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Airway Management! Time for a change?

Darren Braude, MD, Ron Walls, MD, and Mel Herbert, MD MBBS FAAEM
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EM:RAP September 2012 Written Summary 540 KB - PDF

Darren and Ron discuss the 4th edition of the airway manual. There might even be some controversial statements on the teaching/practice of standard airway management. So don't swallow your gum! We warned you.

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Minh L., Dr -

Thankyou Darren, Mel and Ron for a thought provoking episode.
Its an appealing arguement to make, claiming technology will improve clinical outcomes.
I would counter though.
Firstly from a human factors viewpoint, it would be less resilient to learn and train one device or technique. If it fails or is lost, you need to be just as successful with alternative techniques. No one is claiming we should stop using a scalpel blade for surgical airways even though cutting diathermy is technologically superior and gives better surgical field conditions. This is the problem I have with choosing A technologic approach to solving airway management. Why stop at asking for a video laryngoscope in your ED, why not ask for a flexible endoscope? where does it end?
Ron Walls does declare on his company website, Airway World, his disclosures but I thought this should have been stated during this episode. He is sponsored by several airway device companies including major video laryngoscope brands.

Secondly I think the intubator should do what they are best at rather than try to use a device they are not. If its my child, I dont care what device is used as long as the operator is competent and trained to use whatever device they choose. You have to be careful in dogmatic decrees saying one device or technique is superior to another as a blanket statement. We know the evidence is that video devices improve glottic views, but not intubation success or times in a convincing manner compared to direct laryngoscopy. This Canadian meta analysis of the Glidescope showed this
Its like saying if we all drove Volvos no one would die in crashes. Fact is it depends on a range of variables including the driver.

The arguement that why should we not adopt the superior video device as standard of care is naive. It ignores the fact that direct laryngoscopy is incredibly successful and simple technique with a long history of safety and success.
I worry about this obsessive pursuit to achieve the perfect glottic view for emergency intubations. The fact is you do not need the perfect view to intubate and the only way you will learn that training direct laryngoscopy. would you not want your resident to learn resilience and know what to do if a suboptimal view is obtained?
And video devices give the temptation that an oral intubation attempt may be successful when in fact an alternative techique such as surgical airway was the better option to choose first.

The greatest difficult airway device is the one you carry between your ears, does not need batteries or light source and should always be ready to go when you choose to use it.

Kevin M., MD -

"I will unequivocally state that it is wrong for people to practice direct laryngoscopy in 2012."

Says the physician who is paid money by companies who make video laryngoscopic equipment.


I love EMRAP. But I love it because it does a lot of the work I don't have the time to do. Because it takes a good hard look at the data and helps me make better decisions. I love it because provides a place where we all can go to become better in our very difficult field.

We don't need Hero Worship and having a big name, or having contributed to the field doesn't give you license to say anything, no matter how completely ridiculous, especially when you make absolute statements and don't disclose your financial stake in the implications of those statements.

I'm stunned.

prestwig1 -

I agree with Kevin M. M.D. 100%! I have only one thing to add. SHAME ON YOU MEL!

brendanC -

Ooops my videoscope just broke, I wish I had trained on how to do direct laryngoscopy. Technology failure is a common recurrent event and to not be well versed in direct techniques is asking for trouble. In the same fashion that someone who only does US guided IJ approach will be in trouble not just when the US doesn't work but when someone has a thromboses or irradiated or used up IJ. I'm sure Ron Walls can dictate where he is willing to work but not everyone has that luxury. Lets hope we have a counterpoint via EMRAP next month so the site can maintain its status as THE source for emergency medicine education.

Ray G., M.D. -

I do own a video laryngoscope and do use it regularly. I also use the old 1940's technology as well. I do agree that in the future we will be using video largynscopy instead of direct but the time is not 2012.

Dr Walls seems to have gotten into Glottic fixation. The name of the game is oxygenation and ventilation by what ever means. If your first and only attempt at airway management is my Knife then fine, if you decide to attempt a supraglottic airway as your only airway attempt then this is valid also. IF you do think that this is a difficult airway try for ventilation (via supraglottic device) first and then if you have the training go to flexible endoscopy or to your colleagues. It seems a little cowboyish to say with this video largyngoscope i can intubate anything and not worry about the other devices, skills. I am sure this not what Dr Walls meant but this is how it cam across.

A problems that does not seem to be mentioned with the indirect scopes is that time to intubation is lengthen, even in normal theatre patients with no predictive airway problems. This is fine in the controlled environment of theatre but in the rapidly desaturating patient this is dangerous and deadly.

I would also disagree with Dr Walls in that it seems that he is implying (i might be wrong and am happy to admit that) that going to his course or any course means that you are able to use flexible endoscopy for intubation in the difficult airway. You need to have done at least 5-10 in a controlled environment be that theatre or the ed. Before even attempting this by yourself.

I would also want to agree with Minh that as a rural generalist doc I do not want to be tied down to one technique/tool/device as this is often not available, not charged, broken etc. We need to be resilient and knowledgeable about all of the techniques and tools available and able to adapt.

To Mel:

Your 5 year old child needs to be intubated in the ED. You have a intubator who has done over 500 successful RSI's using the 1940's technology. He has done 5 intubations with the Glidescope. Which one would you like him to use? Does this change if your child sats are starting at 85%?

Like all tools/techniques/technology in medicine. It is the right technique with the right technology for that patient in that environment on that day that matters. Not what we used.

Mel H. -

I am loving the discussion. I love these devices but I too think you have to learn BOTH methods. I was NOT aware that Ron Walls takes money from device makers and I will indeed check with him!

Minh L., Dr -

I would counter argue further by suggesting that in 2012 it is irresponsible to teach video larygnoscopy before direct laryngoscopy and moreover a comprehensive airway strategy that is not weighted towards glottic fascination.
Dr Levitan showed a Glidescope video sent to him of a young patient with epiglottitis where intubation attempts failed despite video larygnoscopy and CPR is commenced. He makes the point that you should n ot get focussed on the perfect view and repeated intubation attempts despite a great view. Video laryngoscopy may present things as a mirage that you will never reach before the patient arrests.

clay -

wow. i am intrigued by the resistance here. i happen to agree with dr walls 100% for a myriad of reasons, but admittedly its a bit of training bias, as we had many of these devices in our ED and we did a ton of research comparing them against eachother and conventional techniques.

Whereas actually definitively showing a superiority to DL with VL is difficult in terms of research design, for lots of reasons including inability to randomize pts who need emergent intubation, the data is pretty clear that overall succes rates are better with VL, esp with difficult airways, and most importantly first attempt success is greater among all users of different training levels. although much of this data is unpublished and is only in abstract form, its out there. and this months Annals article CMAC vs DL by Sakles, Mosier and Chiu and the entire team at UofA Tucson, AZ, is just the first of these studies that are headed toward publication. There have been many small studies presented in abstract form that all show the same thing...VL (nearly all devices studied) is as good as or better than DL in all airways with exception of blood, fluid, vomit etc in the airway that can contaminate the camera.

So, if youre one of those people that cringes and revolts and turns away at the hint of radical practice changing develpments, i would urge you to think this one out, be patient. dont make the change now if youre not interested, but be ready to experience an advancement in ED airway mnmgmt, not scared of change. and if you do not know how to use VL, i suggest you go to a demo at a conference, an airway course, or ask the rep from Storz or Verathon to come to your ED and let you try one out.

This is not Ron Walls trying to plug his favorite companies bc hes being paid to do so...he is stating the facts and his comments are evidence based, even if much of this data hasnt hit the big journals yet...relax and be willing to adapt. you will all love VL someday, i assure you.

Kevin M., MD -


Just for the record. I'll take my record of over 2000 successful intubations using DL over the course of my career with just two requiring surgical airway, both of which the anesthesiologist couldn't intubate using VL, over any of the of the abstracts you site.

Insofar as your comment about Dr. Walls not plugging his companies because he is paid to do so, well. I'll reserve the right to maintain a healthy skepticism whenever anyone with a financial stake in an expensive treatment fails to disclose his financial stake in that treatment and then makes such extreme statements as....

