CORRESPONDENCE

next door to a children's hospital with open-heart capability. Think about the products of these standardized, homoge-

nized, "quality-assured" residencies. How will they recon- cile the artificial and idealized world of their training with the settings in which the vast majority of emergency physi- cians practice? How will they mesh wi th a less "high- powered" medical staff? How will they relate to the private patients of the middle class after training in the county hos- pital?

A wide range of experiences can yield a common end. In our desire for quality, let us not destroy programs, ideas, and pathways that lead to the same goal. Let us not focus pri- marily on structure and process as means to a desired out-

come when it is the outcome with which we are concerned. Don' t judge our graduates by the shallow facts and figures describing the hospitals in which they trained.

I, for one, am willing to be judged by my performance, by my Board, by my patients, and by my peers. [The views expressed herein are solely those of the author, and do not represent official policy or opinion of the Department of the Army or the Department of Defense.]

Kenneth Frumkin, PhD, MD Department of Emergency Medicine Madigan Army Medical Center Tacoma, Washington

Nasotracheal Intubation: Myth vs Reality

To the Editor: Two medical myths that frequently find their way into

print involve the common lifesaving technique of blind nasotracheal intubation. I would like to put them to rest.

The first, and certainly the most dangerous, is the belief that nasotracheal intubation should not be performed in the presence of a head injury, especially if there is a question of a basilar skull fracture. There is a widespread fear that the nasotracheal tube will pass intracranially in these patients. One can only speculate as to how many people with severe head injury have succumbed to hypoxemia or cerebral edema from hypercarbia because of failure to utilize this relatively simple technique for intubation. While it is true that nasogastric tubes have, not infrequently, been placed intracranially in this situation, a diligent search of the liter- ature reveals only one case of intracranial intubation by the nasotracheal route with the nasotracheal tube. 1 This case, in reality, only demonstrates that the operator did not un- derstand that the technique of blind nasotracheal intuba- tion involves listening for expired air to pass through the tube. 2 Rather, it is quite obvious that in that case, as well as in cases of other inexperienced operators, the "shove it down the nose until you hit air" method was employed. Now that a model to teach the blind nasotracheal intuba- tion technique in a nonemergency setting is available, there is no reason for those who need to use this procedure not to be fully acquainted with the proper method. 3

The second myth (and the simpler to dispel) is that of using lidocaine cream to coat the nasotracheal tube prior to placement. Again, while this is recommended frequently, it is clearly inappropriate. Lidocaine cream neither adequately lubricates the tube for its passage through the nose (often causing increased trauma) nor has an anesthetizing effect during its brief contact with the mucosa. It has been shown clearly that lidocaine cream will abrade the mucosa, es- pecially of the vocal cords, during passage of the tube. 4 A suitable and readily available substitute is water-soluble lu- bricating jelly, which both lubricates and causes much less damage.

Kenneth V Iserson, MD Section of Emergency Medicine Arizona Health Sciences Center Tucson, Arizona 1. Horellou M E Mathe D, Feiss P: A hazard of nasotracheal intu- bation, letter. Anaesthesia 1978;33:73-74. 2. Iserson KV: Blind nasotracheal intubation. Ann Emerg Med 1981;10:468-471. 3. Iserson KV: Blind nasotracheal intubation: A model for in- struction. Ann Emerg Med 1984;13:601-602. 4. Loeser EA, Stanley TH, Jordan W, et al: Postoperative sore throat: Influence of tracheal tube lubrication versus cuff design. Can Anesth Soc I 1980;27:156-158. '

162/379 Annals of Emergency Medicine 14:4 April 1985