Why Do I Elevate the Head of the Bed for Fiberoptic Intubation?

A few objections I hear a lot in relation to intubating patients in the upright or semi-upright position are: I’m not comfortable elevating the head of the bed after inducing anesthesia.  I’m concerned about hypotension and cerebral perfusion in the head-up position after the induction of anesthesia. I think that underlying this objection is the ingrained bias that all patients …

Why Do I Face the Patient for Fiberoptic Intubation?

Many years ago, I was struggling to intubate a patient endoscopically.  The patient had difficult airway anatomy due to head and neck cancer.  I was standing at the head of the bed, the patient was supine, I couldn’t get the scope around the base of the tongue, and I couldn’t see anything except soft tissue.  The ENT surgeon watched me …

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Quality Thinking About Quality – Part Three: Scientific Revolutions, Rarely Occurring Events

In Part Two, I discussed the Joint Commission’s Universal Protocol, explained why it hasn’t worked at preventing wrong-site surgery, and proposed a better approach.  I also discussed the problem of airway disasters and suggested that it is time for a new approach to airway management.  Here I’d like to discuss how revolutions in science (including the clinical sciences) often occur, …

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Quality Thinking About Quality – Part Two: Wrong-Site Errors, Airway Disasters

In Part One, I explored the concept of quality, discussed performance demands and the choices workers face when system demands exceed performance capabilities.  Let us consider well-intentioned efforts to prevent wrong-site surgery, as well the bugaboo of airway mishaps. Wrong-site, wrong-implant, wrong-patient errors occur at an alarming rate in the U.S.  The Joint Commission came up with a safety procedure …

Have I Really Accomplished More Than 6000 Fiberoptic Intubations?

Yes.  Really.  Starting in late October 2004, I kept careful records of all my endoscopic intubations. Taking into account days off—vacation, post-call, holidays, family leave, etc.—I worked about ten months per year and consistently performed well more than 400 endoscopic intubations per year. In mid-June of 2014, I accomplished my 4000th endoscopic intubation.  I calculate this took me about 98 …

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Quality Thinking About Quality – Part One: What is Quality?

Now that’s an odd title.  “Quality Thinking About Quality”.   We typically don’t think of the attribute of quality as having anything to do with the act of thinking.  There’s a good reason for this.  Because it doesn’t.  Using the noun quality as modifier of the gerund thinking is simply incongruous.  It makes no sense. What is quality?  How do we …

Three Simple Steps to Incredibly Easy Fiberoptic Intubation

Perhaps the single most common reason for the reluctance of clinicians to attempt flexible endoscopic intubation is lack of experience, and therefore skill, with the bronchoscope.  There seems to be widespread perception that endoscopic intubation is difficult and time-consuming.  Nothing could be further from the truth!  With the proper technique and about a dozen attempts, the typical clinician can become …

Tips and Tricks for Fiberoptic Intubation

Here are several tips and tricks to help you become adept at endoscopic intubation very quickly. 1. Unless contraindicated, give the patient glycopyrrolate (0.1 mg IV) several minutes before intubation to reduce saliva formation. 2. To allow the endotracheal tube to pass more easily through the vocal folds, lubricate the cuff with a water-soluble lubricant.  Consider using a flexible tip …

How to Get Good—Really Good!—at Fiberoptic Intubation

I live in Colorado and I like to ski.  When I began learning how to ski, I did so on very gentle green runs.  This is true of almost all skiers and snowboarders.  As a beginner, you learn on the easy stuff before attempting the more difficult stuff.  But a not-so-funny thing happens on the way to intubating a patient …