Monday, June 8, 2009


Everybody loves the latest gadget. Medicine folks are no exception.

A couple of years ago the latest hot item in anesthesia was the video laryngoscope. People looooooooooooooooove the video laryngoscope.

A laryngoscope is an instrument used to intubate, or place breathing tubes into the windpipes of, patients. It consists of a blade and light bulb that snap onto a handle, forming, more or less, an L shape. A Macintosh or "Mac" blade gives you an L with a slight curve, to follow the contours of the tongue, and a Miller blade gives you a perfectly straight "L." Macs are the most common first-line choices for intubating patients.

Most of the time when the laryngoscope is inserted into a patient's mouth and used to lift the tongue and epiglottis out of the way, the vocal cords come into view and a tube can then be passed into the trachea. For beginners confronted with challenging airways, this is harder than it looks; for most seasoned anesthetists, this maneuver does the trick nine times out of ten.

Over the years many life-saving back-up devices have been developed to assist in difficult cases. The gum elastic bougie, perhaps the lowest-tech of low-tech devices, is one. It's basically a floppy rubber rod that can be eased blindly into the windpipe such that a breathing tube can then be threaded over it into the right place. Others include the fiberoptic bronchoscope - a camera at the end of a slender, flexible, snake-like tube that can be used to navigate through tough anatomy; the intubating laryngeal mask airway (LMA); the light wand; and other such technologically snazzy gadgets.

Lately, though, the sexy video laryngoscope has been the go-to guy (or gal) in many centers. Have a set of vocal cords so far behind the epiglottis you practically need a periscope? Grab the Glidescope or the McGrath or the Storz Camera or whatever brand of video laryngoscope your hospital orders. You'll see those cords sans problème.

Except when you can't - when even the flashy, Fifth Avenue, glamourous device du jour can't show you squat past the epiglottis. This is rare, admittedly, but I have seen it happen to one of my colleagues, and it happened once to me.

What then? You're at the supposed crème de la crème of airway devices. Do you demote yourself to the lowly bougie?

Here's what I've learned from intubating people three or four times a day, day in, day out. Fanciest isn't always best. The bougie is by no means lowly, and the basic laryngoscope blades will save someone's life.

I see many clinicians around me jump right to the video laryngoscope at the slightest suspicion of difficulty. I've had people in the O.R. ask me with a hint of criticism in their voices after a tough airway, "Why didn't you just go right to the video laryngoscope?"

I once saw a patient and realized I had been her anesthesiologist for a previous operation. When I looked at my record of that event, I noticed I had myself jumped directly to the video laryngoscope because my physical examination of the patient and a couple of features in her history suggested a very challenging airway. I also noticed, though, that the device had proved inadequate, and I had achieved the intubation with the help of an intubating LMA instead.

For this patient's second operation under my care I took no chances. I asked a second clinician to be present in the room to help me in case of trouble. I had the difficult airway cart, the video laryngoscope, and a prepared intubating LMA ready for immediate use. I gave the anesthetic, then snapped a Miller blade onto my regular laryngoscope handle.

I took a look. No cords.

I adjusted the blade position and asked my assistant to apply pressure to the cricoid cartilage. Still no cords.

I manipulated the cricoid myself and found if I shifted it over to the side, voilà! - lovely white vocal cords, as far away from me as they could possibly be, but visible. This was why the video laryngoscope hadn't given me a good view. Her glottic structures were totally deviated from the midline - a feature that was not obvious externally.

"Can you just put your finger where mine is right now and hold it right there?" I asked the person who was helping me.

"To the side like that?"

"Yes, just like that."

The breathing tube slid right into position. I hooked up the oxygen, gave a manual breath, looked for chest rise, for condensation in the breathing tube, for carbon dioxide exhalation on my monitor. I listened with a stethoscope: breath sounds on both side of the chest. Now I could breathe. I sent the bulky equipment away, keeping only what I thought I might need if I needed to repeat the intubation.

