Video Laryngoscopy 100% of the time… every time.

[MalloryWeiss]

If you have a decked out 2021 Tesla Model S Plaid in your driveway… why drive the 1989 Honda Civic?

Once upon a time the only way to place a central line was by doing it “blind” aka using landmarks. Today, not using an ultrasound is considered to be below the standard of care (unless it’s an emergency).

How many of you have similarly evolved your practice to using a video laryngoscope 100% of the time (McGrath)?

- optimizes first attempt success (therefore you’re reliably faster, fewer attempts, makes you consistently more slick in private practice)
- nobody is forcing you to look at the screen, so if you’re feeling proud that day then just use the McGrath as a regular mac blade and look directly
- less torque required therefore less sympathetic response and less traumatic to oropharynx/epiglottis/tongue/etc. (I see some people barbarically crank and contort the patient’s head to get a good view… YIKES! Guys… there is a better way, and you can bet that if I’m going in for a lap appy, I’ll be kindly requesting Video)
- less risk of dental injury

Sure there is some marginal upfront cost (3-5k I think, not including the disposal blades)… but who cares? That’s a drop in the bucket compared to the SAFETY benefits that video provides.

I use it 100% of the time, and I think one day it will become the standard of care (similar to ultrasound for lines). In my house, we have one McGrath in every OR. Anyone else out there who is proud to be on the video train?

(To clarify: not suggesting we wheel in a Glidescope for every case. I’m talking handheld devices)

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[Precedex]

lame and you are doing yourself a disservice.

 

[Neopolymath]

This isn't the emergency medicine subforum




(joking, joking!)

 

[MirrorTodd]

I'm teaching residents. So no.

 

[MalloryWeiss]

lame and you are doing yourself a disservice.

People said the same exact thing when ultrasound came around for line placement.

But I’ll wait for you to tell me exactly why your approach is safer and better for the patient.

 

[MalloryWeiss]

I'm teaching residents. So no.

Question: why not have them intubate with the screen off, and use it as a traditional Mac blade / direct laryngoscopy. If they struggle and can’t get the view, press the on button and leverage the technology that the year 2021 provides us?

 

[abolt18]

Question: why not have them intubate with the screen off, and use it as a traditional Mac blade / direct laryngoscopy. If they struggle and can’t get the view, press the on button and leverage the technology that the year 2021 provides us?

Why not just DL, knowing your limits, and if you are not satisfied with the view, switch to VL?

And there are times when VL fails or cannot help you. Mastering the skills of DL and keeping up those skills is a must IMO.

 

[MalloryWeiss]

Why not just DL, knowing your limits, and if you are not satisfied with the view, switch to VL?

And there are times when VL fails or cannot help you. Mastering the skills of DL and keeping up those skills is a must IMO.

100% agree that DL is a valuable skillset that all board certified anesthesiologists should maintain.

It is precisely why I suggest intermittently performing directly laryngoscopy with a VL device (and simply not using the video feature unless it’s needed). The value here is time, less instrumentation/trauma.

 

[sevoflurane]

NO

 

[dabears505]

Just the other day, had an icu intubation, dude had so much garbage coming out of esophagus and trachea, every time I put scope in, camera got covered and image was completely occluded. It helps to still be able to use the DL stuff ever once in a while. It's good to keep your skills up.

 

[MalloryWeiss]

NO

For Covid intubations… the national consensus was to optimize first attempt success via VL. Why aren’t we optimizing first attempt success, ALL the time?

Pride? Ego? Machismo?

As anesthesiologists, we are the experts in patient safety. … and I’m still waiting for a fellow physician colleague to offer a legitimate counterargument that traditional DL is safer.

And once again, the McGrath STILL ALLOWS YOU TO DL.

 

[sevoflurane]

For Covid intubations… the national consensus was to optimize first attempt success via VL. Why aren’t we optimizing first attempt success, ALL the time?

Pride? Ego? Machismo?

As anesthesiologists, we are the experts in patient safety. … and I’m still waiting for a fellow physician colleague to offer a legitimate counterargument that traditional DL is safer.

