# Intubation



## Muppet (Jun 9, 2015)

@Red Flag 1, Our resident anesthesiologist. You're thoughts doc. Any doc or provider for that matter. I know. Not "combat medicine" but advanced airways are in our scope. Takes a re-learn... I like it though.

M.


----------



## Red Flag 1 (Jun 9, 2015)

T


----------



## x SF med (Jun 9, 2015)

It sucked practicing intubations on each other...  really sucked... but you did not want to hurt your buddy so it was great training from a care standpoint.  Except for all the puke.

Teeth are not a lever.  If you can, get a straight line.

ETA - it really pisses me off in any movie/tv show when they show anybody trying to intubate from the side rather than being set up at true north of the  patient's capitus.  How the hell can you see anything in the endotracheal path from the side?  HOW?   The side is for your assistant (if you have one) to see if the external structures move as the tube passes while you are watching the internal structures.


----------



## Red Flag 1 (Jun 9, 2015)

x SF med said:


> It sucked practicing intubations on each other...  really sucked... but you did not want to hurt your buddy so it was great training from a care standpoint.  Except for all the puke.
> 
> Teeth are not a lever.  If you can, get a straight line.



We


----------



## Muppet (Jun 9, 2015)

Red Flag 1 said:


> We had an Oral Surgery Resident who was doing his two month anesthesia rotation. The guy used to lube up a 7.0mm ETT, and do nasal intubations on himself. He used Lidocane 2% jelly and  & 5% ointment on the tube and in his nose, then push it in his nose and literally suck the tube past his cords; it was funny as hell to watch. I don't know if he ever finished his residency or not, but he was fun to have around.



I have taken several difficult airway classes, a couple from Rich Levitan. He would scope himself in class to show us the anatomy of the glottis. It was rad. We were taught that the "hockey stick" shape is the best shape but each airway is different. The "over curve" of the tubes I have seen obscure the sight pic of the cords. We are lucky to now have video for intubation, using either the CMAC or King vision for difficult airway. As you know, in EMS, all tubes are crash airways and we may not have the chance to prep for the above pic. I challenge that by saying, as long as the pt. is being ventilated with waveform cap, we can breathe ourselves a little and prep said tube. I near some critical care medics voicing disapproval to the sett up...

M.


----------



## 8654Maine (Jun 9, 2015)

Never get cavalier about the airway.


----------



## Red Flag 1 (Jun 9, 2015)

Muppet said:


> I have taken several difficult airway classes, a couple from Rich Levitan. He would scope himself in class to show us the anatomy of the glottis. It was rad. We were taught that the "hockey stick" shape is the best shape but each airway is different. The "over curve" of the tubes I have seen obscure the sight pic of the cords. We are lucky to now have video for intubation, using either the CMAC or King vision for difficult airway. As you know, in EMS, all tubes are crash airways and we may not have the chance to prep for the above pic. I challenge that by saying, as long as the pt. is being ventilated with waveform cap, we can breathe ourselves a little and prep said tube. I near some critical care medics voicing disapproval to the sett up...
> 
> M.



If


----------



## lushooter (Jun 9, 2015)

Red Flag 1 said:


> Perhaps some discussion of experiences in the field would be helpful; along with how you have approached and solved the limitations found in the field.


As someone fresh out of EMT, I would be very interested in reading over some of these experiences.


----------



## Muppet (Jun 9, 2015)

Many of my field intubations are that of the: cardiac arrest or peri arrest state. In PA here, we have an protocol that allows the usage of Etomidate to facilitate intubation but that is not used by many places including my unit for many reasons that include: poor protocol, not allowing for proper dosage, no paralytics and post intubation sedation. In the past  few years after seeing that protocol, I have only needed to actually need a pt. RSId and in those cases, I properly ventilated the pt., they need that. The airway protecting is great but if they are not ventilated properly, as @8654Maine elluded to, dead...

I do like having the CMAC for video. The blade is shaped like a Mac-4 so I don't flip the camera up unless I need it. I use the CMAC as a traditional Mac 4 unless camera is needed, in that case, an assistant flips it up for me and I transfer sight from direct to camera...

M.


