I got to insert an LMA the other day. I had previously done one when I was in the Dominican as part of a surgical medical mission team. The anaesthesiologist let me put one in on a patient who was having a hernia repaired. I slipped it in, and then that was that. I went back to my post in the post-op area.
Here’s how my first field LMA went.
Fifty-year-old obese lady. Witnessed arrest by onlookers, but no shock advised when the first responders got there. Asystole for us. The first time I went in for the tube, I couldn’t see anything. The lady had a significant overbit and I had trouble getting the mouth open wide enough. There wasn’t any emesis in the airway. I was just looking at tongue and throat. No chords, no epiglottis. After bagging some, I put a pillow under her head, and also got out the bougie. The problem with the bougie was to store in our house bag, it gets rolled up, so it was sort of hard to manipulate. I didn’t see anything, but gave it a try passing it. It just kept going down so I knew I wasn’t in.
A couple of years ago, we changed our protocols so that medics were limited to two intubation attempts defined as inserting the blade into the mouth, not attempts to pass the tube. So far I have gotten all my tubes within the two-attempt limit. I wondered what I would do when forced for the first time to not go in a third time. Technically we can go in a third time, but we have to have a pretty good reason for it. I suppose I might have if I had seen the chords and was sure I could get it, but I was lost on this airway, so I put in the LMA.
I had been thinking about doing an LMA on a code -- we can use it as an alternative instead of a backup airway, but the truth is I like intubating and never wanted to give up a tube. I was talking with a medic about LMAs the other day, and while I didn't say it, my reaction was, I'd put one in, but I always get the tube.
It has in fact been quite a number of years since I haven't gotten the tube -- and I have had some tough tubes, including a five hundred pounder -- but maybe he was just an easy tube despite his weight. It has certainly made me a bit cocky. Again, every time someone tells me about a hard tube and how they had to go to a backup airway, I think, I probably would have gotten the tube.
When I was in paramedic school, I zipped in my first 9 tubes in the ER, thinking man this is easy. Then I missed my next three (possibly my next four) and was quite shaken by it. I had some trouble intubating early on in my career, but I had thought now that I was skilled enough that I could intubate anyone, Mallanpotti be damned. And maybe I would have gotten the tube in this lady. Of course it might have taken me a couple more attempts, which wouldn't have been good for her at all to try so many times.
The LMA went in quick and easy, and held in place through a difficult extrication. We maintained excellent capnography throughout so she was getting well ventilated. I did detect a bit of abdominal distension so the seal mustn't have pristine. Still overall I was very impressed. I can tube pretty quickly but the LMA was in in less time than it takes me to open up the ET roll, take out a a sterile tube, stylet and attach a syringe. It was open up the package, attach the syringe, check the inflation, deflate, open the mouth and slide it in. Good to go. Very quick.
But I am finding myself still thinking about not getting the tube. It's like a puzzle I got two attempts to solve, but they won't let me play again. I try to figure out how I could have approached it differently, and wonder where the key to it lay. I guess I'll never know. And I hope my cockiness is not dooming me to a string of difficult airways ahead(maybe all these tubes I have been zipping in have just been a two year strek of easy or lucky tubes). But if a bad streak does come, and it might well, I've got the LMA now watching my back.
I'll keep you posted.
