The EMBER Project
Build a more successful approach to problem-solving during laryngoscopy

Doing the same thing over and over again and expecting a different result may be the definition of insanity, but attempting intubation again and again without understanding why you failed in the first place may be even crazier.

If your initial attempt at intubation fails, standard wisdom is you should change something in your approach before trying again, but for airway educator Richard Levitan @airwaycam, this axiom falls far short as practical advice for a physician facing an unexpected difficult intubation.

If in the face of initial failure during laryngoscopy your answer to the problem is, “just change something, anything!” the likelihood that you will hit on the right change is low. As the stress builds, even experienced physicians can find that “best” solution to be elusive if you don’t have an organized approach to problems frequently encountered during laryngoscopy.

“Don’t just do something different! Do something SMART!” Dr Richard Levitan

Dr Levitan is not just deploying a witty throw away line, but firing a first salvo in the mental battleground where he believes all successful intubations start. Doing something smart begins with the process of “micro-dessecting” our laryngoscopy practice so that we can engineer a better one. His approach goes something like this:

  1. Divide the process of laryngoscopy into three phases.
    1. Epiglottoscopy
    2. Exposure of the Larynx
    3. Delivery of the tube
  2. Identify which phase of laryngoscopy your problem resides in.
  3. Choose your solution(s) based on step two.

This simple mental reorganization adds important granularity to the process of laryngoscopy because it’s the first step in building a mental framework that will help you in a moment of crisis identify where your problem resides (epiglottosocopy,  laryngeal exposure, or tube delivery) so you have a more informed basis upon which to act.

This mental framework also passes another important test: it’s built by someone who lives the job, and understands the environment in which his model is being used. Airway knowledge (like much of what we learn as Emergency Physicians) inhabits a rapidly changing and often chaotic environment. If we don’t build mental models that allow us to deploy our skill and knowledge effectively in tough situations, then it’s essentially worthless.

“You know what we need to do in our jobs? We need to make the first step of every procedure we do, something we believe we can do.”  – Dr Richard Levitan

Now that you have this new framework on which to build your laryngoscopy skills, let’s take a look at what each phase looks like. Mastering each of these skills is an essential part of building an airway “toolbox” that will help inoculate you against stress by giving you more confidence to face the challenges encountered during laryngoscopy.

1. I can’t see anything!!!
Problems in the Epiglottoscopy Phase

grade-4-viewIn the soft, murky world of the oropharynx, the “I can’t see anything!” moment is one of terror. One that piles on the stress in an already stressful situation. That increased stress further erodes your situational awareness, by impairing your brain function and making it harder for you to get control of the situation.

Once you’ve identified your in an “I can’t see anything” situation, don’t panic! Instead, think incremental first steps – in this case, epiglottoscopy.  Epiglottoscopy as a concept works because it forces you to approach the problem in a stepwise fashion.

The most common cause of the “I can’t see anything!” situation is going too fast and too far with your laryngoscope blade.  So take a deep breath, and forget about trying to see the cords. Then pull back, check your grip and make sure your holding the laryngoscope with a light touch, and start again by thinking epiglottoscopy.

Here is Dr George Kovacs  @kovacsgj  of AIME airway giving some pointers on the “light touch” grip and why it is so important for successful epiglottosocopy.

Once you’ve lightened your grip, open the mouth and distract the jaw. Work your way forward slowly and incrementally: find the uvula which will point your way. Move SLOWLY down the base of the tongue and look for the tip of the epiglottis. Fluids may be obscuring your view in which case reach for the suction.

  • Keys to overcoming the “I can’t see anything!” scenario
    • Think epiglottoscopy NOT laryngoscopy
    • Start with a light “two finger” grip
    • Lost? Pull back and start again
    • Find the uvula to point your way
    • Move SLOWLY down the base of the tongue
    • Look for the tip of the epiglottis
    • Fluids? Advance with Suction FIRST

Can’t see anything? Give your airway suctioning & decontamination skills an upgrade!

A word about airway suction. Over the last few years it has been given a major upgrade by airwaynaut Jim Ducanto MD @jducanto. When faced with an airway where the “I can’t see anything!” scenario is caused by airway fluids, Perform your epiglottoscopy with the suction in your right hand and advance with it into the oropharynx slightly ahead of the  laryngoscope blade. I also highly recommend you add Suction Assisted Laryngoscopy and Decontamination SALAD skills to your repertoire for the “I can’t see anything!” scenario.

2. Problems In the Laryngeal Exposure Phase


The second stage of intubation is exposing the structures of the larynx. This is really what we mean when we say laryngoscopy. Successful tube delivery depends on first being able to get an optimal view of the glottis and surrounding structures.