----------



## x SF med (Jun 9, 2015)

Muppet said:


> Many of my field intubations are that of the: cardiac arrest or peri arrest state. In PA here, we have an protocol that allows the usage of Etomidate to facilitate intubation but that is not used by many places including my unit for many reasons that include: poor protocol, not allowing for proper dosage, no paralytics and post intubation sedation. In the past  few years after seeing that protocol, I have only needed to actually need a pt. RSId and in those cases, I properly ventilated the pt., they need that. The airway protecting is great but if they are not ventilated properly, as @8654Maine elluded to, dead...
> 
> I do like having the CMAC for video. The blade is shaped like a Mac-4 so I don't flip the camera up unless I need it. I use the CMAC as a traditional Mac 4 unless camera is needed, in that case, an assistant flips it up for me and I transfer sight from direct to camera...
> 
> M.



In many cases, taping in a j-tube and bagging with force will keep enough pressure to properly oxygenate the pt.


----------



## Muppet (Jun 10, 2015)

x SF med said:


> In many cases, taping in a j-tube and bagging with force will keep enough pressure to properly oxygenate the pt.



Agreed, without hyperventilating the pt. that, as we know would cause increased intra thoracic pressure, decreasing CCP, also blowing off co2 resulting in vaso constriction. And also forcing the esophageal spincher open, puke in face sucks. It's a slippery slope as we know. We use end tidal co2 with wave form to guide us... Agreed though as long as we know the limits...

M.


----------



## TLDR20 (Jun 10, 2015)

x SF med said:


> It sucked practicing intubations on each other...  really sucked... but you did not want to hurt your buddy so it was great training from a care standpoint.  Except for all the puke.
> 
> Teeth are not a lever.  If you can, get a straight line.
> 
> ETA - it really pisses me off in any movie/tv show when they show anybody trying to intubate from the side rather than being set up at true north of the  patient's capitus.  How the hell can you see anything in the endotracheal path from the side?  HOW?   The side is for your assistant (if you have one) to see if the external structures move as the tube passes while you are watching the internal structures.



Hate:
Training on other non anesthetized patients is fucking stupid.

As for intubations, in the combat medicine scenario they are most always placed incorrectly, and the advanced airway should be a cric, unless you are an 18D or SOCM medic, even then I would stay away from an intubation unless you know you are proficient.


----------



## Muppet (Jun 10, 2015)

TLDR20 said:


> Hate:
> Training on other non anesthetized patients is fucking stupid.
> 
> As for intubations, in the combat medicine scenario they are most always placed incorrectly, and the advanced airway should be a croc, unless you are an 18D or SOCM medic, even then I would stay away from an intubation unless you know you are proficient.



King airways work well... Question @TLDR20. Once you use whatever advanced airway you decide on and the pt. is on a helo, is waveform cap used to monitor the tube and co2?

M.


----------



## x SF med (Jun 10, 2015)

TLDR20 said:


> Hate:
> Training on other non anesthetized patients is fucking stupid.



I could not agree more, I din't say it was a practice that should continue, just that we were required to use it.  NG tubes were not bad, ET I could not understand why we did it.


----------



## policemedic (Jun 10, 2015)

x SF med said:


> I could not agree more, I din't say it was a practice that should continue, just that we were required to use it.  NG tubes were not bad, ET I could not understand why we did it.



For clarity's sake, you mean nasal intubation right?  Trying to perform orotracheal intubation on a non-sedated partner seems ... counterproductive.


----------



## x SF med (Jun 10, 2015)

policemedic said:


> For clarity's sake, you mean nasal intubation right?  Trying to perform orotracheal intubation on a non-sedated partner seems ... counterproductive.



We did both, and the ototracheal was hugely counterproductive (each person had to tube and be tubed once with lots of lidocaine gel), we all much preferred the use of the non-live training aids.  It sucked.  The NG tubes were much easier to handle.  I'm glad they wait to tube you until after the anesthesia is at plane 5 when you go in for surgery.


----------



## TLDR20 (Jun 10, 2015)

x SF med said:


> We did both, and the ototracheal was hugely counterproductive (each person had to tube and be tubed once with lots of lidocaine gel), we all much preferred the use of the non-live training aids.  It sucked.  The NG tubes were much easier to handle.  I'm glad they wait to tube you until after the anesthesia is at plane 5 when you go in for surgery.



Where was this done?


----------



## x SF med (Jun 10, 2015)

TLDR20 said:


> Where was this done?



300-F-1 at Sam, it was stopped by SOCOM/MedCom not long afterwards.


----------



## Red Flag 1 (Jun 10, 2015)

board.


----------



## TLDR20 (Jun 10, 2015)

Muppet said:


> King airways work well... Question @TLDR20. Once you use whatever advanced airway you decide on and the pt. is on a helo, is waveform cap used to monitor the tube and co2?
> 
> M.



Depends on what the platform is.


----------

