As you already know, in the months when we have a 5th Monday, we have an extra airway series episode. This month, the team is talking Laryngoscopy. Be sure to head to our Prehospital Paradigm Podcast YouTube channel to see the team demonstrate each of the skills discussed on this extra episode.
Prehospital Paradigm Podcast
Extra Monday Episode - UH EMS Airway Series, Part 3 - Laryngoscopy
[MUSIC] Hey everybody, it's the pre-hospital paradigm podcast. I'm Scott Wildenheim, I've got Caleb Ferroni and Ray Pace and Dr. John Hill with us yet again, special five part series for all of 24. So what we're doing is we're doing us fifth Monday special rather than a bunch of individual recordings like we did for the 23 season. And for the 23 season we're going to do an ongoing sub-series on EMS airway management and we're going to hit a broad bunch of topics. We're going to start with just the BLS management of the patient as well as the proper setup and preparation of the patient. We're going to go into the super glottics. We're going to talk about the different intubation techniques. And then onto video laring guys could be direct laring guys could be some surgical airways. I think we'll even throw some tracheostomies in there and we'll just talk about basically anything with an airway adapter on it, right? >> I think if you like CPAP, you're going to like this. >> I hope so. All right, so stay tuned for this installment of EMS airways. All right, guys, well, how about onto? >> D.L. >> Intubation, well, let's start with intubation as a whole. And we'll break that down into D.L. and V.L. And we'll start with just all the general intubation concepts. And I guess first things first, we talked a lot about preparation. We talked a lot about preparation for, in general, right, to take an airway. How about some specific things for setup for intubation, right? There's going to be a couple of things that are going to differ a little bit. To take an airway with VT-tube rather than our superglottics like we talked about in the previous episode. >> Let's walk through some of the pre-assessment first. And you do a lot of RSI teaching with these geography departments. So, let's talk about lemon and melon potty and what can we do to determine how difficult this is going to be? >> Well, I think that I personally think, and then please follow up on this, that just looking at your patient, you should have a pretty good idea as to what you're getting into. And that obviously comes with time and there are some visual aids out there like the Malman-Patty score that we can use. But, I mean, first and foremost, I think that you want to put yourself in a position to succeed. So, getting into, especially if you're electing to RSI, but let's put that aside. When I'm intubating, I want to be somewhere where I'm comfortable. That doesn't always happen. I mean, sometimes for us, we're in somebody's kitchen floor, maybe a side of the road, upside down in a car, I don't know. But if we can get them into an environment that I control like the back of my squad, obviously I'm happiest. Ramping is huge if you're able to with the patient. And part of that evaluation, we like to use lemon scales. You're going to look externally. You're going to evaluate the 332 roll. Do you want to explain that? Somebody else? Using the patient's three finger, which again, I don't, how many of you are we taking? Let me grab your hand and stick it in your throat. You want to measure between the incisors and the teeth there, and then you're going to go from the mandible down to the hyoid bone. You should have two fingers, sorry, three fingers there as well, and then from the hyoid down to the thyroid, should then be two fingers, right? And if that works out, it's probably going to be an OK intubation or easy, or if you're not able to do those three things, then it might be setting up for a harder intubation, where we add M, N, M. We evaluate now M, Malman-Patty score, and I think that we could probably put a visual up for that, but it has to do with how much of an airway you can see externally internally. Oh, looking for any obstructions or the neck obesity, N would be neck mobility, whether or not you have able to move it if you need to trauma specific, and then S, I add always lemons, I add the S for saturations. And we talked a little bit about reserves. Reserves pre-oxygenation, stuff like that, absolutely important. No, of course. But again, I mean, I personally believe you should be able to look at a patient and determine whether or not it's going to be a tough intubation. And there's no problem with peaking, either. If you take your your, that's just go up and take a look first and then go back to bagging, pre-oxygenating and saying, OK, I got an idea of what I'm about to deal with. Let me set up for that while you're oxygenating. Remember, in our protocol, we insist that you put a nasal cannula on and run that continuously through your attempt. We do want to secondary something ready in case we fail our intubation. I used to be the guy that would say, give me the intubation because I love intubation and I'm going to get it. I think that's the wrong way of thinking now because someday I'm not going to be there. So I think that if it's an easy intubation or easier or not, you should have probably your least seasoned person do it to give them a chance to learn. I'm the appropriate patient on the appropriate patients and I don't mean patients that you only are going to get one one shot at. You probably make the best operator working. But don't discredit your other medics who might not ever get that chance. And I know in our department, we each kind of take the chair when we get in the back of a squad for an arrest or something. And everybody kind of just falls into their roles. I know who's going to use the electric, who's going to use medications, who's going to innovate. But maybe swap that up once in a while so that if I'm on a Kelly Day, you know, they should be somebody else to do it. And that happens every function. But again, selecting your equipment is very important. You obviously have, we'll talk later about video guided learned scopes. There's just Laurentioscopes. There's, you know, that we've already talked about the bogeys knowing what tube to grab is going to be important, especially when you get to the Peds, you do the age divided by four plus four. We'll give you the diameter that you should be using. And do you want to talk about cuff pressures now? I don't, I want to talk a little bit more about, we need to get to the cuff pressures. We'll get to that. But I really want to talk about that pre assessment. We talked about mail and