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#41 brandon911

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Posted 17 July 2012 - 07:09 PM

Let me also add that i do way less intubations on the Aeromedical side of things. And it's not because my nurse partner is doing them all because she is the nurse either. :) I have performed a lot more intubations in the field on the 911 truck. I know how 911 service ground paramedics get talked about for their intubation skills or lack there of. Not from anyone on this board. Just overall from other publications and things of that nature.



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#42 Jwade

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Posted 17 July 2012 - 07:40 PM

I disagree that it boils down to ego. But it's your opinion and you are entitled to it. I want to do what is best for patient's. I know that we all want to. I just don't always think that is the best way. I have no ego.

I have been a paramedic supervisor at a busy 911 service here in Indiana for the last 6 years. 16,000-20,000 calls per year. RSI capabilities. I have performed lots of intubations. In the field, ED and OR. Not nearly as many as you have Brian.

I have been in the Aeromedical Industry for the last 3 years. All with RSI capabilities. None of which have video scope intubation. I also feel that I am very profecient in Airway management especially Intubation. I never brag about myself but I believe my peers and medical directors would agree.

I would have no problem grabing a video scope if I anticipated a difficult airway or was having trouble intubating a patient. I just don't agree with using them first attempt on every intubation. Especially from a cost stand point for us as prehospital providers depending on what scope we decide to go with.

Advanced Practice Provider? If I sound like an idiot I'm sorry. Are you a nurse? CRNA?



Brandon,

After going back and reading the entire thread yet again, I think some things are getting lost in translation....I don't think Brian or myself are advocating using a video scope on EVERY intubation, I think somehow, this perception permeated the conversation, and led us to where we are now..........I feel the bottom line is, after doing a thorough airway exam and obtaining some relevant patient history, I do not think it's out of line to grab a video scope on a patient where you suspect or have known airway difficulties. These critical thinking skills are why MDA's and CRNA's have such great airway skills. They always use the right tool for the job......

In my 11 years of Air Medical experience, I also did a lot more Intubations on the ground ambulance, however, the quality of training and continuing education with the Air Services was unmatched. You are certainly entitled to your opinion and I respect it, I just see all to often, people don't know what they don't know.....Education, Experience and Critical Thinking Skills are imperative to a successful outcome. Expecting things to remain status quo, in a direct linear relationship is asking for something to bite you in the A$$ down the road.......I have seen it happen many times to people who were stuck in their ways.........

One last thing, Im not sure, I would qualify 16 -20k calls as busy by any means.........How many ambulances for those calls?

JW
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#43 brandon911

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Posted 17 July 2012 - 08:05 PM

I definetly agree with the majority of what you said in your last post. I would love to change the training mind set of 911 ground providers. 911 ground providers see quite a few more patients on a regular basis than we do in the helicopter. I wish the training was the same for 911 ground providers as it is in the Air medical world. Doesn't make a lot of sense to me. I agree.....right tool for the job. I am not opposed to video scope intubation. I am hoping to add one to my difficult airway box at the 2 services I work for. Not sure if you are implying that I have no education, critical thinking skills or expirence and that I don't know what I don't know. I am not a CRNA. I do however have extensive education, training and expirence in airway management. No I do not get to intubate everyday. I chose a different profession. But I am here on this forum asking people of the same level of service as myself or higher what they think about it and what they are using. I am always trying to stay up to date and get as much knowledge as I can about airway management. Talk to some of your CRNA people and ask them to let 911 paramedics and flight crew members into the OR and let us retain our skills on a routine basis.