And once again, the McGrath STILL ALLOWS YOU TO DL.

because glidescopes break down and aw disasters happen at places that donn’t have them. Think expanding hematoma status post acdf at a surgery center when their VL was broken. Been there.
Keep your skills up

 

[sevoflurane]

We have 60 some OR’s that start every day…. 60 VL is not cheap.

 

[MalloryWeiss]

I’m excited to see how this thread ages over the next 10 years because it’s just a matter of time that the standard of care evolves.

Same way it did with 1) central lines and ultrasound, 2) regional blocks and kicking nerve stimulators to the curb, 3) open cholecystectomy vs laparoscopic, 4) manual vs self driving vehicles, etc. Cost will also continue to decrease.

 

[nimbus]

If you have a decked out 2021 Tesla Model S Plaid in your driveway… why drive the 1989 Honda Civic?

Once upon a time the only way to place a central line was by doing it “blind” aka using landmarks. Today, not using an ultrasound is considered to be below the standard of care (unless it’s an emergency).

How many of you have similarly evolved your practice to using a video laryngoscope 100% of the time (McGrath)?

- optimizes first attempt success (therefore you’re reliably faster, fewer attempts, makes you consistently more slick in private practice)
- nobody is forcing you to look at the screen, so if you’re feeling proud that day then just use the McGrath as a regular mac blade and look directly
- less torque required therefore less sympathetic response and less traumatic to oropharynx/epiglottis/tongue/etc. (I see some people barbarically crank and contort the patient’s head to get a good view… YIKES! Guys… there is a better way, and you can bet that if I’m going in for a lap appy, I’ll be kindly requesting Video)
- less risk of dental injury

Sure there is some marginal upfront cost (3-5k I think, not including the disposal blades)… but who cares? That’s a drop in the bucket compared to the SAFETY benefits that video provides.

I use it 100% of the time, and I think one day it will become the standard of care (similar to ultrasound for lines). In my house, we have one McGrath in every OR. Anyone else out there who is proud to be on the video train?

(To clarify: not suggesting we wheel in a Glidescope for every case. I’m talking handheld devices)

I’ve spent 25 years personally doing my own cases. I actually wheel the glidescope in every time I plan to intubate. Several of my partners who have as much and more experience than me do the same. It’s the best way to intubate in my own hands and my patients deserve the best way.

 

[MirrorTodd]

Question: why not have them intubate with the screen off, and use it as a traditional Mac blade / direct laryngoscopy. If they struggle and can’t get the view, press the on button and leverage the technology that the year 2021 provides us?

We don't have McGrath's so that's kind of a moot point for us. I would not be able to convince our anesthesia department to buy a bunch of Mcgrath's.

 

[nimbus]

I also had a peds attending (and later partner and fellow volunteer) who would wheel his own capnometer from room to room on a cart. He told me some of his colleagues would snicker, ask him why he does that, and say they don’t need it. Time proved him right.

 

[MirrorTodd]

I'll have to look into any studies that have been done, but maybe you already know...How much safer is it actually? How much less of a sympathetic response? How much more first attempt success? How much of a decrease in risk of dental injury?
I will look up the data myself, but it'd be good to see some stuff that backs up your claim already.

 

[nimbus]

We don't have McGrath's so that's kind of a moot point for us. I would not be able to convince our anesthesia department to buy a bunch of Mcgrath's.

The problem with mcgraths is that they tend to walk away from the OR and end up on eBay.

 

[MirrorTodd]

The problem with mcgraths is that they tend to walk away from the OR and end up on eBay.

It is harder to walk out of the hospital with a glidescope.

 

[narcotics999]

The problem with mcgraths is that they tend to walk away from the OR and end up on eBay.

chip it and you can trace them to the end of world.

 

[nimbus]

I'll have to look into any studies that have been done, but maybe you already know...How much safer is it actually? How much less of a sympathetic response? How much more first attempt success? How much of a decrease in risk of dental injury?
I will look up the data myself, but it'd be good to see some stuff that backs up your claim already.

