southerndoc said:
I'm sure you have intubated many more people than most emergency physicians, including Ron Walls himself. I respect your views.
The case reports of esophageal perforations secondary to intubation was recently reviewed at my facility after an intubation attempt resulted in an esophageal perforation. One of our anesthesia attendings, who was present for the review, brought forward that most of these case reports were presented after failed intubation attempts with Miller blades. Was I premature in drawing the conclusion? Perhaps. A definite cause-effect relationship wasn't evaluated, so who knows.
At what point do you think it's reasonable to not "bury" the Miller? I've intubated more than 100 patients (a very low number compared to you I'm sure), and I still bury the Miller when I intubate. It's the way I was taught. I have not developed the skill of knowing the "exact spot" to place the Miller, like I have developed with the Mac. I may never develop this sense with the Miller since I almost always intubate with the Mac and since I adhere to the method described by Walls, et al. I'm not going to chance it either. All of my intubations, minus my brief OR rotation that resulted in about 30 intubations, are done emergently, where I do not want to do the "dance" that Walls describes.
certainly not implying that what you do, intubation wise, is incorrect...far from it....just concerned that readers may take away from said posts that a Mac blade is somehow intrinsically "safer", which in my humble opinion, it is not.
Anyway, heres probably the best trick I know of, regardless of which blade you are using.....
Left hand is holding the handle....eyes looking down the dude's throat....dont see what you need to see right away?????
Take your right hand, grasp near the dude-you-are-intubating's-adam's apple (like you are applying cricoid pressure), push down. Still dont see it? Wiggle it from left to right.
Sounds silly, but this is probably one of the most common tricks-of-the-trade used by anesthesia providers. I see it used everyday, either by myself or someone else. You are essentially moving the anatomy left or right until you can see it.
Heres another way of looking at it, Sir. Dont use the Miller blindly. You can follow a visual path, after good head extension, in 95% of patients, from posterior tongue, insert a little more, and theres the tip of the epiglottis...again, most of the time after inserting the Miller 2 to the base-of-the-tongue-depth, one can approximate how much more to "exactly" insert it before lifting up......
....but hey, thats splitting hairs on technique. I think a clinician should use whatever technique they are most comfortable with, and use which blade they're most comfortable with.
Just think its wrong for a clinician to attach his name to the "correct way" to do something (sorry, I've been in private practice for ten years and I dont know who Dr Walls is), when in fact, there may be other techniques and "tweaks" available.
Just my 2 cents. Dont let someone convince you one blade is better than the other, or that one technique is better than the other. Learn the tricks-of-the-trade for each blade, use both of them alot, then YOU decide which is better. And better means you dont miss, with rare exception.
If I were teaching ANYONE intubating tricks, heres the TOP FIVE:
1)For a Mac blade, put a pillow under pts head. Maximize head
flexion. The head more anterior assists laryngeal-pharyngeal allignment. Yes, its a little harder to get the blade in, but once you hit the vallecular space, the glottis is usually looking up at you. Usually the bed
lower than normal will help you. To give you a visual, for difficult airways during my residency, Dr Grogono would put the OR bed as low as possible, raise the head as high as possible with pillows (sometimes the pts chin would be literally touching their chest), then he'd work for 10-15 seconds to get the Mac3 in.....I NEVER saw him miss. Not one time. Again, this is what he was comfortable with, and he knew how to optimize the intubation environment for his selected blade.
2)For Miller blades, pillows are a hindrance. Remove the pillow. Maximize head extension. Best case scenerio is a shoulder roll. So if you are anticipating difficulty, put a shoulder roll in. Open the mouth, let the tip of the blade touch the posterior pharynx while applying some inferior pressure on the tongue. Now, concominantly, take a stance like you see on
ER when Anthony Edwards is intubating whilst inserting the Miller about another inch. If you dont see cords you can usually see what you need to see to adjust your blade direction.
3)The right-hand-move-the-larynx-from-side-to-side-while-pushing-down-at-the-same-time is probably the biggest trick used by anesthesia providers.
4)HAVE A BOUGIE AVAILABLE....or whatever your institution calls the long,orange-stylette-thinghy with an angled,somewhat angulated tip. If you see just the bottom of the cords and cant quite get the styletted ETT in, no need to kill yourself. Stick the bougie in...but heres the trick....DONT PULL OUT YOUR BLADE JUST YET. Keep it where youve got it and have an assistant slide the tube over the bougie. Sometimes, if you pull your blade, even if the bougie is through the cords, the ETT wont follow it and wont pass the cords.
5) Looked a cuppla times and dont see anything you need to see? LET A COLLEAGUE (if available) LOOK. Even anesthesiologists have bad days with airways....dont be proud. Call for help if you need it.
There you have it. Jet's TOP FIVE intubating tricks-of-the-trade.
Hope they help you someday.