16,000-20,000 calls a year for 4 ambulances paramedic / emt crew is busy in my opinion. A lot more busy than the 43 transports I did last year by helicopter. With 0 intubations during those transports. But again.......my opinion. :)


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#44 Jwade

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Posted 17 July 2012 - 08:41 PM

I definetly agree with the majority of what you said in your last post. I would love to change the training mind set of 911 ground providers. 911 ground providers see quite a few more patients on a regular basis than we do in the helicopter. I wish the training was the same for 911 ground providers as it is in the Air medical world. Doesn't make a lot of sense to me. I agree.....right tool for the job. I am not opposed to video scope intubation. I am hoping to add one to my difficult airway box at the 2 services I work for. Not sure if you are implying that I have no education, critical thinking skills or expirence and that I don't know what I don't know. I am not a CRNA. I do however have extensive education, training and expirence in airway management. No I do not get to intubate everyday. I chose a different profession. But I am here on this forum asking people of the same level of service as myself or higher what they think about it and what they are using. I am always trying to stay up to date and get as much knowledge as I can about airway management. Talk to some of your CRNA people and ask them to let 911 paramedics and flight crew members into the OR and let us retain our skills on a routine basis.



16,000-20,000 calls a year for 4 ambulances paramedic / emt crew is busy in my opinion. A lot more busy than the 43 transports I did last year by helicopter. With 0 intubations during those transports. But again.......my opinion. :)


brandon911


Nope, wasn't implying anything specific towards you, just my observations in general having been in EMS since 1992......Also, the more educated I have become myself has enabled me to see things that I just didn't know previously..........

When i was flying Rotor out in Arizona, my MDA wife would let any of the crews schedule time with her in the O.R. and also my paramedic students that i was teaching........Arizona is predominantly MDA as they do all of their own cases, however, there are exceptions, CRNA's are making in roads into the workforce out there as the market dictates......One of my best friends Mike Mackinnon who used to contribute to this site when we were flying together is now a CRNA out there. I wish more MDA's and CRNA's would take the time to let people into the OR, but, as we all know, the trial lawyers have screwed that up and made most people afraid.............

@ 20k a year with 4 ambulances is about 13 calls per 24hours........
@ 16k a year is about 10.5 calls per 24.........

I agree, if that is only with 4 trucks, that could be painful, sounds like you guys were understaffed........I was comparing it in my mind to the 130k calls per year where I was working the ground.........Thanks for the info!
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John Wade MBA, CCEMT-P, FP-C, RN

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#45 BrianACNP

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Posted 17 July 2012 - 11:22 PM

Acute Care Nurse Practitioner. See I am smart!!!

brandon911


I figured you'd get it..... :) Saying advanced practice (or clinical) provider is a way to combine NP's and PA's.....that's my world now.

Never said you weren't smart, educated, nor ill-trained. You work in a busier system than what I came from....but it's all good experience.

Good conversation!
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#46 rick k

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Posted 17 July 2012 - 11:35 PM

I think the video assisted intubation has a place in the field. Equip us with the difficult airway blade (we don't have yet) and let it be up to the provider on which to use first (traditional versus video). It would seem to be tougher to keep up a skill when you're only expected to use it when it really matters (ie video equipment failure).
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#47 brandon911

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Posted 18 July 2012 - 12:06 AM

We were under staffed. Now have 5 trucks and 2 transfer trucks. We used to do transfers as well. So we were busy as sh*t!!! Thanks for all the great replies and excellent conversation!!! This is what it is supposed to be about. Good professional conversation amongst providers of all levels. And Rick I absolutely agree with you!!!

Thanks again everyone!!!

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#48 Mike MacKinnon

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Posted 23 July 2012 - 02:58 AM

Aloha all!

Has been awhile since ive been here but i heard about the glidescope questions and thought id chime in.


For those who dont know me, ive been our of flight for ~7 years been a CRNA for the last 4. Good times.

Anywho, lets get right to the business. As someone who has been intubating for, ohh, 10+ years I cant think of a better tool for EMS/HEMS than the portable glidescope or new McGrath.

Here is why.

No matter how good you are at intubation it is harder with a blade than with nearly any video laryngoscope. That is just how it is.

Now add to that that in HEMS/EMS you will see some of the most difficult intuabtions at high risk for aspiration requiring a need for 'speed' etc to get to definitive Tx, well... it only makes video laryngoscopy more relevant and useful.