Before glidescope, I was successfully able to intubate the vast majority of patients with a MAC4 to the point where I’d need an alternate method every year or 2. Some of them were more of a struggle though. With glidescope there is no struggle. Easier is better so I don’t need to read a study to know it is better. And if something better than a glidescope comes along, I’ll use that too.

 

[nimbus]

chip it and you can trace them to the end of world.

Well chipped dogs still get lost😉

 

[nimbus]

ASA Adopts Basic Monitoring Standards

Related Article: ASA 1986 Monitoring Standards Launched New Era of Care, Improved Patient Safety With precedent-setting resolve the American Society of

www.apsf.org

From 1987. Capnometry and pulse oximetry were controversial at that time.

“The ASA committee debated whether to include capnography and pulse oximetry as the “standard of care’ ‘At that time, it was felt impractical to mandate very specific (and very expensive) high tech equipment when the greatest focus of the effort was the general extension of the vigilance of the anesthesiologist. The committee also considered the questions of the consistency of performance of these two instruments and the availability at that time relative to the potential demand. However, E. C. (“Jeep7’) Pierce, M.D., committee member and past president of the ASA, now states, “Capnography and oximetry are becoming so widespread that they will he functional standards. Projecting current trends, it is likely that by the end of 1988, enough oximeters will have been sold for there to be one available for every operating room in the country”.

 

[MirrorTodd]

Before glidescope, I was successfully able to intubate the vast majority of patients with a MAC4 to the point where I’d need an alternate method every year or 2. Some of them were more of a struggle though. With glidescope there is no struggle. Easier is better so I don’t need to read a study to know it is better. And if something better than a glidescope comes along, I’ll use that too.

I get what you are saying and I believe that when price becomes less of an issue, VL will take over in the vast majority of case. But how MUCH of an improvement was it really? Were you REALLY doing so much damage to those few cases that were a little bit more difficult (I find that hard to believe)? To me, converting to VL for everything isn't necessarily improving things all that much, certainly not so much as ultrasound increases central line and block safety or a surgeon going from open to laparascopic procedures.

 

[nimbus]

I get what you are saying and I believe that when price becomes less of an issue, VL will take over in the vast majority of case. But how MUCH of an improvement was it really? Were you REALLY doing so much damage to those few cases that were a little bit more difficult (I find that hard to believe)? To me, converting to VL for everything isn't necessarily improving things all that much, certainly not so much as ultrasound increases central line and block safety or a surgeon going from open to laparascopic procedures.

Mostly minor damage…scraped teeth, cut or pinched lips, transient hypertension and not too common but it still happened from time to time. All those things can happen with VL too but in my hands they are less frequent with VL. An improvement is an improvement. Everything counts.

 

[fakin' the funk]

The "they said the same thing about ultrasound" argument is dumb because VL is not ultrasound. It's not categorically, evidence based faster or safer or more reliable than DL. It's a product with a useful niche, with important drawbacks and limitations.

I would say easily 50-75% of all VL intubations I've ever seen by others didn't "need" VL. It's overused in the general population and it's very useful in certain situations.

 

[OTCAwesome]

I bought my own McGrath so I've always got it in my bag. I got it for like $1000, they give you the discount if you're an anesthesiologist and buy directly. In terms of the cost, for our practice, the mcGrath blades are cheaper than the disposable blades, or reprocessing the non-disposable ones. I've used it on plenty of actively vomiting blood/bile/pizza bites patients, in that case you just use it to DL.

 

[Sugammadank]

I use it 100% of the time, and I think one day it will become the standard of care (similar to ultrasound for lines). In my house, we have one McGrath in every OR. Anyone else out there who is proud to be on the video train?

Whenever someone tells me they use VL 100% of the time, my first thought is, "This person sucks at intubating."

Don't get me wrong, I like McGraths. But people above have pointed out multiple reasons for why VL shouldn't be 1st pass. Also, unless McGraths and their batteries become significantly cheaper, I don't see every hospital converting to 100% VL for every OR.

