Dim Bulb

What do you do when your laryngyoscope bulb is either not lit or too dim to see anything?

I know you are supposed to check your scope every morning. I do. My preceptee does when I am precepting a new medic. Maybe I should check it too. You snap the blade in and it comes on. But is it really bright or is it just lit?

I’ve had dim bulbs before, but with a little tightening they have lit up fine. I’ve also had no bulbs before and often wondered where the bulb went. Did the night crew intubate someone and lose the bulb down that person’s gullet?

So anyway, we’re doing a code and my preceptee says he can’t see anything. I tell him to reposition. No, no, he says, he can’t see, it’s too dim.

I tell him to tighten the bulb. He does. The light is still weak. I finally go in and it is dim. I can see the epiglottis, but underneath is just darkness. My other partner hands me his penlight, and pen light in mouth (yuk) I am able to see the chords and get the tube.

But say you don’t have a pen light or your partner’s pen light is just too yucky, what do you do?

Well, first off, when you check your equipment in the morning, make certain the bulb is not just lit, but bright. (Maybe you should if you use the same gear all the time, make it a habit to replace the batteries on a regular schedule. When we opened up the scope, the batteries were starting to corrode). Carry a second handle. We do have a second handle in our pedi kit, which I would have remembered, I think.

You can also do a blind intubation either digital, bougie, or a blind capnography intubation.

To do a blind capnography intubation, attach the capnography filter to the end of the ET tube, insert the stylet – it will fit as long as it is the thin kind — hook up the capnography to the machine, turn it on, and then go in for the tube. Once you think you are in, glance at the monitor. You either have a wave form or you don’t. You’re either in or you are out. In a breathing patient, make certain you have at least four good wave forms, and then pull the stylet and proceed with your routine checks.

For apneic patients with a pulse, you just have to have your partner ready to attach the ambu bag when you ask. No more looking around for the capnography filter — it is already in place. Keep in mind as always for pulseless patients you will need a little CPR to get your wave form reading.

The following are typical ETCO2 strips on intubation. The tiny bumps are CPR, each compression creates a small tidal volume that releases CO2, ventilating the body by compression only. The large wave is from the first ambu-bag ventilation on the just placed ET tube.

Make certain you have an extra capnography filter available as backup because if by chance you miss your tube and gastric contents come up, they will contaminate your filter in addition to your tube.

But most of all check your equipment. When we did put new batteries in the scope, the difference between the light with the new batteries and the light from our backup scope was immense, even though the backup scope was acceptable.

For more on capnography, check out Capnography for Paramedics.

10 Comments

  • DavisEmt says:

    This is going to sound stupid:But I don’t really have anyone I trust to ask.How do you know when you are a competent medic, because I know every call isn’t going to run perfect, but I’ve been a medic a year (only 3 months for a busy service) and it just feels like the mistakes are never ending. I haven’t hurt anyone, but I definitely don’t feel I’ve helped anyone either.Is there a way to know when you’re just not cut out for this job, I just don’t want to hang on in denial until I actually do cause damage.Any input would be great, as I respect your medicine and ethics, and well today was a bad day…..

  • dhep1980 says:

    any experience with lighted stylets? a.k.a., “light wand” ?If you’ve used them, what’s your experience been? If not, what’s your opinion in general?

  • Rogue Medic says:

    PC,Using the flashlight outside of the neck, pointing at the neck (either touching the neck or just a bit away from the neck), can be helpful also. Not just when you are having problems with a bulb or batteries, but when there is vomit, or other stuff, in the airway that cannot be kept clear. It gives a reddish appearance to everything, but can improve your view, especially if the light is right over the trachea.

  • Rogue Medic says:

    DavisEmt,Keep working at improving. Keep asking yourself what you could do better on every call. Keep asking others for advice, especially the doctors and nurses at the hospital when you bring in patients. Bug people, but learn. Think about ways you can apply what you have learned.Review calls in your head. How could you have done things differently? Would it have made a significant difference?Get a set of questions that you ask everyone, so you have both a starting point for questions and something to return to so you can cover the important stuff.I ask everyone about chest discomfort, difficulty breathing, weakness, dizziness, nausea, vomiting, diarrhea, fever, head ache, visual disturbances, changes in things – medications, appetite, urination, BMs, . . . . Anything answered with a positive, even if only tangentially related, gets investigated – when did this begin, PQRST, SOAP, whatever works for you. Once you have a set of questions, and you feel that it is in an order that helps you to remember, but also helps you get to the important stuff first, just keep using it, modify it as needed for your style, keep returning to where you left off asking questions once you follow one line of questioning. You may still be asking questions when you arrive at the ED – that’s OK. Stick around and listen to the questions the nurse asks, the doctor, too.

  • RevMedic says:

    Peter – I recently ran a code and remembered your hint about having the EtCO2 pre-attached to the ETT. While I was able to clearly see the cords, I had immediate feedback – with the very first ventilation – that I was in. Great tip and thanks!

  • brendan says:

    ….Or change blades. The problem isn’t necessarily the handle.

  • Medix311 says:

    Great ideas. I’ve seen mini-mags held in a medic’s mouth. I’ve seen firemen holding big box lights over a medic’s shoulder. But I really like your capnography ideas. I’m gonna put them to use.

  • Medic13 says:

    I dropped my handle one time on a code, of course the bulb broke…except we have the fiberoptic blades and thus the bulb is in the handle. We don’t carry a second, or pedi handle, so that was a true PITA. I got PD to stand over me with thier Mag and I’ve never had a more clear view, lol.

  • Rogue Medic says:

    Redundancy is important in dealing with emergencies. If the bulb is dim, there should be another blade with a better bulb. Different style blade or different size blade. How many patients have ever needed a 4 Miller? No, veterinary patients do not count. All that matters, with a longer blade, is the amount of blade you put into the patient’s mouth, as long as the blade fits in the mouth. Someone who puts the blade all the way in, then pulls back, should not be allowed to touch patients.A second handle is important, even if you have non-fiberoptic equipment. During an intubation is not the time to change batteries. Maybe something in the kit was touching the contact the contacts and draining the batteries, maybe the handle is not screwed together tightly, maybe a bunch of things, but not having backup airway equipment is dangerous.

  • PC says:

    Thanks for all the comments.Roguemedic, as always, great contributions to the discussion. I will have to try that flashlight trick on my next intunation whetehr I need it or not, just to see what it looks like.dhep1980– I tried a lighted styley on a manequin. Interesting, but I have no experience using it on a person.davisemt- rogue medic has some good thoughts for you. I will try to answer your question in a blog post later this week.brendan — you are right — most of the time, the problem is with the bulb within the blade as opposed to being a handle batteries issue.Thanks again for commenting.PC

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