“Did you just, uh... Did you just grunt? You really shouldn’t be, you know, grunting while intubating.”
The paramedic in the back of the ambulance with me is a tired, sweaty mess. We are going through DSI training and working on intubation.
“My shoulder is burning,” he says. “I need to take a break.”
I tell him, “Listen, you have to use your glutes when you intubate.”
He looks at me like I have gone insane, and without further explanation, I guess I can’t blame him. For all the much-needed focus on improving intubation techniques out there—ramping the patient up, align axes, getting “the view,” SALAD and more—most training misses something huge; how we position our bodies before intubating and how proper biomechanics can be used to our advantage when intubating.
Properly positioning the patient before intubating is important, but how you position yourself before intubating is even more important.
After 16 years in EMS, I can make a fairly good assessment of how well an intubation is going to go just based on the body positioning of the person doing the intubation. Seeing nothing more than where and how they stand in relation to a patient I can get a pretty good sense if this will be an easy intubation for them or if it is going to be a struggle.
Many people attempt to intubate patients using the forearm smash to the face approach (FSTTFA). It usually does not go well. They might get the endotracheal tube in there, but it is an ugly ride on the struggle-bus.
The FSTTFA (see figure 1, below) is bad for everyone involved—both you and the patient. People adopt this technique because they learned to intubate this way and it sort of works, at least just well enough so that people just keep doing it. Every patient they intubate with this technique ends up being “a really hard tube.” Using the FSTTFA approach is an inefficient way to intubate patients.
Most people learned to intubate on manikins that had lightweight heads and they needed to use a forearm smash to the face to keep the lightweight manikin from lifting off the ground when they were intubating it. Using manikins with unrealistically light heads formed bad habits that for many people carried over into the real world. In addition to making viewing the glottic opening harder and causing your shoulder to burn, using the FSTTFA makes fitting the endotracheal tube in a patient’s mouth difficult as your wrist is covering half of their mouth.
Figure 2 below shows another example of the FSTTFA. Note the elbow being several inches below the wrist.
Using your whole body to intubate allows you to progressively adjust how much power you put into the laryngoscope and allows you to use much more efficient from a biomechanical perspective. Figure 3 points out some of the issues you’ll encounter if bad biomechanics are used when intubating.
So how do you intubate with your glutes?
To be honest, it really isn’t about using just your glutes as much as it is about using your whole body to intubate. Thinking about using your glutes is a good prompt to get you to use your entire body when intubating a patient and made for a catchy headline.
Start by standing behind and to the side of the patient at about a 30 - 45-degree angle to them, not parallel to them. Standing at an angle to the patient gives you options. Angles equal options. Extend your left hand with the laryngoscope in it like you were going to shake someone’s hand but you decided to ignore social norms and are doing it with your left hand, bringing it across your body to about your midline, (figure 4 below).
Stand up tall. Resist the urge to crouch down and get near the patient. You are going to be bringing the patients airway into your line of sight and avoiding putting your face in the splash zone. Put the laryngoscope in the patient’s mouth. You will not be able to see much at this point but that is okay, keep the faith and it will all work out.
Many people say to follow the tongue down but this advice needs to be clarified; trying to glide the blade down the tongue often results in shoving the tongue down and into your way. Instead of sliding down the tongue think about "hopping" the blade down the tongue in small increments. Lift the tongue and advance just a little bit and then repeat as needed—lift and advance, lift and advance, tiny little hops down the tongue until you see something else you can identify.
The epiglottis should start to come into view at some point. Nextyou need to displace the jaw up and forward a little bit. Just a little bit. Depending on your laryngoscope blade choice now is the time to either sweep and lift the epiglottis or put upward pressure on the hyoepiglottic ligament causing the epiglottis to rise out of your way and giving you a view of the glottis. Remember, you don't want a view of their carina, you just want a so-so view of the glottic opening. If you go for the view that lets you see their alveoli, you'll have a great view, but you will struggle to get the tube to go where you want it to go.
A patient that is easy to intubate may not require much power to lift the jaw and tissues to get a view of the glottic opening but a patient with an extremely anterior airway and stiff jaw may require you to generate some significant power to displace the tissues to get a view or to pass the tube. If you need more power drive your left elbow rest into your iliac crest and step or rock forward using your entire body to move the patient’s tissues. You should not feel your shoulder burning at this point, (figure 5 below). This is the beauty of using your whole body here.
There should be several inches of space between your forearm and the patients face if you do this right, your left arm should come diagonally across the patients face, if you are in the wrong position your arm will be parallel to the patient’s face, (see figure 6 below). A good test to see if you are using your whole body is to see if you can maintain this visualization for sixty seconds without burning out your shoulder.
Use your whole body.
When you use your whole body to intubate you have numerous options in how you can move the laryngoscope to adjust your view; you can move your wrist in all four planes, raise or lower your forearm, pronate or supinate the radius and ulna, internally or externally rotate your arm at the shoulder, abduct or adduct the arm, and use your lower body to drive your torso forward or backward and up and down. When you try to intubate like you are Salt Bae sprinkling some salt, you can use your shoulder and some muscles in your wrist and not much else. Using your whole body to intubate gives you options, doing the Salt Bae face-smash gives you no options and other than you can skip shoulder day for one arm.
What about if they are on the floor?
Many of the same principles apply when intubating a patient on the ground. If at all possible, elevate the patient's head with whatever you can find. Our video laryngoscope Pelican case is about the right size to put under a patient's head to ramp them up a bit. When intubating on the ground EMS providers often go with either the head-in-the-lap move (yuck) or the cover-me-I'm-under-fire-prone maneuver. Neither of the aforementioned techniques let you use your whole body. The head in the lap relies on shoulder strength and the prone intubation puts you in the Salt-Bae face-smashing position. Unless then you are actually under fire and then there is some merit to keeping a lower profile, then again I have never been under fire but I tend to think there are no ET tubes in a gunfight.
To use your whole body to intubate a patient on the ground there are two options. Option one is for you to get on both knees and be at around a 45-degree angle to the patient, option two is a to get in a lunge like position with one knee on the ground at a 45-degree angle to the patient.
What about if they are trapped in a car / strapped to a table upside down in the dark and it is raining / they're trapped under a collapsed building and I have to crawl in there and I can't use my whole body to intubate?
Just use a friggin i-gel. Seriously.