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The First 'Tube'

Lone Star


Well Dear Reader, I've done it now...

I had an O.R. shift today...and got my very first 'live intubation!!!!

Before you offer up the congratulatory statements and the accolades (not that I'm going to ignore any of them....), I have a confession to make.

For my first few attempts, I panicked and bailed out of the attempt. I don't know if that would qualify as a 'balk' or a failed attempt...

First off, the way they do things in the OR is completely foreign to me, and DEFINATELY different than how we do things in the field!

I watched the Nurse Anesthetists put their hands near the patient's ears and that is how they would tilt the head into the 'sniffing position'. We're taught to use either the head-tilt/chin-lift method or a jaw-thrust. They open the mouth by putting their hand on the back of the neck and lifting, while we're taught that the neck is pretty much a 'no touch zone' for that....we use the 'scissor method', but when trying to open the airway and start your laryngoscope blade, the right hand is in the wrrong position, because it effectively blocks sthe insertion of the laryngoscope blade along the right side of the tongue.

Another couple of reasons that induced the panic was that I was painfully aware of the 30 second time limit on setting the tube and being uncertain just how deep I could insert the laryngoscope blade into th oropharynx. I didn't want to go too deep and possibly injure the patient. It's nerve wracking as hell!!

I had a great team of a Nurse Anesthetist and Anesthesiologist to work with on my first successful intubation. One of the other attempts, I had both th NA and the Aestesiologist barking at me about how succinylcholine and propofol 'wear off' and other things I couldn't understand,

This team I was with during the first successful intubation, they spoke in low tones and were generous with the positive reinforcements throughout the entire procedure. The Anesthetist even applied the Sellick maneuver to bring those cords into view. Once they slid into my field of view, it was like having 'buck fever'!

I saw the cords, I saw the anatomy of the oropharynx and was completely awe-struck! I was transfixed by the view and hated to 'spoil it' by stuffing a tube in the middle of it! While the airway mannequins resemble the human anatomy, there are some MAJOR differences!

For example, no one tells you that a patient who is effectively under the influence of RSI (yeah, the combination of Propofol and Succs pretty much equals RSI), the patients tongue effectively occludes ANY hope of viewing the oropharynx! I would have sworn that his tongue swelled up!

Nor do they tell you that the patients tongue does a great immitation of bread dough.....pick it all up at once by grabbing the blob of dough in the middle and you'll fully understand what I mean....it tends to 'ooze' over the edges of our laryngoscope blade.....

They also neglect to tell you that the first time you attempt to insert a laryngoscope blade into a live person's mouth, you become painfully aware just how LONG that damn blade becomes! During the intubation practice drills on the mannequin, you don't care that you might inflict some sort of 'injury' to the 'soft tissue' of the dummy, but thinking about it during your 'live attempts' can paralyze you with fear of hurting your patient (at least it did for me).

Someone on the team 'pre-formed' the ETT as I was sinking the blade and exposing the cords. They offered it lying across the palm of their hand, as a knight would offer a sword to a Noble. I didn't take my eyes off the cords as I picked up the tube, so I didn't know that I had picked it up and had it positioned upside down.....DOH!

I flipped the tube and began the inseertion. During the 'practice drills' I wasn't able to 'drop a tube' in the mannequin without the use of a bent up stylet....but today I didnt need one.

Watching that tube and cuff slip between the vocal cords was an awesome sight to say the least!! I sunk the tube into the trachea until I watched the 'black mark' slide past the vocal cords. The NA attached the oxygen to the tube and began to 'bag' the patient. While holding onto the tube (they told me that they would secure it), I was watching for chest rise. For a minute, I thought I had either inserted it into the esophagus or had gone blind because I couldn't see a noticeable chest rise. The NA stated that the chest was rising. I watched the condensation 'fog' the end of the tube and got to see a wave form on the monitor confirming that it WAS in the trachea.

Dear Reader, I almost walked out of that OR on a cloud! I had several NA's that knew why I was there ask me if I' been successful yet, and they all were overjoyed that I had gotten that first tube.

To say that the mannequin is just like intubating a 'real person' is like saying that the Grand Canyon is 'just another big hole in the ground', or that the Empire State Building and Sears Tower are 'just a couple skyscrapers'....

I can only hope that my next OR rotation will see me hitting the last of the required intubations without incident and with more confidence and skill....

Until next time, Dear Reader.....

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Congrats, Lone Star. You popped your cherry. LOL

I recall my OR time was a mixture of fear and abject terror. As you say, a mannequin is NOTHING like the real thing, although these toys have certainly improved dramatically since that time nearly 30 years ago. I also think it's nice to have a controlled environment for your first attempts- with the pros standing right there to keep you from screwing up. I also feel it's vital to be able to see the real anatomy up close and personal and see what it actually looks like in all it's glory. Pictures, videos, and drawings simply don't do it justice.

It's also very deceiving when you realize that nice, paralyzed and bone dry airway you see in the OR is the last time you will EVER see one. LOL EVERYONE who arrests always just had a huge meal and/or a ton of booze with tons of emesis in their airway, their necks are the size of my thighs, their airway is constricted because of asthma, and too often there is some type of funky anatomy involved.

Best of luck on your next ones, bud.

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