Let’s Intubate!

Janel Feliz Martir
uvmmedicine blogger Janel Feliz Martir ’16

As third-year students at the UVM College of Medicine, we have privileged access to a nationally-renowned simulation center.  Here, we expand our clinical expertise by practicing procedures on patient dummies, ensuring that we are competent when the time comes to perform them on real patients. For example, during our recent Bridge Week, we learned how to perform proper bagging and endotracheal intubation, and we learned how to use a GlideScope.

I gripped the curved Macintosh blade tightly in my left hand. I moved the dummy patient’s head into the sniff position (head and neck in gentle extension). The mouth opened, and I easily visualized a perfect Mallampati class I airway (meaning that I can clearly see the dummy patient’s uvula, tonsils and soft palate). I inserted the laryngoscope into the mouth, displacing the right side of the hard plastic tongue, and searched for the epiglottis at the very back of the throat. I saw it! I advanced cautiously until the end of the blade crouched into the vallecula, a moist fold behind the tongue. Remembering what Dr. Stebbins said about not using the teeth as a fulcrum, I made sure not to move my wrist as I lifted the laryngoscope handle toward the ceiling all while maintaining the handle at an approximate 45 degree angle. I met some resistance, and I was amazed at how much physical strength I had to muster just to lift the tongue enough to see the vocal cords. “The dummies are hard to intubate…,” I remembered both Dr. Stebbins and Dr. Beatty saying prior to our training session. And they were right.

My sim lab partner and classmate, Josie, thankfully helped me. She held the laryngoscope in place long enough for me to insert the plastic tube. We used a stylet, a stiff but flexible piece of metal wire we insert into the plastic tube to help with tube insertion. I visualized the pink folds of voice box and inserted the plastic tubing between them, advancing the tube until it reached about 21-22 cm as indicated by the markings on the tube. I removed the laryngoscope and Josie inflated the cuff with air using a syringe. She handed me the valve and bag apparatus, which I attached to the tube. I squeezed the bag and we both watched as the torso triumphantly rose. We made sure the stomach did not rise as this would mean we were pumping air into the patient’s stomach. We looked at each other and smiled. Good teamwork!

By the end of the intubation session, we had learned valuable life-saving skills. “You are literally breathing for this patient,” said Dr. Kathleen MacDonald, an attending anesthesiologist at Fletcher Allen, as she watched us press the bag. The training session prepared us for our session with the anesthesiology service the next day where we had the chance to shadow an attending anesthesiologist and anesthesia nurse. Some of us (including me!) even got to practice and perform intubation on a real live patient!

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