Tag Archive | "Charlie Eisele"

An Introduction to Video Laryngoscopy


The GlideScope Ranger in use by Dr. David Cannell, during a medical mission in the Philippines. Photo Verathon

“…video laryngoscope provided excellent laryngeal exposure in a patient whom multiple experienced anesthesiologists had repeatedly found to be difficult or impossible to intubate using direct laryngoscopy.”(1)

Let me put my view of video laryngoscopy right up front. Video laryngoscopy is better than direct laryngoscopy. It reliably provides a better view and requires less force than direct laryngoscopy. There’s less trauma to the patient. First-pass intubation success rates are higher and require less time than direct laryngoscopy. Video laryngoscopy is better for our patients and should be the standard of care for oral tracheal intubation.

Wow, Charlie, those are pretty bold statements! I make these statements based on five years of experience with a variety of video laryngoscopes in the field, the operating room (OR) and cadaver labs. I have these views based on the scores of journal articles and studies I’ve reviewed. I have these beliefs from conversations EMS, anesthesia and emergency medicine professionals from the U.S., Canada, Europe, Australia and Asia. Ask anyone who has ever used a video laryngoscope and you’ll find very few who don’t agree with most of my statements. Yep, I’m pretty comfortable with my point of view, but this wasn’t always my position.

I’m a tightwad. Just ask my wife and anyone I’ve worked with. I hate spending money, especially my own. Also, I am a skeptic. I look at new technology with a suspicious eye. I see no reason to change for the sake of change. Imagine my thoughts back in 2006 when I first saw a video laryngoscope. Wow! That’s a lot of money for a camera and some lights. I’ve done just fine intubating patients for over twenty years with my metal sticks, why should I change? It took me at least a year of working with the instrument before I started to believe there was a better way to intubate my patients.

Direct laryngoscopy has changed very little since its implementation in medicine over a century ago. The early ’90s saw several developments in the anesthesia world. In operating rooms, flexible and rigid fiber optic devices were used to place endotracheal tubes in patients with difficult airways. Even seasoned professionals needed extensive practice with these devices.(2) It was incredibly rare for these instruments to find their way to an emergency department, let alone in the hands of EMS providers.

I’d like to tell you that anesthesiologists used fiber optic instruments as the springboard to video laryngoscopy, but I can’t do that. Video laryngoscopy truly had its birth in the profession of surgery; specifically laparoscopic surgery. The earliest patent I could find for a video laryngoscope was issued to Dr. Jonathan Berall in 1998.(3) The first commercially available video laryngoscope was designed by Canadian surgeon, Dr. John Allen Pacey and introduced in 2001.

I have to make a disclosure here. Dr. Pacey is one of my EMS heroes. He’s a soft-spoken man, but vigorously passionate in caring for his patients and developing new technologies. I’ve known Dr. Pacey for years and I’m honored and humbled to call him my friend. Earlier this year, I was privileged to interview him for this website. During the interview, he told the story of how he developed the GlideScope. I’ve heard the story countless times, but each time it’s told, I listen with wonder. Watch the video interview and see what I mean.
It took me a while to understand that video laryngoscopes are not traditional laryngoscopes. I was routinely frustrated and typically unsuccessful because I tried to apply direct laryngoscopy skills. My epiphany came when I finally realized it isn’t a laryngoscope, it’s a camera! With that paradigm shift, I became proficient. It’s the function of every video laryngoscope to place a miniature camera and light in the supraglottic region and transmit the image to a monitor.

A number of instruments are on the market, and they differ in the location of the viewing monitor, shape of the blade and method of inserting the endotracheal tube. Monitors are either attached directly to the laryngoscope handle or at the end of a cable that is connected to the handle. Attached monitors are compact and typically take up less room in gear bags. When you adjust the handle with an attached monitor, you also have to move your head to stay in front of the screen. Detached monitors provide a larger viewing screen and don’t require you to move your head when you adjust the handle.

I’ve seen three blade shapes; a modified Macintosh, an L shape and the proprietary angle of the GlideScope. Remember, the blade is the vehicle used to place the camera and lights in the supraglottic area using the least amount of force. I’ve found the greatest success by using my thumb and two fingers to manipulate the blade; it just doesn’t take much pressure to obtain a view. If you have to apply significant force to obtain a video view, you need to perfect your technique or try different shaped blade.