"I will unequivocally state that it is wrong for people to practice direct laryngoscopy in 2012."

That's just a flat out absurd statement to make and frankly, as amazed as you seem to be at the resistance to Dr. Walls' statement and failure to disclose his financial interests, I am at least as equally amazed that you aren't bothered by these issues.

clay -

thanks for your thoughts. im not disagreeing with anything written here, i think its healthy discussion just for the the record. but no, i am not bothered by the comment that people shouldnt be practicing DL bc thats my belief as well. like i said before i have a training bias, i use VL 100% of the time first look, but have done equal numbers of DL and VL ETI in my career and feel perfectly competent doing both. for example, I like the CMAC for the very reason the blade is a MAC blade and i DL take a look and then use the video to intubate.

I agree with you that his comment is probably not applicable to veteran DL masters like yourself, but probably applicable to those of us new to the field or in training (im only a couple years out of residency). Just as nasal intubation attempt used to be standard for a difficult airway..ive done zero of those!! any comment as extreme as his should be viewed with a bit of skeptism, but i am not at all concerned that there is financial interest here or any agenda. I agree with his statement, probably bc of my own background and research. Everyone knows Walls work and his involvement with device manufacturers and his track record speaks for itself IMHO. not concerned in the least that his comments here are related to personal interest even if he is getting paid.

To clarify, what im sharing is my opinion/bias and i have some background in this area. Because of this background Im simply sharing with readers that I too believe that VL should, and will, replace DL entirely, and nows the time to jump on board. Take it or leave it.

Also, FWIW i have had more "device failures" (light source out, batteries, etc) with conventional 25 yr old DL blades than i have with multiple different VL devices. I actually trust them more tha old DL blades....that said be aware that some of the devices namely the pentax, the mcgrath and a couple others absolutely suck, so be sure to do your homework before purchasing. I recommend the CMAC or the GlideScope...i have ZERO financial disclosures to make.

And last comment...if you do not know how to use flexible endoscopy for intubating, learn it. you will save a life at some point in your career if you have this in your tool kit. i have had two cases (anaphlaxis/angioedema and huge neck abscess) that were intubated like this and nothing, not even cric would have worked otherwise. Optically enhanced laryngoscopy is a must have skill for EPs these days. Enjoy it! Its fun!

Mel H. -

Again I am very excited to see the discussion, even though it is a little personal and heated.

Does anyone disagree with the concept - that you take one of these blades and try and tube the "old way" - keeps the skills up. If you fail, you look up at the screen and get another view...

Regards Dr. Walls, remember the reason you get to use paralytics and indeed in many cases are "allowed" to intubate in the ED is because of Ron Walls the the NEAR studies...

Minh L., Dr -

Respect must be paid to Dr Walls I totally agree. He is a pioneer and great mind in this area.
Therefore although I do not agree with his statement I offer evidence from the latest published literature from his home nation of Canada

Griesdale DE, Chau A, Isac G, Ayas N, Foster D, Irwin C, Choi P
[Video-laryngoscopy versus direct laryngoscopy in critically ill patients: a pilot randomized trial.] [JOURNAL ARTICLE]
Can J Anaesth 2012 Aug 30.

PURPOSE: Endotracheal intubation in critically ill patients is associated with a high risk of complications that tend to increase with multiple attempts at laryngoscopy. In this pilot study, we compared direct laryngoscopy (DL) with video-laryngoscopy (VL) with regard to the number of attempts and other clinical parameters during endotracheal intubation of critically ill patients performed by novice providers.
METHODS: Patients were randomized to either VL or DL for endotracheal intubation. Exclusion criteria for the study included: requirement for immediate endotracheal intubation, cervical spine precautions, anticipated difficult intubation, oxygen saturation < 90%, or systolic blood pressure < 80 mmHg despite resuscitation. The providers, predominantly non-anesthesiology residents in their first three years of postgraduate training, received a one-hour teaching and mannequin session prior to performing the procedures.
RESULTS: Forty patients, mean age 65 (standard deviation, 16) yr were randomized to VL (n = 20) or DL (n = 20). Sixty percent of the patients received endotracheal intubation for respiratory failure, and all patients received a neuromuscular blocker. Multiple attempts were required in 25/40 (63%) patients, and this did not differ with technique (P = 1.0) Video-laryngoscopy resulted in improved glottic visualization with 85% of patients having a Cormack-Lehane grade 1 view compared with 30% of patients in the DL group (P < 0.001). Total time-to-intubation for VL was 221 sec (interquartile range [IQR 103-291]) vs 156 sec [IQR 67-220] for DL (P = 0.15). Video-laryngoscopy resulted in a lower median SaO(2) (86%) during endotracheal intubation [IQR 75-93] compared with a median SaO(2) of 95% in the DL group [IQR 85-99] (P = 0.04).
CONCLUSIONS: Video-laryngoscopy resulted in improved glottic visualization compared with DL; however, this did not translate into improved clinical outcomes. The trial was registered on number, NCT00911755.

clay -

Dr Minh,
thanks for your perspective and the citation. Apologies up front bc i doubt anyone here is interested in an academic banter session about this but I would just like to say that this study doesnt really apply to us. Ovberall, I am very careful using the studies on this topic that are done in non ED patients. this is just my opinion. All the papers out there about this subject have methodological problems, in the ED and out of the ED, so im not just singling this one out. this is a hard area to study.

And the exclusion criteria unfortunately, pretty much takes out a substantial portion of my patients. So i cant take much from it. and whats with a 63% multiple attempt rate?!? I know thats not yours!

I think the take home from this study is actually that in controlled "urgent" intubations, in the hands of the least experienced operator you can find, VL performs as well as DL. Its kind of a win for VL, really...That doesnt apply to you with your experience for sure, or me and i have much much less than you. But Im EM trained and take care of ED pts.

Anyway, some of my partners were/are reluctant about VL as well (im a small town community doc btw) but we got the CMAC, and most of them dig it. They pretty much DL with it and universally love the video to get bearings and things seem a little more gentle overall. many opinions out there though. The guys who rock at DL now are not going to change their practice, nor should they. Id pass off a airway i was struggling with to some of my older partners in a heartbeat. Experience trumps a lot of things in medicine, esp procedurally.

Most importantly though, I think, is it Its way more mellow and is really fun! I guess i just like it better than DL, and i dont have to bend over and get all up close with the airway:) And its pretty clear in the existing lit that it is as safe or better in all airways, all operators, so thats comforting as well.

I dont think thats a bad idea "taking a look" and then incorporating video, except that doesn't work w the majority of the devices and their blades just based on technique and camera angle etc (ie. glidescope). Its great with the CMAC, which is just a MAC 3/4 blade. The attendings that trained me will commonly turn the screen away and make residents DL to get trained on both simultaneously. thats the way to do it i think.

EMCrit -

Folks. The healthy debate I see on this page is excellent. Many have written things that I was thinking during the piece.

I want to chime in and say that Dr. Walls doesn't take any money from ANY device manufacturer. I have known Ron for many years and you will have to go far to find anyone with more personal integrity.

While his course benefits from the device manufacturers offering their products for use by participants, I do not believe they subsidize or pay the course. Ron correct me if I am wrong.

I believe he could make a very nice supplemental income by talking on behalf of any of the device companies, but then you would have trouble believing a word he said. This is why I believe he has chosen against this throughout his career.

Minh L., Dr -

Scott thankyou for the information. My apologies to Dr Walls if I have inadvertently misclaimed that he has any conflicts of interest. It still would have been prudent to openly declare at the beginnning of the interview if there were no disclosures rather than assume so particularly as there is clear advocacy for one type of device such as video laryngoscopes which are expensive systems.
CPJ, I appreciate where you are coming from.
I think the evidence is not as convincing as made out for a number of reasons and you can take it as you may, either side of the fence
You have to be careful about airway research being done on devices tested by one or two providers and making comparative statements of device performance. A lot of VL research has been done this way. These studies in fact are only showing differences between airway providers rather than the devices themselves.
Studies , randomised and using a large group of providers, probably emulate real world experience better when comparing devices and techniques.
I truly believe that VL and DL are not mutually exclusive techniques and training in both allows for more resilience in your approach.

