To teach intubation skills on living patients, even those that have practiced on a manikin, can be challenging. With fall comes the new crop of trainees eager to learn how to intubate. There will also be a new group of instructors teaching their first students to intubate. It’s important to anticipate the common errors so we can safeguard our patients. Here I describe the all of the barriers, physical as well as psychological, that interfere with your student’s learning of the intubation technique. I offer tips on how to help your student conquer those barriers, while keeping your patient safe.

The Dummy vs. the Real Thing

I’m assuming that your student has mastered intubating the manikin before moving on to a patient. However, intubating the dummy differs from intubating a typical patient.

The dummy’s plastic face is very stiff and noncompliant. The mouth already lies fully open and is difficult to open further. In contrast, you must open the patient’s mouth, and do so without blocking your laryngoscope. Being soft and very compliant, the human cheek will hang limply, obstructing the view.

The dummy’s head is so light that it takes little effort to lift the entire mannequin off the table. Often instructors have to hold the mannequin on the table to help the trainee out. In contrast, the average adult head weighs about 5 kg. The added weight makes balancing the head on the blade and lifting the head into the proper alignment technically more difficult. Holding the head in proper position, especially through a long and difficult intubation, is very tiring.

You can often see the dummy’s larynx even without the laryngoscope lit because the pale plastic reflects light so well. In contrast, the mucous membranes in the human patient are darker. The larynx, deep in the hole, lies in shadow. Placing the laryngoscope light correctly and then interpreting the view is easier if you know what the real larynx looks like.

The dummy’s tongue is fairly firm, difficult to shift from side to side and will remain out of the way of your blade. Your patient’s tongue will be a soft, slippery mound of flesh. It will invariably block your view if you fail to control it.

It’s helpful to tell your student how the dummy differs from the patient before they start so they will know what to expect and can more easily adapt technique.

Students Are Scared

Your student may or may not admit it to you, but they are terrified that they’re going to hurt the patient. This fear is sometimes paralyzing and will make your student slow and task oriented. To start, they will either be concentrating on the intubation, or aware of the monitors and drugs being given — but typically cannot do both at the same time. I allow my students to concentrate on the intubation and take care of the other tasks myself until they become more facile.

It’s normal for first intubations to be frightening. But you know that if the student approaches the patient with gentle, purposeful movements, and ventilates the patient between attempts, the likelihood of hurting the patient is low. Panic hurts patients, apprehension does not. Teach your student to use apprehension as a tool to heighten awareness and promote caution. If she believes she can intubate, she will.

In addition, being an adult learner, your students will also be afraid to look inexperienced or inept. They are returning to a status, like a child, of depending on a more experienced person to guide them step-by-step. Not an easy thing for any adult, independent ego. You will have to be patient, encouraging, and reassuring.

This link will take you to the videos from the Intubation chapter in Anyone Can Intubate, 5th edition. They show both patient intubations and animations.

You, The Instructor Will Be Anxious

Let’s be honest. It will be hard for you, the instructor, to be patient because you really are worried that your student will hurt the patient. You will occasionally be tempted to rip that laryngoscope blade from your student’s hand. I know, every September I personally find it hard to talk students step-by-step through their first intubations.

You must think 2 steps ahead of your student and by watching them predict where and when they may need instruction. Not easy, but with experience it gets easier.

It’s important to know when you can let your student proceed, and when you should step in and take over. Some of the criteria I use to step in include:

• What’s the patient’s medical history:  frail with little reserve or young and robust?
• How long is the intubation attempt taking?
• What’s going on with the pulse, blood pressure and oxygen saturation?
• Is the student using reasonably good technique or do they need to be shown how to do things better?
• Does this appear to be a technically difficult intubation?
• Have they already tried and failed in this patient and why?

Your first duty is to safeguard your patient, but your second duty is to build technical skill and confidence in your student. If you do step in, don’t make your student feel incompetent. Once the intubation is complete, tell them what you did to succeed.

Students Must Learn How To Prepare

When preparing equipment, students commonly forget something. I teach the mneumonic SOAP for preparing the work station.

• S: suction
• O: oxygen and other gases
• A: airway equipment and ancillary equipment
• P: pharmacy

Of all the things students forget, suction is high on the list. Suction is essential to improving visualization when secretions block the airway and is life-saving if there is emesis during the intubation. Suction comes first.

Even when students verify that the suction tubing is present, they often forget to actually check the suction, and by checking I mean making sure that it really will suck when turned on. Sure, it may look like all the parts are connected, but if there is poor seal anywhere in the apparatus, your suction won’t suck. I always have my students turn it on and place the tubing against their finger to verify vacuum.

Which Side Do You Stand On To Teach Intubation?

Good question. It depends where the location where you’re intubating. Standing to the right side gives you an unobstructed view of your student’s hand and blade position with respect to the mouth. This works well in the emergency department or in the field.

However, if you’re in an operating room standing to the right places you outside the anesthesia cockpit, with the anesthesia machine between you and easy access to the patient’s head. When you’re on the right side in the OR, it’s impossible to easily step in to either look at the view over your student’s shoulder, or take over the intubation without walking (briskly) all the way around the OR table.

