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Four Steps to Improve Your View

By Mark Rock, BA, NREMT-P

Taking the following four steps will consistently improve your ability to visualize the glottis:
1. Place the patient at the level of the paramedic’s mid abdomen;
2. Use a straight laryngoscope blade;
3. Predict the difficult intubation; and
4. Respond to the predicted difficult intubation with use of the following three techniques: 1) sniffing position, 2) head and neck extension beyond the sniffing position and 3) the BURP maneuver.

Read the accompanying article here.


  1. Paramedics can often not adjust the patient to be at the paramedics mid abdomen, but good concept. This is have the argument with hospital providers that can take their time and make every adjustment possible.

  2. EMS educators must accept some of the blame for the controversy regarding intubation.

    I would like to contribute the following responsibilities that EMS educators have to their students to ensure they are prepared to intubate:
    1. Teach the proper technique for intubation. This includes elevating the head approximately 1-2″ with a folded towel or foam pad. Students must be taught the difference between hyperextension of the neck and the sniffing position.
    2. Teach the students to lift the ET handle at a 45 degree angle, moving toward the intersection of the far wall and ceiling. This should be done with a fixed wrist and minimal movement of the elbow. The motion should come from the shoulder.
    3. The education program has to invest in quality equipment that actually looks like a real airway and then maintain that equipment. Manikins with torn pharnyx, mutilated cords and missing teeth/jaws are useless.
    4. Have all the equipment and supplies that should be available in the field available for teaching. Teaching students to intubate without a functioning suction unit is teaching the students to fail. Ensure multiple size ET tubes are available and replace them after they are worn out. If you are teaching intubation with ET tubes where the pilot tube for the cuff has been torn off after repeated use, you are teaching students to fail.
    5. Make the students practice intubating the manikin on a table or stretcher until they master the technique. Then make them intubate on the floor until they can do so without fail. Introduce fake vomit and force them to suction the airway, then intubate.
    6. Start students out intubating as a team. Have a member of the team bag the mankikin before, between and after attempts are made.
    7. Do not release students to their OR rotation or the field to intubate until they have mastered intubation in the classroom. If you release the students to intubate in OR or the field before they have mastered intubation in the lab, you are not teaching them to intubate, you are asking someone else to do so.

    There has been no study that I am aware of that has demonstrated intubation in and of itself is detrimental. Multiple studies have shown that medics spend too much time trying to intubate and make patients hypoxic, or that they do not know how to intubate or that we fail to appropriately manage the airway and ventilation after intubating the patient. These are the areas that need to be addressed.

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