Allow me a martial arts analogy. The Filipino based martial art of Escrima and its older relative, Kali, are actually traditionally weapon based fighting styles, using sword and dagger, or later stick and baton. The same weapon based techniques are used to teach the unarmed techniques. This was historically based when the Spanish invaded the Filipino nation and banned weapons so the native Filipinos trained using the same techniques to maintain a highly effective martial system of fighting. The same techniques were trained and used in combat no matter if the fighter picked up a stick, sword, dagger or used just their hands and feet.
Technology does not replace the fundamental skill and mental tactics. This is the same with VL and DL in my view.

Grant -

Just to chime in here (resident perspective) on a few instances where I believe DL has an advantage. DL allow physical manipulaton of the glottic structures, ie suctioning, and FB removal.
I have had 3 case of FB leading to code, including one case an infant who was found to have a grape blocking the airway. Removal after visualization with DL was the way to go. You can see the problem airway with glidescope, but now what??

Second case, thermal burn to trachea, which was swollen and almost shut. Intubated over a bougie (placed straight end first) with a small tube. It took precise placement of the bougie into the small hole remaining in the airway with significant downward pressure to pass it through.

Both of these examples would have been very hard, or impossible with a video scope. In my mind an advantage of DL is in cases where a tube will not just pass into the trachea easily. Good DL technique allows the intubater to see the problem, and then do something about it.
In no way does this take away from the importance of video technique, but it seems to me that good DL skills go hand in hand with video skills in the mgnt of airway for its own reasons.

EMCrit -


This brings up a clear and necessary distinction. I believe when you are speaking about Video, you actually mean Video with a blade geometry that precludes use as a direct device (i.e. the traditional glidescope shape). Any of the video laryngoscopes that mimic standard Macintosh geometry can be used for all purposes

Kevin M., MD -


If it is true that Dr. Walls does not take money from manufacturers, then I am very happy to hear that. If he does, then, as you said, it would be difficult to believe a word he says.

That being said, Financial interest or not, the quote in my first post in this thread is so absolute and hyperbolic that it is simply stunning to me and frankly, while I can try to dismiss it as simply overemphasis to make a point, I find it difficult to do so.

Our specialty is changing all the time and we all find ourselves needing to upgrade our games in many areas, but a collective decades of practice has certainly taught us that there are many way to skin a cat. DL is a useful adjunct IMO. We have a glidescope in our ED and I have used to as a training tool for medical students and paramedics and even once I used it in a difficult airway to confirm that the cervix appearing structure in a man with a huge neck mass, was the only possible airway. Then I used my Mac 4 blade and a bougie and intubated without a problem.

As even Dr. Walls pointed out, people of his stature have to be very careful about the statements they make because, since they ARE considered "The Experts," the poor slob of an emergency physician who finds him or herself down the barrel of a lawsuit has virtually no chance in front of a jury with with a Ron Walls or a Jerry Kaufman testifying in absolutes that the vast majority of us know to be untrue.

Our specialty has enjoyed the benefits of those who made it possible for us to practice in the manner we do, but we have also suffered from many of those same people financially exploiting emergency physicians in virtually every conceivable way including undemocratic "contract' groups and "Experts" making thousands of dollars for a few hours work raking over the coals in front of juries those of us who make our living one patient at a time without the benefit of teams of specialists and subspecialists ready to jump in and take over or even help.

You say Dr. Walls' integrity is above reproach, that goes quite a bit of ways with me because you seem above reproach, but I've known many Emergency Physicians who know him well who view him quite differently. So I'm left ultimately with a suspicion, and one that isn't helped by statements such as

""I will unequivocally state that it is wrong for people to practice direct laryngoscopy in 2012."

That is just indefensible IMO.

EMCrit -


I am bringing Ron on the EMCrit podcast to see his responses to just the questions you raise. I too was a bit surprised and dismayed that the statement was made.

I can almost support the statement, "All departments should have access to video laryngoscopy equipment."

This would be a way to force a hospital to add these devices to the ED--a good thing.
And then follow with the statement:
The individual technique chosen (DL vs. VL) should be based on the clinician, the patient, and the situation.

clay -

great discussion all! thx for thoughts. i love airway and optically enhanced laryngoscopy and am very interested in how it will all play out as its role becomes more well defined with time. appreciate all the perspective here.

George K. -

This discussion has been fascinating. Enough to cause me to subscribe…

Declaration: I am co-director of a Canadian course in Airway Management called Airway Interventions and Management in Emergencies (AIME). Over the last 17 years, I have taught thousands of emergency physicians and paramedics. We receive no industry sponsorship nor is there industry presence at our courses. Our instructor (emergency physicians and anesthesiologists) to learner ratio is 1:6, and we teach the use of a multitude of devices based on evidence and experience. I have authored airway textbook chapters and edited two editions of a text – ‘Airway Management in Emergencies’. I have been involved in airway management device design (and hold airway device patents in Canada).

Here are 10 points that I would like to offer as part of this online discussion. I apologize that this is not referenced at this point.

1. Television or radio. Predicting the future is never easy. I do agree that video laryngoscopes (VL) will continue to play an increased role in airway management. However this move has to date been driven by market/industry forces more than evidence. I submit that direct laryngoscope (DL) use may never be obsolete, and is far from unethical. Perhaps the best analogous scenario is that of the radio, when television first appeared. Both effectively did the same thing, serving as a technological conduit for entertainment and mass communication. Television provided that extra visual experience that most would agree is 'better' or at least more enjoyable in the right setting. As prices dropped, almost everyone (in the western world) got one. But most still have a portable radio available.

2. Airway device industry and market forces. As medical devices, laryngoscopes do not require the same rigorous proof of effectiveness (evidence) required by the pharmaceutical industry, beyond proving that the device materials are safe (i.e.. compatible with human tissue and won't break). Devices are therefore often introduced for clinical use before they have necessarily been established as effective.

3. Current evidence (my take). Some studies suggest that VLs are more successful than DL, with study endpoints generally the view obtained, or intubation success. . However, rarely does published evidence compare VL with best attempt DL (i.e., DL with BURP/ELM, head lift when not contraindicated and use of a tracheal tube introducer [bougie]). Many would consider this the current gold standard for DL, and that to which VLs should be compared. Furthermore, the evidence against DL comes from prehospital based outcome data that has clearly demonstrated that in the hands of relatively inexperienced (paramedic) users, intubation using DL in the studied prehospital cohorts is associated with negative outcomes. Does this mean DL is bad? No, it confirms what we already knew: that direct laryngoscopic tracheal intubation is a difficult skill to learn and maintain, with about 50 repetitions required to gain competence in the 'normal' controlled environment of the OR. Regarding the growing literature in support of VL, beware of generalizing results from any large case series reporting high success rates with any device. Many such studies are done in the controlled conditions of the operating room, in the hands of experienced users. To my knowledge there has only been one prospective randomized trial of sick emergency patients comparing an indirect device (Airtraq) with DL by experienced users. This European prehospital study (physicians) was randomized at the scene to DL or Airtraq. While the significantly higher success rates for DL was interesting, the fact that failed Airtraq was followed by successful 'rescue' by DL was impressive. Although the Airtraq is a different class of device, the growing literature in support of its use has not demonstrated superiority over DL in the hands of experienced users. Current evidence does seem to support a more favorable learning curve for VL over DL. This may be important for clinicians who will not be able acquire and maintain skills with DL. Many would argue for such providers, alternative oxygenation strategies (extraglottic devices) should be used.

4. What about the difficult airway? Does VL add value? There is some observational evidence to support this. However, as stated, many studies fail to address the incremental value of VL over first attempt DL with ELM, head lift and tracheal tube introducer.

5. Use it or lose it. Knowing that DL is a difficult skill to acquire and maintain, and that it remains the most common rescue technique after a failed primary indirect approach, competence is dependent on regular ongoing use. Future studies should address learning curve and maintenance of competence using VLs compared to DL, because this is where VLs may prove superior.

