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)


Building Better Cardiac Arrest Care – Part 1


For many years the approach to patients in cardiac arrest has been held hostage by algorithmic care that stifled innovation and did nothing to improve overall survival. Now a combination of new technology, and a realization that one size does not fit all, has led to innovative approaches in care.

The result is an opportunity to move away from the status quo in favor of approaches designed to fit the needs of local environments – where decisions are driven by real-time feedback on the quality of our CPR and the patient’s pathophysiology in order to achieve the two core goals of advanced cardiac arrest care:

  1. To rapidly optimize cardio-cerebral perfusion.
  2. To find and treat reversible causes of cardiac arrest.

The Building Better Cardiac Arrest Care series is about physiology-driven resuscitation in cardiac arrest care, highlighting new concepts and new tools to improve our approach to these patients.


If you asked me about mechanical CPR in the ED a year ago, I would have said, “why would I want another tool cluttering my resus bay that hasn’t been shown to improve outcomes? Well, we recently got a Lucas CPR compression system in our ED, and its arrival has coincided with a great post by Dr Salim Rezaie on cognitive offloading (using physical action to alter the information processing requirements of a task to reduce cognitive demand) during cardiac arrest. So I’ve decided to put a discussion of the two together, since I think there is no better way to frame the argument for using one than Dr Razaie’s post.

Within the choreography of a resuscitation, multiple critical actions need to occur, but which ones?  Each action we take is a calculated choice. With finite time and cognitive bandwidth, every action we say yes to is also concomitantly a no to others. Small changes in the choices we make to achieve our goals during a resuscitation have the potential to significantly impact the quality of our cardiac arrest care. 


Beyond ACLS: Cognitively Offloading During a Cardiac Arrest

beyond-acls-765x575That’s why I love posts like Salim’s on cognitive offloading during a cardiac arrest. He’s taken the time to deconstruct a standard ACLS approach with the goal of reducing our cognitive burden to give us a better chance at rapidly transitioning to the important task of defining the problem behind the cardiac arrest.

We all know the H’s & T’s and the importance of reviewing potentially reversible causes of cardiac arrest. It’s also no mystery that the faster you can get to thinking about them, the faster you can make lifesaving decisions about care.  But if the basic requirements of the ACLS algorithm keep you incessantly occupied by a multitude of details that demand your full attention (monitoring for quality CPR, issues with IV access, repeated medication dosing, time wasted on prolonged pulse checks) then how realistic is it in the real world of cardiac resuscitation to expect you are going to have enough time to find the cause and reverse the problem?

And what if you’re working in a resource poor environment with too few hands, or you have a patient with difficult access, or is 400 pounds and requires herculean strength to maintain high quality CPR?  Well then, you may never get there at all – or at the very least your arrival may be significantly delayed.

Finding a better pathway to that cognitive space is Salim’s goal. His solution? Leverage the concept of cognitive offloading to get you there faster by rethinking the basic tasks required for optimal perfusion during CPR so you have more time to think.  To me this makes a lot of sense.

A rapid sequence review of recommendations for cognitive offloading during a cardiac arrest

Now on to the Lucas – With Dr Jim Horowitz

Which brings us to mechanical CPR. It turns out that about the same time Salim posted we were getting familiar with our new Lucas device.  It’s benefit is not simply replacing the physical work of CPR with a machine, but reducing the cognitive work needed to ensure your team maintains high quality chest compressions throughout a prolonged resuscitation: watching for provider fatigue, calling for new CPR providers, ensuring the right depth, rate, and quality of compressions, and directing the CPR providers throughout a code are all tasks that distract a team leader.

For Jim (our VTE and ECMO expert and my favorite cardiologist to have at the bedside during an arrest) the benefits of offloading CPR are obvious: it means more time to initiate ECMO.  And as he mentions in the video, mechanical CPR tends to make codes quieter, and makes placing lines and intubation easier during active CPR. This is significant offloading in action and can reduce distractions or delays in getting to that all important cognitive space.

I wish I’d had the Lucas 2 in some of the rural hospitals I’ve worked in, where it was often me and one nurse on an overnight, and I had to grab the clerk to help with CPR. I was lucky if I could get a LMA and an IO in quickly enough to take my turn doing CPR.

Cognitive offloading is something most good Emergency Physicians do intuitively to get through their day, but the concept was never explicitly taught to me during my training. I vote that it should become a core content lecture for every residency program in the country.