Two of the L shaped instruments I’ve used with monitors attached to the handles have an endotracheal tube channel on the right side of the blade. Once you have a clear view of the glottis, advance the tube through the channel into the glottis. The other method of placing a tube is manually placing the tube with your right hand. Some of my European friends prefer to place the tube without a stylette, but I’ve had much greater success using one.

Each device offers other features such as video and still recordings, disposable or reusable blades, battery type, air worthiness certificates, ruggedness, size and monitor size. The best way to determine which video laryngoscope is best for you is to put one in your hand. Try as many as possible. Start with manikins, and then move to the cadaver lab and patients. I’ve used pretty much everyone out there, so let me know if you have any questions.

Let’s talk about the elephant in the room; cost. I’ve met very few folks who weren’t impressed with the view, ease of use, and superiority of video laryngoscopes over direct laryngoscopy. I’ve met very few folks who didn’t hesitate when they saw the price tags and I was one of them. While I am still a card carrying tightwad, I do believe you get what you pay for.

How many of you old timers remember using a Porta-Power and Come-Along for vehicle extrication? When Ed Curtrell showed us a new fangled hydraulic tool, a Model 32 spreader, he wanted $5,000 for the system. Show me a rescue unit today without a high pressure hydraulic tool; it’s the industry standard. Last year, the State of Maryland required every ALS unit to have cardiac monitors with 12-lead ECG capabilities. How much did you pay for your most recent monitor? It’s the standard of care.

With all of the recent literature, articles, and editorials questioning EMS providers’ competency to provide endotracheal intubation, I just don’t understand why folks aren’t running to this proven technology. End-tidal carbon dioxide capnography isn’t cheap, but we embraced it and made it a standard of care. Because of adverse court settlements involving direct laryngoscopy, the attorney for a community based emergency physicians group proactively recommended the group drop direct laryngoscopy by its emergency physicians. The group now either intubates in the emergency department via video laryngoscopy or places a supraglottic airway.

The two operational medical directors who have had the greatest impact on my EMS career are Frank M. Yeiser, Jr., MD and Douglas Floccare, MD. Both of these men taught me that same thing; just do what’s best for your patient. Friends, video laryngoscopy is what’s best for your patients.

Take care and be safe.
Charlie

References
1. Richard M. Cooper, Can J Anesth. 2003;50:6, 611-613.
2. Clifford Boehm, MD Assistant Professor of Trauma Anesthesiology, R Adams Cowley Shock Trauma Center. Personal communication, 2008.
3. Jonathan Berall, US Patent 5,827,178, www.uspto.gov.

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Charlie Eisele, BS, NREMT-P

Charlie Eisele, BS, NREMT-P has been active in EMS since 1975. After 22 years of service, he recently retired from the Maryland State Police, Aviation Command where he served as a State Trooper, flight paramedic, instructor, flight operations supervisor, director of training, and tactical paramedic. For over 25 years, Charlie has been a collegiate level educator and curriculum developer. He has served numerous programs including the University of Maryland, and its R Adams Cowley Shock Trauma Center, College of Southern Maryland, Grand Canyon National Park, Marine Corps Base Quantico, Virginia Department of Fire Programs, and Maryland State Police. Charlie is the co-developer of the internationally delivered advanced airway program at the R Adams Cowley Shock Trauma Center. He is the Airway and Cadaver Lab Course manager for the University of Maryland critical care emergency medical transport program. He’s the co-developer of the EMS Today airway and cadaver lab program. Charlie has been recruited nationally to provide airway management curriculum and education for a variety of private, federal, state and local organization. Charlie is an Eagle Scout and a published author. He serves on the Journal of Emergency Medical Services Editorial Board and is a member of the program board for the EMS Today Conference & Exposition.

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Roadmap to the Glottis


When we intubate a patient, all we really want to do is place the endotracheal tube in the glottis. Let’s face it, the glottic opening can be a tough feature to locate on a good day, let alone wh

To get two the epiglottis and the posterior cartilages, your two new best intubation buddies, you have to get past the tongue first. Illustration JEMS/Wainwright Media

en things just aren’t going well. Blood, vomit, laryngospasms, edema; you know the drill. If you want to find the glottis, stop looking for the glottis. What? Read on, friends, I’ll show you.