6. The soiled airway and FB retrieval. Suction is usually successful in allowing VL use in the soiled airway, but not always. The direct visualization of the oropharynx obtained with DL optimizes chances for foreign body visualization and removal, or dealing with the grossly soiled airway.

7. Equipment failure/availability. Without doubt, equipment failure can happen with DL. However, using a high quality rechargeable battery system with bulbless blade (light bundles) is less likely to fail or be out of service than a VL system.

8. Cost. Until recently, the price tag associated with VL systems has prevented their universal accessibility. Prices are now dropping substantially, but not yet to the per-use cost of DL.

9. Redefining success. Thankfully, this message is now out there and understood by most. Airway outcomes are not determined by placement of the conduit (endotracheal tube) but by the uninterrupted delivery of oxygen. Plastic doesn't save lives, oxygen delivery does. We need to move away from the technical imperative of 'getting the tube'. Intubation success (as opposed to airway management success) reporting is inconsistent and at times misleading. The minimum standard reporting should include first attempt success. There is clear evidence that bad outcomes are associated with increasing number of attempts. 'Ultimate' success as per above is misleading as it can be associated with adverse events known to cause bad outcomes. Although first attempt success may also be associated with adverse events, it is a better clinical process marker of success. Airway management adverse event reporting must include the incidence of hypotension and hypoxemia. These two events are universally accepted as significant contributors to poor outcomes. We (emergency physicians) need to study airway device effectiveness in the ED environment. We need to compare success to an accepted gold standard and use standardized reporting. This should at the very least should include first attempt success and the incidence of important adverse events (hypoxemia and hypotension).

10. Desert Island equipment. I often get asked what would I take as emergency airway equipment to work with in a remote area. There is no simple correct answer and this list is as much personal preference as anything else. When I go 'North' to work in a small ED, this is what I routinely want/have access to (beyond the obvious i.e. O2, various ETTs etc.)…

BMV device with PEEP valve, nasal prongs, a quality DL (Mac 3/4, Philips 2), tracheal tube introducer., LMA supreme, #10 scalpel, #6 ETT (for a bougie assisted cric). As prices come down (under 2G) maybe an indirect device (one for which there is reasonable evidence and with which I have experience)
So, is DL unethical? In inexperienced hands, performing any procedure (at least, unsupervised by an expert) is probably unethical. In competent hands, DL is very effective. With the effectiveness and low cost of DL, I’d argue the burden of proof lies with the new devices. That proof, which we still await, must include prospective studies comparing with optimized DL, reports of first-attempt success, standardized reporting of complications, and well-done acquisition/maintenance of competence curves. I wish the researchers good luck with these endeavors: with the high first-attempt success of ‘best attempt’ DL (optimized DL +/- bougie)by competent users, sample sizes may be be awfully large!

Thanks for the opportunity to express my views on this subject.

George Kovacs MD MHPE FRCPC
Medical Director Lifeflight, EHS Nova Scotia
Professor, Departments of Emergency Medicine and Anesthesiology
Dalhousie University
Halifax, Nova Scotia
Tel. 902 473 2214
Fax. 902 473 3617

Minh L., Dr -

Dr Kovacs thats a great list of points to consider, thankyou from Downunder! You reminded of another point I forgot to raise!

An emergency airway technique must be resilient and succeed in varying conditions. There are multiple factors to this equation.

The video display screen of VL devices is an achilles heel, especially so in the prehospital outdoors settings

I have been fortunate to test three VL systems in the outdoors setting. Its simple enough for anyone to do this in a basic manner by taking the VL system outside on a sunny day. Not many VL displays can deal with screen glare and washout on a bright daylight setting. When VL systems cost thousands of dollars and can be defeated by ambient light levels, that to me is not a resilient system.

clay -

dr minh,
what devices did you trial?

Aaron A. -

Great discussion. In my experience with difficult airways, the fixation on 'seeing the cords' leads to lazy prep and management, and a failure to consider what to do if DL/VL fails. If you prep and position well, both DL and VL should have a high success rate. Secondly, using the Glidescope does not solve the problem of aligning anatomical structures to successfully pass an ET tube; the storz is much better and is a good choice to transition (no disclosures to make). Bottom line, many inexperienced operators pat themselves on the back because the VL makes it so easy, and their laziness bites them in the butt on the one in a hundred truly difficult airways. Even with the VL, we still have to do all the other stuff right to be successful.

Minh L., Dr -

cpj, I tested a King Vision, Glidescope ranger and Pentax AWS. The best was the King Vision and I have to disclose I do get company support by way of donated devices for an airway course I teach.

David W. -

Stepping in with a liiiiitle trepidation.

I know that my point of view has already been covered multiple times, and by people far better than I.

With that said, I am a technology fan ... nay, not fan, advocate and staunch supporter.

I will choose to take ANY tool that gives me an edge in favour of my patient and allows the maximum benefit to my patient ANY time.

With that said, I have always held to the knowledge machines are machines ... they break, they hiccup and they have a nasty tendency to not do 'as advertised' usually with a Murphy-Law like exponential ratio of presentation to event combination.

I *LOVE* technology. I keep a backup for every battery driven device I have. Failsafe, upon failsafe.

This goes from the Glidescope, to the manual laryngoscope to the digital intubation and so on. Of course, there are rescue airways to step in, but the objective is to have that first pass / first attempt success and I believe that is where we are focused on in this presentation and discussion.

*BUT* when the technology fails before I even get to try my first attempt, I had BETTER be prepared to proceed to any number of alternative plans dependent upon my patient and the situation. By prepared I mean competent, knowledgeable and capable.

So, video laryngoscopy? Yes. Only? No.

It applies to my electronic stethoscope with a regular no-batteries needed let alone included stethoscope to have ready to go. It applies to the computer patient record keeping device with the pen and paper. So it should with every other aspect. I agree that to rely exclusively on one method and device is dangerous, but to exclude it as a high priority tool could be equally negative in its impact to the patient and the practice.

Just my two cents worth.

Mike J., M.D. -

Jeez, and here I thought I might have something profound to add. Gotta say that having a range of skills is necessary for the competent ED doc. I will admit to a lower competency level in VL than DL and so I continue with DL.

Looks like I'll have to register for the airway course!

Michael M., M.D. -

I never fail to be amused by the love for new techniques and technology. I have been out of residency 20 years; have intubated hundreds of people (maybe thousands). I have worked at major trauma centers, teaching centers, and suburban emergency departments. I have worked with newly trained graduates, utilizing ultrasound for central line placement and video laryngoscopes for intubation. I can place a central line and intubate a patient in a fraction of the time, compared with the new graduates utilizing the new technology!? I have had to do one cric and one manual (digital) intubation in 20 years; I have created 2 pneumothoraces in thousands of central lines. I am not enamored with the new technology, and realize some people need the additional help. It is my opinion that residents should be trained without the new technology first, and then learn to use ultrasound and video as an adjunct.
Mike M.

Mel H. -

For the record, I talked with Ron, he takes no $$ from device makers. Continue the debate with this in mind. Those leveling those accusations owe the man an apology.

Brendon S., M.D. -

The most difficult case I've had intubating in the last 20 years was using a Glidescope where I got a great view of the cords but couldn't pass the tube. I bailed out and used the standard laryngoscope where I couldn't see the cords but easily passed a tube with the help of a bougie. Another one with a cancer of the tongue was rescued with a laryngeal mask. The number that can't be managed by these techniques approximate the number that are helped by Thrombolysis for stroke - virtually none.

Kevin M., MD -


Since I accepted the accusation as fact, I'll gladly proffer an apology to Dr. Walls regarding that particular accusation.

Now I await his apology to our specialty for his outrageous and completely wrong comment that not only could cost patient lives, but also may cost Emergency Physicians law suits.

BTW, I am curious if Dr. Walls takes money to testify against Emergency Physicians and if the answer to that question is yes, has he ever taken money and made anything approximating that statement. Now I have no knowledge of Dr. Walls engaging in such parasitic behavior against our specialty so the following comments are not directed at him unless he actually does do so, however.....