More to come.

Thanks to Dr Jim Horowitz for coming and demonstrating the Lucas 2 device to our residents and faculty. You can also download his iBook manual for the Lucas 2  for free here.

(None of us have any conflicts of interest with this device).


Download, bookmark, aggregate, follow & create for a happy new year!

The holidays are over and with it 2015 is coming to a close. One of the missions of the EMBER Project is to help you organize your flow of information so that it’s relevant and accessible when you need it. Here are four skills and some tools we’ve come across in 2015 that will help you learn, teach, and grow as a physician and an educator.



screen568x568ACEP Toxicology Section Antidote App – By American College of Emergency Physicians.

Some information can be stored in the cloud or your hard-drive for leisurely review. When taking care of your critically ill patients there is some information that can’t be left to a Google search. Mobile apps are still useful when you want critical information at your fingertips that is easy to access and trustworthy. The ACEP Antidote app is one of those. and will be on my iPhone in 2016.



dded87_3069f29a335c688a8b97789585bc1d89Critical Appraisal Skills Programme (CASP) – Making sense of evidence. 

Industry funded research, profit motive and competing interests that don’t always align with patient or public health interests make critical appraisal of the medical literature  a top priority The developers of this site from Oxford have developed workshops and tools for learning how to critically appraise medical research.


icontexto-inside-twitterI use Twitter as my tool to network and to organize the flow of EM relevant news, research, opinion and just plain interesting voices.  Here are a couple of the breakout voices I’ve been following in 2015 and will be watching for in 2016

@AirwayNauts By Jim DuCanto & Friends.

Those involved in the solemn deliberate study and practice of navigating, sailing, exploring, and innovating airway management are known as “AirwayNatics”.

@brennafarmer1 One of my smartest friends; wears more hats well than anyone I know.

Medication Safety, Patient Safety, Emergency Medicine, Toxicology expert.

@jameshorowitzmd  Jim is my go to guy for advanced VTE care in sick patients. I expect many great insights from him in 2016

Cardiac Critical Care. Co-Director Pulmonary Embolism Advanced Care team 

If you want to see the complete list of who I follow on Twitter in Emergency Medicine here it is. Feel free to pick and choose for a great stream of information. Then add it to one of the apps below!


News aggregators like Feedly help you collect, follow and share the many streams of information into one place, and are your lifeline for keeping track of it all.  Here are the one’s I liked most in 2015 and will continue to use in 2016.

flipboardNYCFlipboard aggregates articles, video, podcasts, and social media into a beautiful and mobile, print-style digital magazine. With it’s browser widget and other tools it makes collecting and sharing news  easy. In addition it allows you to create and curate your own magazines with multiple editors if you.  By far my favorite aggregator.

pocket-appThe one thing Flipboard doesn’t do is allow for collecting for offline reading. For this I use Pocket. A great tool if what you are looking to do is “clip” an article, video, or other content for later.




311605691_640In 2015 I hosted an innovation in medical education Design Challenge where I encouraged our residents and many of my expert colleagues to free their lectures from their hard-drives, and find easy and creative ways to translate their knowledge from powerpoint slides into more accessible and visually appealing alternatives.

One of my favorite tools of 2015 was Haiku Deck, it’s a wonderful alternative to Powerpoint.  Here are a few decks I made in 2015. I’m sure I’ll be making more in 2016.


That’s it for us at the EMBER Project this year. Happy New Year!!


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!

All of us in Emergency Medicine have been getting an accelerated education on dealing with the adverse effects of synthetic cannabinoids on our patients. K2 or Spice has become so popular in NYC it’s not uncommon for us to see a half-dozen or more of these patients a night in our ED.

One of the challenges in making the diagnosis is the variable nature of the drug’s effects: from wild agitation and psychosis to somnolence and an almost comatose state. Whether this is a dose or time related response (or just the simple fact that there are numerous compounds being sold as the same drug) knowing what’s going on with your altered mental status patient just got a little more complicated.

Our paramedics on the street are also becoming experts and learning on the job how to pick up clues that their unresponsive patient is in fact high on K2. They see it up close daily and have a lot to teach us. Thanks to Michael Paulino for sharing this clinical pearl with me today. it’s one I didn’t know about, and one I’m sure to use on my next shift.

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