Anatomy of the Larynx
The larynx is made up of three single cartilages and three pairs of cartilages.

The thyroid is the largest of the laryngeal cartilages. It’s within this cartilage that the glottis is located. The anterior ends of the vocal cords are attached to the thyroid cartilage. This feature gives us the ability to directly move the glottis to improve our view. Known by different names, external laryngeal manipulation (ELM), backward upward rightward pressure (BURP), digital physical laryngeal manipulation; the procedure of manipulating the thyroid cartilage to optimize the glottic view has been described for many years.(1–3)

The cricoid cartilage, the most inferior of the laryngeal cartilages, is the only laryngeal cartilage that’s a complete ring. In pediatric airway, the cricoid cartilage is the narrowest part of the airway. Non-cuffed tubes fit snuggly into the ring to prevent air leak. Cricoid pressure has been used to improve glottic view during laryngoscopy, but I think you will find that laryngeal manipulation does a better job of optimizing the glottic view. One of the very best studies I’ve read on the use of cricoid pressure was published in 2007. The authors concluded, “We recommend that the removal of cricoid pressure be an immediate consideration if there is any difficulty either intubating or ventilating the ED patient.”(4) As an airway professional, you owe it to yourself to read the entire study.

Let me now introduce to you, straight from the back of the tongue—the most important airway landmark, the intubator’s very best airway friend, the gateway to the glottis—THE EPIGLOTTIS!

Remember when I told you to stop looking for the glottis? I want you to start looking for the epiglottis. Remember from our last lesson that the inferior (extrinsic) tongue muscles are connected to the mandible, hyoid and epiglottis. We can use that connection to locate the epiglottis. I’ve found the epiglottis to be easier to locate on a more reliable basis for both novice and experienced providers. Sounds like a study in the making.

Try this: Insert the laryngoscope blade into the patient’s mouth and just follow the tongue posteriorly until you locate the epiglottis. Lift the epiglottis and there’s the glottic opening. Most of the time, it’s just that easy.

Posterior Cartilages
The second best friend of the intubator is the group of three pairs of cartilages, which lie along the posterior border of the glottic opening; the corniculate, cunneiform and aryetnoid cartilages. The arytenoids sit on top of the posterior portion of the cricoid cartilage. The posterior end of each vocal cord is attached to an arytenoid cartilage. The length and medial-lateral positioning of the vocal cords are accomplished by movements of the arytenoids. The arytenoids can’t be seen in the standard laryngospic view because they’re buried in tissue.

The corniculates sit on top of the arytenoids and are seen during laryngoscopy immediately lateral to the interarytenoid notch. The cureiform are embedded in the aryepiglottic folds. They give support to these membranes, which connect the arytenoids to the epiglottis. In the standard laryngoscopic view, the cuneiform can be seen immediately lateral to each of the corniculates.

Collectively these cartilages go by a variety of names: the arytenoids, posterior cartilages, nodes. Regardless of which term you use, know that they are the posterior border of the opening to the glottis and are identified by a notch in the middle and two pairs of bumps on either side.

Conclusion
So there you are. Your new best intubation buddy is the epiglottis, and your second best buddy, the posterior cartilages. I find it ironic that these most helpful features lay right behind our nemesis, the tongue. A good knowledge of the airway anatomy is really a roadmap to success. Bust open that A&P book that you’ve got shoved up there on the shelf. It will make you a better provider.

Take care and be safe.
Charlie

References
1. Benumof JL & Cooper SD. Qualitative improvement in laryngoscopic view by optimal external laryngeal manipulation. J Clin Anesth. 1996;8(2):136–140.
2. Knill RL. Difficult laryngoscopy made easy with a “BURP.” Can J Anaesth.1993;40(3):279–282.
3. Levitan RM, Mickler & Hollander JE. Bimanual laryngoscopy: A videographic study of external laryngeal manipulation by novice intubators. Ann Emerg Med. 2002;40(1):30–37.
4. Ellis DY, Harris T & Zideman D. Cricoid pressure in emergency department rapid sequence tracheal intubations: a risk-benefit analysis. Ann of Emer Med. 2007;50(6): 653–665

Watch a video of Charlie explaining how to visualize the glottis.

