Make no mistake…as a paramedic you are expected to display and possess the attributes of leadership. First of all, practice approaching the patient with confidence, yet maintaining absolute compassion and humility. Acting with confidence is not the same as being ‘cocky’ and ignoring the input of your team.
You are a leader and therefore the patient and the members of your team will be looking to you for guidance and inspiration. Apply your team by engaging them. Make eye contact with the patient and assure him/her that they are in good hands. Try not to use frustrating statements like ‘sir would you please just relax’. Instead, ask him/her to count their breaths, or assign someone to engage the patient in conversation and hold his/her hand if possible. If you are sedating them, ask them about details of their hometown, or what they would cook for dinner. Smell is the sense most associated with emotion with neural proximity to the hippocampus and limbic system. So, if this is engaged, anxiety can be reduced. They will continue to benefit from your expert verbal interventions because hearing is the last neural pathway to be lost with anesthetic induction.
Your colleagues will also appreciate your compassion and humility. Engaging your colleagues and delegating responsibility will be more predictive of success. Outline as much as possible your expectations. We are all familiar with training environments in which we were not engaged in the process. These not only are less predictive of success, but also provide less opportunity to learn and improve. Ask an EMT or first responder to care for a patient's anxious family member. Ask for assistance with ventilations, supplies or communications. Ask if they can feel the tube passing through the tracheal rings or assist in confirmation. In other words, do not be an obstacle to their advancement and education. As your team improves, they will likely save your behind—if necessary.
Approach with the expectation for success, but prepare for failure. It is not only acceptable, but admirable, to pass on the intubation and simply provide adequate bag-valve mask ventilations enroute, rather than wasting precious time with unsuccessful intubation attempts and causing airway trauma and laryngospasm. Some may degrade you for this, but an experienced emergency department (ED) physician will appreciate your decision.
In addition, it is universally accepted that direct visualization of the tube passing through the chords is the best standard of successful intubation. All of us regularly face patients in which the cords are not visualized. A trained ED physician will understand your decision not to waste an extra 1–3 minutes confirming your guess-placement as the oxygen saturation decreases below 90, but instead to continue easy ventilations using an airway adjunct. After all, the process of ‘confirmation’ is intended to be exactly that…confirming what you already know to be true. It is not intended to be a diagnostic first-line test for a ‘push and pray’.
There are limitations with colorimetric capnometry especially in a cardio-pulmonary arrest. It may likewise take 3-6 ventilations to recognize unsatisfactory waveforms in capnography. Read about these limitations and their physiologic basis. There is no confirmatory test as quick and accurate as direct visualization of tube passage through the cords.
If it is not going easy, rather than furthering your failure, ask one of your colleagues that hopefully you have trained with, to take a try. It has been said that the definition of insanity is doing the same thing without changing, and expecting a better result. It really is a finesse manoeuvre of proper positioning and arm extension. If you have not positioned for success, success will be less likely. A second attempt with this same incorrect position will not help you. Someone else may have an improved approach, or may note a subtle anatomical landmark that you have failed to notice. This is surely a better option than causing soft tissue bleeding or torqueing on the teeth by far. These failures are even more likely to occur on the second direct laryngoscopy attempt as your arm fatigues. Again, this is not your personal failure.
As an ED resident physician, my job is to confirm paramedic airways. It is obvious when a traumatic tube placement was made. That medic usually claims it as a success and it certainly is a success if the patient's life was at risk, but considering the other better options that might have been available, a traumatized larynx and broken teeth may not seem worth celebrating. When I hear the words, ‘I never miss’, what I hear is ‘I'm too unconfident to ask for help and too untrained to consider alternatives’. Spend a few days training with anaesthesia in an operating room is my recommendation. They will thoroughly assess your technique from an expert perspective. You will be humbled and improve.
Tennis legend and humanitarian, Arthur Ashe, said, ‘One important key to success is self-confidence. An important key to self-confidence is preparation’. Do all of these.