Why be against it? If it was up to me I would remove ALL blades from every practice and replace em with VLs. Why make it harder when it can be easier, decrease risk, decrease time and increase success rate.\


Right?
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Mike MacKinnon MSN CRNA
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#49 BrianACNP

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Posted 23 July 2012 - 10:17 AM

Aloha all!

Has been awhile since ive been here but i heard about the glidescope questions and thought id chime in.


For those who dont know me, ive been our of flight for ~7 years been a CRNA for the last 4. Good times.

Anywho, lets get right to the business. As someone who has been intubating for, ohh, 10+ years I cant think of a better tool for EMS/HEMS than the portable glidescope or new McGrath.

Here is why.

No matter how good you are at intubation it is harder with a blade than with nearly any video laryngoscope. That is just how it is.

Now add to that that in HEMS/EMS you will see some of the most difficult intuabtions at high risk for aspiration requiring a need for 'speed' etc to get to definitive Tx, well... it only makes video laryngoscopy more relevant and useful.

Why be against it? If it was up to me I would remove ALL blades from every practice and replace em with VLs. Why make it harder when it can be easier, decrease risk, decrease time and increase success rate.\


Right?


About time you made it back here!!


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#50 Jwade

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Posted 23 July 2012 - 04:43 PM

Aloha all!

Has been awhile since ive been here but i heard about the glidescope questions and thought id chime in.


For those who dont know me, ive been our of flight for ~7 years been a CRNA for the last 4. Good times.

Anywho, lets get right to the business. As someone who has been intubating for, ohh, 10+ years I cant think of a better tool for EMS/HEMS than the portable glidescope or new McGrath.

Here is why.

No matter how good you are at intubation it is harder with a blade than with nearly any video laryngoscope. That is just how it is.

Now add to that that in HEMS/EMS you will see some of the most difficult intuabtions at high risk for aspiration requiring a need for 'speed' etc to get to definitive Tx, well... it only makes video laryngoscopy more relevant and useful.

Why be against it? If it was up to me I would remove ALL blades from every practice and replace em with VLs. Why make it harder when it can be easier, decrease risk, decrease time and increase success rate.\


Right?


Mike

I agree 100% ! I think people need to start moving past the traditional mindset that anything other than a DL is a " BackUp" device or maneuver and start to think of them more in line with the Anesthesia world in that, use whatever is easiest to get the job done the first time.

I WISH we would have used those back in the day at AirEvac 5 when we were flying together! Would have been helpful a few times in the Sells ER at 3am!

JW
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#51 brandon911

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Posted 23 July 2012 - 08:26 PM

Mike, Jwade. I simply disagree. But again thank you for your opinions. I have seen plenty of airway providers miss with the Videoscopes. In my expirences it isn't always " faster " or " safer ". I know I am just a paramedic. But I have been intubating people for the last 7 years and seen many airways. To say you would take all blades away and replace them with videoscopes to me is wrong. Technology will fail some day. Screens break. Wires get cut throug. But you are more than entitled to your opinions. :) Thanks for the replies.

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#52 Mike MacKinnon

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Posted 24 July 2012 - 02:21 AM

Hey Brandon

Its ok to disagree but you need evidence to do so. In every study done, and i do mean EVERY one, the success rate for intubation increases dramatically with a VL. By dramatically I mean from 70% - 98%.

In a number of studies done where people who have never intubated before were taught to use the glidescope they were able to achieve a 98% success rate after the first time they used it. That is unheard of with a blade. I can tell you that since ive been teaching intubation to medics, nurses, residents and SRNAs over the last decade. Most recently ive been teaching RTs at our facility in case back up is needed late at night. Where i work there is no anesthesia at night for intubations and only one ER doc, if he is busy then the RT is the second line. After 2 years of trying to teach them to use a blade doing 5 intubations a quarter in the OR we quickly realized it was not gonna happen. We switched to glidescope and they caught on instantly. Why make something more difficuly than it already is? Makes no sense.