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Charlie Eisele, BS, NREMT-P

Charlie Eisele, BS, NREMT-P has been active in EMS since 1975. After 22 years of service, he recently retired from the Maryland State Police, Aviation Command where he served as a State Trooper, flight paramedic, instructor, flight operations supervisor, director of training, and tactical paramedic. For over 25 years, Charlie has been a collegiate level educator and curriculum developer. He has served numerous programs including the University of Maryland, and its R Adams Cowley Shock Trauma Center, College of Southern Maryland, Grand Canyon National Park, Marine Corps Base Quantico, Virginia Department of Fire Programs, and Maryland State Police. Charlie is the co-developer of the internationally delivered advanced airway program at the R Adams Cowley Shock Trauma Center. He is the Airway and Cadaver Lab Course manager for the University of Maryland critical care emergency medical transport program. He’s the co-developer of the EMS Today airway and cadaver lab program. Charlie has been recruited nationally to provide airway management curriculum and education for a variety of private, federal, state and local organization. Charlie is an Eagle Scout and a published author. He serves on the Journal of Emergency Medical Services Editorial Board and is a member of the program board for the EMS Today Conference & Exposition.

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Five Anatomical Features that Affect Ventilation


Understanding respiratory and airway anatomy can help EMS providers properly ventilate a patient using basic skills. (Illustration JEMS)

I have a huge interest in anatomical studies. Besides finding anatomy just plain interesting, I think a thorough knowledge of the human body helps us do a better job taking care of our patients.

Bag-valve mask ventilation is a real cornerstone of airway management. You have to accomplish it successfully, and you can’t move on to advanced techniques without it.

When encountering difficulty in mask ventilating a patient, it’s usually because of one of the three following problems:

  • A poor mask seal;
  • An obstruction somewhere in the airway; and
  • Increased intra-thoracic pressure.

In one study of more than 1,500 patients, five criteria were recognized as independent factors for difficult mask ventilation: age older than 55 years, body mass index (BMI) of more than 26 kg/m2, presence of a beard, lack of teeth and history of snoring. (1) You should be able to determine the existence of these criteria fairly quickly just by looking at your patient and speaking with their family.

I’ve put together my own list of the top five anatomical features I feel affect our ability to provide quality mask ventilation to our patients. Stop right now and write down the five parts of the airway anatomy you think have the greatest impact; compare your list to mine when you finish the article.

Number 5: The Abdomen
I’d like a nice flat tummy. Hey, who wouldn’t? But the Centers for Disease Control says we’re all getting bigger. They determined the average adult male has a BMI of 26.6 and an adult female a BMI of 26.5. (2) In general, the larger the abdomen, the more difficult it is to ventilate a patient.

As the diaphragm contracts, it moves inferiorly into the abdomen. This movement generates negative pressure in the thoracic cavity and air rushes into the lungs. To exhale, the diaphragm relaxes and returns to its normal position. Air pressure in the thoracic cavity increases and air leaves the lungs. That’s how it’s supposed to work. Add some weight to the abdomen and the diaphragm doesn’t work so well.

Try this: Lay supine on the floor and determine your ease of breathing. Have a trusted friend place a five-pound bag of sugar on your belly. What’s your ease of breathing now? Keep adding bags of sugar until you really have to work just to draw a breath. This is exactly how an obese patient feels when we place them supine.

In a patient with a large abdomen, the additional weight on the abdomen raises intra-abdominal pressure, which pushes the diaphragm superiorly into the chest. This movement reduces space in the thoracic cavity, reduces tidal volume and raises intra thoracic pressure. When the diaphragm contracts, it not only has to move the normal abdominal contents, but it also has to generate enough intra-abdominal pressure to raise the weight of additional tissue sitting on the abdomen. This is why these patients report increased dyspnea when placed supine and why we have a more difficult time ventilating them.

Number 4: The Neck
I have two questions about the neck: How clearly visible are the anterior landmarks? How mobile is the neck?

