Only Two Attempts

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.