Airway Dogmalysis #3: Never Allow Success With Poor Technique

Training Issues and Fixes #3: Allowing Success With Poor Technique.

“Nothing is more dangerous in airway management than success with bad technique.” – Scott Weingart

“No one cares how long you have been doing it if you are doing it wrong.” – OOM

Passing a tube through the vocal cords is the ultimate goal in the act of intubation, but the end does not justify the means. If poor technique was used to get there, you need to evaluate why the student/trainee has to use it in order to successfully execute the skill. Prying with the blade, hand positioning, head positioning, blade selection, etc. All of these things matter and are all potential failure points for the procedure. If they do not cause the procedure to fail altogether, they carry a high risk of cutting a patient’s lips, breaking their teeth, or damaging the airway anatomy; increasing the risk of morbidity and mortality.

The physical simulation model also plays a role in this. Not all intubation trainers were created equally, and none of them are exact replicas of real human anatomy. I think all of us have experienced the Fred the Head trainer… So there are some ingrained technique problems just secondary to what we have available to train on. Not everyone gets a cadaver lab and not everyone gets OR rotations, but we can still work to perfect technique to the greatest degree possible regardless of the task trainer’s constraints.

Operators must be diligent in their practice and training to perfect the proper techniques. The trainees  must get beyond “the way I was taught” and “the way I’ve always done it” in order to have the greatest possible positive impact on the patient. I have yet to have held a training event where this mindset and the poor techniques they are defending stand up under any real pressure or scrutiny. These issues become more and more apparent when the task trainer becomes of higher and higher fidelity. 

The Problems:

#1 The Mindset of the Trainee

There are those who will use their years on the job as a justification for continuing with poor technique. They know what they were taught in their initial education and that is what they have been using ever since. It is very difficult, in some cases, to break these old habits and foster the adoption of a new mindset.

“Well I’ve been doing it this was for twenty years and never had a problem…”

 This is the translation of that phrase:

“I haven’t done this enough or been exposed to enough context to see that what I am doing is a problem.”

This student or trainee may very well come from a low acuity, low frequency system, and their access to expert feedback may be limited as well. Their exposure to the newest content is limited and they may simply be lost in comparison to the standard of care. When the clinical situation demands that they step up and perform this invasive skill, they are falling back to their most recent experience or training event, or worse they defend the outcome with their tenure on the job.

These are great opportunities to make a positive impact on these students. Take your time with them, very clearly explain and unpack the “why” behind the content and give them plenty of time and reps to practice with it. But hold them accountable to the standard of care.

#2 The Attention of the Instructor

It should not matter to you if they put a tube through the cords or not. Have you ever been to a shooting course that was run by a real master of the craft? Ever notice what they pay close attention to? (Hint: it is not the holes you make in the paper). They pay attention the your fundamentals. Position, grip, sight picture, etc. Any one of those can cause you to shank a round away from your intended target… which can be quite dangerous in some cases. The same is true in intubation, and instructors must be vigilant in how the trainee is accomplishing the task, not just ramming plastic into the trachea.

There are some techniques that have been able to persist over time. These are only a few examples of technique errors the instructor should be looking for.

1.) Grip – the student is holding too high up on the handle. Meaning, their hand is up near the end of the blade where the batteries go instead of closer to the blade. This grip almost necessitates prying because the student has no leverage to displace and lift the jaw and adjoining tissues. It also promotes other nonsense like resting the forearm on the patient’s face to anchor the head down so that they can lift and move the jaw. It also makes it quite difficult to manipulate the end of the blade. The fix is to have the student hold the laryngoscope as close to the blade and the patient’s face as possible. It allows for better control of the tip of the blade and better muscle recruitment so that the jaw and tissues can be lifted easier.

2.) Instrument Approach – most airway simulators do not have a floppy tongue and tissues. It is plastic or rubber that stays up and out of the way for the most part. This model allows for a direct, mid-line approach without a need to really sweep and control the tongue. It is a baked in training scar. With video laryngoscopy, this is just fine. A mid-line approach and progressive laryngoscopy is the way that instrument is designed to be used. With direct laryngoscopy, this is not the case. DL requires a lateral approach and rotation of the handle/blade that sweeps the tongue to the left side of the mouth and keeps it there so as not to obscure a view of the vocal cords. This is easy to miss in the training environment that is not a live patient or a cadaver, and the right approach/habits must be reinforced so that the poor habits do not carry over in to real life patient care situations.

Of note, I did see a recent video of the @sangrialovingairwaydoc take a lateral approach and rotate a AirTraq blade into place. This is an approach not unlike how an OPA is placed. I have to say I am eager to try that myself and see how I like it.

3.) Prying – this issue is well addressed in most training environments. In fact, using the teeth as a fulcrum is a hard critical failure point for NREMT testing and most training events. Yet, the issue persists. In some cases prying is the only way that an operator using other poor techniques can manipulate the tissues in order to obtain a view of the vocal cords. Prying is the culmination of ignoring the preparation phase of RSI/intubation. Positioning the patient properly defeats the need to pry. Ramping the patient and placing the tragus of the ear even with the anterior surface of the chest (aka “ear to sternal notch) aligns the airway anatomy and visual axis so that it is easier and faster to obtain a view.

 If they grip it too high, they usually have to pry. (See #1).

 If their eye relief is poor they will pry. An eye relief issue means that instead of maneuvering the jaw and tissues up out of their view, they are moving their own head around the anatomy and prying the mouth/jaw open in an attempt to get a view of the cords. Think about the video of Ace Ventura looking through the pipe in Snowflake’s tank. This is simply defeated with aligning the airway axis’ by elevating the ear to sternal notch and good “valleculoscopy.” See below.

 What ends up happening more often than not is that the more the operator pries with the laryngoscope, the further anterior and out of their line if sight the glottic opening moves. This is most common when the operator is using a Mac blade that is not seated in the vallecula and they are really only engaging the soft tissue of the tongue:

 (check out this video from the AIME page on youtube). Valleculoscopy using a curved direct laryngoscope blade

This highlights the danger of the approach in part 2 where the operator buries the blade as far back in the oropharynx as they can and tries to “back out until the cords drop into view” instead of progressively engaging the anatomy and using the blade the way it was designed to be used.

The Operational Realities:

Are operators still successful in intubation despite these poor techniques? Yes. Should they be allowed to continue to use these techniques because “it works for them?” Absolutely not. The end does not justify the means. Nor does it justify increasing the risk of unnecessary injury to the patient.

You see, the danger is that the operator is out in their clinical space performing the skill with a false sense of security. They think that they know what they are doing, and are good at it because they “got the tube” in training despite the fact they used atrocious technique. These poor techniques will only become more and more apparent the more and more difficulties are encountered during the procedure. A patient with predicted airway difficulties can ill afford an operator complicating things with poor intubation technique. In fact, that poor technique will likely fail to overcome the physical difficulties (provided it was assessed in the first place).

As instructors it can be hard to tell an experienced provider that their technique is not only incorrect, but dangerous. They will inevitably double down on their “I’ve been doing this longer than you have been alive” experience as their justification for continuing to do it the way they have always done it. It is all ego, and it is a formidable opponent in the training space. You must address poor technique, and attach the mindset  that it is not about satisfying the “need to get the tube” but that it is more about doing so in a manner that does not expose the patient to undue harm or danger.