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In order to help promote scholarly thinking in a forum that has turned a bit adversarial lately, I would like to seek the opinion of my esteemed attendings and upper levels (and anyone else) here about an idea I have.
First, is everyone familliar with the "bougie" for intubating? I had never even seen one before residency and now I am finding it an invaluable tool. In fact, I like it so much that I am seriously considering a study to compare the bougie versus the routine ETT technique for first line airway, not as a backup.
Now I hear the screams coming from the gallery already so please just hear me out. In my lifetime, I have probably done less than a total of 30 intubations. Half of these I have done since starting my residency in July, and the other half were as a paramedic. One of the critical points for me in intubation has always been passing the damn tube. I'm talking about when I have a great or at least good view. For whatever reason, I have never really determined the best way to shape the tube nor have I determined how deep the stylet should go for ease of insertion. I bet on over half my intubations, I had to take the tube out, and re-shape it, or attempt to turn a good view into a great view. As we all know, one of the biggest visual obstructions when intubating with a "good" view versus a great view is the tube itself.
What I have been doing lately is to simply obtain my view, whether it is poor, good, or great, and then I insert the bougie first. Then I simply have someone pass the tube over the bougie and I then take it from them and pass it while maintaining constant direct visualization of the tube passing into the trachea. I feel it gives a much better path for the tube to follow and may even cut down on trauma to the cords. It certainly has been a time saver in my opinion because I don't have to find the stylet, insert it in the tube, shape the tube, and try one to 2 passes before I get it in. Another great thing is that I find myself able to insert the tube exactly to the point where the cuff passes the cords, whereas with the traditional stylet I have often hit an end point where I have to try and slide the tube off the stylet while advancing it to the correct position.
I know it seems like the "wuss" way of intubating, but I am finding it an incredible asset. At minimum I believe it can help those new to intubating to be able to gain their "view" confidence over many months until they can master the tube placement without it. I just think it is a great bridge tool for newcomers in the field. And I believe it could be even more important for people who do not intubate regularly, like small town ED docs and ALS units that don't run a ton of calls.
For those that don't know what a bougie is, it is a long narrow, soft, nurf-like consistency stylet-looking thing that is about 2 feet long. It is much narrower than the ET tube itself and much easier to pass into the trachea. It has a "bent-up" tip to allow you to feel when you hit cricoid rings if you simply have a terrible view. It is passed into the trachea some 4" or so (some advocate sinking it, but I get a bit nervous doing that). Then you slide the ETT over it and watch it go into th trachea, and then remove it out the end like a stylet.
I am hoping to come up with a way to prospectively study the device and determine how useful it could be in the situations I am describing. It only costs $8.00 and can be kept in your pocket even when on off-services. That is where I have seen it most useful...you know, those IM floors where the code is run very poorly and you have to step over the bed to get into the corner to try and intubate in a contorted position. And I can't even imagine the implications this device could have on prehospital EMS calls.
Let me know what you think.
First, is everyone familliar with the "bougie" for intubating? I had never even seen one before residency and now I am finding it an invaluable tool. In fact, I like it so much that I am seriously considering a study to compare the bougie versus the routine ETT technique for first line airway, not as a backup.
Now I hear the screams coming from the gallery already so please just hear me out. In my lifetime, I have probably done less than a total of 30 intubations. Half of these I have done since starting my residency in July, and the other half were as a paramedic. One of the critical points for me in intubation has always been passing the damn tube. I'm talking about when I have a great or at least good view. For whatever reason, I have never really determined the best way to shape the tube nor have I determined how deep the stylet should go for ease of insertion. I bet on over half my intubations, I had to take the tube out, and re-shape it, or attempt to turn a good view into a great view. As we all know, one of the biggest visual obstructions when intubating with a "good" view versus a great view is the tube itself.
What I have been doing lately is to simply obtain my view, whether it is poor, good, or great, and then I insert the bougie first. Then I simply have someone pass the tube over the bougie and I then take it from them and pass it while maintaining constant direct visualization of the tube passing into the trachea. I feel it gives a much better path for the tube to follow and may even cut down on trauma to the cords. It certainly has been a time saver in my opinion because I don't have to find the stylet, insert it in the tube, shape the tube, and try one to 2 passes before I get it in. Another great thing is that I find myself able to insert the tube exactly to the point where the cuff passes the cords, whereas with the traditional stylet I have often hit an end point where I have to try and slide the tube off the stylet while advancing it to the correct position.
I know it seems like the "wuss" way of intubating, but I am finding it an incredible asset. At minimum I believe it can help those new to intubating to be able to gain their "view" confidence over many months until they can master the tube placement without it. I just think it is a great bridge tool for newcomers in the field. And I believe it could be even more important for people who do not intubate regularly, like small town ED docs and ALS units that don't run a ton of calls.
For those that don't know what a bougie is, it is a long narrow, soft, nurf-like consistency stylet-looking thing that is about 2 feet long. It is much narrower than the ET tube itself and much easier to pass into the trachea. It has a "bent-up" tip to allow you to feel when you hit cricoid rings if you simply have a terrible view. It is passed into the trachea some 4" or so (some advocate sinking it, but I get a bit nervous doing that). Then you slide the ETT over it and watch it go into th trachea, and then remove it out the end like a stylet.
I am hoping to come up with a way to prospectively study the device and determine how useful it could be in the situations I am describing. It only costs $8.00 and can be kept in your pocket even when on off-services. That is where I have seen it most useful...you know, those IM floors where the code is run very poorly and you have to step over the bed to get into the corner to try and intubate in a contorted position. And I can't even imagine the implications this device could have on prehospital EMS calls.
Let me know what you think.