potty. And, you know, if nobody's familiar with it, it's essentially the amount of space you have between a tongue in the heart. Palette, right? How much, how much physical room, obviously, that whole heart palette seems going to be your melody for. So correct. And although if you read a report that I were to have written, you will see a score, be under no illusion. Again, personally, just for for discussion here, I don't grade that real time, right? Much like we talked about off camera, like you just stated, you know, done it long enough. I can take a peek and take a peek and say, okay. I love your point about take a peek, right? You can't, from out here, of course, there's indicators out, you know, externally that a patient may be a difficult. But, until we've all had those cases that, you know, we were surprised. We got in there and be like, oh, it's just a railroad track. This is easy. And there's other, you know, tiny, skinny little people and you're like, oh, this is going to be easy. And then you're like, trying to be careful to get you back on itself. You get in and maybe you're seeing that you have an accessible amount of swelling. Maybe I not want to ruin that attempt and if I'm getting passive oxygenation and good bagging, just leave it being let the docs deal with it with anesthesia. So my take a peek, right? I just take a tongue depressor and have a look, right? Not the tongue depressor is underutilized in the EMS world. I hate to sound like a complete work, but it's one of the few things that I have in my pant pocket, right? It's really dorky. Take a look. If you look at the National Registry skill set in the way it's taught, even if you're applying a oral pharyngeal airway, you already use a tongue depressor to do it. So I mean, it's there. Yeah. Then when I take a look, I'm really looking for essentially one thing, I mean, other than hobbyists. The blood near a way or any obstruction or anything like that is, can I see the uvula? Yeah. That's it, right? Yeah. If I can see a uvula with my skill set at this point in my career, I feel like I probably should be able to get this done from a direct laryngoscopy. And if you're like, yeah, it's really the uvula on the tongue. That's a mama patty one. You're right. Good. How much of the uvula? How much of the uvula? I'd go a little farther. You can see more veteran kids. And if you have an XPH patient as it would go, ah, nice with the mouth, you can see the top of their epiglottis, too. So if you do that peek and you can see the tip of your epiglottis, probably, probably going to be an airway with at least someone should get experience on. Yeah. Yeah, I agree. Watch for your geriatrics, maybe not even geriatrics, people with bridge plates or false teeth. Those are easily dislodged, so always have a good pair of McGill sitting somewhere readily available in your every kit. Take them out and take them out, especially. Well, I'm talking if you knock them loose, you didn't realize it, but yeah, if you take them out, I mean, that's going to make your airway even that much easier to get into. Absolutely. So some more of that preparation stuff that you kind of alluded to is if you've got time and you can do it safely, move them out to your ambulance. And we talked in earlier episodes about the cases where you should be running and dropping a tube are very few far in between, right? Those absolute crisis situations. You should be able to be burn patients, burn patients and that's really expanding hematomas of the neck and angioedema. Yeah. And a flex. Right. So how many cases? Right. They're rare. They're rare. Yeah. But you're still going to be more organized, right? You're still going to have all you should still have all your stuff out because those are the bad airways that can go bad, just that's going to be your focus is getting a bit too short. Sure. Sure. And it's, hey, I'm setting this up. Somebody prepped the neck, right? Because I know I'm going to fail over to that because I've already gone past my super. I know I, my upper airway is going to close almost super on the water. Yeah. Super gothic is not going to work in this particular case because we've got edema that's, that's completely closing the airway off. We've taken that out of our middle option, right? So we have to go from innovation to the extreme, which is a surgical cricothorotomy of whatever, you're permitted to do the, but as far as, as far as that prep, if you're doing direct laryngoscopy, this is, of course, in today's world, a little less prevalent because of the introduction of video laryngoscopy into the field is if you have your cop there, just put the patient on the cot, you know, then that, that far off, off the ground. So you can just kneel and then put the head up. We've talked about this before, you have a, I'm going to end it up, you put the head middle on the 30 to 45 degrees. Yeah, you try to get the head away. That has some physiological benefit to from, you know, the patients, unlike the vomit or less like vomit. You get, if they're a bigger guy and you, instead of having all that weight on their chest and there's all the weight down, it's easier to bag, easier for them to, to breathe, if they're less likely to vomit because you're not flat and having all that reflux up, you're having gravity on your side, and instead of having all the soft tissues go back towards the bed, it's going to go down hip. So it's, I think it's very easy to just come up over top and then it's a great practice honestly, if you have the tomahawk somebody, if you are anterior to them, you have no way of getting up and above them to practice that in the patient. Ramping, ramping is absolutely huge, positioning the patient for success. We should put putting the ears to the sternal notch and that's moving the patient's head quite a bit upwards, but by doing so, you are setting yourself up for success. That might even actually almost be a little too low to begin with, it's almost going to be here. The, the, the, the, the point here is we often confuse the head tilt chin left of BLS, right, which is to pull the tongue anatomy up and away from the air away. That gets confused with sniffing position, right? Some people think those are interchangeably and they're not, like, nobody's ever like walked up to you with flowers and be like, "Here's smell this, and your first instinct was to go like this and throw your head back, right? No, what do you do? You lean out and forward to sniff, right? And that is, when you read or you interpret that sniffing position, that, that ear to sternal notch, into your point, probably could be up a little more, but, you know, that ear to sternal notch alignment is