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Life of the Tube

No single technique can confirm tube placement for every minute of a call. Constantly monitor your patient's status, chest expansion, bag compliance and EtCO2. Photo JEMS

By Charlie Eisele, BS, NREMT-P, & Jimmie Meurrens, BS, NREMT-P

Is the juice worth the squeeze?

We ask ourselves that after every prehospital journal or magazine article we read. When we dive into the literature, we want to come out more knowledgeable and capable of using the information on our next call.

If you’re like us, you like to know that you didn’t waste 20 minutes or more reading something that’s going to take another class or special permission to use. So we promise that after consuming the information in this article, you’ll be able to immediately apply it and improve the level of care you deliver in the field.

Wake-Up Call
Nationally recognized EMS textbook author and JEMS contributing author Bryan E. Bledsoe, DO, FACEP, recently wrote, “[Endotracheal intubation] is problematic and the procedure should probably be stopped.” He added, “Everybody better get used to LMAs, Combi-Tubes and similar rescue airways because routine prehospital ETI is probably a thing of the past.”

For those who haven’t heard about recent studies on the success rates and efficacy of prehospital intubation, Bledsoe’s comments might seem like a step backward in prehospital medicine. But his concern is valid. Several prominent studies have strengthened a growing concern about this intervention, and as EMS professionals, we can’t ignore what the science is showing us.

Specifically, we should note the findings from a St. Luke’s-Roosevelt Hospital, Columbia University 2004 study. The researchers found that endotracheal (ET) tubes placed by paramedics in the prehospital setting were incorrectly placed “at a concerning rateÚ and appeared to be associated with poor outcomes.” What rate constitutes “concerning?” Nearly one-third. In the 10-month study, the researchers found that approximately 29.5% of intubated patients arrived at the emergency department (ED) with improperly placed ET tubes.

Those results are similar to those of research conducted by the University of Pittsburgh School of Medicine in 2006. In a detailed study of roughly 2,000 patients, the researchers found a 22.7% error rate associated with paramedic prehospital intubation.

These two studies, and a number of others, suggest that prehospital intubation may be adversely affecting patients due to misplaced or dislodged tubes, leading to subsequent inadequate oxygenation and ventilation management. Such findings and expert commentary should serve as a wake-up call to all prehospital providers. We shouldn’t be concerned that a procedure may be taken away, but rather that we’re performing a procedure with substandard skill. It’s time we all get on board to reduce the incidence of prehospital intubation errors and ineffectiveness.

Thus, the art of post-intubation management is born. Its principles will guide you in properly confirming tube placement and securing the tube to prevent inadvertent extubation and to ensure maximum tube efficacy. Additionally, implementing specific oxygenation and ventilation strategies will provide optimal therapeutic benefit to both hemodynamically compromised and head-injured patients. Individually simple; the applied sum of these principles is profound.

Confirm the Tube
No single technique is 100% positive proof of proper tube placement every minute we’re with the patient. But a mere hunch, suspicion or feeling is not adequate. Confirmation relies on assessing multiple parameters and weighing the validity of each. Don’t let one parameter sway you into believing a tube is good if all the other elements say it’s bad. Let’s look at a few commonly used parameters.

Direct visualization: This method provides an instantaneous value. It’s valid as long as you’re looking at it. Ever have the glottis squarely in your sights, slide the tube and look away at the last second? We have. You can watch the tube all the way in, withdraw the laryngoscope blade gently, and still drag the tube out of the glottis while removing the blade.

Tube depth: Measured at the incisors, a general rule of thumb is that the depth should be three times the tube diameter. For adult males, look for a depth of 21Ï23 cm; in adult females, aim for 20Ï22 cm. A change in tube depth is a good method to identify tube movement, but it doesn’t tell you if the tip of the tube has curled up and moved. You can secure the tube so well that you couldn’t pull it out with a come-a-long and a pair of vice grips, but just flex the patient’s head and out pops the tip of the tube.

Epigastric sounds (or the lack thereof): Listen for these sounds before lung auscultation. If you hear sounds, the tube is probably in the esophagus. If no sounds are noted, it means no air is entering the stomach. Sound quality is dependent on obesity, thoracic trauma, ambient noise, pregnancy and patient movement, as well as the provider’s skill, experience and equipment.