 

[MalloryWeiss]

The "they said the same thing about ultrasound" argument is dumb because VL is not ultrasound. It's not categorically, evidence based faster or safer or more reliable than DL. It's a product with a useful niche, with important drawbacks and limitations.

I would say easily 50-75% of all VL intubations I've ever seen by others didn't "need" VL. It's overused in the general population and it's very useful in certain situations.

Everyone on this thread, yourself included, keeps missing the point that I have reiterated several times:

YOU CAN DL WITH A MCGRATH.

Video optimizes first attempt success. Period.

Video not helping you? Well hey… look direct because:

YOU CAN DL WITH A MCGRATH.

 

[pgg]

We just had this thread a couple days ago:

Percentage of goosing intubations?

What do you think your percentage is with DL? I’m sure with VL it’s < 1%

forums.studentdoctor.net

Which linked to this older thread and rehashed it:

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

Using plain old laryngoscopes to DL isn't about ego. I reach for ultrasound 100% of the time now for arterial lines, and nobody would call that "standard of care". Earlier today I was doing a case with a resident, and I asked (as I always do) if he wanted the ultrasound. He didn't, missed his first stick, got the second stick on the other arm. Unnecessary, but no big deal. In another room, a different resident used the ultrasound for an a-line, and got it easily. A third resident passing through to give a break jokingly said it was cheating. All I can do is just shake my head. I think ultrasound should always be used for placing any line, if it's available. I would want it for myself if I was being stuck.

Ultrasound has obvious benefits for placing lines and doing nerve blocks. Easy first-pass success, easy visualization of occasional aberrant anatomy.

Most airways are going to be EASY intubations with direct laryngoscopy for reasonably experienced people. Most airways you can slip a tube in with a gentle lift to give yourself a grade 3 or 4 view. You don't have to crank it up to a tachycardia-inducing grade 1, just because you can. That simple fact is never, ever, ever going to change.

If the day comes that I need to be intubated, I honestly DGAF what the tube jockey uses to visualize my vocal cords. It just isn't going to matter a bit for my easy airway. I continue to be completely baffled by this weird crusade to make VL the standard.

I certainly reach for VL when I think an airway might not be a chip shot. No ego there.


And another thing ... there's a dangerous line of thinking amongst some VL evangelists that it makes every airway easy, to the point that I've seen people induce people they should've tubed awake because they were sure VL would get it. And VL isn't magic.

 

[MalloryWeiss]

Whenever someone tells me they use VL 100% of the time, my first thought is, "This person sucks at intubating."

Don't get me wrong, I like McGraths. But people above have pointed out multiple reasons for why VL shouldn't be 1st pass. Also, unless McGraths and their batteries become significantly cheaper, I don't see every hospital converting to 100% VL for every OR.

You are welcome to make ad hominem attacks about my intubating skill. I anticipated it, and intentionally titled this thread in a polarizing fashion to generate discussion about how we should be leveraging technology, innovation, and disruptive thinking to enhance patient safety. For me, risk mitigation is the name of the game - every single day.

Because of ego, I too was an exclusive DL guy for years. But somewhere along the way, I saw the light.

We’ll see how this thread ages, my friend.

 

[fakin' the funk]

Everyone on this thread, yourself included, keeps missing the point that I have reiterated several times:

YOU CAN DL WITH A MCGRATH.

Video optimizes first attempt success. Period.

Video not helping you? Well hey… look direct because:

YOU CAN DL WITH A MCGRATH.

You're yelling at me about a product I don't have. Sort of limits the upside of your argument. But whatevs.

 

[zizzer]

To be fair, your point is likely true for people with subpar DL skills like some EM docs or CCM docs who haven't done thousands of them (not questioning your skills btw). However, most anesthesiologists aren't unnecessarily rough, are aware of hemodynamic effects, and are quite skilled with DL.