really what we're going for for innovation. That's going to line up all of our visual access to get, to get a view and then subsequently introduce a tip. I don't want to get this wrong. You're not going to get this all the time, you're not just, maybe it's a football player and they've got their pads on, maybe, you know, there's always something that, anatomy, you're not going to get it. What if they have tight pulses or still in your facility? Yep. So, yeah, especially trauma. We're obviously not doing this with a trauma patient. We want to keep that, you know, and this is where video guide alert scope comes in beautiful because I don't have to manipulate the neck as much, however, right? Don't need to do it with that either. That's correct. I wanted to talk a little bit about that, right? Is the direct viewer and the scope or DL as we've been calling it, right? That's often referred to, is DL dead? No, no. And I think we're all immigrants here. It's hard to know, right? Do you have a tool for most of the time that is, you know, I'm a Mac for. Quick, quick, quick. Yeah, we're talking about video. Oh. Do you have a tool that is, you know, quicker and faster and, yeah, you can use that most of the time. That doesn't mean you get to throw away your, you get to throw away your standard laryngoscope. You know, there's times whether that's, you didn't charge the, you know, somebody, somebody didn't charge the head on the, on the video laryngoscope. It was working just fine and then sunspot and then all of a sudden, it's not. Well, you're only as good as your view, too. If you get something blunt or something covered in your view, you're, I, you know, condensation, which air tracks kind of nice and new blades heat when you turn them on the tip, but it's not going to work out. It's perfect. Yeah. Nothing's perfect. And that's in that space, right. But yeah, I think that was really the, we shouldn't stop training with, with, with our, with our backup. Yeah. And then there, again, there's cases where it may just need to be the first, the first guy bleeds. Yeah. Um, hematemesis. You're not going to get a good look. You're just going to get, you're, you're going to blood on it. And then once you're blooding on, you're done. So you just do direct studio. Yep. So yeah, don't stop, don't stop practicing with, with actual wipers on to it. Yeah. Yeah. And we've, and we've talked about in the previous episodes, right, is when you are a practice and you know, try practice with different blades, that's about the time when one of the LEDs doesn't work or, you know, your partner comes back from the truck with one thing, be like, here, here's a Mac three. Okay. Know the difference. Okay. I'm going to make it work. No one in Adam, you're moving out of the way. You're using a Mac. Know it's going to the molecular and just understand that there are differences in the tools now. Oh, I can still. Okay. I'll be out of the way with the Mac. If, if it's big enough in the label, it's not cheating. Okay. I'll bite. Yeah. You're clearly baiting, right? And what? I don't know. What, of course, his references is that, you know, the textbook way, right, the classical teaching is that with a Mac blade, we're going to put this in the molecular and then we're going to lift up and basically can't deliver the epiglottis up the epiglottis up. Whereas a Miller blade, you're just going to directly move the epiglottis out of the way. Okay. And there are fundamentalists that just think that is it, right? You can also grab the epiglottis and move it out of the way with this. Frankly, it's Scott's, my personally preferred method. I've, I've heard people teach just like, try the molecular first and if you don't get a good view, you know, you know, back it up and then hook the up, you know, and get a good luck. And it's just, I just would prefer to do the thing that I know can give you. It's designed. So if you put that in the molecular and you have it deep enough by putting pressure downwards or forwards on your view, it's got a flop rolling out. That's correct. So sometimes it might be your not deep enough and that's going to give you the better view. So I almost always, when I use this, I go too deep, come back out and let it slide till I see it flop over. And then at that point you're, you're right where you need to be. So if you see this while you're intubating, you're doing something wrong. It's probably your positioning, you probably didn't ramp, but this would not be happening. And I don't like this either, but I don't like that, I don't like that particular handle either. But I know Scott does, or not Scott Ray, I think you were a fan of this one, aren't you? We have a curved one. So we actually use this either one's fine with me, but a lot of times I find I hold it completely different sometimes. And other people like, you hold it right hand. I hold it, I hold it almost down at the, I hold almost down here. Yeah, that's more of a, it's like, it's down here. And all honesty is where my hand is, I'm not doing this. I don't think I've ever really done that, but it's what you talked about, what works for you. And I hold an air track pretty similar back and forth. Well, air tracks designed to be three fingers on a thumb gripping it. You're going to pop the top off and you're going to lose that camera view and, and you should not be struggling. A lot of these things are not forceful, and I think that's what people confuse it with your point is. Sure. Everybody, everybody thinks you, it's, you need to man handle it, you don't. No. No. That's what he calls damage actually. You know, the, the reason those devices that you talk about, the air track being basically for the three finger, that is how a anesthesiologist would traditionally hold this is, you know, just with a couple of fingers. And you know, I find if there's anything that gets tired when I'm innovating, it's, it's my thumb. The only other thing I wanted to say about DL is that we often line it up with the axis and we try to. So first of all, I would hope anybody watching this is aware that this channel is not a place to try to dump the tube right, but if you know you're a student or you're watching this for the, for the first time, this is your view channel and you don't stick, you don't stick things. Don't obstruct your view. But yeah, you don't put anything in this channel to obstruct your view. So you're actually going to bring that, introduce that tube from another position. In my case, I like to bring it completely in just essentially 90 degrees from the side. We'll talk about different ways to orient the tube and I'm a traditional hockey stick guy. So I would, I would bend it