As for EMS, well frankly this becomes even more relevant. Most paramedic programs never get an OR rotation to intubate and if they are lucky they will get a few while second rider, if not their first one will be on their own. Then they will be lucky to get a few a month, dude i do 5-8 a DAY and I can say with 100% certainty that the glidescope is easier than any blade ever created.

As for your concerns about technology, well that just shows yer age ;) Ive watched bulbs roll down peoples throats at 2 am on the side of a freeway and though "fuk me". Ive had batteries die in fiberoptic blades, had plastic blades snap in half in a mouth. These things happen to anyone anytime with anything. However, you simply have to have a backup plan and everyone does. So that argument just does not hold weight.

So let me sum this up.

The research and myself clearly have shown these things to be true:

1) It is easier to intubate with a VL
2) It is faster to intubate with a VL
3) it is safer to intubate with a VL
4) The % of first time pass is significantly increase with a VL even for novices

When you think of these issues and then put that into the perspective of the environment you work in (EMS/HEMS) where the airway wont likely be 'easy' to begin with.... well it makes no sense to see this any other way.

I know you have not met me, dont know me but in the past ive been a prolific writer here in FW, i now run my own website for anesthesia so have been absent for the better part of 6 years. However, im a no nonsense individual who just tells it like it is but i do so with research backing me. Sure, everyone can have an opinion but the one which is right is the one with evidence/proof. (no offense). Oh, and i only posted a couple but there are literally hundreds confirming this.

Now i do agree blades should be taught but with the ever decreasing amount of actual intubations done by medics and even HEMS one can not expect excellent laryngoscopy skills. It just does not happen.

Comparison of intubation success of video laryngoscopy versus direct laryngoscopy in the difficult airway using high-fidelity simulation.

Abstract
INTRODUCTION:
A number of devices, including video laryngoscopy, are used to aid in managing difficult airways. The goal of this study was to compare timing and success of video laryngoscopy to standard laryngoscopic intubation using a simulation mannequin in normal and difficult airway scenarios.
METHODS:
Residents and attending physicians of a PGY 2-4 emergency medicine residency program participated. A single, high-fidelity simulation mannequin was used. Each participant received an in-service on the video laryngoscope (GlideScope). Three airway settings were used: standard, decreased neck mobility, and tongue edema. Participants intubated with a Macintosh blade and video laryngoscope in each scenario, and graded the best view achieved using the Cormack-Lehane classification. Outcome measures included time to view the vocal cords, time to intubation, grading of view, and intubation success or failure. Institutional Review Board approval was obtained.
RESULTS:
Fifty-two participants were enrolled. Participants successfully intubated the mannequin faster using the Macintosh blade in both the normal and neck immobility settings (9.4 seconds faster, 95% CI 3.2-15.7, P = 0.004, 16.1 seconds faster, 95% CI 3.6-28.7, P = 0.01). In the tongue edema setting, however, video laryngoscopy provided a better grade view of the cords, a higher success rate of viewing the cords at time of intubation (50% vs. 12%), and a higher rate of successful intubations (83% vs. 23%). The GlideScope also significantly reduced the time needed to view the cords (89 seconds reduction, 95% CI 54.4-123.7, P < 0.0001) and intubate (131.3 seconds reduction, 95% CI 99.1-163.6, P< 0.0001) for the tongue edema setting.
CONCLUSIONS:
In the most difficult airway case, tongue edema, the video laryngoscope provided an enhanced view of the cords using less time, increased intubation success, and decreased the time to intubation.