Breath sounds: Listen before you intubate. Are they the same or better after you dropped the tube? During the 2007 EMS Today Conference & Exposition, Bob Page, CCEMT-P, spoke in detail about capnography. He made a great point: We should listen to breath sounds to help judge bronchial placementƒnot for tube confirmation.

Listen bilaterally along the axillary line to ensure you have bilateral breath sounds. Again, sound quality can be affected by obesity, thoracic trauma, ambient noise, pregnancy, patient movement, provider skill and equipment. If the tip of the tube is above the glottis, you can still get breath sounds. You’ll also hear breath sounds if you’re doing proficient BVM ventilation.

Chest expansion: Visualize and palpate the chest. You should identify symmetrical rise and fall of the chest with each ventilation. Remember that Esophageal ET tube placement can cause chest movement. Also, remember that the quality of chest wall movement is affected by obesity, pregnancy, lung disease, chest trauma and patient movement.

Bag compliance: This tells us the ease with which the lungs expand when we ventilate. Simply put, if it’s easy to bag the patient, compliance is sufficient; if it’s difficult to bag the patient, you’ve achieved poor compliance. You should check compliance before and after placing the tube to identify any changes. We want consistently good compliance. A change in compliance may reveal an airway problem.

Increasingly better compliance may mean we’re doing a good job of opening the lower airway and ventilating the patient. But it can also mean the ventilation circuit has a leak somewhere. Is the tube disconnected from the BVM? Is there a cuff leak?

Increasingly poor compliance may indicate a dislodged ET tube, gastric distention, ET tube obstruction (due to blood, secretions, a tube kink or a patient biting the tube), an expanding pneumothorax, mainstem intubation, or that the patient is breathing against your ventilation attempts.

Esophageal detector devices (EDDs):These devices come in two styles: syringe aspiration technique and self-inflating bulb. Put the unit on the ET tube and withdraw the syringe or release the bulb. If the syringe draws easily or the bulb fills with air, the tip of the tube is presumed to be in the rigid trachea. If the syringe doesn’t easily withdraw or the bulb doesn’t inflate, the tip of the tube is presumed to be in the soft, flexible tissue of the esophagus or somewhere other than the trachea.

EDDs are inexpensive, and most studies have found them to be reliableƒwith 95Ï100% accuracy. However, false positives (i.e., the ET tube is in the esophagus but the bulb inflates) have occurred in patients with esophageal intubations who have been vigorously ventilated prior to using the EDD and in patients who have had BVM ventilation without cricoid pressure. False negatives (i.e., the ET tube is in the trachea but the bulb doesn’t inflate) have also occurred and are associated with a tube depth greater than 22 cm, obese or pregnant patients, a kinked ET tube, status asthmaticus, pulmonary edema, tracheal injury and bronchospasms. Despite the false positives and negatives, the EDD remains a good tool.

End-tidalCO: Measuring EtCO via capnography has truly become the gold standard in tube verification and the expected standard of care. San Diego Fire-Rescue Assistant Chief Criss Brainard noted during his session at this year’s EMS Today that it provides “objective, quantified and documented proof.” This objectivity is established via a numerical value with breath-to-breath waveforms that can be used to verify ET tube placement and guide ventilation rates. It also provides documentation to back up your assessment and action.

False readings occur on rare occasions. False positives (i.e., when the ET tube is in the trachea, but no EtCO is detected) are associated with operator error, sensor contamination, unit calibration, cardiac arrest with poor CPR, pulmonary embolism, severe asthma and pulmonary edema. False negatives (i.e., the ET tube is not in trachea but EtCO is present) have been linked to operator error, sensor contamination, unit calibration, hypo-pharyngeal intubation (supraglottic tube placement) and severe gastric distension.

Patient status: How is your patient doing? How are the vital signs? There’s always a case when the patient gets worse regardless of your actions. However, in most cases, the patient should get better, or at least not deteriorate.

Endotracheal tube verification is a collection and assessment of multiple factors. Don’t let one sign convince you to leave the tube in place when everything else is saying “no.” Not sure of the placement? Pull the tube and bag ’em at the very least.

Secure the Tube
How much time did you spend last year training to place a tube? And how much time did you spend training tosecure the tube? We do a disservice to our patients and our profession when we think our job is done once we drop the tube. Typically, we move an intubated patient four to five times before we turn over care to hospital staff. Moving the patient is one of the prime opportunities to lose a tube. Let’s see what we can do to lessen that chance.