You should be able to visualize, or at least very easily palpate, the thyroid cartilage and the cricoid cartilage. At times, there can be so much tissue covering these features that it appears the patient doesn’t even have a neck. If you can’t locate these features, it will be difficult to manipulate them to optimize the airway.

The thyroid cartilage is the largest of the laryngeal cartilages. It’s within this structure that the vocal cords and glottic opening lie. External manipulation of the thyroid cartilage can enhance glottic alignment with the upper airway. (3)

The cricoid cartilage is immediately inferior to the thyroid cartilage and anterior to the esophagus. For years, providers applied cricoid pressure in an attempt to improve glottic view during laryngoscopy and to reduce the introduction of air into the stomach during assisted ventilation. Although the 2010 American Heart Association guidelines don’t recommend routine use of cricoid pressure, some major medical institutions and EMS programs continue to find it useful in their programs.

To locate these structures, start with your finger at the sternal notch. Move your finger upward with gentle pressure on the anterior neck. The first hard ring you palpate is the cricoid cartilage. Continue to move your finger slightly upward, and you’ll feel a small depression immediately superior to the cricoid cartilage; this depression is the crico-thyroid membrane. Move your finger further upward, and you’ll feel a large, prominent structure, which is the thyroid cartilage.

Neck mobility directly affects our ability to position the airway. Placing a patient in the sniffing position improves glottic alignment with the pharyngeal area. (4) A good field landmark to obtain the correct position is to elevate the head so the ear canal is even or above the level of the sternum. The more easily you can manipulate the patient’s neck, the easier it is to align the three airway axes and find the right position to maximize air flow.

Number 3: The Teeth
Strictly from an airway management point of view, teeth really just get in the way when you’re trying to obtain a glottic view or attempting to place an adjunct in the patient’s mouth. Try to mask ventilate someone who’s missing teeth, and that’s a completely different story.

A good set of teeth gives form to the face and allows for a good mask seal. No teeth will give you just the opposite. I’ve heard stories of packing the cheeks with gauze to improve the fit—even tried it myself once. But friends, nothing beats a Grade A set of original issue teeth to provide a good mask seal and a stable platform from which to ventilate.

The down side to a full set of teeth is that they take up space in the mouth and reduce mouth opening distance as compared to our edentulous patients. It may be difficult to insert airway adjuncts into the patient’s mouth when the distance between the upper and lower incisors is less than 6 cm (about three fingers).

Number 2: The Mandible
When shopping for a mandible, you want two features: mobility and alignment.

Remember the last time you cared for a patient with a clenched jaw? You can’t open the mouth. You can’t insert an oropharyngeal airway (OPA) device. You can’t insert a suction tip. The ability to open the mouth wide certainly makes it easier to mask ventilate or insert airway adjuncts. The simple capacity to displace the mandible anteriorly and pull the tongue off the back of the throat can make all the difference in moving air. We can induce poor mobility by simply applying a cervical collar or applying posterior pressure on the mandible while trying to get a good mask seal. As with the neck, your ability to move a patient’s mandible can really enhance your ability to ventilate them.

The optimal alignment of the mandible is directly below the maxilla so there’s a smooth transition from the nose to the chin. An uneven surface reduces your ability to obtain a good mask seal. A significantly receding mandible may not allow you to fully displace the tongue off of the throat with a chin life or jaw thrust.

 

Number 1: The Tongue
When I look at a sagittal view of the upper airway, the first feature that always draws my attention is the tongue. Look at the size of it. The tongue takes up about 85–90% of the oral cavity. (5) It’s the largest structure in the mouth, highly vascular and just waiting to obstruct the airway. The tongue presents us with challenges to basic and advance airway techniques.

The superior (intrinsic) muscles don’t attach to any structures outside the tongue, which is great when you need your tongue to change shape to form words. In the less-than-conscious individual, this is the portion of the tongue that relaxes, moves posteriorly and obstructs the airway. You drift off to sleep, your tongue relaxes, and the snoring starts. You get an elbow to the ribs, you roll over, your tongue flops forward and the snoring stops. This is why we place patients in the lateral recovery position. Correct placement of an OPA device holds the superior muscles of the tongue off of the back of the throat to create an open air passage.