Can J Anaesth. 2012 Jan;59(1):41-52. Epub 2011 Nov 1.
Glidescope® video-laryngoscopy versus direct laryngoscopy for endotracheal intubation: a systematic review and meta-analysis.
Griesdale DE, Liu D, McKinney J, Choi PT.
Source
Division of Critical Care Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, Canada. donald.griesdale@vch.ca
Abstract
INTRODUCTION:
The Glidescope(®) video-laryngoscopy appears to provide better glottic visualization than direct laryngoscopy. However, it remains unclear if it translates into increased success with intubation.
METHODS:
We systematically searched electronic databases, conference abstracts, and article references. We included trials in humans comparing Glidescope(®) video-laryngoscopy to direct laryngoscopy regarding the glottic view, successful first-attempt intubation, and time to intubation. We generated pooled risk ratios or weighted mean differences across studies. Meta-regression was used to explore heterogeneity based on operator expertise and intubation difficulty.
RESULTS:
We included 17 trials with a total of 1,998 patients. The pooled relative risk (RR) of grade 1 laryngoscopy (vs ≥ grade 2) for the Glidescope(®) was 2.0 [95% confidence interval (CI) 1.5 to 2.5]. Significant heterogeneity was partially explained by intubation difficulty using meta-regression analysis (P = 0.003). The pooled RR for nondifficult intubations of grade 1 laryngoscopy (vs ≥ grade 2) was 1.5 (95% CI 1.2 to 1.9), and for difficult intubations it was 3.5 (95% CI 2.3 to 5.5). There was no difference between the Glidescope(®) and the direct laryngoscope regarding successful first-attempt intubation or time to intubation, although there was significant heterogeneity in both of these outcomes. In the two studies examining nonexperts, successful first-attempt intubation (RR 1.8, 95% CI 1.4 to 2.4) and time to intubation (weighted mean difference -43 sec, 95% CI -72 to -14 sec) were improved using the Glidescope(®). These benefits were not seen with experts.
CONCLUSION:
Compared to direct laryngoscopy, Glidescope(®) video-laryngoscopy is associated with improved glottic visualization, particularly in patients with potential or simulated difficult airways.


Expected difficult tracheal intubation: a prospective comparison of direct laryngoscopy and video laryngoscopy in 200 patients
A. Jungbauer, M. Schumann, V. Brunkhorst, A. Börgers and H. Groeben*
+ Author Affiliations

Department of Anaesthesiology, Critical Care Medicine and Pain Therapy, Clinics Essen-Mitte, Henricistr. 92, 45136 Essen, Germany
*Corresponding author. E-mail: h.groeben@kliniken-essen-mitte.de
Accepted January 11, 2009.

Next Section
Abstract

Background The Berci–Kaplan video laryngoscope was developed to improve the visualization of the glottis and ease tracheal intubation. Whether this technique is also effective in patients with an expected difficult intubation is unclear. We have prospectively evaluated the conditions and success rate of tracheal intubation in patients with a Mallampati score of III or IV.

Methods Two hundred patients, undergoing general anaesthesia, were randomized to be intubated using direct laryngoscopy (n=100) or video laryngoscopy (n=100). Visualization of the vocal cords, success rate, time for intubation, and the need for additional manoeuvres (laryngeal manipulations, head positioning, and Eschmann stylet) were evaluated.

Results Video laryngoscopy produced better results for the visualization of the glottis using Cormack and Lehane criteria (P<0.001), success rate (n=92 vs 99, P=0.017), and the time for intubation [60 (77) vs 40 (31) s, P=0.0173]. In addition, the number of optimizing manoeuvres was also significantly decreased [1.2 (1.3) vs 0.5 (0.7), P<0.001].

Conclusions Video laryngoscopy, when compared with direct laryngoscopy for difficult intubations, provides a significantly better view of the cords, a higher success rate, faster intubations, and less need for optimizing manoeuvres. Therefore, we feel that the video laryngoscopy leads to a clinically relevant improvement of intubation conditions and can be recommended for difficult airway management.

Improvement of Cormack Lehane scores via direct laryngoscopy versus video laryngoscopy in morbidly obese patients undergoing elective weight loss surgery
Improvement of Cormack Lehane scores via direct laryngoscopy versus video laryngoscopy in morbidly obese patients undergoing elective weight loss surgery



By:
Sunita Goel, MD, DNB, D.A Consultant Anesthesiologist, Saifee Hospital, Mumbai India
E. Andrew Ochroch, MD, MSCE Associate Professor Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia USA
Ashish Sinha, MD, PhD Assistant Professor Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, USA






Abstract:
To evaluate the change in Cormack and Lehane (CL) (1)scores of morbidly obese patients undergoing elective weight loss surgery using the Macintosh laryngoscope followed by a video laryngoscope.
Methods:
Fifty patients with BMI > 40 kg/m2 undergoing elective bariatric surgery were evaluated for their Cormack and Lehane scores on direct laryngoscopy and re-evaluated for the same CL scores with video laryngoscopy. The time to intubation with video laryngoscopy, neck circumference, SaO2 decrease during intubation as well as the number of attempts required for intubation were recorded.