IMO, an Emergency Physician who takes money to testify against other Emergency Physicians is suspect and someone I would never care to associate with in any form or fashion. If one of these ER docs also happens to be considered on the level of a Jerry Hoffman or a Ron Walls, then doubly shame on him for using his name to, in effect, create an impossible situation for an Emergency Physician to prevail.

Just my opinion, but one shared by the VAST majority of ER docs with whom I have spoken.


Ron Walls is good, but not God.

I sat in his course in Hawaii when he said that if we did not do a certain method the way he was training us, that he would testify against us in court! That is no way to push standard of care.

His comment implied that he does get compensated. Not by the manufacturers, but by the lawyers suing emergency physicians and looking for an expert. He sees himself as the definition of standard of care. Does he charge plaintiffs when he testifies against those of us who error in his eyes? I don't know. His comment left me furious. Perhaps being an expert witness should be part of full any speaker's full disclosure.

I love having a glidescope near, but I have failed at the glide scope and used direct as my backup a few times.

I also work in an ER with one single glidescope but at least a half dozen airway carts that don't have glidescopes.

Much of what he taught me, I have incorporated into my methods, but anyone with the ego to threaten his own colleges that he would "testify against them in court' is not someone I want defining standard of care.

I was teaching some pediatric fellows who were feeling insecure in their direct intubating skills and they shared their consensus that the glide scope would be their tool of choice. This sounded more like a cruch than a tool.

What will they do when one single drop of blood gets on their glidescope?

I did like Ron's course, but if you depend on a glidescope, you don't have enough skills in your skills set.

B Yer man
Roch ester NY

Sean G., M.D. -

Yeah the statement about it being "wrong" to practice DL in 2012 is simply put very naive. I am always amazed at how really smart people can have such a narrow focus. Ron Thank u so much for all u have done for our sport, but you and all ED physicians that practice in a top Academic University setting comprise about 10% of all ER docs. 90% of us don't practice in those arenas. Probably 80% of all current practicing ED docs are proficient at DL and have been doing a damn good job of it for a number of years, and have very little if any experience with VL. Also to state that you "wouldn't practice" in a place without (paraphrasing) all the latest gadgets, capnography, VL, flexible scope etc is a shame, because guess what Ron? Many pts seek treatment in these ER's and thank God there are a lot of competent ER docs who would deign to do so, or else what would ER Med say to these folks? "Sorry guys your SOL...shoulda lived closer to USC or something".....yeah these two statements are short sighted and ill advised. I for one have a glidescope, don't really like it I always intubate faster with DL and have been doing so since about 1994, also don't enjoy US guided central lines. I had one PTX as a second year resident in the early 90's and since then probably near a thousand CVP's without any complications the old fashioned way. Perhaps folks like me should get out of ER medicine so the 10% of ER docs who do everything with all he latest gadgets can cover all the shifts thru out the country. Oh....not interested in that I guess.....

Minh L., Dr -

Mel, thankyou for reassuring me in regard to the financial disclosures of Ron Walls. My apologies for incorrectly assuming this.
as part of my monthly reading, I came across this case report in Anesthesiology on pharyngeal injury as a result of VL intubation.

A quick search revealed several similar reports in the recent years.

to me this refutes the claim by Ron that VL is significantly safer than DL. both techniques are complementary and not exclusive.

Andrew M., M.D. -

This is some fiery commentary and I'm eager to listen to the Sept. edition of EMRAP. Alas, I left my sunroof open last weekend and my iPhone was rained upon. Subsequently, I am experiencing device failure. Fortunately, I have a practiced second approach (listening on my old iPod).

VL has it's role and has probably become the gold-standard approach, particularly in the trauma and anticipated difficult airway patient populations (assuming the clinician is practiced and skilled at VL).

But, I see no downside in teaching/learning/maintaining a second skill set in the form of DL.

Steven S., M.D. -

"DL is dead and we shouldn’t teach it." What did you say? Maybe after a randomized trial comparing speed and number of attempts, on difficult airways—hey where’s the beef, show me the money, what is the evidence, come onnnnnn Ronnnnnn.

How about a race—an airway race. No, not with garden variety airways, but with the bloody, the frothy, the chili-cheesy, the anterior-cant see the arytenoid kind of airways, done in a standard ED; you with the VL method and me with an ETT, laryngoscope and a plastic coated stylet. Caveat: when I need a gum elastic bougie—I do not have time to look for that, I uncoil the end of the stylet and push it two cm beyond the beveled end, aim it anteriorly, then thread the tube (beveled side down) over the stylet in a screwing motion and move on to the next patient. If you’ve got an ED full of patients you can not be delayed by technology—and technology has too many ways to fail.

Sure teach it, teach DL—teach them both. But don’t mandate your preference with a broad, one size-fits-all, procrustean statement like: everyone should only intubate using video laryngoscopy. That’s CMS and JC’s job (e.g. Blood cultures in every pneumonia, Beta Blockers for every STEMI, nursing Harm Assessment in every patient, tPA for every stroke, send every Guiaic Card to the laboratory to be tested and read by qualified lab technician...)..Sorry, got side-tracked.

Ron Walls, you may be Galileo and have discovered that the world is not flat and that the earth encircles the sun but come onnnn Ronnnn you’ve got to persuade me what the truth is. Otherwise you get the same respect that I give CMS and JC. Besides, from where I stand the world does seem pretty flat?

Ron W., MD -

Now I know why the phrase, "don't shoot me, I'm only the messenger" has remained so popular. Thanks for the fascinating discussion. I have dedicated my life and professional career to improving airway management, advocating for emergency medicine (and emergency physicians) and trying to help us all save more lives. Of course, I deliberately made a provocative statement, and, with the exception of the personal comments, I am heartened by the healthy debate that has ensued. A couple of clarifications. Firstly, I do not take money, any money, from device manufacturers. I don't own stock, hold a patent, or have any remote way of profiting when people buy airway equipment. We have had equipment donated or supplied to our airway courses over the years, but this is equipment of all kinds, including DL and bougies, etc. I do provide expert testimony in civil suits, predominantly airway related, for both defendants and plaintiffs. The majority of my airway related cases have been at the request of the defendant. I appreciate the passion and defensiveness with which people resist change, and the subjective nature of their reasons for that. Direct laryngoscopy, like nasotracheal intubation, digital intubation, and TTJV, will always have a place in that 1% of the 1% of airways, for which a very particular approach is needed. For routine, and difficult airways, though, the clear superiority of video devices is as obvious as the superiority of optimal management of sepsis over "seat of the pants" management. I am confident about this evolution of care with respect to airway management, and the pace clearly is accelerating. So, for those of you with your thousands of intubations and central lines, I would suggest that you keep doing what you do best, but open your mind to the possibility and likelihood that you could do even better. The push back is not new to me, not even unfamiliar. I have heard it before when I advocated that emergency physicians routinely use NBMA and RSI in the eighties (ironically, almost all the pushback was from other emergency physicians, who characterized my recommendations as "dangerous", "radical", "ivory tower", and "negligent." I have heard it with respect to routine confirmation of tube placement with ETCO2, which is the standard of care statement I made in Hawaii and have made in many other places. If that leads someone to fiercely resent me, but use ETCO2 for every intubation, I have done my duty. I'll be on Scott's EMCrit in the next few months, so we'll have a bit more chance for discussion. Pending that, I'm grateful for all of the energy, zeal, and passion in this thread, and I hope that I have convinced at least a few of you who are firmly anchored in DL, as was I, by the way, that, rather than shoot the messenger, why not try to read the message?

Derek I., M.D. -

I am so surprised at the reactions of some of the emergency physicians to Dr. walls's podcast. We use new technology in so many ways in the emergency department: ultrasound for central lines, etco2. All these technologies took a while before they caught on as routine lcare, and I feel it will be the same for video laringoscopy. There's a related issue here. with the advent of CPAP, residents are doing fewer intubations.

in this discussion about laryngoscopy, we are missing the main question: which means of intubation provides the best outcomes and safety for patients. I think vl clearly wins out here.

