Gum Elastic Bougie or ETT Introducer in EMS

I have had a few questions lately about the "gum elastic bougie". I’m very pleased that this simple yet highly effective adjunct for difficult intubation is finally gaining popularity. The earliest versions of this thin endotracheal tube "guide" were made of gum elastic (latex) coated wire. It was basically a malleable "stick", a little more than double the length of an ET tube. Only one version still contains any latex gum anymore, since most are now latex-free plastic. But first, what is a Bougie?

The definition of Bougie: “A thin cylinder of rubber, plastic, metal or another material that a physician inserts into or though a body passageway, such as the esophagus, to diagnose or treat a condition. A bougie may be used to widen a passageway, guide another instrument into a passageway, or dislodge an object.” One of the most common uses of the term in medicine refers to a weighted esophageal dilator.

Introducer is probably a more accurate description. You put the narrow bougie (introducer) in first when confronted with a difficult intubation, and then send the ET tube down over the long stylet. An even better technique is to pre-load the introducer in the ET tube, holding them together in your right hand. That way you are not fumbling when trying to hold the introducer while feeding the tube down over the top.

Another name this type device can go by is ET Tube Changer. RT’s have been using these for years to permit changing an old tube, or one with a bad cuff for a new one, without needing to perform laryngoscopy. You just slide down the "changer", and pull out the old tube while leaving the changer in position. Then you slide the new one on to the previously noted depth. But the length and diameter of these tube changers and introducer’s and bougies are all nearly the same. So by whatever name, for our practical purposes in EMS they remain the same.

The first time I saw one about ten years ago, it was in the back pocket of an anesthesiologist at Shock Trauma in Baltimore. When I asked what it was he explained it and shared that he had not performed a surgical airway since starting to use it. That really got my attention, and after trying it once I was hooked.

The nice thing about this device is the ease of learning & skill retention. The problem with many alternate airway techniques is that they are very different from your normal intubation technique.With a bougie, you are still using the same basic technique as normal. Scope in left hand, tube in right, passed under direct visualization. That makes it easier to learn and retain the skill, even when used infrequently.There are several different bougies available.

My favorites are the #JEM370 from Instrumentation Industries, and the SunMed #9-0212-70. Either is stiff enough to enhance control. One of the two available SunMed models has a “bent” or coude tip, which allows you to feel the movement of the stylet tip against the tracheal rings during insertion. This is the least expensive alternate or backup airway adjunct on the market. It can help you secure a definitive airway under the toughest field conditions. These devices are less than 10 bucks each. Bang for the buck wise, this is a great value for what it can do in a pinch.

Update at http://phillydan.spaces.live.com/blog/cns!B2AD15EED4F62B2B!1390.entry

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About Dan White

I'm a retired Paramedic and EMS Instructor with 35 years EMS and emergency medical product experience. I love canoes, cars and EMS. I write about EMS Technology on the Paramedic Blog, the Insights on Innovation column for EMS1.com, on AmbulanceWorld.com and Multibriefs.com. I work for Intersurgical, Inc. managing EMS sales and distribution. I can be reached directly at 573-240-0002. Follow me @Paradan on Twitter
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15 Responses to Gum Elastic Bougie or ETT Introducer in EMS

  1. Nae says:

    Hi Dan ~

    Nice reading up on these. I have practiced with the combitube … which I am sure is quite different on an actual person. What does it feel like on a real person? I\’ve also practiced ventilating. I found it to be very hard until the engineer (EMT III) had me initially control the blade with my right hand, and after I got it in position, switch it to my left hand and insert the tube.

    I still haven\’t figured out how you guys pay attention to vitals, ask questions, listen to EVERYONE, assess, and take care of everything at once. I\’ve been told that I, "Do everything I am told reasonably." I\’m not quite sure what "reasonably" is, nor have I been told how I can improve and do better. Sigh. Perhaps that is one of the negatives of being in a small town and only being a volunteer.

    Thank you for continuing to cover all of this information in such an easy way to understand.

    God bless you and keep you,

    Nae :o)

  2. Eric says:

    Dan – I really like the fact that these have come down in price.  On of our medics has used these before & suggested we get them.  My question (as the new Training Officer for our agency), is this:  We have CombiTubes as a backup, and the PerTrach as the ultimate backup.  Our protocols call for 2 attempts at intubation on scene before we drop in a CombiTube or other maneuver.  Will having the Bougie increase our scene times and airway attempts?  It seems to me that if we have another tool to play with, we\’ll hang out longer to use it, rather than go with the CombiTube or whatever.  I know your feelings on the CombiTube, but this is more of an overall, philosophical question.  Thanks!

    • Scott Hubbell, Flight RT says:

      My suggestion would to allow the bougie on the 1st attempt. If it is good enough for a missed airway attempt…why miss?

      • Chad says:

        Scott,
        I am a RRT/RN who works for a busy flight program who is using the Bougie on every intubation. Just wondering how your thoughts on the best way to store the Bougie. We have had some issues and are looking for help!!

      • phillydan says:

        Coil it carefully into circle with small piece of tape or two, has worked best for me. Do not fold.