You’ve successfully inserted the ET tube through the glottic opening. Now start securing the tube. Before withdrawing the stylette, manually pin the tube against the upper incisors and inflate the cuff. This technique will lessen the chance of moving the distal tip of the tube while withdrawing the stylette.

An anchoring system has three components: the anchor (the patient’s head), the tube, and the anchor connection between the two. Anchor connections for securing endotracheal tubes in the field can be broadly classified into four groups: 1) adhesive tape, 2) cloth tape, 3) commercial devices and 4) homemade stuff.

Adhesive tape:Applied to the face and tube, adhesive tape is primarily used for pediatric patients. The act of taping is personal and more elaborate than origami, so we won’t try to convince you that one method is best. But we will share some tricks that have worked for us.

Tape doesn’t secure well in the presence of facial hair, blood, vomit, burns or any loose material on the face. So dry the skin and apply tincture of benzoine to help with adhesion. Of course, a towel and benzoine won’t remove facial hair and should not be used on burns.

Apply the tape to the maxilla. Wrapping the tape completely around the head (occiput) also works well. Anchoring the tube to a movable structure (such as the mandible) increases the chance of displacing the tube.

Determine the tube depth at the incisors and write it down before you start wrapping tape on the tube. It would also be prudent to leave the number at the incisors exposed so you can see it to check for movement. (Tip:Create a tab at the end of the tape by folding over the end of the tape on itself; this will make it easier to unwrap the tape from the tube.)

Cloth tape:Tie cloth tape (aka, twill or umbilical tape) to the tube, wrap it around the patient’s head and then tie the ends of the tape together. We were amazed to find more than 20 studies on which kind of knot to use; it was a tie between the girth hitch and clove hitch. If you’re not sure how to tie these two knots, check with a Boy Scout nearby.

Do not overtighten the knot on the tube; it can occlude it. This is especially true with the Endotrol Tracheal Tube and pediatric tubes. Use a bow (yes, a bow) to tie the ends of the tube together so it will be easy to untie the tape when necessary.

Commerical devices:In researching this article, we found more commercial devices than we thought could possibly exist. With that said, we won’t even begin to discuss individual devices. Some are excellent; others, not so great. The key is to know how to use what you have before you need it so you’re not pulling out the instructions in the middle of a call. You can use a variety of means to actually secure the tube to a commercial device. We find that clamps work best but, like cloth tape, you can overtighten the clamp and occlude the tube.

We like the fact that most commercial devices have some kind of bite block attached, because this is commonly overlooked. Unlike on an oral airway, the bite blocks on commercial devices are usually so short they don’t tickle the patient’s gag reflex. Speaking of bite blocks,use them. If you forget, your patient will remind you. An oropharyngeal airway (OPA) is good, but be gentle. Vigorous movement in the mouth can dislodge the tube.

One last note about commercial devices: Dutton’s Corollary states, “The chance of something actually working in an emergency is inversely proportional to the number of moving parts it has.” Simple is better.

Homemade stuff: Clinician-fashioned devices and techniques reveal highly detailed and personal contrivances, which can be ritualistic. ET tube security seems to bring out the inventor, the handyman, and the obsessive-compulsive in all of us. Some of the homemade or modified devices we’ve seen include wire, sutures, Velcro_, plastic tubing, molded rubber, tongue depressors, umbilical clamps, safety pins, rubber bands and cable ties.

Our favorite is IV tubing. We like the tubing from a 60-drop set. It’s easy to carry and virtually immune to blood, sweat, facial hair, vomit and rain. It works well when trauma results in poor facial structure.

Throw it on the tube with a girth hitch, slide the hitch to the lip, wrap the tubing around the patient’s head, and tie it off in a bow. However, it can be overtightened, so we don’t recommend it for Endotrol or pediatric tubes.

Secure the Patient
Forall intubated patientsƒtrauma or medicalƒapply a cervical collar and head blocks or use a specially designed head/airway immobilizer (see p. 53). This limits excessive head and neck movement. You will get questioning stares at the receiving hospital when you present an intubated medical patient with a collar and head blocks. But, if it keeps your tube in the right hole, who cares if they stare?

