On my 2nd intubation attempt ever, I placed the ET tube in the stomach. Can't stop beating myself up over that one. Any advice regarding how not to continue failing at this?
Whoops.
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I'm assuming you mean esophagus. No worries-- happens to everyone when they are first learning-- and even when we're not ;-) Are you learning how to intubate from an anesthesiologist? This is key. Just follow their advice, take your time and use good form. Note the airway anatomy when you're in there. And don't beat yourself up over it. You'll get the hang of it.
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+1 to forget about it. Shouldn't even bother you for more than a minute. Nobody ever died from tubing the esophagus. Recognizing an esophageal intubation is the key.
Think about it this way: you've got a 50% rate of successful intubations so far...that's much better than most learners start out with!
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false
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get a laryngoscopic view of the cords and put the ETT between the cords and you wont put it in the esophagus, plain and simple. dont guess, dont take chances, dont try to approximate angles and curves that may not be there. someday you will have to do that to intubate a difficult airway but that shouldnt be your focus right now. get good at laryngoscopy technique. dont be in a rush to grab the tube.
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It happens... you'll do it a fair number of times before you get it down.
As mentioned above, putting the tube in the esophagus isn't the catastrophic part. Failing to recognize that you've done so is. Learn from your mistakes and move on so that you do it better the next time. Part of what helped me was learning the anatomy and trying to recognize what I was seeing as I was manipulating everything, that way I could know where I was putting the tube rather than guessing. After that, it was all about learning the right way to give myself the view I needed.
BTW. a great thing you can do while learning is to verbalize what you're doing. If you say "I'm putting the blade in the vallecula", "I have a grade 1 view of the cords", your preceptors will have a bit more confidence that you're not totally clueless and are going to be less likely to snatch the blade from you while you're getting your bearings.
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Wait 'til you wet tap your first epidural. 😀
Don't sweat it. Focus on methodical and consistently good technique, optimal positioning. Slow down - your average well-preoxygenated elective patient won't desaturate for quite a while, so you have plenty of time.
It takes dozens of repetitions to start feeling comfortable with even routine intubations under optimal conditions. Many more reps after that to be proficient. Many many many more reps after that to have enough numbers to see a few unexpectedly difficult ones to develop general confidence for all comers.
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Just keep doing them.
It's all finesse and diligence.
Putting a tube in the esophagus isn't bad.
Leaving it in there is.
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One time I goosed it at a code. Pt must've had a GIB cause I got sprayed with black liquid with each chest compression. Usually esophageal intubation is not that immediately obvious though.
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This message is mainly directed at medical students and residents as most anesthesiologists know this lesson far too well. Real Story:
As stated, recognizing that you are in the goose is paramount. Being confident that it isn't in the goose without doing all the maneuvers we are trained to do to rule it out.... well, that sort of thinking can have disastrous consequences- it has happened.
Sevo as a PGY4 several years ago:
16 y/o obese female scheduled to go to the OR for alveolar lavage 2/2 alveolar proteinosis. Chronic hypoxia with SOB. Pao2 on room air = 50mmhg. Double lumen goes in without a problem. Confirmed placement fiberoptically.
Washed ea. lung out with 6-8 liters of warm NS. Here is a pic from the case:
http://img.villagephotos.com/imageview.aspx?i=27221628
"Big time" liver attending from Germany relieves me for a water break. I come back and he's getting ready to exchange the DLT for a single lumen 🙂() as her sats are still 85% on 100% 02... he wants to send her to the ICU with ETT in place to wean via protocol.
He pulls out the DLT and intubates. Sats go down... expected.
But then they keep on going down and spider sense starts going off:
http://webspace.webring.com/people/ds/spideyanimations2/spidey84_spidersense3.gif
I see no ETCo2. He is confident he's in the right place. I hear no BS. Gergaling above the diaphragm. Sats 65%... "just wait" he arrogantly states: "the sats are going to come back up". I'm pissed. He won't listen.
Pulmonary attending friend of mine is giving me the 😱 eyes...
I urge him to pull the tube and to PLEASE JUST mask her. He gets pissed at me for such a proposal. 900cc TV getting pushed in rapidly. Tension is in the air. I make a decision to grab the black snake, push him out of the way and look down the tube despite the fact that he told me not to. He's yelling at me as gastric rugae pop up on the screen. Patient is blue as can be....
I take charge and re-intubate. I could have killed him that day. He could have killed her that day... and he was my attending.
Real Story dudes....
He let his guard down and forgot one of my rules in anesthesia:
"TO BE SURE IS TO BE BLINDSIDED"
You've gottsta keep the forest in mind... during difficult cases, codes, pre-ops, etc. Get too close to the tree and you are gonna miss something.
Failing to recognize an esophageal intubation is a killer every single time.
Don't get caught blindsided cuz you think you are invincible. 🙂
As stated, recognizing that you are in the goose is paramount. Being confident that it isn't in the goose without doing all the maneuvers we are trained to do to rule it out.... well, that sort of thinking can have disastrous consequences- it has happened.