Minh L., Dr -

Ron Walls, thankyou for your response and I apologise for mistakenly assuming your financial conflicts of interest. I am a follower of the Airway world webinars and thought I recalled a session in which you seemed to state that you had COI with Glidescope company. My inaccurate recollection so please forgive me.
I do not support or agree with personal attacks or criticisms of Dr Walls. I believe he truly is expressing an honest opinion as a widely regarded expert in the field.
I respectfully disagree with his statement and opinion, still.
Only this week I reviewed a paper by Melbourne colleagues of mine on a RCT comparing the CMAC vs McGrath VL devices in an elective anaesthetic setting of anticipated difficult intubation defined as MP3-4. All the VL research finds the same thing..great views obtained but five cases of the McGrath failing of which three were rescued with DL and bougie. CMAC had only one failed intubation which was rescued with the McGrath!
A colleague of mine was doing an anaesthetic list last week and shared this case with me. No anticipated difficult airway but on induction, failed DL, failed VL, failed bougie attempt, rescued with LMA.

My point is that you need a wide range of skills to provide safe airway management as NO ONE TECHNIQUE is sufficient..which implies NO ONE DEVICE is best.

I totally agree with ROn Walls in that I see in the near future, we will all own our personal VL device as they will become that affordable and disposable. I predict though that we will still be teaching and using DL for a long time to come despite the wider availability of VL. If experienced anaesthetists like in the Melbourne study , still need DL to rescue VL in anticipated difficult airway, I dont see anything removing the need for that skill in the future.

I appreciate Ron wants to provocate a healthy debate which it seems it has apart from some nasty personal comments which are inappropriate.
thankyou sir

Mel H. -

FYI: I just removed a post that I considered totally unprofessional. While I don't like to censor any post and this is the first one I have ever removed. It is just not ok to attack people personally. Attack the comments and the facts. This is not youtube, personal attacks are beneath us.

Minh L., Dr -

well done Mel, thankyou. This debate should be about how we improve patient care and safety, not about who has the biggest..laryngoscope.

Steven S., M.D. -

On EMCrit would you please give us the data that has led you to you to your conviction. Im still pretty sure the world is flat. P.S. Thank's for your passion Ron-Galileo-Walls.

Sean G., M.D. -

Ron I truly hope you were not offended by my comments. I began by thanking u for your service to our practice and that was sincere. I tend to speak bluntly almost harshly because I find if you don't people often times don't listen. I stand by my criticisms of the language you used. Saying its wrong to do DL in 2012 is telling the vast majority of competent practicing em docs that have dedicated their lives to pt care that they are doing something wrong. I certainly agree VL is important to learn which is why I pushed our dept to get outs but IMO the literature certainly has NOT conclusively argued that it's wrong to do DL. It's interesting you used the sepsis analogy. The Manny Rivers protocol was fun and all the high tech approaches with us eval of vena cabal collapse and arterial wave forms etc are great but in the end we end up doing a strangely similar thing we used to do when we pushed fluids gave broad spectrum abx early and evaluated urine output and lactate levels.... Seems to me we have vastly increased the expense of our sepsis treatment to end up treating most patients in a very similar fashion.

Ali R. MD -

I’ll start this with the disclaimer that I teach for Ron’s Difficult Airway Course (and get paid for my lectures) and am on the EM faculty at Brigham and Women’s, where Ron is Chair. I get no money from any device manufacturers, airway-related or otherwise (although I often joke that I wouldn’t mind any because daycare is getting expensive) and I have never testified in an airway-related malpractice case.

However, I disagree with Ron’s statement above – but more on that later. An expert of his stature doesn’t need me to come here to defend him personally but I thought I’d give you my $0.02 anyway.

First, I’d like to point out to all those attacking him (rather than disagreeing with his statement) that the reason that we’re all able to perform RSI is the work that Ron did thirty years ago. That should tell you two things: 1) That he’s been practicing a very verrrry long time (and Ron, if you’re looking to give up your Chair position anytime soon, I know a guy…) and 2) He has been right before on major airway issues, despite those who vehemently disagreed and attacked him. We should view his comments in the appropriate light and discuss their merits as professionals. I can also vouch for the fact that he doesn’t receive any funding from any airway device manufacturers and is truly a stand-up guy.

Ron and I had this debate a few months ago at a dinner, since he knows I like to train the residents for whatever eventualities they will encounter in the non-ivory tower “real world”, where VL-scopes have still only partially permeated. His most salient argument that night was his comparison of VL to U/S guided central lines. In our ED, we require that all IJs and femoral lines be placed under U/S with verification of wire placement prior to dilatation. Now, there are many of us who feel more than comfortable placing a central line without the ultrasound but the evidence has shown us that we’ve sometimes just been getting lucky – anatomy can vary significantly and U/S guided lines are definitely safer. I couldn’t get away with telling a patient that I wanted to place an IJ based only on anatomical landmarks because I wanted to train a trainee or practice what it would be like if the ultrasound broke down. So why, if we accept that the evidence shows us that VL is superior to DL (hold your horses… more below), can we get away with intubating patients with DL if we want to train trainees or practice our skills in case the VL ever breaks? Would any reasonable patient opt for a non-U/S guided central line? I doubt it. Nor do I believe that they’d opt for a PGY-x performing a DL intubation when the evidence shows that, generally, we do better with VL (again, see below). Experienced operators who have performed thousands of tubes? Do what you want… but don’t be afraid of what is coming down the pipeline just because you’re better with something with which you have more experience.

My issue with Ron’s statement is that we’re not there yet, and likely won’t be for a while. We have one of the fanciest airway carts in the world in our ED (all bought and paid for – nothing donated) and I’d be performing a disservice to one of my patients if I, and my residents, didn’t use it. However, I also work at a couple of critical access hospitals, one of which is a 2-bed “ER” in the UP of Michigan, and they don’t have VL available. I take a personally-owned (and paid for) portable VL device when I go there but I don’t think that patients treated when I’m not around are getting substandard care just because they’re being intubated via DL, since that’s all that’s available. Now, I really should be convincing the administrators to buy a VL-scope but that’s another discussion. In case my BWH residents end up at a similar place, I have them use the C-Mac like a Mac and then fall back to the VL if needed, and they seem to feel comfortable with the DL training that protocol provides.

In terms of the evidence, Minh (love your blog/podcast, by the way), you’re right in that there are studies on both sides. For the points above, I relied on the supposition that VL has better evidence behind it and I’m sure that Ron will discuss this in much more detail on EMCrit (again, awesome blog/podcast Scott – you guys have replaced the radio in my car). Notably a recent meta-analysis (open access, no industry funding) supports this as well, but mostly in non-expert intubators, getting back to my point of those of us who are experienced continuing to do whatever works.

Thanks for the spirited discussion, and Mel, thanks for the great work.

Minh L., Dr -

thanks Ali, that is very helpful. one point to raise though in regard to the analogy with USS guided CVC insertion. This is not the same thing really is it? Dr.Seth Trueger and I debated this recently and he wrote a very good response here on his blog site
In terms of patient safety and quality of care, for VL and DL , it still remains an operator dependent factor. The technology does not level the playing field as Ron suggests.

Sean G., M.D. -

Dr Minh I do think its an appropriate analogy, US guided CVC placement and VL, both are modern mechanical adjuncts to what used to be largely a human endeavor. Both have provided a likely safer and more accurate way to perform a procedure on a patient. The literature I believe is more robust on the benefit of US guided CVC then on VL over DL, but to me they are somewhat analogous scenarios. I would like to offer another analogy. If Ron is going so far as to say we should not even be teaching DL to students anymore, to me this is like saying children don't need to learn math because they have calculators.

Mel H. -

I will be interviewing Ron again on Monday and will post a link for you all..he has much more to add and explain!

Minh L., Dr -

thanks Mel, sounds like a good idea for a followup interview! I know Scott Weingart is planning to do the same. I got an email from a colleague who is attending Ron's Difficult airway course this week and he talked about this controversy sparked off by this EMRAP episode.
I think anyone is entitled to an opinion and be wrong and despite the best of intentions, can still offend many colleagues in the process.
This unfortunately has created a backlash whereby the original intent/message from Ron has been lost, not to say that i think the original message was an overly helpful one to begin with.