Also, secure the patient’s torso and hands. It doesn’t make much sense to strap the patient’s head down and let their body roll around. Self-extubation is common, so secure the patient’s hands below their waist. Sedatives and paralytics are poor replacements for properly securing a patient.

Provider-induced extubation is another top way to dislodge an ETT, especially when moving the patient. The best prevention is to slow down. Have one person manage the airway throughout the move. Verbalize this process so everyone is aware which person is in charge of each part of the move. Disconnect the BVM before moving the patient. If you need to ventilate, stop the move. Plan the move and ensure everyone knows the plan. Move slowly, and pay attention to what you’re doing.

Oxygenate & Ventilate
We briefly touched on capnography for tube confirmation. It’s also an extremely valuable tool for continued definitive tube confirmation as well as for guiding ventilation. Hyperventilation was for a long time the treatment of choice for all head-injured patients. Over time, however, it has proven to be an ineffective treatment modality for some head injuries.

When you hyperventilate someone, CO levels fall and cerebral vasoconstriction ensues. This vasoconstriction is great for head-injured patients exhibiting signs and symptoms of herniation syndrome, e.g., blown or unequal pupils, posturing or Cushing’s triad (i.e., decreased pulse and respiratory rate, increased systolic BP, and widened pulse pressure due to increased intracranial pressure). But for all other head-injured patients, the hyperventilation and subsequent vasoconstriction will unnecessarily reduce cerebral blood flow.

Also, remember that maintaining oxygenation should be your first priority. Specifically, you shouldn’t sacrifice SpO for EtCO levels. With that said, overzealous and uncontrolled hyperventilation shouldn’t occur. You should have set end-target EtCO values for head-injured patients with and without the signs and symptoms of herniation. Check with your medical director for numerical guidance.

Just as hyperventilation is out for all head injuries, so is the concept of hyperventilating intubated patients who are hemodynamically compromised. Those patients consist of post-arrest, multisystem trauma and those who are otherwise sick/injured and hemodynamically unstable.

For example, consider a patient who has been shot twice in the abdomen. His abdomen is becoming rigid and distended, and he’s hypotensive, tachycardic, cool, pale and diaphoretic. Your physical exam findings and baseline set of vitals indicate intra-abdominal bleeding. Because he has a GCS of 3 and an absent gag reflex, you correctly decide to intubate him to secure his airway. What now?

In addition to rapid transport and responsible fluid therapy, your treatment considerations should include a ventilation strategy that assists the patient’s inherent respirations at a rate and depth great enough only to maintain acceptable oxygenation.

Every consideration should be given to not inducing positive pressure ventilations. The positive pressure induced into the patient’s thoracic cavity would increase thoracic pressure and reduce venous return, worsening his already compromised hemodynamic status.

However, assisting his ventilations enough to maintain only oxygenation allows for his inherent respirations to continually apply negative pressure in his thoracic cavity. This negative pressure assists venous return and helps maintain the circulation the patient so desperately needs. The same physiological principle applies to the other subsets of patients mentioned as well.

Confirm the tube; secure the tube. Ventilate the patient; oxygenate the patient. Simple, but profound. Our job is done when the receiving physician accepts the patient with a thumbs-up to the tube. We hope to read journal articles in the near future that sing the praises of superb prehospital airway care. It starts with you. Do what’s best for your patientƒand strive to improveƒso the juice becomes worth the squeeze.

Charlie Eisele, BS, NREMT-P, is a flight paramedic and state trooper. He has been an EMS and technical rescue instructor for more than 26 years and serves as an airwayinstructorfor the R Adams Cowley Shock Trauma.

Jimmie Meurrens, BS, NREMT-P, has been a paramedic for 10 years and is a flight paramedic for the Maryland State Police, Aviation Command.

Learn more from Charlie Eisele at the EMS Today Conference & Expo, March 2-6 in Baltimore.


1. Bledsoe BE. “Research review: More doubt about paramedic endotracheal intubation”.www.merginet.com.

2. Wirtz DD, Ortiz CA, Newman DH. “Rate and outcomes of unrecognized esophageal placement of endotracheal tubes by paramedics in an urban emergency department”. Academic Emergency Medicine 2004;11:591-592.

3. Wang H, Lave J, Sirio C. “Errors in prehospital endotracheal intubation (abstract)”. Prehospital Emergency Care 2006;10:107-108.

