Merry Xmas folks!
Ok some holiday reading
First here is the article
Higher operating tables provide better laryngeal views for trachealĀ intubation
Simple things help. Knowing the optimal height of the patients head in relation to your own body can help a difficult intubation become easier.
This article suggests that its more comfortable and you get a better laryngeal view if you have the patients head at your xiphoid process or nipple level.
Comfort is important as it means you dont get stressed. this is good.
I know of more than a few failed prehospital intubations as a result of the intubator not positioning the patient adequately including trying to intubate on the ground.
This is sometimes not possible to change but often it is! If you can move the patient to a better position, including off the ground to a height that suits you, then thats going to help you get first pass success.
Prehospital and Retrieval Medicine - THE PHARM dedicated to the memory of Dr John Hinds 
…and 360 degree access.
Seems obvious, but how many times have you seen people attempting to intubate in a crowded resus bay or ICU room – hampered by monitor cables, suction and O2 on either side, monitors placed behind them, airway trolley on the left hand side (not right) meaning instruments are passed across field of view.
I believe that we can learn a LOT from the prehospital arena and apply them to ED/ICU.
A standardised approach – not just the obvious, like ramping and position ear-to-sternum…but meticulous attention to :
– patient at optimum height for laryngoscopy
– airway equipment standardised across OT-ICU-ED
– trolley placed on right side so airway kit passed with no disruption to view
– bougie for all RSI, preloaded in Kiwi grip
– 360 access to patient, with only ONE conduit of monitor cables/suction/O2 hindering access
– monitors visible to operator
etc etc
And, of course, use of an RSI checklist – goes without saying!
…use a stool Seth.
But I take your point – especially if patient needs to be ramped or table tilted head up.
I wonder how Mr EM-Crit manages?
in the middle of DL, it’s much easier/less disruptive of all the lines & tubes, to use my knees to adjust my height down, then to climb up a stool
Use a stool to sit down š
In fact it makes you comfortable in uncomfortable situations.
…but Seth, if you set up your resus room correctly, there should be a minimum of lines n tubes disrupting access.
This is a real bugbear of mine – sure, there needs to be plumbing…but those tethers – IV, monitor cabling, suction, vent tubing should all be positioned a much out of the way as possible
The feng shui of resus room planning. Gonna be talking about this at smaccGOLD….
Even if we assume the equipment is all tidy (which will never happen in a sick/time-sensitive patient in an urban US ED) it’s still a fair amount of time to climb up on a stool or precisely drop a bed to the right height, whereas my knees work remarkable quickly and there’s a built-in feedback loop.
OK, OK – you can guddle around on your knees if you insist, Seth.
But tell me you at least use a checklist whilst you are down there…