much like that and then get my view and introduce this. Again, he's got a different way and we won't, we'll talk about it. But when I rotate this in, now this is pointed exactly where I want it to go. A couple other things that I just wanted to point out is we forget about our wrist is a gimbal. All right, although we're taught to do everything midline once, once you get your view midline, you could rotate, rotate your hand up and out, right? And make more space, right when you're introducing that you want to start on the patient's right side of their mouth and sweep the tongue to the left the way you're away. There's not just a straight in that is, yeah, there's like, there's like three or four little nuanced things in there, right? Is getting in there, displacing the tongue, getting your view, you can rotate, rotate your wrist out, make some space, right? Optimize that view and then deliver, deliver your two. The other thing that we need to talk about is you just don't bury that, you just don't bury that in the, in the patient's airway, right? Because this is the concept of progressive laryngoscopy, where we're going to take, we're going to advance little by little, right? And then what am I viewing? Okay, no, that's still all tongue, all tongue, all tongue. Okay, I'm starting to, you know, appreciate airway structures, top of the epiglottis. I'm going to advance a little more, a little more, a little more. Our students were, even though they, I taught them exactly that way, right? You watch them struggle. >> All right, back up and let's slow down. Go bit by bit by bit by bit and tell me what you're seeing, right? And then boom boom boom boom boom boom boom boom boom boom boom boom. They can drop it in. >> But you definitely know your anatomy. Know what you're looking at because things change. And if you get in there and you see something that doesn't look right, it's probably not right whether that be a traumatic or just the way that they were built. You just know that you're anatomy, know what you're looking at. Like Scott and I have done just for fun before thinking pictures and put them upside down and it's a gooey looking airway. Okay, what are you looking at? It's like, hmm, I know this, I know this. And it's like, you get a thing through it and you're like, oh, this is upside down, okay? And then it's like, yeah, just know what you're looking at. Know where the tongue is. If you're looking for the tongue underneath of you, it sounds wrong. >> Yeah, I think too, you have to know your equipment. So you have to practice and that's hands on training with a mannequin. And you need to innovate. I think one of the things that we try to push in hands on training to at UH is innovate in realistic environments. So a lot of times when you go to do training, it's like, oh, they're on this nice table or a very well-lit room. I'm going to bend over and just do this. All I have to do is kind of lean down and it's like, no, in our world, a lot of times it's not perfect. It's the ditch, the side of the road, the floor, most of the time. So move the patient to the floor then and abate how you would on the floor. If this is what we're going to do, then you should practice that way and you have to practice with your equipment. And not all equipment is created equal even for DL. Everybody stuff's a little different. We use the Inabrite brand that we're showing right now in our department. We're very happy with it. Everybody just has different stuff, so you have to know how to use it. >> You're right, there's a lot of differences. There's a blade out there that's just plastic. And it actually gives a little bit when you're moving, if you do. So there are differences, the bulbs reflect very well off the cords because they're phosphorus, right? So that makes a big difference. So you should have them illuminated really well. You should see pretty white cords in there. This is not the time to say, okay, I need a 702. You should have already had that ready. >> Load it up. >> Yep. >> And just another point about the tools, right? There's different types of handles and blades, right? So this is more of a traditional, yes, there is a special bulb in here, right? Or a series of bulbs in the older ones, but that does fit on a standard. And this is a fancy laryngoscope handle base, but it's a standard base. There are also fiber optic ones that have the bulb in the handle and the blade is nothing except conductive channel, fiber optic conductive channel down to here. Those are not interchangeable, right? So if you're working at multiple agencies, if you're purchasing stuff, you really got to make sure you're matching up the equipment with what your capabilities are, right? So that's just two weeks ago, I was on an ambulance and there was a fiber optic base and standard blades. And somebody was going to have a really, really bad day when they went to go use that. It's like, guys, these things need to work together, right? So pay attention to that, especially if, again, you got random equipment or stuff donated or whatever, pay attention before you put it in service, right? >> Remember, the teeth are not pivot points. >> Okay, is that bad? >> That's bad. >> That's frowned, huh? >> That is frowned. >> That goes back to knowing your equipment or knowing how to use the equipment, knowing that the Mac blade that if you're not getting it, you may not be deep enough. You may not be in the right spot. And that's why you're struggling or the Miller blade's not long enough. It's not the right size either. I've had issues where I've had to change my blade size because I guessed wrong doing my initial assessment or I've had to struggle a lot to get because I was too stubborn to give up and say I need a different size blade. >> That's a great point. I don't care if you're the best innovator in the world, it might not be your day. And if you're in there and you're spending a lot of time and not just another second, just another second, just another second, that adds up. And your oxygen reserve is gone. >> When I usually have someone call out what your pulse axis is doing. >> I love that. And when I teach the RSI, I go a little further and I tell them, you know, if you're doing this, hold your breath until you get that tube. And if you're feeling like you need to get a breath, they've already needed it. So back back out and no one to relax and take another shout at it, get the oxygen back up. >> That's a metal thing for providers, you gotta be ready to accept input from others. That, you know, when you're trying to do direct laryngoscopy. >> Anything. >> If you're trying to deliver an endotracheal tube, right, and things aren't going to