The inferior (extrinsic) tongue muscles connect to such external structures as the mandible, hyoid and epiglottis. It’s these connections that are critical to opening a patient’s airway. When using a chin lift technique, the mandible moves anterior along with the attached inferior tongue muscles. Since the inferior muscles are connected to the superior, airway obstructing muscles, the tongue is lifted off of the back of the throat and opens the airway. Since the epiglottis is also attached to the inferior muscle group, it lifts upward as the mandible moves anteriorly. This is an added airway bonus.

There you have it folks, my top five anatomical features that impact our ability to mask ventilate a patient. How did my list compare to yours?

In an upcoming article, we’ll build on this lesson and look at features of the airway anatomy that impact our ability to provide advance airway management.

For now, put this information to work for you: Specifically, look at these airway structures on all your patients and note their variations. Consider the ease with which you could mask ventilate each patient and what you could do to optimize it.

I’ll leave you with a quote from a good paramedic and a great friend.

“The consistent delivery of basic airway skills is usually more helpful than an occasional act of brilliance,” —Robin B. Davis, NREMT-P

Charlie


References

  1. Langeron O, Masso E, Huraux C, et al. Prediction of difficult mask ventilation. Anesthesiology. 2000; 92(5):1229–1236.
  2. Center for Disease Control. National health and nutrition examination survey. Centers for Disease Control and Prevention, National Center for Health Statistics. 2003; Publication no. 03-0260.
  3. Levitan RM, Mickler T & Hollander JE. Bimanual laryngoscopy: A videographic study of external laryngeal manipulation by novice intubators. Ann Emerg Med. 2002; 40(1):30–37.
  4. Levitan RM, Mechem CC, Ochroch EA, et al. Head-elevated laryngoscopy position: Improving laryngeal exposure during laryngoscopy by increasing head elevation. Ann Emerg Med. 2003; 41(3):322–330.
  5. Iida-Kondo C, Yoshino N, Kurabayashi T, et al. Comparison of tongue volume/oral cavity volume ration between obstructive sleep apnea syndrome patients and normal adults using magnetic resonance imaging. J Med Dent Sci. 2006; 53(2):119–126.

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Charlie Eisele, BS, NREMT-P

Charlie Eisele, BS, NREMT-P has been active in EMS since 1975. After 22 years of service, he recently retired from the Maryland State Police, Aviation Command where he served as a State Trooper, flight paramedic, instructor, flight operations supervisor, director of training, and tactical paramedic. For over 25 years, Charlie has been a collegiate level educator and curriculum developer. He has served numerous programs including the University of Maryland, and its R Adams Cowley Shock Trauma Center, College of Southern Maryland, Grand Canyon National Park, Marine Corps Base Quantico, Virginia Department of Fire Programs, and Maryland State Police. Charlie is the co-developer of the internationally delivered advanced airway program at the R Adams Cowley Shock Trauma Center. He is the Airway and Cadaver Lab Course manager for the University of Maryland critical care emergency medical transport program. He’s the co-developer of the EMS Today airway and cadaver lab program. Charlie has been recruited nationally to provide airway management curriculum and education for a variety of private, federal, state and local organization. Charlie is an Eagle Scout and a published author. He serves on the Journal of Emergency Medical Services Editorial Board and is a member of the program board for the EMS Today Conference & Exposition.

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Welcome to EMS Airway Clinic!


Should we intubate?

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Welcome to the first edition of the “EMS Airway Clinic.” I’m Charlie Eisele, your host, guide and pathfinder through the world of prehospital airway medicine. We created this site to do one thing: provide patients with the best care possible. We’ll do just that by targeting the folks who directly impact patient care: educators, medical directors, and street level, mud on your boots, stretcher carrying EMS providers. It doesn’t matter your level of training or how many letters you have after your name, you will leave this site with stuff you can put to use immediately.

When the title came across my desk, I just had to ask, “What the heck is an airway clinic?” Prince.edu gave me a couple of answers:

  1. A medical establishment run by a group of medical specialists;
  2. A meeting for diagnosis of problems and instruction or remedial work in a particular activity;
  3. A health-care facility for outpatient care; and
  4. A musical clinic is an informal meeting with a guest musician, where a small-to-medium sized audience questions the musician’s styles and techniques and also how to improve their own skill.

