I know you are supposed to check your scope every morning. I do. My preceptee does when I am precepting a new medic. Maybe I should check it too. You snap the blade in and it comes on. But is it really bright or is it just lit?
I’ve had dim bulbs before, but with a little tightening they have lit up fine. I’ve also had no bulbs before and often wondered where the bulb went. Did the night crew intubate someone and lose the bulb down that person’s gullet?
So anyway, we’re doing a code and my preceptee says he can’t see anything. I tell him to reposition. No, no, he says, he can’t see, it’s too dim.
I tell him to tighten the bulb. He does. The light is still weak. I finally go in and it is dim. I can see the epiglottis, but underneath is just darkness. My other partner hands me his penlight, and pen light in mouth (yuk) I am able to see the chords and get the tube.
But say you don’t have a pen light or your partner’s pen light is just too yucky, what do you do?
Well, first off, when you check your equipment in the morning, make certain the bulb is not just lit, but bright. (Maybe you should if you use the same gear all the time, make it a habit to replace the batteries on a regular schedule. When we opened up the scope, the batteries were starting to corrode). Carry a second handle. We do have a second handle in our pedi kit, which I would have remembered, I think.
You can also do a blind intubation either digital, bougie, or a blind capnography intubation.
To do a blind capnography intubation, attach the capnography filter to the end of the ET tube, insert the stylet – it will fit as long as it is the thin kind -- hook up the capnography to the machine, turn it on, and then go in for the tube. Once you think you are in, glance at the monitor. You either have a wave form or you don't. You're either in or you are out. In a breathing patient, make certain you have at least four good wave forms, and then pull the stylet and proceed with your routine checks.
For apneic patients with a pulse, you just have to have your partner ready to attach the ambu bag when you ask. No more looking around for the capnography filter -- it is already in place. Keep in mind as always for pulseless patients you will need a little CPR to get your wave form reading.
The following are typical ETCO2 strips on intubation. The tiny bumps are CPR, each compression creates a small tidal volume that releases CO2, ventilating the body by compression only. The large wave is from the first ambu-bag ventilation on the just placed ET tube.
Make certain you have an extra capnography filter available as backup because if by chance you miss your tube and gastric contents come up, they will contaminate your filter in addition to your tube.
But most of all check your equipment. When we did put new batteries in the scope, the difference between the light with the new batteries and the light from our backup scope was immense, even though the backup scope was acceptable.
For more on capnography, check out Capnography for Paramedics.
