New to the Blogroll September 27, 2007
Posted by keepbreathing in Blogroll, Doctors, Medical Blogs, airway management, my life, respiratory therapy.trackback
Please welcome to the blogroll Postcards from Kiddieland, the tales of Dr. Bee, pediatrics resident. Dr. Bee is rotating through the PICU, which is a fascinating place to be indeed! Best of luck to Bee, and remember that no matter what the attendings might say, Albuterol really does not cure Croup.
My Tubes&Lines class was intriguing. It was basically a review of the reasons to intubate and the methods of doing so, followed by a few minutes of intubating a plastic airway dummy. I did fine with the Macintosh (curved) blades, but the distaste for Miller (straight) blades that I learned in RT school is still with me. It just seems so much easier to flick the blade into the vallecula than to flip the epiglottis out of the way; any thoughts on this from medics or anesthesia types?
As far as the Lines part of the class, it was hilarious. The teacher held up an Arrow A-Line Cath Set and said
“You’ll just have to watch people do this to learn about it. It’s sort of like putting in an IV but weirder. You’ll have to suture it, but don’t ever suture somebody elses line because you’ll regret it.”
And then we were done. This is medical education at it’s highest level, folks: the philosophy is apparently derived from that oft-used axiom of “See One, Do One, Teach One.” I think I like that better anyway. Sometimes learning things in the classroom can actually be counterproductive, because real-world medicine and textbook medicine are so dissimilar. Not that I’m saying classroom education is worthless, because it certainly does have a lot of value to it. Indeed, without classroom learning nothing that happens clinically makes sense. I guess what I am getting at is that it seems that classroom should learning should more closely approximate the real world sometimes.
Since you asked….
I rarely use the Miller blade, maybe twice in my whole career (14+ years). You can always pick up the vallecula with a Mac if you need to, or try a 3 instead of a 4.
Lately, though, at our institution, we are very hot on 2 relatively new “toys” that we have much success with - the glide scope and the lightwand.
The glide scope gives you an LED screen (fairly large at that, too) and you no longer have to sweep the tongue to the left, you just go down midline.
The lightwand takes a lot of practice, and you must darken the room to see the light just above the sternal notch. Also, you must have a completely obtunded patient (either through drugs or disease) in order to use it - reflexes will not work with this device.
Never underestimate the sniffing position, and cricoid pressure. Those two enhancements have bailed me out of more jams than any device I’ve ever used.
oops - in first paragraph, I meant try a 4 instead of a 3. Sorry for messing up your comments section. My bad.
I can fall down a flight of stairs with a Mac #3 and a fistful of tubes, and accidentally intubate five people on the way down.
That said, the very first CRNA who taught me something said, “If the only tool you have in your toolbox is a hammer, you wind up treating every problem like a nail.”
He asked me what blade I preferred to use, and naturally I said “Macintosh #3.”
The sadistic bastard approved heartily of my choice…and then made me use a Miller blade for the next week. But I learned to appreciate it later. Now I’m proficient with both.
On the subject of more tools in the toolbox, what supraglottic airways do you have at your disposal? LMAs? King LT Airways? Any little gadgets like gum bougies? All are useful adjuncts to have around.
Two toys I have in my personal airway kit that I find useful are a Grandview blade (think tongue shovel) and a Viewmax blade, which is a 3.5 Mac blade with a prismatic lens attached, that refracts your view 20 degrees upwards. It’s great for those really anterior views.
I love the Bougie. Not only is it a handy tool, it’s got a funny name: The Bougie! I’ve seen the Grandview too, and it’s a good tool to use.
As far as other adjuncts, we don’t really have many. For some reason, the hospital doesn’t let RTs use the LMA, so if we try twice and nobody else around can intubate, we’re supposed to call up Anesthesia and have them deal with it. This isn’t so much solving the problem as it is pushing it aside, but c’est la vie.
Terry, is the lightwand the same thing as the stilette?
I’m honored to have been added to your blogroll! Today was airway day, apparently. One extubation, one kid who developed post-extubation croup after having an IJ portacath placed for hemodialysis for HUS, one kid with mucolipidosis admitted for observation after being tubed for CT/MRI because he has a “crap airway” (attending’s words, not mine) and has a trach tray at the bedside just in case, and one kid who got tubed in the ER because he couldn’t protect his airway (pneumonia, maybe sepsis, but MRCP, seizure disorder, dev delay, hypotonia, etc.).
Then again, in the PICU, it’s always airway day, isn’t it?
Ben,
Whatever blade you use…
1. Find the epiglottis FIRST during your laryngoscopy.Don’t barge in. Place the blade where it belongs.
2.Lift and find those anatomical airway structuers. Sometimes it’s like in a textbook, and (like today at the 3d floor SKRH code ) sometimes there’s a limited view. This case was harder because of limited cervical mobility, a small mouth and small submental area(small jaw,no room to squish the tongue into).Burn the image of the arytnoid cartiliges and the arytnoid notch into your memorybanks. If you can see those structures, put the tube ABOVE them. If you can’t see those structures and head position is good….
3. Cricoid good, ELM better.External Laryngeal Manipulation isn’t the Sellick maneuver.That’s to squeeze the esophagus between the cricoid cartilidge and the cervical spine and prevent gastric regurge and insufflation.ELM has you manipulate the larynx with your right hand as you employ the laryngoscope with your left hand.There’s the BURP (backwards, upwards to the right position) maneuver to pull the larynx up towards you and push it down towards the bed to get a better view. .An assistant can hold pressure where you tell them.
4. No structures? TOO DEEP…RETRACT.
Don’t get me going.
AJC
KB - it is a flexible stylet (sic) with a light at one end of it and thin batteries at the other end. Takes a little practice but with experience you can intubate even the most anterior of patients, just look for that light above the notch. Here’s a link: http://www.aaronmed.com/enproductslightflex.html
It’s also good for bad dentition, as you never really have to touch the teeth.
I like Mac 3 for all my intubation’s I used a miller once in clinicals but i found it awkward to use I only missed on intubation in my clinicals and i was with the miller Give me a mac any day