plan, you're absolutely right. That's like, one more second, one more second, and it adds up really, really quick. >> And the story says, you know, it's time. >> Who in this room's been in an airway too long, right? >> Well, everybody at some point, right? >> Even the basics listening, this is your job to say- >> Yeah, absolutely. >> Stop. >> Smack us on the back of the head, don't. >> No, no, no, no, no, no. >> It's like 1988, 85. >> Yeah. >> Heart rate's increasing. >> Yeah, absolutely. >> Yeah, absolutely. >> And I got question marks for blood pressure. >> You remember good basics are the ones that are sitting there and saying, hey, idiot, stop looking at the monitor, look at your patient, they're doing something. [LAUGH] >> Maybe they can't fix it, but they can tell us something's wrong. They can recap in the graph like we said, they can read pulse oximetry, you know? >> There's another, did you want to say something? >> No. >> There's another bad habit that I certainly have fallen into the trap of. And that is when you can't get a good view or you think you have a good view and then you go to deliver the tube and you're just like, well, it seems like it goes wherever it goes. >> Then you go right back at it without making any adjustments? >> That, well, I mean, you're bringing up a great point, right? >> Yeah, if thing one didn't work, change something. >> Don't do thing one again. >> Yeah, change something, Einstein's definition of insanity, right? And same thing over and over, expecting different results, right? But I really wanted to talk about visual acuity, right? So to have depth perception, you have to have both eyes focused on something, right? And what do we do when we're having a hard time getting a tube? And we instinctively get closer and closer and closer and closer to it. And what you're doing is you're taking away your depth perception, the closer you cram into it and trying to see better. You're actually counterintuitively making it more difficult to figure out where. And it's a real simple test. I mean, where's your focal point, right? Just put your finger in front of your, you know, and move it back and forth. >> It used to be here. [LAUGH] >> And it's getting further away over here. >> Right, right. But, you know, if I'm basically, if I'm there, I can probably still figure the depth perception out. But, you know, if I cram in closer, I'm actually doing a disservice to myself and my patient, right? And if you've never done that, it's like, you advance the tube and it's just like, you think it's going to go in and it just, it misses completely. And you're like, how does that happen, right? That doesn't even make sense. That's because you're only seeing 50% of the picture because you've crammed in so close. It'll be whatever your dominant eye is, okay, in my case, it's my right eye. So, I would only see this side, right? >> I think tube sizing is very important. Make sure you get the right tube. >> To the bigger, the better. >> The bigger, the better. >> Especially this matter. >> Yeah, in this case. >> This, obviously, 602 is not big enough for this patient. >> Correct. >> Tube, the distal cuff pressure is going to be very important. And I actually, before this, I did a little looking 60 to 80% of the time, pre-hospitalally, the tube pressure is incorrect, which is huge. So, 20 to 30 centimeters of water should be where it's at. And there are devices out there commercially to buy it. >> I don't know if that, we got another one. >> I think there's a hole in that below. >> Oh, yeah, I think we got another one. >> This is a new one. >> Yeah, so the bad EMS habit is what? >> Give it all, slam it, slam it, none do it, right? And this is raw car. >> Right, the concept, we talked about this with Dr. Yaski when she was on with the Peds cuffs, but it applies to the adults as well as cuff to seal. How much do you put in? You put in until it seals up. Does that have to be the plumbing here? This I put in 5 1/2 mLs. I mean, assuming that was a properly sized airway for my patient, they would absolutely seal up in the trachea, right? And that is, there's more than enough, there's not much give there. This is pliable, yet not rock hard, right? Like I said, I put 5 1/2 mLs in there. So some of that is kind of touch and feel, and yeah, there. See, I put that on, I didn't even push back much, so. >> Yeah, and there are some studies that I've read out there for EMS that if you don't have a device, you can always feel quite a bit, relit least that for a second, see where it comes out to, and then unscrew it, and that's about right. >> That's about right. >> But always, it's really not a lot of pressure when you think about it. >> No, you don't want to hyper-inflate it, and cause it needs to have a trauma. >> Correct. >> Do that, hyper-inflate to the cup. >> Trachea, yep. >> Trachea, yep, yep. >> And there's an easy fix that if you've given too little, you're going to hear some squeaking or hear air coming around the tube. >> Yeah. >> Do a little more. >> We drive respiratory nuts because we're going, what's the answer? >> 10. >> No, the answer is not 10, all right? >> But then we're taking it off and screwing it back on with 10 more. >> All right, yeah, the answer isn't 10. The answer is enough to seal it up, and that should be the default answer, even though, sadly, I think a lot of times it's not. What's one of the first things, not the first thing that they do, when respiratory does, when they- >> They should squeeze that and determine how much is- >> Well, they come along with a gauge, with a cuff later, and they see what those pressures are. There is a device, I didn't bring it with me, but there is a digital device. It's a 10ML syringe that will give you a readout of what that pressure is. >> 20 to 30, that's where we should be. >> Yeah. >> And I thought it was amazing that 60 to 80% of the time our cuff pressures aren't wrong, like we had discussed earlier, I thought it'd be higher. >> I figured it'd be higher, yeah. >> Maybe it's not a good job of educating, yes. >> Maybe somebody did, yeah. I don't know where that study was done, but that was the post-education re-survey. >> Right, exactly. >> And then there are different types of endotracheal tubes, right? Some can have a very fancy, and there's one that has a, basically, a piece of fishing line, and here with a little ring that you can, you know, manipulate that tip if that's something that your, you know, your agency's invested in. The ones we've been buying as of late all come preloaded with stylets and whether you love or hate a stylet. I think it is super convenient to have it there, right? And then just dump it if you dump