Not too long before or after I took care of this patient, I went to evaluate another patient up on the floor who wasn't sure her epidural was working. When I walked in with an ice-filled vinyl glove, her eyes widened with curiosity and some amusement. "What is that?"

I wasn't able to find a tongue depressor nearby to snap in half for pin-prick testing or an alcohol swab to check for cold sensation, but the ice dispenser was right outside her door. "It's my super-duper sensory exam device," I replied.

The patient chuckled. "I like it. I like home-made stuff. Too many gadgets these days."

I do like the gadgets, but I agreed with this patient. I will never underestimate the importance of the basics - basic stuff, basic skill. I believe in them, and in keeping things as simple as possible. The sophisticated technology has its place, and I appreciate it, to be sure, but I also believe we should know what to do, or try to do, or how to improvise, if all we have are a pair of hands, a flashlight, a stick, and a rubber hose.


dm said...

Ah, what a wonderful post.

I've just started my first third-year med school rotation in anesthesiology, and have wished so many times for a video laryngoscope after having a ~30% personal success rate in intubation. It's good to know that the basic Miller / Macintosh blade are still powerful tools.

Do you ever use a stylet? Do you personally prefer a Macintosh blade for most situations? Have you ever broken a tooth? I would pay so much for a 10th of your skills :)

rlbates said...

Wonderful, T!

T. said...

Thanks, Ramona!

DM - It's harder than it looks, isn't it? I think it takes several hundred intubations to feel truly comfortable and competent with the easy ones, and another few hundred to feel comfortable tackling the tougher ones. Don't worry! Try to pick up pointers from all your teachers.

I do use a stylet, especially to bend the tube into more of a curve for more so-called "anterior" airways. I do pick up a Mac for most intubations, but being able to use the Miller is essential, again for those out-of-the-way airways.

I started out a bumbling, un-confident novice. It was truly an "ugly duckling turning into a swan" experience - and I'm STILL LEARNING, as this post will attest! Keep at it. P.S. - enjoyed perusing your site! :)

Elaine Fine said...

And would you believe the laryngoscope was created for musical purposes? Manuel Garcia, the son of Manuel Garcia Sr., and sister of Maria Malibran and Pauline Viardot, invented it so that he could observe his vocal chords in action while singing.

T. said...

Little did he know how many future lives he would help save! :)

Anali said...

LOL! Flashlight, stick and hose. Shall we call you Dr. MacGyver? : )

dm said...

T, ha, I completely agree about the part of starting out as a 'bumbling, un-confident novice'.

The scary thing is that the anesthesiologists make everything look so easy! During my surgery rotation, I'd see the anesthesiology attendings laugh and joke around when intubating and doing A-lines -- I had no idea that the procedures were so difficult!

PS: I am in awe of the fact that some anesthesiologists can detect a 1% change in SpO2 just by listening closely! Perfect pitch is amazing :)

T. said...

Anali - I used to LOVE that show! :)

DM - honestly, you don't need perfect pitch! All you need is a habit of listening for that sound CONSTANTLY. Almost a compulsive habit. If that's in place, then when the tone changes, you won't miss it, even if there's other stuff going on in the room.

gcs15 said...

I agree that keeping it simple is sometimes best. For my patients with neck pain, I often recommend filling an old athletic sock with rice, tying a knot in the sock, and heating it in the microwave. The patient then lies down with the sock under their neck and over their shoulders, and they can sleep comfortably while the sock applies heat to the muscles and joints. Simple, inexpensive, and effective; avoids the risks of burns with sleeping on a heating pad.

The patients love it, and love the fact that it's so simple and doesn't cost an arm and a leg.

Technology is great, but sometimes can complicate what should be straightforward.

Anonymous said...

i agree keeping it simple is always the best but we get so easily carried away with the flash and glare of the new stuff abandoning the old and reliable ones

Øystein said...

Nice post!

I can relate to this. In photography it's all about the newest (and largest) gear. But in the end it's the result that matters. What camera I used does not matter to the recepient.

A true professional should not be reliant on one specific piece of equipment to get the desired result.