I don't see that anybody has pointed out that VL with hyperangulated blades is more inconvenient to set up. The extra time to lube and stylette a tube, retrieve, plug in, and orient a corded rolling machine isn't a lot in itself, but it's annoying when adding to your setup time every case. McGrath will solve some of these problems if you use it as regular DL, but if it's not hyperangulated like you say, is it really helping you that much? Many places, including my place don't have them anyway.

Not to brag, but I'm pretty good and gentle with DL. If somebody has a bad airway exam, I use VL. If they are borderline, I have a VL available to be safe. If an unstyletted ETT isn't going in gently, I'll use the VL.

Therefore, I save myself a lot of time and keep up my skills by using DL, and I don't think it jeopardizes safety because I have VL when needed.

 

[MalloryWeiss]

To be fair, your point is likely true for people with subpar DL skills like some EM docs or CCM docs who haven't done thousands of them (not questioning your skills btw). However, most anesthesiologists aren't unnecessarily rough, are aware of hemodynamic effects, and are quite skilled with DL.

I don't see that anybody has pointed out that VL with hyperangulated blades is more inconvenient to set up. The extra time to lube and stylette a tube, retrieve, plug in, and orient a corded rolling machine isn't a lot in itself, but it's annoying when adding to your setup time every case. McGrath will solve some of these problems if you use it as regular DL, but if it's not hyperangulated like you say, is it really helping you that much? Many places, including my place don't have them anyway.

Not to brag, but I'm pretty good and gentle with DL. If somebody has a bad airway exam, I use VL. If they are borderline, I have a VL available to be safe. If an unstyletted ETT isn't going in gently, I'll use the VL.

Therefore, I save myself a lot of time and keep up my skills by using DL, and I don't think it jeopardizes safety because I have VL when needed.

The hyperangulated substitute blades are available for the McGrath which can take the place of the traditional MAC 3 or 4 blade.

P.s. I promise I’m not a rep for the McGrath

 

[coffeebythelake]

Maybe when price point of these devices comes down considerably, and VL becomes so ubiquitous that it is in every room and available. Losing the skill in DL'ing will be unfortunate.

 

[pgg]

You are welcome to make ad hominem attacks about my intubating skill. I anticipated it, and intentionally titled this thread in a polarizing fashion to generate discussion about how we should be leveraging technology, innovation, and disruptive thinking to enhance patient safety. For me, risk mitigation is the name of the game - every single day.

Because of ego, I too was an exclusive DL guy for years. But somewhere along the way, I saw the light.

We’ll see how this thread ages, my friend.

How long until you earnestly advocate for using ultrasound for starting all peripheral IVs?

Maybe surgeons should start doing office procedures in an operating room because it's objectively a 12% more sterile environment and the lighting is better.

What you don't seem to be getting is that some procedures are such trivial affairs that "leveraging technology" to do them is just ridiculous academic handwaving. Which is OK until you start casting shade on people who laugh at it for the absurdity it is. But you do you.

 

[Mehd School]

The light on the mcgrath is weak, so DL'ing with a mcgrath is much more challenging than with a normal laryngoscope. In the past three months alone I have had two ICU intubations where I could not get there with a mcgrath but was able to intubate with a miller. I had a code yesterday where vomitus during chest compressions immediately rendered my mcgrath useless.

 

[GassYous]

Had a covid airway in residency where the intubated patient self extubated. The icu spent a ton of time messing around with fiberoptics and glides and couldn't get it so they called us. Mac 3, tube no problem. 30 seconds in and out.

Then one of our dumb attendings came and messed with the tube for some inexplicable reason and lost it again. Spent like an hour playing around with a mcgrath and couldn't get it then we got it again with a mac3.

 

[Katheudontas parateroumen]

Where I have found VL to be most useful is in situations like codes and Crashing icu/floor/ED intubations where positioning is not on your side. Having a glidescope or any VL vastly improved the view with minimal or no position adjustments. I will commonly intubate from the side with my VL while on the other side of the bed someone is doing compressions so then I don’t have to take time to push the bed back and go from up top. Freaks people out at first for some reason but it definitely works. Other times I still prefer DL is if I’m seeing lots of stuff in the airway. DL is a true skill that needs to be kept up. Even people that use VL all the time like pulm people I see struggle because I don’t think they know the angles or proper movements. And of course, VL has not become universal… at least yet. I would say that practicing lines “blind “ is also still a skill set to be done in the proper setting. There are always emergent situations where we gonna have to go old school.

