In the out-of-hospital environment, the ability to manage our patient’s airway is perhaps the most crucial skill we can possess, and one that is often taken for granted. Whether it is establishing an airway on the trauma scene patient, or being able to successfully manage the worst case event of an unexpectedly extubated patient, when Murphy’s Law brings the gremlins to our transport world to wreak havoc on our day, we have to have the skills ready to respond immediately.

Prepare for the worst  
As skilled providers and masters of our craft, we owe it to our patients and their families to be prepared for the unexpected – from the time we make contact until the moment we drop them off to our destination facility, and during that time, we should hold the mentality that failure is not an option. I have been fortunate to have worked with many great mentors throughout my career, one of which, my first medical director, referred to flight paramedics as holding the expectation of being the ‘airway masters’. His true belief was that, as professionals, we brought many skills and abilities to a scene, but the most important was the expectation that we should have the ability to secure and control any airway.

With that in mind, we need to ask ourselves: are we adequately prepared, possessing both the mental preparedness and tactical skillset. Over the course of my career in EMS and air medical transport, I have witnessed the airway training that we do on the mannequins placed on the waist-high table with all the lights on in the training room – talking about the weekend plans with our cohorts while we casually pass the tube into the airway, which at this point is worn enough that you can do so blindly, just hoping to miss the tear on your way to the trachea.

This practice brings back memories of my paramedic school clinical time in our local hospital operating room, and one anaesthesiologist who imparted the following wisdom when asked how many successful intubations we needed in the week: “If you want my advice, do your dozen and take the week off, because the first time you have to do it, it’s going to be dark, you’re going to be on the floor in a filthy house, the dog is going to be barking, the wife is going to be screaming and he is going to be vomiting all over himself.” That comment has stuck with me over the years and can still be applied to our airway management training strategy. 

Do we train the way we fight? When was the last time we practised intubations with the mannequin in the aircraft? On the floor wedged between the bed and the wall in the dorm room, or, more appropriately, in the bathroom folded up behind the door? Do we practise with the lights off or utilising distracting sounds, movement or interruptions? 

As practitioners and medical professionals, there are several things we can do to train and prepare for success. 

Prepare yourself
Having confidence and mental presence is one of the first things I try to teach students and new crewmembers when it comes to airway management. Taking a breath, being able to relax and adaptively function during airway management is a skill developed from training and experience. Having the ability to remain calm during a failed or difficult airway can be the difference between success and failure. 

Back to basics
The key to a successful airway management strategy is to not have to intubate. Intubation and advanced airway placement is a great tool and one we need to hold proficiency in. However, a lack of BLS skill in bag mask use can potentiate the anxiety of advanced airway placement. Knowing what to do and how to do it is not nearly as important as possessing the skill of knowing when not to do it. This holds especially true when it comes to taking a patient’s airway, which should not be done lightly. I recall a conversation with one of our transport medical control physicians who was questioning our decision to sedate, paralyse and intubate when he reinforced that he would ‘hold us more accountable for the airway we take that we shouldn’t have, than not taking the one we should’. Having the ability to successfully and efficiently manage the BLS airway will allow us to escalate the management on our terms, and not the patient’s. Being proactive and not reactive to a situation will always lead to better results.

Prep time reduces intubation time
Take the time to prepare for every scenario. This means having a full complement of blades, tubes, bougie, stylet, backup airway device, and cric materials. On a potentially difficult airway, our medical director advocates locating and landmarking the cricothyroid membrane and marking it with a sharpie as a mental note to himself and the others on the team that in the event of a failed airway, that would be the course of action. Over the years, I have even adapted my preparation to include the placement of Magill forceps, following an intubation attempt that revealed the cause of arrest was an unwitnessed foreign body, which necessitated my having to withdraw and reattempt when I had the necessary equipment. 