I immediately threw out the first and third. Number two has merit, but I really like number four. EMS Airway Clinic is an informal meeting with guests to provide a variety of styles and techniques to improve our skills.

Are you allowed to intubate?

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Here you’ll see articles, videos, podcasts and a variety of other vehicles to share best practices in airway management. I really like case studies. They’re a great way to gain experience without having to make mistakes yourself. Sometimes, you just want to know how something works, so there will be “how to” items. We will provide timely news stories that impact EMS airway management and previously published articles to download, and we’ll keep you up-to-date on relevant studies and journal articles.

Here’s a preview of upcoming topics:

  • The Glottis Is Not Your Friend
  • Quotes from My Airway Heroes
  • Video Interview with Dr. Jack Pacey
  • Roadmap to the Larynx
  • Sun Tzu: The Art of Airway Management

My vision is that this site be reader driven, so tell me what you want. What topics interest you? What tools and techniques have you found successful? I know you’ve got case studies and war stories; let’s hear them.

I’m a huge fan of professional, open discussions, so expect me to weigh in on controversial topics. Say, something like “should we intubate?”

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Charlie Eisele, BS, NREMT-P

Charlie Eisele, BS, NREMT-P has been active in EMS since 1975. After 22 years of service, he recently retired from the Maryland State Police, Aviation Command where he served as a State Trooper, flight paramedic, instructor, flight operations supervisor, director of training, and tactical paramedic. For over 25 years, Charlie has been a collegiate level educator and curriculum developer. He has served numerous programs including the University of Maryland, and its R Adams Cowley Shock Trauma Center, College of Southern Maryland, Grand Canyon National Park, Marine Corps Base Quantico, Virginia Department of Fire Programs, and Maryland State Police. Charlie is the co-developer of the internationally delivered advanced airway program at the R Adams Cowley Shock Trauma Center. He is the Airway and Cadaver Lab Course manager for the University of Maryland critical care emergency medical transport program. He’s the co-developer of the EMS Today airway and cadaver lab program. Charlie has been recruited nationally to provide airway management curriculum and education for a variety of private, federal, state and local organization. Charlie is an Eagle Scout and a published author. He serves on the Journal of Emergency Medical Services Editorial Board and is a member of the program board for the EMS Today Conference & Exposition.

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Should EMS Intubate?


The Intubation Debate

Intubation is one of many tools in the EMS provider’s airway management toolbox. (Photo A.J. Heightman)

Did you make it to the 2011 EMS Today Conference & Exposition? What a great experience! I had the honor to moderate a panel discussion titled “Should We Intubate?” Four great panelists and about 200 folks in the audience resulted in lively debates and a challenge to be great EMS providers. As the moderator, I really didn’t get the chance to stand on my soapbox, so I’ll take that opportunity now.

Why does the thought of taking endotracheal intubation out of the hands of paramedics invoke such a visceral response? I didn’t whine when the EOA left. No heartburn when I put MAST back on the shelf. What is it about an ET tube? Because for decades, it’s all we had.

Endotracheal intubation via direct laryngoscopy has been used since the late 1800s.1 Numerous BLS airways were developed during World War II. Extraglottic airways appeared in our airway kits in the early 1980s.2 Flexible and rigid fiber optic laryngoscopes made their way into operating rooms in the early 1990s. It wasn’t until the turn of the century that laryngoscopy changed for EMS with the development of video laryngoscopes.

For about 110 years, direct laryngoscopy has been THE method to place an endotracheal tube. In EMS, we’ve relied on this method for about 40 years (depending on how you write the timeline). We reinforce the dogma that the endotracheal tube is the airway of choice by referring to all other devices as “rescue airways.”

Should we intubate?

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So I ask the question: Should we intubate? When it’s appropriate, absolutely. The endotracheal tube is a wonderful tool that has been successfully placed and managed for decades outside of the operating room. It continues to be used successfully by EMS professionals on a daily basis.

I’ve read a ream of studies professing the evils of prehospital endotracheal intubation. While there are descriptions of hypoxemia and trauma during endotracheal tube placement, the vast majority of the described evils come from what is done after the tube is placed; hyperventilation, hypocarbia, unrecognized misplaced tubes and reduction of blood return to central circulation.