it if you're not a stylet person. The, when these get used, and I've given some caution to people over the years, if you wind up using these to do like a surgical crank or something, obviously this is, it's only going to go in about that far. A lot's going to be hanging out. People want to trim these down. Depending on what you, the brand you buy and how they're made, cutting this channel that this, that this air line goes into may actually leak on this end. So that's just, you're not going to know, and you're not that good. Just, just don't cut it. >> Not only that, but this is really hard to push back into the cut tube. >> Also, yes. >> In the cigarette layer, which you probably shouldn't be doing. >> All of that is completely unnecessary for, for, for what we're trying to accomplish, right? >> And when I teach criks, I just say leave it. >> Leave it long. >> Leave it long, tape it to the patient, move on. >> You have to wrap it around or have it a couple times. You're good, yep. >> You can tape it around their mouth. >> I think the myth of going past 25 is not allowed as, as BS. I think that people, people's anatomies are different. You have people who should second their life as a giraffe. Very long necks. You might go past 25 to get it right. So, do what's right for the patient, not just because you hit a number again. >> It should be based on your visualization of passing the tube to the core. >> There's actually an indicator on the tube that most people usually disregard. They just see it, and then they bury it. And I think that's kind of where that mantra came from. But I think if you have good direct visualization and you watch it go through the chords, as soon as you lose the black ring around it, then you should know, "Yeah, and you just stop," and then hold on to that tube. >> If you're hitting the karina, you've gone too far. >> Yes. >> And if you're -- >> Honestly, you're probably not going to hit the karina. >> You're right. >> Right side, yeah. >> Right. So, which is also important to know your anatomy. I mean, the karina there is at the angle of Louis, or Louis. And if you've gone too far, you have passed that. >> And, I mean, there's a really quick and easy way to tell if you're too deep, right? >> Listen to long sounds. You can see if you did the right main, some or not. >> So, I earlier was talking about my personal affinity for just a routine hockey stick, and that is what a hockey stick looks like, right? >> Maybe to you. >> But what does a hockey stick look like to John Hill? >> So, I do start -- >> Hockey stick, right? >> If I can, but that's my hockey stick. And if I can, if I need more, I will go U-shaped. But this is when I get into the airway, then it gets turned into a hockey stick. But it makes me get a little more anterior with it. >> Yep. >> Which is why I won't sometimes do that. But you can also ask your partner to put crackers. >> Well, crack eye pressure. >> Pressure to help out for those very anterior airways that you can't get into. >> We used to say that we got rid of that method called burp, but I still think it's warranted, in some cases, the backward, upward, rightward pressure here. >> Yep. >> The one thing I wanted to make sure we just -- not out on the spell, but we clarify, as you talked about, adding cracker thyroid pressure. And remember that AHA came out and said, "No routine use of that as part of your airway management." That was not intended to help -- >> Don't do it. >> -- one time, right? >> Yeah. >> So it's not necessary. Don't do it, correct? >> No. >> If you need to get it, you know, get that -- get that view. >> A little more. >> If you're down a millimeter -- >> -- just to be able to get my ET tube up to the -- >> Where I need it to be. >> Yeah. >> That's okay. >> Absolutely appropriate. Absolutely. Okay. For that to happen. So you're not breaking a rule. You're not absent. And it's important for the next person to know, "Hey, it took us a little crack pressure to get the view we needed." Right? You have to re-end debate them, or if, you know, they come off sedation, badness happens, tube goes across the room, whatever, things happen, right? Now that same case that you're making a big view for, we also have the other tool you're fondling over there, which is -- I don't know, personal opinion, but it's a rather indispensable tool. We were talking previous episode that you and I kind of selectively use it. >> I will selectively use it. It's my first fail when I'm in an airway, but sometimes when I take my first look, it might be this is a bougie case. If I want to increase my chances of success, if it's complicated, I might just ask for my bougie. Time that I've ever asked for it before is when I've had anaphylactic patients or angioedema patients that I need to just intubate, I'm always reaching for my bougie to be first. >> Literally. >> Pretty loaded. >> Yeah. Well, I was just going to say it's not preloaded, and you have another provider passing the tube, but you can do it preloaded practice. >> And there's different whole techniques and whatever you want to do, I don't rat mine. I have other people around me, right? So someone can make sure that the tube doesn't come out. I can place it. I can drop this, and I can feed this in very quickly, right? But I've got more hands on board than you guys simply have when you're treating patients in the field. >> I'll even transition, come off, and then put my tube on. I've tried practicing with a loaded, with a tube load, and I just, the balance is all wrong for me. It's something I do not prefer, so I'll just, you know, I'll just do any attempt with this and then whack my partner in the head with it, right? That little bent, that little bent end there, you were talking about getting a little more anterior, you know, sometimes you can't get that tube to rise just into the glottic opening if they're very anterior, you know, with this you may be able to just kind of sneak it up and over a little bit with a much smaller diameter device and then subsequently, you know, pass a tube over it off or you've already got it preloaded, just deliver it from there. If you're bringing that, once you're bringing that tube down, there's a little bit of nuance to that too, you just don't go, just jam it in there like an IV catheter, right? You slide that down, if you feel it hold up at the glottic opening, if you feel it hold up a little bit, simply just twisting that on its long axis will just, you know, that bevel will just kind of work between the cords, right? You don't want to cause cord damage, right? So if you meet resistance in the airway, generally the answer is stop, so stop but you can kind of wiggle