I always stand to my student’s left in the OR. It gives me the most flexibility.

Students Don’t Position The Head Correctly

Head and neck positioning can make an intubation easier or impossible to perform. Always do a final check of the head position before you allow your student to start. It’s much easier to correct poor positioning prior to induction than it is after the drugs have been pushed.

Here is a link to a previous article on how we often make intubation more difficult for ourselves, both by poor positioning of the patient as well as by using less than optimal technique.

Watch Those Teeth!!

The first anatomical part at risk is the teeth. Students invariably will want to rotate their wrist toward themselves.

Inexperienced intubators place their blade gently, and then barely lift the jaw out of fear of hurting the patient. Without lifting, they don’t see the larynx. Failing to see anything, they then use the blade like a lever on the front teeth to lift the epiglottis, placing the teeth in danger. Tell your student that if properly done, they can, and often should, lift the head off the bed without hurting the patient.

Lips Get Caught and Cut

While everyone is rightfully paranoid about damaging teeth, they are often less careful about protecting the lips. Upper and lower lips commonly get pinched between the blade and the teeth and will get cut unless you are take care. While the cut may be small, cut lips are painful, swell impressively, and remind your patient of your care every time they look in the mirror until it’s healed. Have your student check the lips in that last second before placing the weight of the head on the blade by lifting. Show them how to use a finger to push them free if they’re trapped.

You, and your student, should keep rechecking the lips as well as the teeth during prolonged attempts.

Students Often Insert The Blade Too Deeply

Inserting the blade too deeply and into the esophagus is a common beginner mistake. Because you are looking from the side, you will have a good idea about how deep the blade is. If your student can’t identify any landmarks, and it looks like the blade is deep, have them slowly pull the blade back while looking. Often the larynx will fall into view. Link to video clip showing larynx falling back into view with withdrawal of the blade.

Students Confuse Esophagus And Glottis

A straight blade can “tent” the esophagus and make it look like vocal cords if you haven’t actually seen both. It’s helpful for your student to suspect it’s the esophagus if there are no identifiable landmarks. Feel free to share this picture with them. It’s easy to see how a nervous novice could convince themselves that the image on the left has arytenoids.

Students Don’t Sweep Tongue Left

Leaving the blade too far to the right can provide a good view of the cords but no room to pass the tube. Sometimes you can’t even get the tube into the mouth.

Teach your student to ask for help pulling the cheek out of the way. However, if your student routinely has to ask an assistant to pull the right corner of the mouth out of the way, tell them to sweep the tongue further left.

Students Bang The ETT Against The Cords

Students get fixated to the target. The student sees the hole and, determined to pass the tube, may keep pounding the tip of the endotracheal tube against the glottic structures —hoping that it will eventually slide through the opening. Don’t let your student pummel the glottis. Encourage gentleness and precise aiming.

Students Miss The Big Picture

Students don’t know how to put all the steps together. Your student will be moving slowly, and taking each step one at a time rather than flowing from one step to the next. They will fixate on the details and miss the big picture.

It’s like teaching someone to dance. Your partner may know all the steps, but unless those steps are coordinated, the performance at best will be choppy and at worst painful as your partner stomps on your toes.

You will need to help your student integrate those steps to perform a smooth and atraumatic intubation. Explain to him or her how and why one step naturally leads to the next. Help them see the big picture.

Teach Cricoid Pressure

As the intubator, you can often predict what you need to help bring the larynx into view.To ask for good cricoid pressure you must know what makes cricoid pressure good.

To get good cricoid pressure you must be able to direct your helper on how hard to press and in which direction to push if their initial effort is not helping. If your student does not know how to apply cricoid pressure themselves, this will make the task all the more difficult.

Your Student Will Forget To Ventilate

When I was first learning to intubate, I sometimes would forget to ventilate the patient. It would happen when the attempt was prolonged. It would also happen after I had intubated and was basking in the sweet joy of success. Fixating on the intubation and forgetting the ever important ventilation, is unfortunately very common.

My teacher had me hold my breath whenever I stopped ventilating the patient for any reason. It did not take long to imprint the need to ventilate on my brain. Watch your student carefully.

You Can Always Go Back To The Manikin

Remember that you can always go back to the manikin if your student is still having trouble. Avoid making them feel inept if you go back to the manikin. Be encouraging. Tell them that it’s a way to further safely practice and hone skills that they just learned with the patient. It lets you demonstrate different tricks that you might not have time to do in a clinical situation.

To assist you I have posted the links to discussions on how to intubate as well as the differences between straight and curve blades for your students.

This link goes to a step-by-step discussion of how to intubate.

This link goes to a discussion of the difference of straight vs curved blades.

It’s much easier to do a task that you’ve mastered, than it is to teach it. This is especially true when we teach intubation on a patient. However, there are few things so satisfying as taking a new and unskilled student and making him or her a master at your own art. By teaching you are multiplying your lifesaving skills, making the world a safer and better place. By teaching with humanity and respect, you will also teach your student to eventually become a good teacher.

May The Force Be With You

Christine E Whitten MD, Author Anyone Can Intubate, 5th Edition