I often struggle with… things. Most things in fact. In particular, thinking places no small degree of strain upon my dangerously limited capacities. In spite of this I have been thinking lately. Thinking about bougies. You know, those long, usually blue things us paramedics and EM types have a fetish for. I’d like some help with my thinking about bougies so some feedback would be superb.
There seems to me to be a definite movement in the world of EM towards using the bougie as a first line tool in all intubations lately (check out this excellent video for an example) The rationale is that you want to have the best chance at getting the tube in one go, and the bougie affords you that shot. I appreciate that rationale.
But… My thinking has always been a little different. In my mind the bougie is the first tool in my rescue plan, the first step down the pathway of the failed intubation drill. I thought: what happens if I attempt intubation with the bougie and fail? Where do I go then? Of course I have a little play around with some external laryngeal manipulation, adjust my approach and so on. But I’ve just failed with one tool, why should I expect to succeed trying again with the same tool? If I had gone in straight with my tube (stylet in, straight to the cuff, my weapon of choice) and can’t pass the ETT, I then have a technique, a tool that changes things dramatically.
I do like the bougie and in fact used it just the other day in patient I thought was going to be a difficult tube: head injured, about to be RSI’d but short, fat, big shoulders, small jaw, and as it turns out, small mouth opening (the trismus made it hard to pick initially…) Sure enough, grade 3 view, bougies away, success! But most patients aren’t that tough. Most are grade 1 or 2. I still have the bougie loaded up ready to go in case I strike a tough airway that I didn’t predict, but it’s not my first tool. I also appreciate that I need to have a degree of experience with the bougie so it is not an unfamiliar device when I really need it. But every time? Really? Come on now!
So… is my thinking wrong? Am I just stuck in a mindset that was implanted in my head back in the day, a slave to my conditioning? Am I behind the times, should I drag myself out of the dark ages into the modern world of bougieland? Or does my thinking have merit? Are there some situations where going straight in with the bougie is not warranted or necessary?
Please, leave some feedback and let me know what you think. Rest assured I am not just looking for validation of my thoughts, I genuinely am struggling with this issue. I want to be the best I can be at airway management and I am concerned that I may be holding myself back. So fire away, be candid, let me know your viewpoints or how you practice.