The quality of your view will significantly affect your intubation success. The Cormack-Lehane grading system below highlights how the quality or your laryngeal exposure impacts intubation success.

Screen Shot 2017-12-18 at 12.14.35 PM

What essential maneuvers should be in your toolbox to improve a poor laryngeal view?  For direct laryngoscopy, the most important maneuver is making sure the tip of your blade is properly seated in the Valeculla. This engages the hyoepiglottic ligament. and is critically important for exposing the glottic structures. (shown here in one of my favorite airway anatomy videos by AIME Airway.

If valleculoscopy isn’t enough for a good laryngeal view, the next essential maneuver is external laryngeal manipulation or bimanual laryngoscopy. This will help bring the glottic opening into better view.  Sam Ghali @EM_RESUS shows how effective it can be in the video clip below.

Keys to improving your laryngeal view
  • Start with Valeculloscopy
  • External laryngeal manipulation (bimanual laryngoscopy)
  • Elevate the head of the bed or lift the head
  • Lean back to improve your line of sight
  • Mac as a Miller (get under that epiglottis)
  • Mandibular advancement

3. Problems in the Tube Delivery Phase


You have a great view of the glottis, and you’re telling yourself, “almost there now.” You may be tempted to rush the tube delivery, but now is the time for patience. Getting the tube safely and securely past the cords and into the trachea requires some advanced planning (like straight to cuff stylet), and an understanding of what “best view” of the larynx means for optimal tube delivery depending on the laryngoscope being used.

For direct laryngoscopy, getting a full view (grade1) of the glottic opening and making sure you don’t obscure your line of sight to the cords are probably the most important factors in tube delivery.


In contrast, video laryngoscopy can initially give you amazing views of the glottis but this “great view” can actually make it harder to deliver the tube.  When you’re having trouble with tube delivery during VL, pull back from that great view.  @kovacsgj suggests putting the cords in the top 50% of your screen with a 50% view of the glottic opening.

Hyper-angulated blades and rigid stylets can add another wrinkle to the challenges of tube delivery: if you’re seeing the tracheal rings on your screen like the image below you’re approach angle is wrong and may inhibit smooth tube delivery.


Kovacs’ Sign

Sam Ghali @EM_RESUS shows here that in order to get the tube past the cords and into the trachea requires understanding that the “better view” for tube delivery is not the “best view” of the glottic opening. Here is what an optimal view in VL looks like. Particularly when using a hyper-angulated blade.

Keys for successful tube delivery

Summary: Dr Levitan’s Smart Airway

The maneuvers listed above are by no means exhaustive. But that’s not the point. The real strength of Dr Levitan’s approach doesn’t rest within a random list of tips or tricks,  but in the sound mental model it’s built upon. One that can give you the confidence to work through the problem successfully. The impact this confidence can have on your performance is invaluable: decreasing your stress level, improving your situational awareness, and moving your mindset away from an “I can’t see anything!” situation towards the belief that “you got this!”

This business of succeeding in the face of really sick and dying people under high stress is to simply to set the first step in your brain as something you’ve got. And then you set the next step…” – Dr Richard Levitan

So during your next difficult intubation, don’t freak out and just try to do “something different.” Instead, review this post and use it to start building yourself a better laryngoscopy practice based on Dr Levitan’s “Smart Airway” approach. Then you can change what you’re doing based on where you are in the process, and say to yourself “I’ve got this!”  Acting confidently on an informed assessment of the situation? Now that’s smart!

Learning Designed for Humans

Which brings me to a preview of what’s coming to the EMBER Project soon. The longer I teach and practice emergency medicine, the more I realize how important it is that we  continue striving to organize our essential knowledge in more effective ways. If we want to collectively provide better care, and pass what we know on to the next generation of physicians we must focus more consistently on how we learn, and not only what we learn.

Educators like Dr Levitan, who do this well, and then share it with others, are one of our most valuable resources. His approach brilliantly bridges the space between the classroom and the resuscitation room, and considers the provider and the environment in which this essential airway knowledge is needed. It’s an example of what I now call “learning designed for humans,” and it’s something I will be writing more about soon. So watch this space.

Learning for Humans_ Searching for the Heart of Medical Education-2.002

The EMBER Deeper Cuts

Want to understand some of thinking behind these concepts better? Here is more great airway wisdom from Dr. Richard Levitan presented by the master himself at DAS SMACC in 2017.


Dr Levitan’s Extreme Airway Talk (Slides)


Have you noticed a change in your airway box recently?  No, it’s not the new McGrath or C-MAC or any other cool high-tech tool. It’s a more subtle change.

It used to be when you prepared for a sick patient to arrive that you opened up the box, grabbed a handle, and slapped on your go to metal blade to check the bulb before the patient arrived. If that patient didn’t need intubation the blade went back in the box.