Results:
The CL score improved a median of 2 grades (25% 1, 75% 2) from direct to video laryngoscopy; p<0.0001. All patients improved at least one CL grade. The mean time to intubation was 20±12 seconds. Two patients could not be intubated with the video laryngoscope. These two were intubated using an alternate airway device, the Fasttrack LMA.




Mike, Jwade. I simply disagree. But again thank you for your opinions. I have seen plenty of airway providers miss with the Videoscopes. In my expirences it isn't always " faster " or " safer ". I know I am just a paramedic. But I have been intubating people for the last 7 years and seen many airways. To say you would take all blades away and replace them with videoscopes to me is wrong. Technology will fail some day. Screens break. Wires get cut throug. But you are more than entitled to your opinions. :) Thanks for the replies.

brandon911


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Mike MacKinnon MSN CRNA
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"What gets us into trouble is not what we don't know
It's what we know for sure that just ain't so" - Mark Twain

#53 Mike MacKinnon

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Posted 24 July 2012 - 02:22 AM

wassap brian! :)

About time you made it back here!!


Brian


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Mike MacKinnon MSN CRNA
WWW.NURSE-ANESTHESIA.ORG

"What gets us into trouble is not what we don't know
It's what we know for sure that just ain't so" - Mark Twain

#54 brandon911

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Posted 24 July 2012 - 03:21 AM

Thank you for all the studies. I will defintely read them all. I am not saying that I am against video scope intubation. Please do not take it that way. I truly believe that they have their place for difficult intubation. Evidence is one thing. But in my expirences seeing and using a glide scope, cmac and so on, I do not believe it is safer or faster. I believe it is faster and safer for in-expirenced intubator's, but not for a non-traumatic Grade I airway's. Even Grade II's. And I agree that everything will fail at one time or another. DL, VL Supraglottic airway's ect... I remember the first time I used the Mcgrath VL and the blade slipped off where it was snapped into and I had to use an " old miller 4" and the magills to get it out. I also remember when I was on I-65 and I placed a brand new shiney mac 4 led blade in a trauma pt's mouth and SNAP. The blade broke and so did a tooth. Terrible. Evidenced based opinions, non-evidence based opinions....either way I think what I think and feel what I feel. Now I have some questions for you.... If you don't mind :)

Do you only perform VL? Do you ever perform DL? Are you only using VL for difficulty intubations or everyone?
Do you only use a glidescope? Any expirence with the King Vision and your thoughts?


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#55 Mike MacKinnon

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Posted 24 July 2012 - 04:27 AM

Hey Brandon

Ill answer your questions and make some comments after quotes.

[quote]I truly believe that they have their place for difficult intubation. Evidence is one thing. But in my expirences seeing and using a glide scope, cmac and so on, I do not believe it is safer or faster.[/quote]

Well, maybe that is the case in your hands but it isnt what is statistically born out in both experienced and inexperienced hands. So while im not trying to be argumentative I have to tell you that you cannot make that statement without evidence to back it up especially when the preponderance of evidence states just the opposite. Opinions do not really matter in that light. I suspect you have seen people who just have not bothered to learn how to use a VL properly. You cant just pick one up and do it because you have intubated in the past, it is a skill of its own and takes practice like anything else.


