Anyone who regularly watches medical dramas on television has seen paramedics or doctors intubate an accident victim or surgery patient.
The actors make placing the long plastic breathing tube down the patient’s throat and into their lungs seem routine.
But in real life, the process takes great finesse and is done under time pressure: Every minute that passes increases the possibility of brain damage or even death.
That’s why students at Western University of Health Science COMP-Northwest, the medical school in Lebanon, are learning to use a video laryngoscope to intubate patients with a surprisingly high first-attempt success rate.
“What we are doing is exposing our first- and second-year students to the latest tool, which is a video laryngoscope,” Dr. Brion Benninger said. “There is a light and video screen on the laryngoscope which allows medical providers the ability to see where they are placing the endotracheal tube. Ideally, it should be placed just above the two lungs, so that both get oxygen.”
Benninger, professor of anatomy and executive director of the WesternU COMP-Northwest Medical Anatomy Center, said tests indicate the use of the video system greatly improves the success rate of intubation on the first try.
“And when it comes to intubation, time is absolutely of the essence,” he said. “It’s important at an accident, but it’s extremely important in the operating room, because once the patient has been anesthetized, he can no longer breathe on his own.”
There are numerous reasons patients need intubation — from being in an accident to undergoing surgery — but others may have chronic emphysema or are suffering an asthma attack.
Benninger said numerous factors go into whether intubation is accomplished efficiently.
Sometimes, the medical staff, while trying to create an ideal path for a successful airway, will pull back on the laryngoscope, damaging the patient’s teeth or throat region.
“We’re all built differently,” Benninger said. “The skill of the procedure may be more difficult for someone who has a short, thick neck, compared to someone with a long, thin neck.”
Benninger said that for decades the intubation procedure has worked basically the same way. The medical provider places the person’s head and neck in a specific position, then uses a curved or straight metal or plastic blade laryngoscope to view the airway path by moving the person’s tongue out of the way then skillfully moving the blade forward and upward simultaneously, creating a clearer view of the airway.
A long plastic endotracheal tube then is placed down through the patient’s mouth and throat, with the goal of getting air to the lungs.
But, Benninger said, it’s possible to miss the lungs and enter the esophagus, thereby pumping air into the patient’s stomach. That doesn't pass along oxygen to the brain, heart and body.
“This is not for the faint of heart,” he said. “If you miss the first time, you really need to make it on the second try and the clock is ticking.”
Benninger said the video laryngoscope especially helps new medical staff who haven’t had a lot of intubation experience.
He said the video laryngoscopes cost from $1,500 to $4,000 compared to direct laryngoscopes, which only cost a few hundred dollars.
But the video system could boost success rates for the procedure: Although final figures aren’t available, Benninger said a current study in the field with 90 patients is showing an 88 percent success rate for first-try intubations using the video laryngoscopy system.
And, Benninger said, when the same medical providers use a stylette or bougie — a smaller guidance tube inserted into the intubation tube — the success rate in the study is 100 percent.
Benninger has designed an innovative learning environment to acquire the skills of the procedure by integrating interactive anatomy using Sectra Medical System technology that includes a 50-inch screen, high-fidelity simulation models from 7 Sigma; virtual reality hololens ultrasound and live ultrasound Sonvate fingerprobes, which Benninger helped create.
In addition to the high-fidelity simulation models, the students also work with specially prepared donor cadavers at the college's Medical Anatomy Center.
Benninger said his students are using video laryngoscope equipment from six different companies, so they are proficient when they start their third- and fourth-year rotations throughout Oregon and the nation.
“We want all of our students to know how to use this equipment on day one of their rotations, and any other health care providers trained in the mid-Willamette Valley,” Benninger said. “They will be able to say they received innovative training techniques with the latest technology to provide the best health care possible for our Oregon communities and the nation.”
On April 4, Benninger provided a continuing medical education course integrating his teaching techniques on how to use video laryngoscopes and ultrasound for physicians, paramedics and nurses which required cooperation between the Medical Anatomy Center at COMP-Northwest, Samaritan Health Services and the Linn-Benton Community College Occupational Health Center.
Benninger has invented his own video airway system which he hopes will bring interest to the university and improve health care globally.
Jon Mang, deputy fire marshal with the Albany Fire Department, has worked with Benninger for the last two years and said video laryngoscopic equipment will soon be on local ambulances.
“This is great technology,” Mang said. “The students and our staff are getting vital hands-on experiences using the high-fidelity simulation mannequins by 7 Sigma and the donor cadavers from the Medical Anatomy Center.”
He said paramedics are required to make at least 25 successful intubations before passing their state tests.
On an afternoon last week, more than 20 COMP-Northwest students spent their lunch hour learning and practicing with the equipment, including working with a specially prepared male donor cadaver.
“We are also teaching them how to use ultrasound finger probes to check on the tube placement for safety and accuracy,” Benninger said.
He said it is likely they are the only medical students in any country working with both the video laryngoscopes and finger probe ultrasound technology at the same time.
Ciaran Smythe, 23, is a first-year medical student from Happy Valley, near Portland.
Smythe said he tried intubation without the video screen a year ago when he was a researcher with Dr. Benninger and was not successful on a difficult airway.
But with the video, he quickly succeeded.
“I think this is important because when I do my residency, it will include a rotation through many areas, from the emergency room to surgery,” Smythe said. “This is something I need to know, even though my long-term goal is to go into orthopedics.”
University of Portland graduate Matthew LaPlante, 25, from Spokane, said the intubation process “requires a lot of dexterity” and called the opportunity to use the video equipment a good learning experience since he hopes to practice emergency medicine.
Benninger said he was grateful to Dean Dr. Paula Crone and WesternU for allowing him to experiment, design and deliver innovative teaching methods using today’s and tomorrow’s technology for all healthcare providers.
He believes video laryngoscopy will be the gold standard and required procedure to acquire an airway for all healthcare providers and is reaching out to provide such skills to underserved areas globally using Hodei telepresence technology to teach from Lebanon.