the worst intubation

Editorial Team / Admin · Dec 12, 2014

Firstly, intubation is not a sterile procedure, therefore aseptic technique is not necessary.

Secondly, what was the patient's airway history? Do they have a history of being a difficult airway to intubate? Unfortunately, there are some patients where the safest way to intubate is awake. I witnessed one just the other day in the OR where I work. It does appear brutal because of course the patient is not going to like having that tube placed while they are awake. However, there are ways to help: numbing nebulizers, numbing medications, and amnesiac drugs that while the patient will still be awake and able to follow commands, they will not actually remember the event. Going with the fact that you had two people try five times before being successful, this patient had a difficult airway and it's possible he/she was one of those where awake intubation was indeed the safest course of action.

LongislandRN23 · Dec 12, 2014

Sounds like a bad experience to witness. Was this an emergency situation? If it was there might have not been time or it may not have been appropriate to sedate- getting the tube in quickly may have been the priority. Also if the patients breathing was severely compromised sedation as in propofol could have diminished his respirations - perhaps that's why they didn't sedate until after?

MunoRN, RN · Dec 12, 2014

There's nothing pretty about any intubation. Unfortunately there are many times where it's not safe to give the patient any sort of paralytic or sedation. Keep in mind that using a paralytic for intubation in no way reduces the mental stress of intubation, it just makes it so they can't move which is probably far more torturous.

emt2lpn2 · Dec 12, 2014

I've witnessed 3 intubations. 2 in the field 1 in the hospital. Only 2 that was difficult. 1st one that was difficult the paramedic only had me the EMTB, and after we were unsuccessful with the first try we did a king airway. Being that we wanted the airway to be done while we went to start the IV IO drill. The 2nd was with flying a patient out. The nurse didn't get it the first two times, then the medic tried and it was successful. So I'm wondering why didn't the chief or attending didn't intervene, being that the resident was unsuccessful during the first go round.

Fruit Sucker · Dec 12, 2014

Yes, they said he was a difficult airway. What you wrote is very helpful information.

Firstly, intubation is not a sterile procedure, therefore aseptic technique is not necessary.
Secondly, what was the patient's airway history? Do they have a history of being a difficult airway to intubate? Unfortunately, there are some patients where the safest way to intubate is awake. I witnessed one just the other day in the OR where I work. It does appear brutal because of course the patient is not going to like having that tube placed while they are awake. However, there are ways to help: numbing nebulizers, numbing medications, and amnesiac drugs that while the patient will still be awake and able to follow commands, they will not actually remember the event. Going with the fact that you had two people try five times before being successful, this patient had a difficult airway and it's possible he/she was one of those where awake intubation was indeed the safest course of action.

Fruit Sucker · Dec 12, 2014

I'm wondering that, too. Someone asked why they didn't call the anesthesiologist stat, and they said that they don't do that at this hospital.

I've witnessed 3 intubations. 2 in the field 1 in the hospital. Only 2 that was difficult. 1st one that was difficult the paramedic only had me the EMTB, and after we were unsuccessful with the first try we did a king airway. Being that we wanted the airway to be done while we went to start the IV IO drill. The 2nd was with flying a patient out. The nurse didn't get it the first two times, then the medic tried and it was successful. So I'm wondering why didn't the chief or attending didn't intervene, being that the resident was unsuccessful during the first go round.

Fruit Sucker · Dec 12, 2014

Thanks for the replies. I'm realizing that it may just be that it was unnerving to watch and not that there was something incorrect with the procedure. Perhaps you guys are right and there was a reason that they didn't sedate him. This was during an emergency, the patient wasn't satting on room air so the nurse gave him O2 and tried to call for an order for nebulizers, but he just crashed and she had to start bagging him.

dah doh, BSN, RN · Dec 12, 2014

Sorry you are shocked! Intubations in emergency situations are not usually very smooth unless done by an experienced person. As you stated, it was an intern & resident attempting intubation on a patient who was fighting. At my facility, interns & residents cannot order paralytics or propofol for intubation but can order pain meds and anxiolytics depending on the patient's situation. Since you didn't describe the surrounding circumstances, I'm not going to guess other than to say it was probably not appropriate to sedate the patient prior to securing the airway via intubation.

As to the worst intubation...well I think an unsuccessful intubation where the patient dies or needs an emergency tracheostomy has to be worse than whatever you saw.

Editorial Team / Admin · Dec 12, 2014

Thanks for the replies. I'm realizing that it may just be that it was unnerving to watch and not that there was something incorrect with the procedure. Perhaps you guys are right and there was a reason that they didn't sedate him. This was during an emergency, the patient wasn't satting on room air so the nurse gave him O2 and tried to call for an order for nebulizers, but he just crashed and she had to start bagging him.

Witnessing awake intubations is unnerving. Even with the many that I've seen over my career, it's still something I hate to see.

Part of the reason for not giving heavy sedation or sedation at all is because the patient can still control his or her own airway. Propofol or other anesthetic medications will interfere with the patient's ability to continue breathing. In someone with a very difficult airway where even mask ventilation is ineffective, the patient may suffer anoxia for a period of time. Keeping them awake and able to control the airway usually means that the patient will still be able to move some air, even if not very effectively. The only other alternative that I've seen is an emergency tracheotomy, which has much longer lasting effects and is far more invasive than an awake intubation.

applewhitern, BSN, RN · Dec 12, 2014

Seems like your nursing instructor would have been able to discuss this, and give rationales for not paralyzing or sedating the patient. Missed teaching opportunity.

akulahawkRN, ADN, RN, EMT-P · Dec 12, 2014

As stated above, sometimes the best thing to do is intubate the awake, non-paralyzed, non-sedated patient and sometimes that's an emergent event and you just don't have time to sedate/paralyze or doing that would actually be more dangerous for the patient. As difficult for you to watch that procedure, it's also difficult for the intubationist to do it. The reason I say "intubationist" is because there are many people, physicians and non-physicians, that intubate patients.

As a Paramedic, I'm actually glad that I've never had a patient that difficult to intubate... the "can't intubate, can't ventilate" patient is the one that scares me. It's been quite a long time since I've been working as a Paramedic though. Like doing IV's, this is one of those skills that is easy to learn the fundamentals, but so very difficult to truly master.