How do you hold your laryngoscope? Caveman style?

(picture courtesy of Dr Seth Trueger and his homemade laryngoscope trainer)

Jim DuCanto is back, innovating on body positioning and how the way you hold the laryngoscope might improve glottic visualisation.

He calls it the “Paleolithic style” of laryngoscope handling!

Also check out his ” parrot maneuver” for withdrawing the stylet.

In the past this way of holding the handle, we called it “Icepick grip” in prehospital care, used for trying to intubate face to face, front on to an entrapped patient sitting up in a car. The “Icepick grip”, has origins in the martial arts, in particular Filipino combative styles with sword and dagger.

But the way Jim is using it is like suspension laryngoscopy used in ENT and the way the old Jackson laryngoscopes were handled.

Try it out next time you are doing mannikin training. It might suit some. Does it make the glottic visualisation better? Well Jim thinks it does and is worth practising to see if it offers advantages to your own technique.

Thanks Jim!

13 thoughts on “How do you hold your laryngoscope? Caveman style?

  1. Also, I believe wearing a WRIST GUARD (bowling glove, rollerskate/rollerblade wrist pad) keeps you from using your wrist as a hinge….which you want to avoid in order to keep teeth intact. Just use forearm and upper arm torque. Hit the gym!

  2. Paleolithic: that’s a very interesting maneuver and I have never seen before. The ice-pick (or tomahawk) face to face method can work very well ergonomically, especially in the field where there might be no space at the head of the bed to get your body and head into a position to do traditional laryngoscopy. I have never tried using a wrist guard before but in Levitan’s lab, I relearned to hold the laryngoscope hugging the very base of the handle … it prevents one from levering your blade against the teeth, the blade becomes an extension of your forearm and it is ergonomically stronger to pull from the base where the handle meets the blade’s butt end. The cadaver lab had us doing laryngoscopy up to 60-70 times in the morning around 18 diff cadavers using different adjuncts and blades, most with very high BMI’s. Without using proper technique, one’s forearms were blown from muscle fatigue! With this Paleolithic method however, I don’t think it would work as well ergonomically as your elbow needs to be up in the air and you need to be careful that you are pulling in the saggital plane and not off to the side (left elbow will tend to be off midline thus one would tend to be naturally pulling to the left). Probably not a big deal for most intubations but potentially if +++BMI. Not sure how easy it would be to do finer epiglottoscopy with suctioning if there is a big tongue or distorted anatomy using the paleolithic but perhaps with practice. Straight traditional laryngoscopy allows one to dig their elbow into one’s chest and then use your body to lift the larger patient’s jaw forward. Also one can easily apply two hands to the laryngoscope (an adjunctive maneuver as advocated in Kovacs/Law’s AIME course) for extra lift. Mind you that ramping and ear-to-notch face-plane-parallel and an assistant to help head elevate will alleviate a lot of that lifting that might be required otherwise with your laryngoscopic hand.

  3. First impression… It looks a little crazy. Having said that, crazy often works. I’m going to experiment with it. Seems like some potential benefit may be gained in large, open environments inside the hospital where you have room to bring your body to the side as seen in the video. In the more cramped environment of the ambulance and helicopter, this may be a bit more tricky. Worth some experimentation.

  4. One more thought on ice-pick/tomahawk style laryngoscopy … in addition to the field with limited access to head of bed, it’s also my preferred method when doing awake look video laryngoscopy (glidescope) in a patient that I might want to keep sitting. This might be an airway that it difficult where I am really worried will worsen by lying them down and they are keeping it open by sitting up and there is time with good sats. By doing awake look sitting with gentle minimal touch laryngoscopy and tube delivery, my thought is that if I can achieve intubation then I lose nothing. If that doesn’t work then I know I am forced to lie them back.

    Tomahawk/ice-pick will work with DL, glidescope, C-Mac … but not sure if McGrath screen repositions to allow it to work well for either Tomahawk or Paleolithic.

    Paleo … I’ll have to try on a mannequin or perhaps next time I am at a cadaver lab! I am intrigued if it offers advantages vs IcePick/Tomahawk or traditional DL (curved vs straight blade right paraglossal). Would it be an additional backup DL technique as a 2nd or 3rd attempt after other DL techniques have failed? Or are there circumstances where anatomy or disruption favors Paleo over traditional DL?

    What are your thoughts?


    1. Let me put it this way. On the same clinical day that I captured that video, the Paleolithic technique afforded me an improved view (grade 2B to grade 2A to almost grade 1) in a 308 pound middle aged male with Mallapati 3-4 score, OSA, large tongue for mouth–a big guy with difficulty predicted for DL). There are subtle elements that improve the view, which I promise to expound upon. Using the Paleo is possible with the McGrath Mac, as I tried it the same day.
      I promise an airway lab video to expand upon the technique.

  5. My first reaction is that this paleo technique also seems to force your whole body positioning into caveman stance… you are hunched over, twisted and your nose is practically in the patient’s mouth. I have been taught, and also found in personal experience that getting this up close and personal with the airway tends to give poorer views and that standing back and upright tends to give better perspectives and body mechanics.

    Jim, in your video, you were up close and personal when demonstrated both techniques, have you compared views obtained with your paleo technique to one obtained using a traditional grip and an upright posture?

    1. Sean, it is typical for me to get this close during DL, however, I will investigate.

      I am working on an intraoral version of the “Airway Cam”, so stay tuned for when I get that working, because then we will see what is useful with this exercise, and what is not useful. What has been useful so far (for me in simulation) is examining those body mechanics, and “playing” with postures that make the laryngoscopy easier as well as more difficult. This Paleo technique is still a work in progress–I’ll keep sharing how this may be useful, or at least how the awareness of laryngoscopy technique may prove useful when difficulty arises.

  6. Jim & Minh- Interesting technique. Have yet to try it out but one thing that seems counterintuitive is that a big move when you graduate from being a “novice” at laryngoscopy is the shift from “macro” to “micro” movements, and the caveman grip looks like it would make subtle movements much more difficult. Thoughts?

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