that through if you will. Yeah, a lot of classes will teach you exit stage left, so as you take the tube you turn it to the left and point to the left, it'll come off and slide through a lot easier. Again, I think we talked earlier about sometimes you can know that you're in with this because if it does end, you probably hit the carina, if it's just sunk all the way, you're going to probably be on the belly, I guess, right? You may feel the cricoid rings as you pass and it'll click, they call that the Bougie click. I personally have a tracheal click, a tracheal click also, yeah. Some of these do have, like you said earlier, they'll also have a trigger to raise the tip, kude tip, but just again, know your equipment, know how to use it. These are awesome if you train with them, and it's just one more tool for the toolbox. And as you were saying, you pass that, you can feel it ride down though. If you're using a straight one, you may not feel that with a kude tip end. I have used these, I've never felt it, have you? It's not like running it on a mannequin where it's like if you feel it, I would think it would be real subtle. It is. Maybe I just lost the sensation with it. You know, if you advance it basically until you stop, or you've met a stop, you know, carina or a little bit thereafter, that's called hold up, right, if you hold, it would stop somewhere in the lungs. That makes sense. Whereas if I was putting in the belly, it's got a much longer, you know, it's got a much longer travel down to the belly. So it would just like basically keep going, right? And that's what you were referring to is the, you're probably not where you think you are. If you are intubating with bougie, remember that is an extra step. Make sure that once you've passed the tube, you've already added an extra step. Get rid of the bougie, hold your tube tight until you've gotten accurate, that you know you've passed in. And also just, if you have video guide to Laurentioscope, you should be keeping that in the entire time the tube passes. Once I get the bougie where I want it, I shouldn't be removing that and then sliding the tube in. Well, the answer on the test is always going to be watching the tube pass the cords. And the same applies. Yep. So you should watch your bougie pass through the cords. I take out my stuff, my handle, feed in my tube, I go back and you can look. You can see that it's there. You take a second page. Just to visualize this in the right spot. Absolutely. Just to make sure that nothing funny happened. And again, if you're dealing with somebody who's aspirating or vomiting at that point, you can leave suction in the corner of the mouth as I do this. Absolutely. Do you want to be extreme? Just slam it all the way down the esophagus. Or that. And if you miss, I mean, you bring up a good point. If you miss, leave that tube in the esophagus and go back in for your innovation attempt and you'll see what the original one was. If you can get a good mask, so obviously you're going to retreat at that point. If you can get a good mask seal with that hanging out, let's see if this isn't the esophagus, if you can get still get a good mask, you might need two people for that case, right? You've got a couple of things. You've marked where not to go, right? But also most, and I want to say all because somebody is going to watch this and then go find the one piece of equipment that doesn't do so. Most suction tubing that I have come across will fit in the inside diameter of that airway adapter. It requires a little bit of coercion to kind of spin it and twist it in there. It's not like it's not meant to fit there. Turning this into a really nice way to decompress the stomach if that was a case. The decanto suction catheters, which are those large bores, they are very nice, but if you need an even bigger one, right, grab your Ato out of there and it becomes your super decanto decanto suction catheter if you need it, right? But keep that in mind that you can often sneak it right in the inner diameter of that rather than getting a soft suction catheter out and trying to wait a little bit down there. So that's the air track. There are different blade sizes. The sizes are listed on the side. It is a channeled blade that is meant to secure the tube during your visualization. The tube will then slide through it. There are some important remembering things with this is, first of all, if you put that tube too far, distal the end of there, it's going to obscure your view and then be very hard to push through into the cords. It'll go too far down. It needs to be lubed. The tube will be tight. Air will use a small tube for that. This is an example. So the Caleb's point, if you push the tube down too far, you're going to get it in the right bottom corner of your screen, which is a little bit hard to see, obviously, through the camera. The other thing that I see people do wrong all the time is they put the camera on and then they put the blade in and then why is it so dark? Why is it so dark? And it's because you didn't turn on this little light right here, which is going to light up the end of the, we're going to just go blade and heat the tip, which is an important fact that you need to start that early to get it to heat up before you make your... Here, you want to try it correctly sized too. Now that there's been a juice put on it, there you go. This is not meant to be used with a stylot, so the channel is what is supposed to be acting as your former and then when you strip it away, you've got to be careful. You don't pull the tube back out, you just pull the blade away. And when a lot of people want to go to use this, one of the easiest ways they teach is actually just to go parallel and then as you just tilt back. And then right there it is. Look at that. So it's easy view, you can see, take a picture, take a picture if you tap it, push your tube. If you're in too deep, you just pull back. There's my tube, I see the passage and then the way we were always trained was you popped this out of the side, hold it in the corner of their mouth to come out. And then one of the things that we didn't discuss, whether it is either DL, VL, whatever you're doing, is securing your tube. So in making sure that you're going to hold on to that throughout this process, whether you're doing video ringer scope or direct learning jospey, you want to make sure that you are holding on to the tube, securing it with a commercial device and then before Caleb would put that bag on, we would put an end title on this patient and secure it. The other factor in any innovation is any time we go to move this patient, we should be looking at lung sounds, our