Wait a minute; can’t those same evils occur with extraglottic airway devices or even a bag-valve mask? Why yes, they can. You can also add gastric distention, vomiting and reduced tidal volume to the BVM list. We have to do a great job managing any airway device.

As technology has progressed, we’ve been given fantastic new tools to help us do a better job. We’ve all seen studies that show the effectiveness of end-tidal carbon dioxide monitoring to verify tube placement and appropriately ventilate. Since 2003, studies from hospital and EMS settings have published results of the use of video laryngoscopy; shorter intubation times than direct laryngoscopy, high first pass success rates, and Grade I–II views with poor neck mobility.3-5 The gum elastic bougie, (and its plastic alternatives) is such a simple and incredibly effective tool, it should be mandatory in every airway kit. I’m quite sure you can list several other items. Proven technology must be embraced as the standard of care for our patients.

Are you allowed to intubate?

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So, I ask: Should you intubate? It’s entirely up to you. Are you willing to use the tool that best fits the patient, the conditions and your abilities? Are you willing to do what it takes to be a professional airway manager?

I’ll leave you with the challenge leveled at the end of the panel discussion. All of us must drive to excel as medical professionals, to refuse to accept mediocrity as a level of care and to simply do the very best for our patients.

I’m excited and humbled at the opportunity to provide information that will help all of us become better airway managers. I look forward to hearing from you.

Until next time, take care and be safe.

Charlie


References

  1. Bailey B (1996). “Laryngoscopy and laryngoscopes–who’s first?: The forefathers/four fathers of laryngology.” The Laryngoscope. 106(8):939–943, 1996.
  2. Donmichael TA. US Patent 4497318, Feb. 5, 1985.
  3. Agro F, Barzoi G, Montecchia F. “Tracheal intubation using a Macintosh laryngoscope or a GlideScope in 15 patients with cervical spine immobilization.” Br J Anaesth. 90(5):705–706, 2003.
  4. Nouruzi-Sedeh P, Schumann M, Groeben H. “Laryngoscopy via Macintosh blade versus GlideScope: success rate and time for endotracheal intubation in untrained medical personnel.” Anesthesiology. 110(1):32–37, 2009.
  5. Cormack RS & Lehane J. “Difficult tracheal intubation in obstetrics.” Anaesthesia 39(11):1105–1111, 1984.

Glossary

EOA = Esophageal obturator airway

MAST = medical anti-shock trousers

BVM = bag-valve mask

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Charlie Eisele, BS, NREMT-P

Charlie Eisele, BS, NREMT-P has been active in EMS since 1975. After 22 years of service, he recently retired from the Maryland State Police, Aviation Command where he served as a State Trooper, flight paramedic, instructor, flight operations supervisor, director of training, and tactical paramedic. For over 25 years, Charlie has been a collegiate level educator and curriculum developer. He has served numerous programs including the University of Maryland, and its R Adams Cowley Shock Trauma Center, College of Southern Maryland, Grand Canyon National Park, Marine Corps Base Quantico, Virginia Department of Fire Programs, and Maryland State Police. Charlie is the co-developer of the internationally delivered advanced airway program at the R Adams Cowley Shock Trauma Center. He is the Airway and Cadaver Lab Course manager for the University of Maryland critical care emergency medical transport program. He’s the co-developer of the EMS Today airway and cadaver lab program. Charlie has been recruited nationally to provide airway management curriculum and education for a variety of private, federal, state and local organization. Charlie is an Eagle Scout and a published author. He serves on the Journal of Emergency Medical Services Editorial Board and is a member of the program board for the EMS Today Conference & Exposition.

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    Providing emergency patient care on the ground or in the air is complex and challenging. That's why the tools used by paramedics and EMTs must be adaptable in a constantly changing clinical situation — quickly operational, rugged and easy to use. Learn more about EMS airway management.

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    The GlideScope Cobalt AVL video laryngoscope offers airway views in DVD-clarity, along with real-time recording. On its own or when combined with the GlideScope Direct intubation trainer, the Cobalt AVL is an ideal tool to facilitate instruction of laryngoscopy.

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    GlideScope AVL Reusable

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