the worst intubation

I'm shocked by this intubation I saw at clinical earlier. They didn't give the patient succinylcholine or propofol or anything before they tried to intubate him, and he was fighting. The intern and then the resident tried and failed five times to get a tube in him and they bloodied up his trachea before someone got a tube in. They didn't use aseptic technique. My professor said it was the worst intubation she's seen. I'm just feeling upset that they didn't sedate him and he was struggling, they waited until they finally got the tube in and then gave him 0.5 of Ativan. I can't say what hospital it is, but I hope to God I never get taken there. Have you seen anything like this?
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.

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?

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.

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.

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

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. Quote from emt2lpn2I'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.

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.

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.

Quote from veggiestunycThanks 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.

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.

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.

Sounds terrible, but like other posters have said that intubation is not aseptic. Also if the clinicians had any concern that the patient was going to be difficult to intubation from obesity, short neck, physical assessment such as thyromental distance, throat cancer or anything else that may distort the throat they may have been hesitant to given paralytics or heavy sedation. If they paralyzed and sedated or just heavily sedated a patient and could not get the tube or ventilate them adequately by BVM, you end up with a dead patient! Intubation is not always easy!Instead of judging the clinicians, next time ask them questions once it is appropriate, and learn! HPRN