I strike's me that there is somewhat of a bias in the claim that VL should replace DL as standard of care in orotracheal intubation. Almost all of the research and proponents of such a claim, have been experienced intubators who all learnt DL primarily in their training..WHICH IS WHY THEY ARE NOW ADEPT AT VL.

To debate that trainees and junior staff must now all learn VL without the benefit of the skill of DL practice that their seniors gained in their early training, seems to me to be incongruous and perhaps even somewhat self indulgent.

Dr Kath W -

Very interesting discussion. As an emergency registrar in Australia (resident for those in the US) I thought I would present my view with respect to training VL vs DL.
Currently I don't have have much experience with intubations (have intubated around 60 patients). I did an anaesthetic term and did try to take the initiative to gain some VL experience. At the present time; however, I am much more confident with DL, laryngeal manipulation and bougie. I rotate hospitals every 6 months and I know that there will be DL available if I need it.
The department I work in currently does not have VL. The wards which I have covered do not have VL on their resus trolleys. And when I requested the video laryngoscope on nights in resus during a previous rotation there was general confusion amongst the nursing staff: it is not something that they are currently familiar with.
While VL is the way of the future, exclusive use is not quite ready for prime time.

Minh L., Dr -

just listened to the update audio interview of Ron Walls with Mel Herbert.
well done. that is the mark of a true teacher..the ability to recognise personal error and fact that is the mark of a true leader within our profession.

I accept the need to understand and learn new techniques and technology. I get the message that Ron is sending.

I still dont agree with it. To hear that Ron teaches his residents on VL alone was surprising. I dont agree with that.

I dont believe VL and DL are mutually exclusive. even when the time comes when we all own personal VL devices , I predict DL will still be utilised to a significant degree.
The bayonet is still taught and supplied to every combat soldier in all the worlds armies. Why? When we have so much technology in modern weapons and combat systems?

it is still valuable to gain the experience in becoming expert at DL. VL does not replace that value and in fact being good at DL, will help you with VL and vice versa. but depending upon the system being good at VL does not mean you are good at DL.

thankyou Ron and Mel. true inspiration.

Jonathan S. -

I am one of Ron Walls's residents and although I have not intubated a patient with him yet, I have certainly had opportunities to work with him and to intubate with other faculty at our hospitals. I just wanted to clarify one of his statements in response to something that MLC wrote above.

Yes, we routinely, nearly exclusively, intubate patients using VL in our academic EDs. (We also work in one smaller department nearby where they just got VL in the last 1-2 years and we routinely use DL there.) Using VL in a teaching environment has an additional benefit that some people may not appreciate. Most of the time we use a Storz CMAC, which we have at 3 of the 4 hospitals in which we work. For those not entirely familiar with the equipment, it is, as RW said, nearly identical to a Macintosh laryngoscope and, as such, can be used with the same mechanics. For my first 2 years of training, I was encouraged (in some cases, with some faculty you could say "required") to use the VL blade as a DL system, i.e. not to look at the screen at all. I see this as having a few benefits:

1. The attending physician can see exactly what I am seeing and as a result can either feel reassured that all is going well or can teach how to make it better.
2. I can learn DL mechanics, which are directly translatable and can be used without a video system.
3. I can use the screen as one of my backup systems.

It is not atypical for us to start an intubation procedure by calling our plan as follows -- Plan A is CMAC as DL, Plan B is the screen, Plan C is a bougie, etc.

Yes, we have other VL options available, as would be expected at a program that stresses airway management as much as ours, but we still start with typical translatable skills and go from there. I suspect that Dr Walls and his colleagues would agree.

Minh L., Dr -

yeah that sounds cool. problem as you hint at, is that some VL systems are not like DL and so you need to learn a new set of skills. my concern is that if you are only ever taught that system and those skills..what do you do when you dont have that system or it is not working? you gotta have a fall back.
the CMAC training you and I know Scott Weingart does is the current ideal blend.
the distinction really should be made in teaching and the current debate about the skills sets taught and required. The differences between the VL systems were thrust upon us as airway providers, based on little research and more on novel designs and a rough guess about what would give the "perfect view". the plethora of VL systems is not a medically driven product, it is an industry driven impetus.
Now what is happening is that we are seeing designs that are completely different from DL devices and those that seek to emulate the DL devices. And a war is being waged as to which group will come out on top. hence all these studies showing this and that and really I think you can take them all as you may.

What I know is that having a unified skill set makes a heck of a lot of tactical sense in the real world. In the famous movie words of Sean Connery " Dont bring a knife to a gunfight", in other words, be prepared and not fixed on one adaptable.

the problem is many have invested large sums of money in the early gen devices which are not like DL and need more than traditional DL skills. This is why people have had a not 100% glowing experience with VL.

I see this all returning to centre in the next 10 years, when VL will be so cheap and affordable, we will all have one. then providers can pick and choose what works best for them and the patient before them..without worrying about financial constraints nor being regarded as unconventional or substandard.

Adn the VL will take its rightful place as part of every difficult airway algorithim, along with DL which has always and still will be an integral part of any airway algorithim.

Kei K. -

Except for Dr. Minh and Dr. Kovacs trying to debate the evidence, everyone else who opposes Dr. Walls are saying things like, 'I did this many such and such and don't need it.' Or things like 'I did it blind with a bougie and it was fine.' Or even, 'Oh I have this case and that case and VL was bad then and only DL was able to save the airway.' How amazingly unscientific does that sound?
Oh hey, this one time, I prayed to God for this to work and it worked out, so that means there's a God.

Check this:Rapid Sequence Intubation for Pediatric Emergency Patients: Higher Frequency of Failed Attempts and Adverse Effects Found by Video Review.Annals of Emergency Medicine
Volume 60, Issue 3 , Pages 251-259, September 2012

My son is my life, in fact he is more important to me than my own life.
I'm sorry, you tell me you're going to tube my child blind and I'll tell you stop and just cut his neck because you tube him blind and if you don't get lucky and if my kid gets anoxic brain injury because you don't know how to do VL and are macho and cowboy and will attempt DL, you and I will have words outside.

Just because you can do it DL with suboptimal view doesn't mean it should be done if there is another technology that can give you a better view and able to get better first pass success. Obviously the data isn't completely out there yet, but if one of the experts in the field is saying this is the future, maybe we should listen more carefully.

Yes, technology becomes a crutch and it is important to know backups when there is no other option. But to dismiss it outright just because you feel comfortable and unwilling to attempt a change in practice despite growing evidence in support of it borders on ignorance.

This is medicine, it changes constantly, old ways are hard to die sometimes, especially when they've been as successful as DL. So you better have the intestinal fortitude to adapt when there are paradigm shifts that occur in our field because our lives and our children's lives depend on our skills and knowledge that incorporates the best possible practice data out there.

