Only Two Attempts
You and your airway kit
By Alan Perry
My agency only permits two attempts at endotracheal
intubation by a provider before compelling the use of an alternative airway
such as a King airway. In a cardiac arrest situation an ET tube becomes
secondary. Most medics do not have sufficient exposure to the skill itself in
the field and training for intubation skills is sparse if
available at all. Never-the-less the skill is an important one that should be
mastered and practiced as often as possible to be certain it can be done
properly when needed. The equipment needed for the procedure is no different;
it must be kept organized, clean and ready for a variety of patients and
circumstances much like Your Physical andMental Jump-bag. In my position I frequently get the opportunity to examine
jump-bags and intubation kits. What I frequently find is that the kits are
mostly complete, but are clearly only a passing concern to those checking them off;
after all it’s a single check box on the check off sheet. My concerns are multiple, most of which my
contemporaries will dismiss as being minor only because they do not understand
the full effects and implications of this equipment being in sub-par condition.
I will also make it clear that this is not an isolated or universal statement;
there are providers with sufficient pride and knowledge that do maintain the
equipment as best they can. This article will address the knowledge and
expectations for properly maintaining airway equipment specifically, and all of
your EMS equipment generally.
Why is it important
Equipment
that is maintained in a state of contamination and disrepair is subject to
accelerated wear and frequent malfunctions. Airway failures are more often than
not blamed on equipment failures. I wonder why? Contaminated equipment can be responsible
for (pre) hospital acquired infections and death. It is a very tragic thing for
someone to survive a major trauma or illness only to be killed by a pathogen
carelessly introduced by a provider unaware of the consequences of their
actions. Now you are aware.
The Provider
Each intubation attempt begins with the provider’s knowledge
and confidence in the procedure. If intubation is a defined part of your skill
set it is your responsibility to maintain that skill, and find opportunities to
practice and validate your competence. If you are unable to do this on your own
contact your training division for their resources, a nearby agency that may
have the resources or find an airway lab you can attend at a symposium,
community college or medical facility. Recommendations for the number of actual
intubations required to remain proficient vary widely, I have worked with
agencies that keep several airway mannequins in their day room for providers to
practice on at the beginning of each shift, they also have intubation as a
required skill at least once a year as part of a skills drill to demonstrate
competency. When was the last time you practiced?
The intubation or airway kit bag
The
inspection of your airway kit begins with the exterior of the kit; the bag
should be clean and free of stains and other evidence of contamination, the
zipper and other closures should function properly. Once opened the bag should
be arranged in such a way that the contents do not explode or fall out of the
bag, elastic or Velcro should firmly hold all blades, handles and accessory
items in place. The interior compartments should be clean, free of contaminants
and stains, and open and close properly as well. Bags should be cleaned
regularly; bags that are in poor condition should be replaced.
The ET tubes, stylettes and other
consumables
I find open
ET tubes and stylettes in intubation kits with alarming frequency; I believe
that most providers are not aware of the risk of introducing pathogens into the
airway by this route, so this is mostly an education issue. The blades we use
are only required to be clean, but the ET tube and Stylette, like anything else
inserted into a body must be sterile. Taking an ET tube from a stained package
with a hole in it does not meet that standard, nor does the use of a stylette
left floating around in the kit out of its package. ET tubes, Stylettes, NG
tubes, NPAs and suction catheters including the yankauer should come from
clean, unbroken packages if they are going to be used on living patients. Other
items in your kit like tape, water soluble lubricant and securing devices
should also be clean and in good condition.
The intubation blades and handle
We are not
required to sterilize our re-useable intubation equipment so all blades and
handles are “cleaned” after each use, it appears that in most cases the best
they get is a wipe down. There are two problems with this; its effects on
patients and its effect on the equipment. As mentioned earlier we don’t want to
inadvertently introduce any new problems in our patients, blood and bodily
fluids routinely make their way onto our
intubation equipment, and when not properly decontaminated impregnate our
entire kit with unwanted materials. These same contaminates will migrate into
the cracks and crevices of out intubation handles and blades causing flickering
lamps, dim lamps, poor fit and function. That’s because this corrosive goo gets
into and between the contacts and pivot points. A stainless steel intubation
blade should be bright and shiny no matter how old and dinged up it may be,
every crevice should sparkle, the light should be uncomfortably bright to look
at. I have found that soap, water and a small scrub brush will do wonders and
solve a variety of problems with dirty handles and blades.
Catch your breath
Before you
consider respiratory arrest, consider your skills, the condition of your
equipment and what is best for our patients. Make a more thorough examination
of that kit part of your mental preparation for the event and your contribution
to improving your agency’s performance in these high profile events. You
certainly won’t get any awards for having a clean, working intubation kit, but
when the time comes it will work for you and may save your patient.