Know your enemy
A thorough evaluation of your patient’s airway will better prepare you for success. I had the opportunity to listen to a presentation on the use of data evaluation in the air medical environment, where it was presented that a first attempt failure at intubation is followed by an average 40 to 50 per cent potential for complications on subsequent attempts at intubation.

Being proactive and not reactive to a situation will always lead to better results.

The traditional LEMON approach (Look Externally, Evaluate 3-3-2 rule, Mallampati scale, Obstruction/Obesity, Neck Mobility) has recently been replaced in many arenas with the HEAVEN criteria (Hypoxaemia, Extremes of Size, Anatomic Challenges, Vomit/Blood/Fluid, Exsanguination, Neck Mobility). Regardless of the camp you reside in, utilising one or both will increase the first-pass success that has become the gold standard of care.

The hurrier I go, the behinder I get
Coming from the ‘good old days’ of EMS, I was raised into the fold on antiquated advice like ‘hold your breath while you intubate’ and ‘shove the blade in as far as it can go and pull back until you see something you recognise’. We have since come to realise that the way we have always done it has not always been the best for our patients. 

I have since learned to slow down, take a breath, utilise apneic oxygenation while intubating. I try to instill in students and new employees the ethods that intubation is a skill of finesse, not brute force. Traditionally, with the skill of direct laryngoscopy, we have two tools at our disposal: the ‘adult’ and ‘paeds’ handle. I prefer the paediatric handle for all attempts as a reminder of the finesse component. If your airway control requires extreme brute force, a technique reevaluation may be in order.

Additionally, I subscribe to an ‘advance, don’t attack’ philosophy. We have an inherent anxiety of airway control that often comes with a ‘go, go, go’ sense of urgency. As a provider, I obtained much greater success when I slowly advanced into the airway, averaging a centimeter at a time, looking for and anticipating my anatomic structures as I advance. The success in this technique comes from the ability to anticipate anatomy rather than enter forcefully and try to identify structures once in place. This is much more important when dealing with our smaller paediatric patients, where tissue oedema and damage from an aggressive technique can further complicate the procedure.

Plan, plan, plan
Does your airway training regime include practical management of the contaminated airway? We have all experienced the patient that has vomited, thus complicating our airway management strategy.

Preplanning and anticipating for such an event will make the event more manageable when it happens and provide the peace of mind of knowing that you are ready if it doesn’t. Do you have suction present, available and functioning? Is your suction catheter capable of managing beer and pizza, the seemingly preferred last meal prior to a cardiac event? The traditional Yankauer may not be the best choice for our non-liquid suctioning needs. Additionally, are you trained and proficient in the SALAD technique developed by Dr. Jim DuCanto? (https://openairway.org/salad/). SALAD trainers are a very simple and inexpensive tool which can easily prove its worth with the successful management of just one contaminated airway.

Am I where I think I am?
The last component in the process is making sure of where you are. The failed recognition of a missed airway will be detrimental to our patients 100 per cent of the time. We all have good and bad days, and recognition of such, and possessing the ability to set our ego aside and hand the airway off to another provider, takes a true master of their craft.

We all have good and bad days, and recognition of such, and possessing the ability to set our ego aside and hand the airway off to another provider, takes a true master of their craft

Early in my career, before I possessed the ability to know what I don’t know, I had the unfortunate experience of watching a provider attempt intubation on the same patient nine times in succession. The refusal to realise their struggle and allow another crewmember to even look was testament to the definition of insanity (doing the same thing over and over and expecting a different result). 

Once the patient has been intubated, are we utilising end tidal CO2 as the gold standard to check placement of the tube? I am continually surprised at the agencies I interact with who still do not use it for airway placement verification. We can further validate our airway success by the addition of a physiological verification such as equal chest rise, improved colour and equal breath sounds. 

Making a difference
The addition of a realistic training regimen to your agency will not only increase your skills and ability, but the confidence gained by practitioners. And this can not only improve that standard first pass attempt success, but allow us to have the experience to remain calm when it eludes us and we are faced with a less than ideal airway as an adversary we need to control.