Dear Stupendous Students 4,

Myself and Mark McGraw, Director of New Bedford EMS
and one of my "expert" consultants on intubation. 

How do you feel about intubation? Do you think it’s important? Is it one of those skills that can be taught, or does it have to be practiced to be learned? Why do so many practitioners fail at intubation? Before we can answer those questions, lets talk about who is required intubate. Paramedics? Yes, all of them. Nurses? Only some of them. Doctors? Only some of them. Stew on that.

So every Paramedic can intubate, and we learn to intubate during our relatively short approximate 2 year training. Anesthesiologists train for over a decade. Certified Registered Nurse Anesthetists train for close to a decade. Does Captain Obvious need to make a sudden appearance to point out which way I’m going with this? Treat intubation like the privileged skill that it is, and do it right every time. My Paramedic Instructor used to always say, “There’s no excuse for a bad tube.” He didn’t mean you will never intubate the esophagus, he meant have the proficiency to recognize and reverse an esophageal intubation immediately, and the professional responsibility to check tube placement efficiently and frequently. He s right. There is NO ever-loving excuse for a bad tube. There is no pothole, patient movement, or “someone else’s,” fault for walking into the ED with a misplaced ETT. This is precisely the reason we have stethoscopes, capnography, end tidal Co2 caps, esophageal detector devices, visualization, condensation....etc! I mean really, with all of these tools at our disposal to check placement, IS there any excuse for a bad tube? 

For this blog, I sent out a survey to a select few Paramedics I know, that I would consider “experts” in the skill of intubation. It is interesting to see that 4 of the 5 answered the same exact to some of the questions. The fifth didn’t answer any at all and only said “Read Dr. Bledsoe’s articles on ‘The Disappearing Endotracheal Tube.” The questions were as follows, and the answers are summed up by me from the 4 that offered their advice. 

Q: What blade do you prefer and why?

A: Unanimously every medic preferred the Macintosh 4. All surveyors agree it has the versatility to give or take away “blade room” with more or less fingers applied to the base, alternately making it a Mac 3. It was also noted to easily lift the epiglottis when necessary, easily displace the tongue when necessary, give a “light” touch to a more delicate airway, and be used a straight or curved blade. Stellar advice to this question: “Don’t get married to a blade, folks. Anatomy differs and that’s why there are so many blades.” 

Q: Tips for holding the laryngoscope?

A: The majority agreed to hold the blade close to the handle next to the hinge, or at the bottom of the blade in the palm of your hand. One described it as placing your baby finger off the handle and under the blade to “choke up,” on the handle and get better control of the blade, lessening the tendency to lever back on the handle. Stellar advice to this question: “Hold it firm and keep your wrist locked. When you lift, go up and out. Pretend you’re aiming the handle at the intersection where the wall meets the ceiling. Not up, not forward, but right in the middle.” 

Q: Tips for identifying landmarks/cords?

A: Most agree it is most important to recognize anatomy, look at lots of pictures, and realize people have different anatomy that is not always text book looking. One very experienced Paramedic says “Don’t crawl into the patient’s mouth-get back from the patient to improve your visual perspective.” That line of thinking gives perspective to the “difficult tube” scenario because how often do we want to take a closer peep at that which we don’t understand, such as the mucous/blood filled airway?! In other words, step off! Check it out from a distance. Stellar advice to this question: “Know your cuneiform and corniculate cartilages ; where they are, what they look like and where they are in relation to the vocal cords. It helps greatly to recognize them especially with a deep, anterior patient. If you can identify them then you know the cords are above.”

Q: If you had to summarize successful intubation into one sentence, what would it be?

A: Everyone agrees that preparation and positioning are 2 of the most important considerations for consistent success. Here are the 4 sentences: 

1. It is imperative to be 100 percent familiar with the anatomy, don't play with it and move purposefully, watch the tube pass the cords, don't let go of the tube until its secure and recheck often.

2. Pre-planning, help, pre-positioning, insertion, confirmation, and affixing.

3. Successful intubation is the ability to manipulate the airway with a laryngoscope, visualize the cords, place an ET through, inflate, secure and confirm.

4. Set your patient up for success, positioning is the key. 

Q: Other advice/wisdoms/experiences?

A:  All 4 agree that intubation is a true skill that requires plenty of practice. It is one of the most important skills we perform and should be mastered. Line up ears to sternum for difficult intubations and create a ramp like towel or blanket roll to prop the shoulders up. In the absence of C-spine precautions, don’t be afraid to manipulate the head, flexing and extending while visualizing with the laryngoscope and noting how the different movements open and close the airway. Always use a stylet! Most patients with an anterior airway are usually deviated to the left. Stellar advice to this question: “Take 10 sec and set your patient up for success!!!”   

I’m so glad I sent out that survey, and thank you very much to the medics who answered. You guys are so awesome your middle initials are A, you should work for Awesome EMS, people should address you as “your awesomeness,” your cell phone carriers should be Awesome T&T and you should talk on an A-phone, you should have your own TV Network called “The Awesome Channel” that features only shows about how awesome you are, and you should all have a talking mirror that says “you look Awesome today,” every time you look in it! 

It was interesting to see the same advice being repeated consistently among the 4, especially know your anatomy, prepare yourself and your patient for intubation, prop the shoulders, hold the blade with your hand near the hinges, and check and recheck your tube! For the students who ride at NBEMS: The airway bag on all of our trucks is in an outside compartment on the drivers side of the ambulance. That means the driver almost always carries that bag. For that reason, oftentimes it is the driver who intubates, although some medics prefer to intubate their own patient since they will ultimately be responsible for transferring and documenting the tube. Familiarize yourself with the location and contents of this bag, possibly even feel out the crew for what their preferences are when it comes time to intubate. Don’t wait until you’re smack in the middle of a cluster to fumble around for equipment or permission! 

I hope this blog has made you recognize the importance of mastering this very difficult skill. Study airway anatomy repetitiously! Go back to the classroom and practice. Talk to other Paramedics, Nurses, Doctors, Respiratory Therapists and anyone else that intubates about their successes...and failures. NEVER deliver a bad tube. Stellar advice on this subject:

“Think before acting; it is better to come in with no tube than a bad tube...”