Airway & Respiratory, Operations, Training

Tube Sight: You can’t hit what you can’t see

Issue 8 and Volume 34.

Some skills are so crucial, you simply have to practice them all the time. And there_s no practice like real-
people practice. I know that sounds kinda hinky, but it_s true.

EMS leaders complain all the time about a shortage of paramedics, but I think it_s more like a mismanaged glut. There are so many paramedics in some urban systems, they pretty much have to wait in line for a shot at a tube. Some get all scared and shaky when it_s time tostart an IV,fergoshsakes.„

It wasn_t supposed to be that way. Sometimes, I wonder how often we do field procedures that patients don_t need. There_s a big difference between doing thingsforpeople and doing things„to them.

Plenty of us used to intubate several times a week and never thought much about missing. My partner, Les, and I were personally called to a cardiologist_s office one time to tube one of his patients while he handed us stuff. Dr. Carmichael wasn_t the least embarrassed about it, eitherƒsaid he knew paramedics did that sort of thing all the time, and he didn_t. He was right, and I know at least two paramedics who will always respect his humility.

We learned some techniques in those days that you deserve to know about. We discussed one of them many moons ago in this column. It had to do with getting your patient on the cot before you intubate, so you can lower yourself, manipulate your angle of view and manage your leverage. We stole that one from a begrudging anesthesiologist during our training, who relegated us to watching him instead of intubating his patientƒeven with consent. (Oboy, that guy. We_ll always remember him as an„anusthesiologist.)„

Whatever. There_s more than one way to learn stuff, so we watched.„

When it comes to intubation, nobody knows that skill like an anesthesiologist, who does it several times a day. But anesthesiologists don_t intubate white-skinned people in bright sunlight. If they did, they might have to do some learning of their ownƒfrom us. Regardless of anatomic variations, that_s a tough tube. So is a bloody airway.„

Either way, you can_t see a dang thing. In the former case, the light bouncing off of the patient_s skin simply renders you blind. In the latter, you can_t see any anatomic structuresƒjust a lot of red. Only thing you can do is keep that suction handy until you find what you_re looking for. Good luck if you_re confronted with both situations at once.

There is a solution, and like so many things, it involves a very common tool designed for something else. That, and maybe a little common sense. One tool is a brush jacket (or turnout coat). Insert your basic airway adjunct, ventilate the patient, get your stuff set up, and as soon as you_re ready to insert the scope, ask somebody to throw a jacket over your head while you do the deed. It should only have to be there for a few seconds. But chances are, you_ll be holding your breath anyway. (That_s a good way to minimize the time you spend not ventilating the patient.)

Another strategy is to wear a pair of generic readersƒglasses you can buy at a drugstore. Even if your close-up eyesight is perfect, those glasses are designed to magnify things a bit. They can make it easier to see things at a distance of, say, 14 inches. They_re available in various strengths, so try on several pairs before you choose one. Some are physically big enough to double as your basic eye protection equipment. Others are much smaller and come in little hard cases. If they_re small enough, you can stow them rolled up with your tubes so they_re always handy.

If you_re a little more, um … experienced, you may be using reading glasses anyway. Even so, you can purchase industrial-quality bifocal safety glasses with your optimal reading prescription built in. They_re widely available on the Internet for about $10, complete with anti-fog lenses. (Search Google for “safety glasses.”) If you buy _em online, try on several pairs in a drugstore first to find out which prescription works best for you.

One final tip: If you do use the coat, borrow it from the newest rookie you can find. Old, smoky ones can be a little … um, old and smoky. Stinky, too.JEMS

Thom Dickhas been involved in EMS for 39 years, 23 of them as a full-time EMT and paramedic in San Diego County. He_s currently the quality care coordinator for Platte Valley Ambulance, a hospital-based 9-1-1 system in Brighton, Colo. Contact him at[email protected]

For more on the need for intubation practice,