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.