But for the OP, I also welcome VL becoming universal standard unless in emergent situations based on my own experience. It’s the most reliable and better view and plus everyone around the room can confirm placement and not waste time “waiting for color change”. But still has to be in the hands of people with experience.

 

[GassYous]

Where I have found VL to be most useful is in situations like codes and Crashing icu/floor/ED intubations where positioning is not on your side. Having a glidescope or any VL vastly improved the view with minimal or no position adjustments. I will commonly intubate from the side with my VL while on the other side of the bed someone is doing compressions so then I don’t have to take time to push the bed back and go from up top. Freaks people out at first for some reason but it definitely works. Other times I still prefer DL is if I’m seeing lots of stuff in the airway. DL is a true skill that needs to be kept up. Even people that use VL all the time like pulm people I see struggle because I don’t think they know the angles or proper movements. And of course, VL has not become universal… at least yet. I would say that practicing lines “blind “ is also still a skill set to be done in the proper setting. There are always emergent situations where we gonna have to go old school.

But for the OP, I also welcome VL becoming universal standard unless in emergent situations based on my own experience. It’s the most reliable and better view and plus everyone around the room can confirm placement and not waste time “waiting for color change”. But still has to be in the hands of people with experience.

When you said "floor intubation" I thought of this time when some guy admitted for a subarachnoid was found down on the floor in the icu and they were doing chest compressions. Tubed him with DL sitting on the ground with my back against the wall and felt like a badass.

 

[DrZzZz]

When you said "floor intubation" I thought of this time when some guy admitted for a subarachnoid was found down on the floor in the icu and they were doing chest compressions. Tubed him with DL sitting on the ground with my back against the wall and felt like a badass.

Had a buddy in residency intubate someone getting compressions on the floor of the lobby. He was laying on his stomach, propped up on his elbows intubating the guy. Pretty cool

 

[JiPo]

My experience with McGrath has been great. As the OP has said multiple times, you can still DL and treat it like a regular MAC blade. This is great for teaching fresh CA-1s. I can see exactly what their DL view is looking at the monitor.

My residency seriously considered getting McGrath in every room. The disposable blades are cheaper than autoclaving the blades apparently. Our main issue was McGrath going missing/stolen.

The light source for McGrath isn't the best, but I never had issues, tbh. The only time it is better to DL is if there is a lot of secretion or blood, obstructing the camera. Even then, if you are using McGrath (not glide), stop looking at the camera, and look directly into the mouth. I really don't see how DL with a MAC outperforms McGrath other than the cost. I agree that we need to keep DL skills sharp as anesthesiologists, but again, you can always DL with McGrath.

McGrath is basically a MAC blade with a camera. It does everything that MAC blade does if used like a MAC, and not looking at the camera.

 

[jwk]

For Covid intubations… the national consensus was to optimize first attempt success via VL. Why aren’t we optimizing first attempt success, ALL the time?

Pride? Ego? Machismo?

As anesthesiologists, we are the experts in patient safety. … and I’m still waiting for a fellow physician colleague to offer a legitimate counterargument that traditional DL is safer.

And once again, the McGrath STILL ALLOWS YOU TO DL.

As an anesthesiologist - you should be an expert in all forms of airway management.

If you can't DL - the traditional way - you shouldn't be doing anesthesia. Period.

I see a LOT of folks - including board certified anesthesiologists - that can't mask a patient worth a damn. Why? Because of LMA use.

VL is right up there with the top advancements in the field - along with things like pulse oximetry and capnography, and perhaps the LMA - none of which were available when I started 40 years ago.