Sean G., M.D. -

Kei K I suggest you read the counterpoints above. I don't say "re read" because from your comments you obviously haven't actually read the counterpoints. No one has countered that they are not interested in learning VL or that VL is not the likely airway method of choice in the future. The debate has been over the concept that DL is "wrong" should be replaced or should no longer be taught. We all love our children and the macho "you and me will have words outside" is a bit juvenile and beneath this discussion.
On another topic that has been risen in this discussion I feel compelled to comment. On docs testifying against other ER docs. I have to say I believe this is fundamentally wrong. Mel and Stu on this very podcast mentioned how "they don't sue in Chile". Well this is the case in many societies. People don't sue doctors. We certainly do here. Why? I would argue that law suits in this country are by and large motivated by greed. No other country in the world worships the almighty dollar more then the good old USA. The greed IMO is evidenced in every player in the law suit except the defendant ED doc. When a doctor goes to work every day, takes an adequate history and does a focused PE and orders tests he/she feels appropriate and attempts to make a clinical decision they should be able to do so without fear of their career being on the line. Malpractice activity here in the US is driving docs out of practice, forcing unnecessary testing, sky rocketing healthcare costs and disuading students from seeking careers in clinical medicine. It is simply wrong. If a doctor goes to work impaired, doesn't take a history or examine a patient, or other egregious errors sure they should be sued, but the vast majority of suits have none of these. They are simple human errors. Doctor's are humans and we all make errors. Mel and Stu frequently comment on errors they themselves have made in their careers, and clearly they are top ED docs. When we agree to testify against other ED docs we are hurting our profession. It is largely "Monday morning QB" and those who do this really need to do some serious honest introspection at their motives. Any one of us can miss something. That is not malpractice and we shouldn't have to go to work with this fear hanging over our heads. Let ye who hath not sinned cast the first stone is very appropriate here. For those who do take these cases...if you feel ethically, morally you must, because you feel the physician engaged in true malpractice.....TAKE THE CASE PRO BONO!!!!! There is no law that says you have to accept a pay scale typically 3x what you make in an hour pof practicing EM! God knows everyone of us with an MD or DO after our name is making more then enough money we really don't "need" more. If you don't feel you should take the case pro bono I ask you to do this.....Go take a long look in the mirror and ask yourself "Why not?"
Mel I know this is a bit off topic here, but the discussion was raised in the commentary above. I couldn't sleep at all one night last week because I couldn't stop thinking about this. I hope you allow this to stay posted, as I think this is one of our biggest issues in Medicine in the US in 2012. How many of our patients will likely develop cancer because we have convinced ourselves we need that CT to r/o PE? How many people will be uninsured because healthcare costs are so high? Much of this is driven by malpractice claims, and malpractice claims would be much less of an issue if we stopped feeding on our own.

Kei K. -

I apologize, I didn't literally mean to incite actual violence. I wanted to illustrate the visceral reaction I would feel if an actual ED doctor were to discuss with me how he would DL my child if I knew there might be a better way but it would not be taken because he felt confident(overconfident?) that DL is better and he would not use VL even if that were an option. Again, I apologize and do not literally mean to promote violence in what I would hope to be a debate on DL vs. VL and realize that I should have been a tad less personal and worded my reaction differently.

As to your other point about malpractice, I agree with you in that our country has a problem with malpractice, but I think it is a topic for discussion in another forum/time/place.

Sean G., M.D. -

Heard the follow up. Well said Ron. Now I know why I tried to have our dept. get the storz CMAC I thought it felt very similar to DL however we had to go joint with anesth and I guess as a group they out weighed my singular opinion and we got the glidescope which is why I think I haven't embraced it as I have trouble squeezing the tube past the blade. Always see everything great just have trouble passing the tube. I queried my list serve from residency and most of us that grad mid 90s or earlier use the videoscopes as backups and most of these guys are Academics

Chuck S., M.D. -

Just another thought. First, I am old and remember listening to Ron at ACEP when he first introduced RSI so have been doing this a while and I have learned much of what I was taught is wrong and continually needs improving/changing. Therefore I agree we are moving to video as the way to go for the future and have been using it for a while. That said 2 days ago had bloody facial trauma and every time I put the video in got a great red picture. Pulled it and using DL was able to intubate without difficulty. Don't know if cleaning lens, better suction, etc would have solved my problem or not but was glad to have the old fashioned technique at hand. I always like at least two back up plans (think Ron taught me that). How to teach this to new people is a great question and makes me glad I am not at an academic center. Good luck to the teachers.

Hector C. -

I’d love to use VL devices if I could find them easily. In my limited experience community hospitals buy these devices then share them between several departments and keep them locked up in a closet most times. Having said that I think DL as a skill really is priceless. I have worked at facilities where Anesthesia defers to EM docs when it comes to intubating the crashing patient because EM docs at these facilities just encounter these cases more often. I’d hate to think of the prospect of not having DL as a strong skill.

I’m glad to hear that the prices for VL devices are falling. I have considered buying a device myself because I have found that, as an EM doc who travels to many hospitals, depending on the proper equipment to be available has been a major disappointment.

Dr. Ron Wall’s statement is food for thought- a big juicy buffet’s worth of food. I’d be happy to use his controversial, yet expert, statement as leverage with hospital administrations to ensure the emergency department with the equipment needed to use in cases where DL skills fail. I’ve had to establish surgical airways in at least a couple of cases without having the option of VL or other adjuncts. It’s been a soul wrenching experience to second guess myself on such cases, but I did the best I could with the resources available- and even so I think its not good enough.

Minh L., Dr -

I reflected on what Ron Walls said in his followup interview with Mel Herbert. The idea that DL can be learnt during anaesthesia terms, thereby obviating the need to. teach it during ED terms, needs to be approached with caution. With the Use of LMAs and supraglottic airways in the OT for elective anaesthesia, there is less scope to practice DL there. In fact if you wanted to teach VL , its best done in elective anaesthesia settings where the prolonged intubation times are not as big an issue in elective patients.

Ideally as has been described by a resident at Walls hospital, use of a combined DLand VL system for teaching is optimal.

Louis T., M.D. -

While I agree with your concept that we should strive always to be using the best and most available technology in the ED, I feel very strongly that you've made an error in judgment with your statement that video lanryngoscopy should be the standard of care. The main problem is that any piece of equipment that requires power can be broken. Heck, how many times in your career have you grab for a blade to find that the light is out because the battery is dead. And that's with a simple piece of equipment. The more complicated any machine or mechanism is, the easier it is to break. I have two ultrasound machines in my ED, and there has been many times when both were not available. While I agree that video laryngoscopy is superior to direct laryngoscopy, I am not aware of any data that we are causing harm to a significant group of our patients by using the direct method. I think it is more important to teach our residents to recognize situations when they may have a difficult airway, and have multiple rescue devices standing by, including video laryngoscopy.

The comment about having patients sign a waiver that they'll be treated with an obsolete technology if residents want to use direct laryngoscopy is ridiculous and grandstanding. And Mel, with all due respect, if your child was the patient, not only would you want to use the direct laryngoscopy, you would also want the most experienced attending to intubate, and not the resident. You would, and should get that privilege, because of professional courtesy. In reality, however, we have interns and residents perform procedures on sick patients all the time, with us at bedside to provide support. Using your argument that we should never use inferior technology even though they work fine, then we should never ever allow interns and residents to even touch a patient.

I understand your excitement and enthusiasm, but such reckless comments are dangerous to our profession.

Louis T., M.D. -

edit from my comments above:

And Mel, with all due respect, if your child was the patient, not only would you want to use the video laryngoscopy, you would also want the most experienced attending to intubate, and not the resident.

Mel H. -

Louis - I think you misunderstood my comment and it is important to hear the subsequent segments in the following months...not my comments, but those of Darren, Ron Walls and Rick Levitan....coller heads have prevailed :)


Wow! I don't think I have seen this kind of discussion on any topic before on EMRAP. Just goes to show you how heated a topic intubation is! I have to admit, I kind of went crosseyed after following the various commentary. In my humble opinion, most things in Emergency Medicine should not follow a mandated dogma as undoubtedly everything we do will some day not be the right way to do it. I work in a busy ED where intubations are fairly common place which is nice in terms of maintaining those skills. I do believe that the doc intubating needs to be comfortable with the device they use whether DL or VL and ultimately that's the bottom line. I think it is foolish to ignore newer technology which is being constantly re-invented and "perfected" to improve these skills we use to save lives. After all, ultrasound has revolutionized what we do, no one can deny this. I think we are also perfectly trained for improvisation and adaptive medicine. As such I do think it is important to not rely completely on technology to save our buttocks. Training in my opinion should incorporate this so that in the event a power failure, equipment failure/ etc we can still get the job done. I personally use a Glidescope and I will frequently alternate DL with VL to keep my skills in DL up and my choice can be patient dependent as well. I also always have DL at the bedside when using VL (in case of failure - which has happened - screen died). I think it is equally important to have an LMA back up and the old trusty bougie. Being adaptable to our environment is our game baby, we should train our future docs with that in mind and our current docs need to embrace future change to add to that skill set. I can't wait to see what tool we get next, better yet, I hope I invent it!

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Episode 132 Full episode audio for MD edition 232:50 min - 97 MB - M4AC3 Project Written Summary: Peds GU, abdominal pain and special needs children 183 KB - PDFEM:RAP September 2012 Written Summary 540 KB - PDF