end title to see did we lose our tube because that could happen. We're in the business of moving people and to Dr. Hill's point, it's really easy that now that I've placed that tube, that I can reinsert my video ringer scope in, take a look, take a paper and firm, hey, my tube's still in the right place, everything's still good. Adam, it's in a good spot and you decide that you need a bigger tube or Dr. Hill in the ER, he can use his bougie and do a tube exchange through it and it works really well. Yes, and the other things with AirTrack 2, so there's four different blade sizes, two are typically pediatric, two are adult, our agency uses this and then there's some other options you can set it up for your agency. You can record the entire innovation, you can touch the screen to take a picture of it, that's what we do, you can actually upload it into your EPCR because hey, this is when the innovation was performed, it timestamps it shows a picture, very good proof for us, it has pediatric mode, so if you have a pediatric patient, it changes the view of the cords and the brightness that you're going to see the cords and then you can also rotate the screen, so in one of Caleb's scenarios, you know, if you have that patient that's trapped in a car and I need to do some type of innovation, yeah, if you're doing a reverse innovation, that's why I do like this product and it's nice that all you have to do is change the lower unit, whether I'm going to innovate a three-year-old or a 30-year-old, all I'm doing is changing a blade and tapping a button that says now you're in pediatric mode to see some of the differences. Like everything, there are downfalls to the AirTrack, the biggest one being that you're not holding it correctly, arrow-to-arrow is where you want to be, snap on, make sure you turn your light on, if you're holding it like a Lorentzoscope and you do any sort of upward motion, you're going to pop the camera off and it happens all the time and the people, oh, that's AirTrack, it really is not good, it will, it goes back to training, there's actually spots here built for your three fingers and channel for your thumb and that is all you should be using with this, the patient does not need to be ramped for this, this is great for your traumatic injuries, spinal restrictions, you just, like he said, you start in low to the chest, move forward, this is all you should be doing and if I'm going like this or pops it up, you're not doing it right, doing it wrong man, the other point I wanted to make here is this is what we are, oh yeah, there's several different kinds. There's a bunch of different kinds, right? Yes. This is what we're supplying today, right? It's some of our squads, you love the King vision. King Vision is another one that's out there, there's a U-E scope. The graph, the graph, the graph. The graph, the graph. The graph, the graph. Yeah, the graph. Yeah, but yeah, there's a bunch of different kinds and fundamentally, there's a little tiny differences between all of them and you just have to know your device, we talked about it, I mean, we said this multiple times, knowing your tool. Yeah, a charged air track is good for over 200 minutes of use, so it's not like it should be looked at during your squad checks for sure, but if the camera fails, the blades do come with an IP, so I think that's what you're showing. Yes. Yeah, actually, so if your camera did die, you can actually still turn on the light and then you can actually still feed a tube through here, look actually down through this device and still see the cords. Which is all the camera really does. All the camera really does, but it actually provides you with another backup for this device. Air track can also wirelessly Bluetooth sync to your iPads, your phones, we've actually haven't set up in our squad, my guys might not even know it, but you can as soon as you turn the blade on, it'll sync to the iPad and you could actually sit there and watch the iPad doing your intubation attempt instead of the little camera and it works really well because I can put that iPad anywhere I'm comfortable and do the attempt. You get a bigger view. Yeah, much bigger view. Yeah, one of the other things too that we were playing with the king vision so much, a lot of times I actually, if you had a very difficult innovation you looked, sometimes I actually use the king vision in the bougie, pulled this out, then actually introduced my tube and went back into the double take with this. Look man, I said a hundred times once you get through NREMT and pass your test, there's no cheating. That's all you're working with in protocol, there's no cheating, so make it work. There's a great YouTube video out there called Do It For Drew, anybody's ever heard of it or seen it, but it was a crime ambulance company that was doing a transport with a child who was intubated and they keep getting desats, desats, and they're doing everything they can to work the case, it'll end up being that the kid was intubated esophagellae and they just were not getting, drew ended up dying, so it's a re-creation, a re-enactment of the scenario that happened, but it's the family kind of put that together afterwards as an awareness and if you haven't seen the video it gives me goosebumps, but we play it every year at the class, do it for Drew, it's worth it. Just a heads up on don't just pay attention to your equipment, you know, treat the patient. And again, this is the patient you trend, reassess, reassess because things can get dislodged, things can happen. If you are a paramedic or on a critical care and you're transferring with a vent and things don't make sense, disconnect your vent, your vent might be, have broken and failed and always is, you know, you can feel it, you understand it, and you can feel resistance. Yeah, like maybe all of a sudden when I popped a bleb and now I have a new mo and it's really hard to bag. Oh, I'm going to re-listen, oh I have a lack of air sounds, I'm going to needle the chest and probably end up being diverted, which has happened to me where I've had to put a chest in a patient and I was getting transferred as they drove past my ER. Also it is in our protocol to consider in place if you have a chance, a C-caller after you've intubated, anybody you've intubated, regardless of trauma or not, and I think that's a great way to keep the tube in position. Any advanced airway. Any advanced airway. It doesn't have to be another tracheal tube but anything to keep their head from rolling around. And it makes sense. It makes a lot of sense. Absolutely. a lot of things to do. [Music] [Music] [Music] [Music] [Music] [Music] [Music] [Music] You [BLANK_AUDIO]