[quote]I believe it is faster and safer for in-expirenced intubator's, but not for a non-traumatic Grade I airway's. Even Grade II's. [/quote]

Again, where is the evidence for this? The opposite evidence exists. Many fewer broken teeth with VLs, no pulling on the vallecula, no macerating the airway, no need to constantly reposition etc. All these things also increase speed. Additionally, there is no such thing as a known grade 1 & 2 airway. After intubating literally thousands of people (on average 1000 a year), I can say with absolute authority that you will never know how easy or hard an airway is until you stick the blade in. So which one is the grade 1 & 2 when you are on the side of the freeway at 3 am? You wont know.

[quote] Evidenced based opinions, non-evidence based opinions....either way I think what I think and feel what I feel.[/quote]

Hey, nothing wrong with feeling things. Like, you like rainy days or like the mac over the miller blade. However, this isnt about feel its about facts. Regardless of your opinion here the facts are VLs are superior by such an enormous margin that it is overwhelming. Anesthesia providers, the experts in airway (that be me :P) stopped using fiber optics almost entirely when the glidescope came into practice. We pretty much never do awake intubations because of the glidescope. It has been a revolutionary tool and makes intubating easy even in hard airways. That is just a fact it isnt an opinion.

I respect that you have been intubating for some time but ive been doing it alot longer and in much greater numbers. From medic to flight RN to CRNA, I have been intubating since 1999. I was good at airway until i did anesthesia training then i took it to another level if for no other reason than sheer volume of experiences. If for some reason you are having difficulty with the VLs it is only because you have not used it enough.

[quote]Do you only perform VL?[/quote]

Not at all. I probably use it once a day and most of the time i do that for fun or because someone has veneers etc.

[quote]Do you ever perform DL?[/quote]

Yup, on average 1000 times a year.

[quote] Are you only using VL for difficulty intubations or everyone?[/quote]

I enjoy practicing with it so i use it more than difficult airways.

[quote]Do you only use a glidescope? Any expirence with the King Vision and your thoughts?[/quote]

In my group im the goto airway dude. I use everything and I do mean everything.

Lightwand, glidescope, mcgrath, cmac, ILMA, bougie, retrograde intubation, king vision, FOIs, you name it ive used it. Plus i teach airway classes everywhere.

I love the king vision as a backup airway device just because its easy. However as a full time airway device it may be one of the most expensive cost-ineffective devices on the market ;) But it is cool! I actually have a demo model from when they were first released.

Good banter tho ;)
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Mike MacKinnon MSN CRNA
WWW.NURSE-ANESTHESIA.ORG

"What gets us into trouble is not what we don't know
It's what we know for sure that just ain't so" - Mark Twain

#56 BrianACNP

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Posted 24 July 2012 - 10:20 AM

wassap brian! :)


We need to catch up.....lots going on these days in my part of the world!

Hope you are well!! I'm sure you're happier than when you were in Philly.

Brian
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Brian, MSN, ACNP, CCRN

#57 brandon911

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Posted 24 July 2012 - 04:25 PM

Mike. Can you elaborate about why you think the King Vision is so cost ineffective? Or you can private message me if you like. Is it because the blades are disposable and you have to buy so many? I am considering ordering these. Cost wouldn't be too much of a factor for us as will use them for difficult intubations and not every intubation.



brandon911
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#58 Jwade

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Posted 24 July 2012 - 06:42 PM

Thank you for all the studies. I will defintely read them all. I am not saying that I am against video scope intubation. Please do not take it that way. I truly believe that they have their place for difficult intubation. Evidence is one thing. But in my expirences seeing and using a glide scope, cmac and so on, I do not believe it is safer or faster. I believe it is faster and safer for in-expirenced intubator's, but not for a non-traumatic Grade I airway's. Even Grade II's. And I agree that everything will fail at one time or another. DL, VL Supraglottic airway's ect... I remember the first time I used the Mcgrath VL and the blade slipped off where it was snapped into and I had to use an " old miller 4" and the magills to get it out. I also remember when I was on I-65 and I placed a brand new shiney mac 4 led blade in a trauma pt's mouth and SNAP. The blade broke and so did a tooth. Terrible. Evidenced based opinions, non-evidence based opinions....either way I think what I think and feel what I feel. Now I have some questions for you.... If you don't mind :)

Do you only perform VL? Do you ever perform DL? Are you only using VL for difficulty intubations or everyone?
Do you only use a glidescope? Any expirence with the King Vision and your thoughts?


brandon911



Brandon,

You must remember, in medicine we practice EVIDENCE BASED MEDICINE.......We do NOT rely on anecdotal stories to guide the practice of medicine forward. At some point, you might have to seriously stop and reevaluate your stance objectively and without ego involved.