4. Di Bartolomeo S, Sanson G, Nardi G. “Inadequate ventilation of patients with severe brain injury”. European Journal of Emergency Medicine 2003;10:268-271.

5. Williams KN, Nunn JF. “The esophageal detector device: A prospective trial on 100 patients”. Anaesthesia 1989;44:412-414.

6. Zaleski L, Abello D, Gold MI. “The esophageal detector device. Does it work?”. Anesthesiology 1993;79:244-247.

7. Paris BL, Flaxman A, St_rmann K. “The insecure airway: A comparison of knots and commercial devices for securing endotracheal tubes”. Academic Emergency Medicine 2003;10:485-486.

8. Personal conversation with Richard Dutton, MD. R.AdamsCowleyShockTraumaCenter, 2006.


  1. Nice article. I can recomend a book for further reading, which is used as a textbook in certain South African higher education institutions: Manual of Emergency Airway Management by Ron Walls and Michael Murphy, 3rd Edition (ISBN 10: 0-7817-8494-8) (I have no interest in their sales).

  2. Magnificent goods from you, man. I have understand your stuff previous to and you’re just extremely magnificent. I actually like what you’ve acquired here, really like what you’re stating and the way in which you say it. You make it entertaining and you still take care of to keep it sensible. I cant wait to read much more from you. This is really a wonderful website.

  3. Great article! I will have my paramedic students read and post their thoughts. Love this website!
    Patrick Currie

  4. Very interesting article. I just completed a Difficult Airway Class. If you ever have the opportunity to attend one, you will find that all of your points are covered very well. I don’t think you can ever over train in any skill. We are taught to check five ways to determine proper airway placement and we are taught to use a c-collar with a securing device to help insure the tube stays in. I like the assessment, reassessment to ensure nothing has changed. I agree that our job doesn’t stop with tube placement…it’s a continuous process.

    I think it is real easy to become complacent and not keep up with skills and current trends in education. I like the suggestions on what you have found works for you. It’s always nice to learn how others do things that can make my job easier.

    Keep up the good work and I look forward to more information coming from the two of you…thanks for taking the time to do some research and sharing with the rest of us…

  5. These are all essential skills that we all need to utilize to protect this valuable tool. If we don’t fix something in the way we operate we are going to lose ETI as an option. I feel that ETI should be a skill that each paramedic should have to earn, Either through continuing education, confirmation of competency at frequent intervals, live intubation in OR, or a combination of them all. If there was a system like that in place I feel that out numbers would improve significantly.

  6. This was a great article. I am a paramedic student and I really enjoyed reading all about the opinions of others on how to secure the tube and how very important the post management of this amazing skill really is. I do feel that it should not be lost and as an advocate for my patient I still think paramedics need this skill today and to take this away can be very tragic for some of our patients. Thank you so much for such a good article and interesting read.

  7. I am a student in Patrick Currie’s paramedic class at Laramie County Community College in Cheyenne, WY. I thought that the article was informative. Our class just recently completed a difficult airway course and the idea of securing the tube was rarely mentioned. I especially liked the paragraph about verifying the tube by the state of your patient (ie. are they improving and not getting worse). I think that this is overlooked as a way to verify that your tube is in the right place and that your bagging is adequate. From what I have learned so far, paramedics rely on all sorts of technology when the best indicator, your patient, isn’t utilized enough. I agree with the “standard of care” ETCO2, although I didn’t realize that there were so many false positives associated with it. False positives like this are the reason we need to verify placement with multiple different techniques, (visual, misting in the tube, epigastric and lung sounds, color change, as well as ETCO2). The article suggests that the bulb syringe and aspiration devices are 95-100% effective in verifying tube placement. I’m not sure that I as a prehospital provider will find any truth to that, but I plan on testing those devices. All in all, this article was a good read and I hope to see more like it in the future.

  8. As a paramedic student I found this article extremely helpful. We are being trained to intubate patients at a time when it is very controversial. Learning how and when to intubate is of the utmost importance. I found the different techniques of securing an ET tube interesting. I would have never thought to use IV tubing. Our local service uses manufactured devises but it is important to have a backup plan. I also found the concept of using a C-collar and back board to further secure the tube and the patient very helpful. Thank you for a very informative and well written article.