And personally, a McGrath's main advantages are it's small and it's cheap(er). The Glidescope setup with a large screen is far superior IMHO, and I'll take it any day over a McGrath. I've never been a McGrath fan and never will since better alternatives are available.

I'm happy to admit I use VL a lot - but probably in less than half my intubations in the OR. I'm perfectly comfortable using DL, as I have for 40+ years, but I'm also perfectly comfortable using VL as appropriate. But if you never DL, those skills will disappear.

To me it's not much different than a Mac vs Miller debate. Whatever works best in YOUR hands with a given patient should be your first airway device.

 

[coffeebythelake]

Had a buddy in residency intubate someone getting compressions on the floor of the lobby. He was laying on his stomach, propped up on his elbows intubating the guy. Pretty cool

did a couple of these code intubations during residency, exactly like that
mouth full of vomit, no suction around,
VL wouldn't have seen ****tttttt

 

[chessknt]

Had a covid airway in residency where the intubated patient self extubated. The icu spent a ton of time messing around with fiberoptics and glides and couldn't get it so they called us. Mac 3, tube no problem. 30 seconds in and out.

Then one of our dumb attendings came and messed with the tube for some inexplicable reason and lost it again. Spent like an hour playing around with a mcgrath and couldn't get it then we got it again with a mac3.

Did anyone consider that if an icu patient can survive without an airway for an hour then maybe they don’t need one?

 

[GassYous]

Did anyone consider that if an icu patient can survive without an airway for an hour then maybe they don’t need one?

They were bagging the whole time. Patient probably died anyway it was a ridiculously high mortality for them at the time

 

[BLADEMDA]

For Covid intubations… the national consensus was to optimize first attempt success via VL. Why aren’t we optimizing first attempt success, ALL the time?

Pride? Ego? Machismo?

As anesthesiologists, we are the experts in patient safety. … and I’m still waiting for a fellow physician colleague to offer a legitimate counterargument that traditional DL is safer.

And once again, the McGrath STILL ALLOWS YOU TO DL.

OK. Let me share 3 decades of real world experience with you. I like all the new toys and I do think they advance the field. But, The use of a Miller 2 or Miller 3 is still the GOLD STANDARD when there is blood or stomach contents in the airway. So, I humbly suggest you maintain those skills for when the sh@it hits the fan and none of the VL work.

The use of the Mcgrath as a MAC blade is lame. The blade has a different angle on the tip which makes the view easier to obtain. Again, I suggest a careful and gentle use of the Miller blade whenever possible to maintain skill. If that fails I readily agree switching the VL makes sense and should be the next step rather than trying to bloody up the airway with trauma by attempting to do standard laryngoscopy multiple times.

Thus, a better approach or question is "how many times should a provider attempt standard laryngoscopy before switching to a VL"? I suggest 1-2 attempts by the most qualified person in the room then switch to a VL followed by a LMA/Fiberoptic.

Traditional DL isn't "safer" but rather a necessary skill which can be used efficiently and gently by experienced providers. For those without skill (which include many providers today) Watching them perform DL is indeed like watching a horror movie.

 

[aneftp]

Do what’s safe for you and your patients. I’m less cowboy style these days. I don’t use videoscope daily. But I have it available. I’m not gonna to struggle with an airway. One attempt. If not good. Go for video scope.

Why traumatize the patient.

We used to do 3-4 awake fiber optic intubations a week for neuro train wrecks at the 50 OR institution I used to work at 20 years ago. Now I do an awake fiber optic intubation maybe 2x a year. So I’m not as good as I used to be. But video scope has definitely made life easier

Same with ultrasound for blocks and central lines.

Use technology. But don’t forget how to do the airway manually. It’s like being a pilot. The instruments may fail. Intubate when u can once in a while.

 

[chessknt]

They were bagging the whole time. Patient probably died anyway it was a ridiculously high mortality for them at the time

I feel like the majority of ICU patients I intubate are so PEEP dependent they do ****ing horrible any time they lose circuit pressure but maybe Ive just been doing too much end stage Covid these days.