  3. Dan says:

    Great Questions Eric,

    My two cents starts with answering a question with a question, what\’s the big
    rush for shorter scene times? If you do not get a patent airway and/or are
    having difficulty ventilating properly (IE: a BVM only thing available, no EMS
    ventilator), it really won\’t matter how fast you go. From your description you
    have a good airway protocol now. You can do about everything airway wise, that
    any ED can or will do that matters. You are probably as good at these skills as
    anyone else, so I ask again, what is the rush? If you don\’t turn this critical
    emergency situation around in the field right now, it will probably not matter
    how close you are or how fast you drive. 

    I once tested this hypothesis out back when I was stationed in a Medic unit
    right across the street from an ER. On a simulated arrest I took a stopwatch
    and recorded time of no CPR, and times of poor quality CPR (and ventilation),
    using an Annie & running it across the street in my ambulance as fast as I
    could. It really surprised me to learn that this short trip adds 3-4 minutes of
    down time to whatever they have when you roll up on scene. No CPR putting Annie
    on stretcher, crappy CPR moving cot to truck, no CPR loading, crap CPR driving
    across the street, no CPR unloading, poor CPR going into the ED, no CPR moving
    to bed, – getting the point? That\’s just too much time to wait. They will
    likely perish if you do not oxygenate the brain & heart BEFORE you move
    them one inch.

    BTW, I really have no problem with a Combitube other than I see it used more
    often than makes me entirely comfortable. It’s kind of like adult IO’s. I heard
    recently about a guy that got 6 in one year and my first question was – If dude
    is that bad on IV’s, why are we giving him power tools? It leaves me wondering
    why we rely so much on alternate airways. Paramedics can & should be on the
    top of the food chain when it comes to primary emergency airway techniques

    OK, now I’m down from my soapbox:>) The short
    answer is it would add no time at all, if you just used it in place of a normal
    stylet on your second intubation attempt.

  4. Eric says:

    That\’s actually the answer I was looking for!  A definition of insanity is \’doing the same thing the same way over and over again expecting different results".  There are a lot of medics out there (myself included before I learned this) who change NOTHING in multiple intubation attempts.  I teach my new folks to change something – anything, from blade to positioning, but to expect different results with the same equipment, technique, etc is insanity.  Using the bougie on the second try is a great idea.
    I generally run slightly longer scene times than other medics.  The only reason I asked that question is that my physician advisor as well as the QA/AI guidelines look at our scene times.
    And speaking of power tools – we are in the process of adding the EZ-IO to our ambulances.  We currently have Jamshidi\’s for peds & the Bone Injection Gun for adults, although nobody has used the B.I.G. because they\’re too intimidated by it.  We do end up with criticial patients w/o vascular access.  This tool will – in my opinion – make for easier, more reliable IO access.  Our protocol reads that we will use it after 2 unsuccessful IV attempts.
    And getting back to your restraints entry.  We just ended up buying the polyurethane non-keyed Humane Restraints, based on your comments. 

  5. Dan says:

    Hope you never need the restraints :>) Thanks for your intelligent comments. Stop by again.

  6. Nae says:

    Hi Dan ~
     
    Thanks for the laugh!
     
    Happy Holidays.  Stay safe!!!
     
    Nae  :o)

  7. Eric says:

    Well, uhm… I used them this morning.  60\’s year old male very out of it & slightly combative.  Septic, probable electrolyte imbalance, probable metabolic acidosis (EtCO2 of 17mmHg), and SVT.  It was all my partner & I could do to hold him down so that he would not hurt himself.  FD showed up & helped us get him restrained to a backboard.  Very sick man, and a friend of the family! Crazy call.

  8. Dan says:

    Sounds like an awful lot wrong going with the
    guy, & I hope it works out. At least he had a caregiver in charge. You
    should have been there the day I got dispatched to a shooting at my home
    address..

    Just a thought, not a criticism; I prefer to restrain on a soft surface and have
    always used the cot. You probably think backboard to make the last transition to
    ED care easier, which makes sense. I\’ve never tried it, but do you think it
    might work to throw the stretcher mattress on a backboard first? Is it worth
    the trouble? I\’ve seen a couple real head bangers before.

  9. Eric says:

    Dan, That\’s a great idea!  I\’ll remember that for next time – and I hope it\’s a ways away.  I asked our physician advisor this a.m. about adding the Bougie to our arsenal and got a tentative OK.  My boss, on the other hand, is not so excited about it, because he\’s spent almost $10,000 on new \’stuff\’ that I\’ve been working on – the EZ-IO, CPAP, ACLS books, & the restraints.  I love spending the owners\’ money!  Thanks again for your efforts.

  10. Eric says:

    Lets try this again…  Have you seen the "Intubate Mate"?  It\’s a combination biteblock, teeth protector, and oral airway.  It does not affect the tongue at all, so does not keep the hypopharynx open.  What it does do, though, is open and maintain the mouth, and has an optional LED light.  It protects the incisors from the laryngoscope blade.  I saw one in JEMS, then got onto their website http://www.theintubatemate.com.  They sent me two, and from what I\’ve seen, it\’s pretty slick.  I was wondering what you thought about all this.
    Eric

  11. Dan says:

    I
    saw it at EMS Expo I think, but then I failed to follow-up on it. I\’ll have a second look. I remember my
    intial reactions were fairly positive. If you get any field
    experience with it, will you let me know what you think?

  12. Scott Hubbell, Flight RT says:

    I also am a fan of “pre-loading”, however, I have found that can be a disadvantage if the airway needs additional suctioning. That said, I use the bougie before a stylet.

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