Intubate With Your Eyes Closed
Endotracheal intubation can be tough, but there is a way to improve your chances of seeing the vocal cords on the first peek. A subtle change in how you approach the task may improve your outcomes. Obviously, trying this on a manikin first is the best way to go.
Here's the starting point: Sometimes we can improve our sense of touch when we close our eyes and just concentrate on it. Close your eyes and run your fingertips gently over a nearby surface. Can you sense its tiny imperfections? Did you feel things you did not really notice visually? How does this apply to intubation?
Say you've made all your normal pre-intubation preparations, and now you are ready to insert the curved blade into the patient's mouth. When you first pass the blade tip into the mouth, there is not much to see inside, as you have not performed the lift. So you use your sense of feel and knowledge of the anatomy to guide you to the right depth.
What should go where? Looking at the side view of the oral cavity, we can see the base of the tongue and the epiglottis. Our objective is to lift the epiglottis to see the vocal cords. The curved endotracheal blade is designed to indirectly lift the epiglottis by pressure to the vallecula. The straight blade is designed to lift the epiglottis directly. Which is better? Both are good, but personal preference will likely win out. I know of no medical director who specifies only a straight or a curved blade be used on all patients.
Here's the technique I suggest: Keep some very light pressure on the tip of the endotracheal blade against the tongue as you advance the blade. Be gentle and feel. As the blade is gently advanced along the tongue, it will be guided into the vallecula, right where it is supposed to be. When the blade is in the vallecula, you will feel a slight resistance, so just stop advancing there--you are at the right depth to lift and look for the vocal cords. Hold the handle firmly, but don't crush it. A lighter touch will allow your senses to detect subtle changes in the end of the blade. An intubation in the field can sometimes get your adrenaline flowing, and fine motor control can be reduced. Just before you start, take a few nice, slow, deep breaths, and you will be in the zone.
Right now you may be asking yourself how deep you currently insert the curved blade before lifting. Many paramedics might say there's no set distance, but deeper is likely better. You may be able to find the exact depth by incorporating your sense of feel into the procedure. Do you really have to close your eyes? No, not really, but instead of just advancing the blade and hoping for the right spot, feel the tip of the blade.
Next time you are around an intubation manikin, give it a try. You may be surprised at how well it works.
Capt. Dick Blanchet, BS, MBA, has worked as a paramedic for Abbott EMS in St. Louis, MO, and Illinois for more than 20 years. He is also an airline captain with more than 17,000 flight hours.