Sevo as a PGY4 several years ago:
16 y/o obese female scheduled to go to the OR for alveolar lavage 2/2 alveolar proteinosis. Chronic hypoxia with SOB. Pao2 on room air = 50mmhg. Double lumen goes in without a problem. Confirmed placement fiberoptically.
Washed ea. lung out with 6-8 liters of warm NS. Here is a pic from the case:
http://img.villagephotos.com/imageview.aspx?i=27221628
"Big time" liver attending from Germany relieves me for a water break. I come back and he's getting ready to exchange the DLT for a single lumen 🙂() as her sats are still 85% on 100% 02... he wants to send her to the ICU with ETT in place to wean via protocol.
He pulls out the DLT and intubates. Sats go down... expected.
But then they keep on going down and spider sense starts going off:
http://webspace.webring.com/people/ds/spideyanimations2/spidey84_spidersense3.gif
I see no ETCo2. He is confident he's in the right place. I hear no BS. Gergaling above the diaphragm. Sats 65%... "just wait" he arrogantly states: "the sats are going to come back up". I'm pissed. He won't listen.
Pulmonary attending friend of mine is giving me the 😱 eyes...
I urge him to pull the tube and to PLEASE JUST mask her. He gets pissed at me for such a proposal. 900cc TV getting pushed in rapidly. Tension is in the air. I make a decision to grab the black snake, push him out of the way and look down the tube despite the fact that he told me not to. He's yelling at me as gastric rugae pop up on the screen. Patient is blue as can be....
I take charge and re-intubate. I could have killed him that day. He could have killed her that day... and he was my attending.
Real Story dudes....
He let his guard down and forgot one of my rules in anesthesia:
"TO BE SURE IS TO BE BLINDSIDED"
You've gottsta keep the forest in mind... during difficult cases, codes, pre-ops, etc. Get too close to the tree and you are gonna miss something.
Failing to recognize an esophageal intubation is a killer every single time.
Don't get caught blindsided cuz you think you are invincible. 🙂
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I promise... Jet didn't help me proof read this post. 
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I promise... Jet didn't help me proof read this post.
+1
You were obviously channeling your inner Jet, though... strong work on the composition, as well as thanks for the story. Good way to help the message stick... Thank you.
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its easy to say no one died from esophageal intubation
however, one thing to realize is that its often a difficult laryngoscopy/intubation that results in the dreaded "goose"...perhaps they were also a difficult or impossible mask. this is now easily 30-60 seconds wasted time listening, checking for ETCO2, waiting...a patient can absolutely decompensate in that amount of time, even with skilled providers.
cant reinforce enough to stay vigilant, especially if you passed a blind tube
however, one thing to realize is that its often a difficult laryngoscopy/intubation that results in the dreaded "goose"...perhaps they were also a difficult or impossible mask. this is now easily 30-60 seconds wasted time listening, checking for ETCO2, waiting...a patient can absolutely decompensate in that amount of time, even with skilled providers.
cant reinforce enough to stay vigilant, especially if you passed a blind tube
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Yep. Takes me back to the big house when I used to see a good number of face/neck trauma in the morbidly obese. Had a bunch loose their restraints and pull out their ETT in the ICU after edema had already set in.... many of those patients got emergently trached at bedside due to difficult intubation/ventilation. This is our worst fear. Can't intubate, can't ventilate.
Fortunately I have not encountered anyone in PP I couldn't ventilate via 2 hand mask. That is not to say it isn't going to happen (although I don't really do trauma anymore).
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Dude....LOVE IT!!!!
All kidding aside, great post. Great story.
Something for all of us to keep in mind.
Thanks for sharing, Dude.👍
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I promise... Jet didn't help me proof read this post.
that was solid
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Excellent post.
Thank you for this perspective and advice. It is helpful for everyone. 👍👍
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Advice for the future:
When called to a code and the pt was just tubed by someone else (MICU, SICU resident), listen to BS and confirm yourself. Had an anesthesia resident here leave a code after the MICU team waved her off and said everything was fine only to be called back 20 minutes later!!! Pt now with anoxic brain injury.
When called to a code and the pt was just tubed by someone else (MICU, SICU resident), listen to BS and confirm yourself. Had an anesthesia resident here leave a code after the MICU team waved her off and said everything was fine only to be called back 20 minutes later!!! Pt now with anoxic brain injury.
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Does Jet use red?
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You realize I now have to go through some Jet posts to find red and redeem myself... 🙂
OR,
I suppose he could post a little red heretofore 😎
D712
update: Fail. 20 or so JetPearls, a few classics and no RED. Oh well.
OR,
I suppose he could post a little red heretofore 😎
D712
update: Fail. 20 or so JetPearls, a few classics and no RED. Oh well.
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Buck up, little camper... 😀
If it makes you feel any better, I could have SWORN that he used red... but I also did a quick search. No dice here, either. I did have a good time going on a trip down memory lane, though!