  9. Good article. Definitely a good review of tube confirmation. I thought the inclusion of the patient’s status in tube confirmation was was a good point. Using changes in the patient’s clinical condition to add to the assessment of a properly placed tube goes hand in hand with treating the patient, not the monitor. I also thought the reminder about the drawbacks of positive pressure ventilation, namely the decreased venous return was good. A reminder that for every intervention, both the risks and benefits should be assessed. I think it is unfortunate that there are so many undetected esophageal intubations in this day and age. I also find it unfortunate that most of the research on prehospital intubation seems to be focused on the outcomes in systems that have such high rates of esophageal intubation, instead of the outcomes in systems which perform to much higher standards. Research could then be conducted to identify what makes those agencies so successful and test whether it could be extended to those with lower success rates.

  10. The main thing that jumped out in this article was the question of how much time is spent learning to get the tube vs how much time is spent securing the tube. I see a lot of times that the tube is put in place during training and then the securing of it is verbalized. Sometimes the securing devices don’t fit manikens, other times they aren’t available. Since, the issue in incorrectly placed tubes seems to stem from the tube moving more times than not,I would agree that this ‘skill’ could be practiced more often. The five different methods used to check that a tube is in the right place is typically done after initial placement. It is not something that we think about after the tube is placed and we are riding in. Taking that extra 15-30 seconds for reassessment may save lives and bring those incorrect placement numbers down a few points. I do not agree that intubation is a skill that needs to be removed from the scope of practice. It is one that can do a lot of good for a lot of people. If there are better or faster methods of securing an airway, then EMS should move that way. However, if this is the best that is out there, we need to stick with it.

  11. I like that this article doesn’t dwell on low statistics and what EMS is doing badly, but recognizes there’s a problem and talks about what we can do to fix it. I think now that using ETCO2 is pushed by the AHA it will become more of a staple when intubating and hopefully can help improve numbers.

  12. I am currently a paramedic student but have worked on an ambulance for two years as an EMT basic. To run into a situation where intubation can save a life and not have that scope as a paramedic I think will be devastating. To have this skill is important for “that call” where the patient is most in need. Yes there are other skills that can help the patient like an LMA but ultimately an intubation can save a life. As paramedics we need to keep this skill up to date and practice like its the real situation or we will lose the skill and make mistakes which is just bad for the entire profession as a whole. I work in a rural area and to be able to intubate for that call that is 60 miles from the hospital can make a huge difference. I hope to keep this skill in the paramedics scope of practice with all the new technology we have to make sure the tube is in the proper place we should be making fewer and fewer runs with the gut tube. Its a very improtant skill and should be respected as such.

  13. Very Interesting article. I just completed a difficult airway course and the first part of a capnography course. Both courses covered your article points very well. I don’t think you can over-train on any skill. We have been taught to check for tube placement five ways and that using a c-collar can help keep the tube in place. Your point of assessment and reassessment is well taken. Tube placement is just one step in insuring a secure airway and proper ventilation of the patient.

    With any skill, it is easy to become complacent. At this point in my education I can’t imagine not keeping up on intubation skills. However, I can certainly understand how it can happen since I have been lured into a false sense of security with other skills I have used for years.

    Thanks so much for sharing your tricks to make things easier. Love the use of the IV tubing to securing the tube.

    I enjoyed your article…look forward to more.

    Coleen King

  14. Apples and Oranges, apples and oranges, apples and damn oranges. ETI is the “gold standard” of airway management and definitely belongs in the realm of prehospital airway control. The fact that one locale had problems with under-trained paramedics not managing an airway should not be used to condemn the practice of ETI or the role or paramedics providing airway management. This argument has been floated by various and different factions for a decade or two. The fact that no major policy change in prehospital ETI is due to cooler heads prevailing and the obvious, repeated, demonstrated need for ETI. Think how often ACLS has changed in the last 10 years. It’s hardly recognizable from the mid 1990’s. If prehospital ETI was so “problematic” it would have been changed to a “doctors only” skill.

    If a deficiency is identified in a particular skill the training standards should be changed. Perhaps the problem is that most paramedics only intubate once a year during clinical skills check offs and then only under ideal conditions with a manikin that has been so used it could almost intubate itself. More clinical skill stations more often or mandatory ETI on live patients in ERs or ORs would be one suggestion.

    More training in this critical and under utilized skill is what is required.

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