As far as one's experience level is concerned, again, one must objectively look at this and ask yourself some hard questions.

1. Just because you have XYZ years experience as a paramedic intubating, does not really mean much. In the end it boils down to qualitative experience versus quantitative. ( If you have been doing something wrong and careless for 5 years, doesn't mean it's great experience) (This was a general statement, not directed at you personally, so please don't misinterpret) It's the same concept as not all ICU's are created equal, and quality experience varies from system to system........Mike has the added benefit of having both quality and quantity on a daily basis, this is NOT true for EMS / HEMS.

2. Mike and I used to be flight partners on the helicopters so I can back up everything he has said to you so far without reservation.

3. It's all about the evidence, which he has provided beyond a shadow of a doubt and is above reproach when it comes to comparing DL versus VL.............

4. One last thing, when my wife was an Anesthesia resident, she used to LOVE the mac blade, but, she would often say at night when we were discussing cases, how, difficult some of her intubations were. At this point, she didn't really use the miller blade much, and I told her that if she really wanted to have better airway control, she should force herself to only use the miller. Well, she did force herself to change, and she came home one day, and actually said thank you to me.....LOL.....( As hard as it was for her to admit i was right about something). She said it was amazing the difference in airway view's and to this day as an attending MDA for 8 years now doing her own cases, she is a strong advocate of being able to try something new. She loves the Glidescope and she does not think of these devices as " BACK UP" airways, she views them as what is necessary to get the job done efficiently, effectively and without complications.

Sometimes, in order to move forward, one has to be able to take a step back and evaluate outcomes and listen to people who are true experts. I had to learn this lesson the hard way about 10 years ago, but, today, I always ask myself if I am being objective when making an evaluation. One thing I learned in personal counseling / marriage counseling sessions is that our personal filters set us up for failure and being able to recognize when your filters are clouding your judgement can be learned, it just takes time and objectivity.

Respectfully,
JW
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John Wade MBA, CCEMT-P, FP-C, RN

"Have the courage to follow your heart and intuition, they somehow already know what you truly want to become" Steve Jobs

#59 old school

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Posted 24 July 2012 - 07:21 PM

Hey Mike, good to hear from you on here again.

Just curious why you don't use the VL's more (you said you do DL ~1000 times/yr) if they confer such clear advantages in even non-difficult airways?

In light of how superior VL's are, would you advocate dropping DL altogether from both the training regimens and protocols for GEMS and HEMS?
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bring it in for the real thing

#60 brandon911

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Posted 24 July 2012 - 08:02 PM

Jwade. I am seeing this as somewhat of a personal attack. Regardless of how well nicely you put it. :). My paramedic intubation expirence doesn't mean much? I have possibly been doing it wrong? You have no idea what education or training I have, have done or plan to do. What I don't have is a bunch of stories of how what my wife is doing. I have intubated plenty of patients that Physicians could not intubate. I go to the OR at my sponsoring hospital several times a year on my own dime. I take every opportunity to learn what is going on in airway management. I can tell a bunch of stories about how bad@## I think I am. But there is absolutely no benefit to that. So honestly Jwade thanks for your input and stories of your wife's intubation skills and expirences. I want to gain knowledge of what other providers do, why they do it, how they do it and so on. You obviously think I'm a paramedic with a huge ego and I don't have any airway expirence because I'm not in the OR in some way. Again thank you but I respectfully and professionally say that I won't respond to anymore of your comments. They are of no benefit of what I am trying to gain from this.



Same question I was going to ask Old School. What is your take on Video Scope Intubation? Are you a ground provider, Air, OR....ect?
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