Not anymore. Emerging concerns about cross-contamination  and increased scrutiny by regulatory groups has led to some changes in equipment and also a need for changes in practice. Blades need to be appropriately cleaned, sterilized and sealed; once opened they can’t be put back.

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The problem is that the traditional metal blades often had light issues related to multiple use and sterilization techniques – hence the habit all Emergency Physicians have of checking the blade prior to the arrival of a sick patient.

At my institution, the solution has been new disposable blades that are sealed and packaged (and look a lot like the old reusable metal blades) which is why the old habit is hard to break. These disposable blades rarely have bulb issues and there is more than one blade available if you happen to run across a broken one. We also added a non-sterile (not for patient use) blade to check the handle battery function.

So resist the urge to open that packaged blade and check the bulb, because now you can’t put it back in the box. Well, you can but you’ll just be asking for a JAHCO citation.

The Bundle – Clinical resources you can use

Five Things The Joint Commission Thinks You Should Know About Laryngoscopes and Endotracheal Tubes by Linda Hertzberg, M.D.

#Postards from the ED

There are educational courses and there are inspirational courses. I had the opportunity this weekend to participate at BASE Camp. The brainchild of Kevin Ching, it’s an amazing and unique two days of education.

For those of you who don’t know about this great opportunity, it is, as the website says:

a high-intensity, fully immersive weekend of simulated pediatric emergencies where fellows and nurses work together in multidisciplinary teams to manage critically ill and injured children and adolescents

BASE Camp certainly lives up to this, but perhaps the best aspect of the course is the amazing feedback participants get after each case.  By the end of the second day it was moving to see the sense of common purpose and renewed enthusiasm for what we do every day that was clearly visible in all the participants. As I said, there are educational courses and then there are inspirational ones.  This one is definitely both…


#Postcard from the ED

Hey, can I get a  jazz riff — New York style please?

I’m excited to announce that “The Protected Airway Course” now has a home, and the first of the teaching modules are coming online. Our annual Airway & Difficult Procedure Course lasts only two days (and is only available for our EM residents, critical care and PEM fellows) but this learning is 100% FOAM certified, farm to table fresh. And it’s available anytime!

In the coming months we will be translating airway knowledge from our experts around the EM and critical care world and posting it here for you to enjoy. We’re hard at work creating engaging, innovative, interactive tools to teach key topics in airway management that will augment the course and allow for self-paced learning. In each module you will find learner focused tools designed to make the content stick such as:

  • A self assessment quiz to get you started, and make your studying more focused.
  • Bundled multi-media learning tools covering all aspects of the topic.
  • Strategically placed bite sized notes, video clips, and slides to drive home and highlight core concepts.
  • A quick “Summary in 5” podcast from our knowledge leaders for a quick review on the subway home.
  • Guest posts and interviews with our airway experts from around the city, the country, and the world.
  • Some surprising and entertaining bonus airway goodness (I don’t want to spoil it, you’ll just have to check it out).

This month our flagship module is the emergent cricothyroidotomy. This procedure presents many educational challenges: It’s high stakes, low-frequency and performed in the stressful failed airway situation. If you don’t think about it, prepare for it, or feel confident doing it, you will fail to perform this lifesaving maneuver in a timely manner. The goal of this module is to get you on the path to learning not just the procedure but all the tangible and intangible skills required to master the failed airway scenario.

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But wait, that’s not all!  Since airway education should be all year long, and come in all shapes and sizes, we have several new resources for you to get airway pearls straight to your mobile devices.

  • Flipboard magazine to collect all the latest posts and curated airway content in one place.
  • A new “Airway Tools to Live By” page demonstrating new airway tools as we test them.
  • You can follow along on the Airway Tools page or directly on our Instagram account.

The next module should be out next month but we’re understaffed, overworked, and underpaid so be patient as we bring new content to you at regular intervals. 🙂

In the meantime. May the airway be ever in your favor!

Zen Airway and Poetry Inspired by Haiku Deck

There are many reasons to love Haiku Deck. For educators it’s an easy way to free your knowledge from the Powerpoint prison on your hard drive, but it also challenges you to get to the point and hone your educational pearls into shiny drops of educational poetry.  If you are using Haiku Deck to give a talk it also re-enforces the idea the slides are only for emphasis – if you’re reading of them you’ve got too much on your slides.

So here is my latest Haiku Deck, part of a teaching module for our airway course. I was so inspired I wrote a Haiku to start things off.

Airway Haiku

The Airway is hard

How sweet the Grade One view is!

Pearls for you there are


Oh, I don’t have any money invested in Haiku Deck (wish I did). I just really like it.

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