally for disaster. Equally obvious, understand and prepare for difficulties and try to maximize your chances for success.

 

[Birdstrike]

Best airway advice I was ever given?

Learn how to bag a patient first.

Put a nasal trumpet and/or an oral airway and bag. It's not always that easy. If you can bag a patient, you can oxygenate them indefinitely (in most cases) and buy yourself valuable time, turning a seconds to minutes airway crash pattern into a calmer and controlled holding pattern, while you pick plan B.

I don't think anyone should be allowed to touch a laryngoscope or ETT until their "bag-valve mask ventilation skills" are perfected.

Counter-intuitively, many brutally difficult airways are very easy to bag, and vice versa.

Once you're confident with "I know there's a 99% chance I can bag this patient indefinitely, if needed" your confidence with intubation will automatically soar.

 

[Janders]

You did the hard part... you got the view!
In the ED, my next move would be to KEEP MY VIEW, ask for a bougie, place it through the cords, and then railroad a tube over it.
Other things that might help:
-- Firmer stylet, or stylet with different curve
--Smaller tube
--Miller to lift up that floppy epiglottis

 

[HooliganSnail]

Best airway advice I was ever given?

Learn how to bag a patient first.

Put a nasal trumpet and/or an oral airway and bag. It's not always that easy. If you can bag a patient, you can oxygenate them indefinitely (in most cases) and buy yourself valuable time, turning a seconds to minutes airway crash pattern into a calmer and controlled holding pattern, while you pick plan B.

I don't think anyone should be allowed to touch a laryngoscope or ETT until their "bag-valve mask ventilation skills" are perfected.

Counter-intuitively, many brutally difficult airways are very easy to bag, and vice versa.

Once you're confident with "I know there's a 99% chance I can bag this patient indefinitely, if needed" your confidence with intubation will automatically soar.

Best airway post I've seen in a long time. If there is anything I learned during anesthesia (all from CRNA's btw), it is that bagging a patient is the most important skill most doctors never really learn. The goal is to ventilate the patient. If you can ventilate, you can oxygenate, and if you can oxygenate, then you're doing just fine.