May 13, 2017
Dr. Jeff Jarvis joins me in this three part series on tips to optimize your first pass success with intubation.... but now just for any one, this podcast is for "The Occasional Intubator". Let’s face it, as Paramedics we don’t walk around every shift throwing tubes down everyone’s throat! We have to realize that this is a skill that has the potential to save someone’s life, but also has the potential to take one. There have been rumblings back and forth on whether medics should be allowed to perform a skill they don’t use frequently. These arguments are backed by scenarios where providers have failed intubation, intubated the goose, and never used any quantifiable markers to validate placement….. and the patient died. Can we honestly use this as an argument to take away the skill of endotracheal intubation at the Paramedic level? Let’s address this question with some very reasonable concerns that come up regarding airway management training in Paramedic school. With so much to cover in a short period of time, airway management does not get NEAR the time it deserves in our initial education. We are taught that an RSI is a lighting speed process, we are told to hold our breath and when we need to breathe, it’s time to get out! We are led to believe that we will dip the blade into the hypopharynx and immediately see the cords!! These teachings create a nervous and jittery intubator who isn’t breathing because some clown told him to hold his breath! There competency is validated by their ability to perform five intubations in a nicely lit, controlled environment. Under the heuristics and proper set up of an anesthesiologist. So now you are probably wondering… where are the tips?? This just seems like a dig at formal paramedic education! The first tip is to realize that you are an “occasional intubator”. Don’t let that discourage you though, because you can achieve excellence with this skill, you just need to put all the odds in your favor. Tip 1. Positioning 99% of the time in school you will be intubating mannequin heads that are stuck to a flat board. You will find yourself bending down low and trying to get eye level with the larynx axis. Finger tips turn white as you struggle to lift forward enough to see the cords, while trying to not use the teeth as a fulcrum. There are three axis we need to become familiar with when intubating. The oral, pharyngeal, and laryngeal axis. These can easily be aligned by putting the patient in an ear to sternal notch position. When applied properly, you really only need the laryngoscope to lift the tongue out of the way. This technique in cooperation with airway adjuncts also helps optimize First Pass Ventilation (FPV) with a BVM. The saying “work smarter, not harder” really applies simply to the way you position your patient. Tip 2. Delay Your Sequence Intubation is not a game of speed. Get scene times out of your head for a minute and realize that speed means nothing when you deliver a hypoxic patient in peri-arrest. Delayed Sequence Intubation (DSI) is procedural sedation, with the procedure being pre-oxygenation. If you are intubating a hypoxic patient, you are setting yourself up for failure. Take the time to properly pre-oxygenate & denitrogenate your patient. This usually takes about 3 minutes to perform…. Can you wait that long? It may seem like FOREVER, but trust me it will give you a safety net during intubation. The goal of the peri-intubation period is to have the patient spontaneously breathing as much as possible up until the point of intubation. This prevents excessive bagging, gastric insufflation, and some of the negative effects of BVM ventilation. Most induction agents will depress your respiratory drive such as versed, etomidate, fentanyl, etc. So how do we keep this breathing adequately up until the point of intubation?