The expert mindset that will make your intubation skills better.
The first time I plunged a laryngoscope into the murky depths of a patient’s oropharynx I believed the device would live up to it’s name: and help me seek out “the cords” hidden from view so I could slide that tube between them (and in the process feel like that emergency physician I wanted to be).
Needless to say I failed. In fact, I failed on many future attempts as well – reluctantly ceding the laryngoscope to my senior who happily stepped up and “got the intubation.”
It was only later, when I came to realize that what I was holding in my hand was not actually a laryngoscope, that I finally reached a tipping point in my airway training, and that realization has made all the difference.
What you say? Not a laryngoscope? Let me explain. Pick one up for the first time and it may appear (as it did to me) to be a heavy, somewhat clunky, blunt instrument with a single purpose: to push aside any soft tissue that blocked my view of the larynx. Newer models were lighter, some were disposable, and still others were dressed up a bit with video screens and cameras, but that didn’t change it’s purpose for me. It’s still a laryngo-SCOPE after all isn’t it?
But if I had been able to enter into the mind of an expert intubator back then, or listen with more awareness when that expert held one up for demonstration, or if I had even been able to watch them in action with a more trained eye, then something else would have been revealed to me: that in experienced hands, the laryngoscope is something closer to an “all in one” multifunctional airway tool and not a simple “laryngoscope” at all!
This is because the process of intubation has three distinct phases (finding key anatomic landmarks, exposing the larynx, and delivering the endotracheal tube) and that in each of these phases the laryngoscope is manipulated in very different ways: hold it one way and it will help you find those essential landmarks, control the tongue, and deftly maneuver within the oropharynx. Hold it another way and it can help you take advantage of key anatomic structures to expose the glottic opening, and then create sufficient space to deliver your endotracheal tube.
Early in my training, I’m not surprised I missed this. Back then, I was just trying to remember the “prepping for intubation” checklist that would gain me entry to the head of the bed – believing that my dogged focus on getting enough intubations would eventually confer upon me the status of expert. It wasn’t until much later, when I realized that a necessary part of becoming an expert was understanding the mental framework upon which their skill is built, that I reached a tipping point in my own intubation skills.
In the case of laryngoscopy, it turns out that if you want to think like an expert intubator, then it’s smarter to think of the name “laryngoscope” as something of a misnomer, because it doesn’t do justice the real power it has a multipurpose airway tool. Sadly, this subtle understanding of the expert intubator remained lost in translation for me.
Some of the confusion about what a laryngoscope really is may also be historical, since the laryngoscope (as a tool to view the structures of the larynx for diagnostic purposes) was invented prior the invention of the laryngoscope(s) we use today to perform intubation. Some of the problem may simply come from the preconceived meaning embedded in the name laryngoscope itself.
Whatever the source of the confusion, the bottom line is this: novice intubators will still require plenty of practice, but that practice can be more informed if it has the benefit of the expert intubator’s mindset: that the laryngoscope is really an all in one epiglotto-valleculo-laryngo-tube delivery device, and it’s important to think of it as such (even if we still call it a laryngoscope).
Flipping Direct Laryngoscopy
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