The Unfallen Sky.

There is probably no greater self-proclamation of professional prowess among paramedics than the mastery of airway management—specifically endotracheal intubation. One of the greatest compliments you could pay a medic is to say he could “tube anyone” and mean it. By the same token, nothing will tear at the fabric of his confidence faster than failing to intubate, even once. Even outside their own ranks; everyone has an opinion of EMS and their ability or failure to pass a tube. Whether it’s the wide-eyed EMT student who latches onto intubation as a lifelong dream, or the grouchy ER nurse who swears that all the paramedics want to do is to intubate people…even though they aren’t any good at it. What escapes almost everyone, including paramedics themselves, is the irrefutable link between this relatively simple skill and the confidence it takes to perform it.

Despite what the grizzled EMS veterans will say, intubation is a fairly easy procedure that, if anything, we have complicated by insisting that we can do it anywhere and trying to prove it. The fact is that a mediocre instructor could teach an eight year-old how to intubate and most of the other paramedic skills in a weekend (A student recently told me “that would be one cool eight year-old”). What makes intubation so prized and contested is the guaranteed acuity of the situation that necessitates it. In the EMS realm, if someone needs a tube, it is because they die without it. Enter the confidence factor.

Because EMS is such an egocentric profession, confidence among the practitioners is usually a given. But, the confidence inherent to the practice of intubation is necessary, because without it the battle is lost before it begins. It is important that you believe you can intubate every single patient that needs it in order to be successful. You won’t get them all, but you must believe you will or you won’t get any.

I remembered this nearly too late this week. During orientation at my new job, I rotated through the operating room to grease the rusty gears of my own intubation skills. From the start I was paired with an incredible nurse anesthetist who gave me all the room I needed to stand after a very long time of sitting by the sidelines. The first patient we saw was a big guy…no neck and a huge tongue. At this point, I hadn’t told anyone that this would be my first tube in a long, long time. Somehow, as I was putting the laryngoscope together didn’t seem like the right time. Drugs were pushed, the patient slept and I went to work.

Money.

Within seconds, I saw the cords, passed the tube and found my long-forgotten swagger. I hung around for a few minutes before excusing myself to search for the next victory in a day that was now certain to be full of them. However, crossing the threshold of the room left me with the uneasy feeling that things were going too well, too soon.

My next patient was with the same anesthetist, and it looked like a cake walk. During the pre-anesthesia screening, we decided together that this patient, a jolly man in his 60’s had an easy airway. Short teeth, big mouth and a solid chin—no problem. Same as before, everything went smoothly until I put the scope in his mouth and saw…nothing.
Well, nothing but tongue and epiglottis. The biggest epiglottis in history. Seriously…somebody call Guinness. I looked some more, being mindful of teeth that were short and stubby in the holding room but had somehow grown in the sterile air of the OR to the size of grave markers. The patient’s oxygen saturation began to fall, taking with it my confidence, and the anesthetist asked “Want me to have a look”? Please.

I took a little pleasure in seeing him struggle for about 4 seconds before placing the tube, but the damage was done. I stuck around for the duration of the surgery, partially to watch the procedure but mostly to give my wounded ego time to heal.

As we walked from the recovery room back to the OR, I admitted to the anesthetist that my confidence had been shaken. He casually remarked “You won’t get them all” and lead me to our next patient which he handed over to me without a second thought.

Allen Neuharth, the founder of USA Today, once wrote “I quit being afraid when my first venture failed and the sky didn't fall down. “ I was reminded of those words throughout the rest of my day in the OR, which was perfect both in intubations and experience. I left feeling on top of the world, not only because I had done well, but because I recognized the value of doing badly. And between “well” and “badly” is confidence, because without the confidence in success, there can be nothing learned from failure.

Too often, people mistake confidence for arrogance. And, while there is an abundance of the latter in modern EMS, most of the accused are guilty only of believing that they are the best hope for the survival of every patient they treat. The difference between confidence and arrogance is the humility of knowing your own fallibility. None of us can save them all, but it’s the guts to try that sets the best apart from those happy with being good enough.

Anyone who is good at what they do gets that way by believing they can be great, and accepting that they must be human.

Three shining examples of confidence and conviction made news this week with their passing.

Jesse Helms, ever a stalwart of conservative values in the 20th Century died on the 4th of July. Like him or not, you could always count on Jesse to tell it like it was, or at least like it was in his mind. The only upside to Helms’s death is that, should the liberal Barack Obama win the White House, we will be able to power Raleigh, NC from the static electricity generated by Jesse spinning in his grave.

Also from the right side of the aisle passed this week Tony Snow, conservative commentator and former spokesperson for the Bush administration. Once again, whether or not you agreed with him or not, Snow’s candor won over people from both sides of the fence. Ed Henry, the very reporter from CNN told by Snow at a press conference to “zip it”, wrote that he believed “life is too short to get yourself all worked up about one tense exchange, one awkward moment or one misstep.” We should all be so wise.

Finally, Dr. Michael Debakey, THE pioneer of cardiac surgery died at the age of 99. Ironically, he owed the last few years of his life to a life-saving aortic surgery that he himself developed several decades ago. Early in his career (he graduated from medical school in 1932) he commented that “If a patient came in with a heart attack, it was up to God.” Dr. Debakey was never satisfied with that, and spent his career of more than six decades giving the Almighty the best help he could. He performed over 60,000 surgeries, developed hundreds of medical devices and listed celebrities and heads of state among his patient list, though never giving special treatment. “Once you incise the skin”, he said, “you find they are all very similar.” Without question, no one will say that about you, Doc.

No big news to report this week about mother and babies. All is well. We have appointments in the next couple of weeks, so I hope to post new pictures soon.

Do good things with the week to come, learn something new and be safe.