One of the big hurdles to doing a surgical airway is the actual decision to do it. The decision needs to be made, then communicated, and transformed into prompt action.

A French article published Feb 2011 in Annales Françaises d’Anesthésie et de Réanimation looks at adherence to difficult airway algorithms. The authors look at the descision-making involved in a can’t intubate can’t ventilate (CICV) training scenario when they should be abandoning laryngoscopy in favour of a surgical airway. And that decision seems to be a difficult one.

This article demonstrate how, in a training scenario, 10 of 24 emergency physicians needed a hypoxic cardiac arrest as a hint before actually proceeding to an emergency surgical airway.

14 of 24 correctly proceeded to a surgical airway in the 2 minute window given from when ventilation became impossible to the hypoxic arrest.

They were all trained emergency physicians who knew what they were supposed to do in a CICV situation. And this was just a training scenario. Still, almost half of them failed to act when shit hit the fan. It shows the importance of being prepared for those quite rare, but quickly fatal events that can occur in our line of work. You need to not only think through the events briefly, but to play them out in your personal simulator – your mind. Not just go through the steps in a broad sense, but go through every detail of the event and procedure. When to intervene, where to get the necessary equipment, what to do. Visualise the whole thing. So if something like this ever happens, you’ll be prepared, and you will act.

Cricothyrotomy in emergency context: assessment of a cannot intubate cannot ventilate scenario – (Cricothyroïdotomie en situation d’urgence : évaluation d’un scénario dynamique associant intubation et ventilation impossibles), Ann Fr Anesth Reanim, 2011.

Cliff Reid, consultant emergency physician, retrieval specialist and supervisor of training at Sydney HEMS writes a great blog at and has an excellent post on this topic and making things happen. Go read it: It’s up to you….

This entry was posted in Airway management, Anesthesia, Emergency Medicine, Prehospital Medicine and tagged . Bookmark the permalink.


  1. Minh Le Cong says:

    Hi Thomas! Great article to highlight.Must admit , am not surprised by the results. You need to be an airway kung fu practitioner, friend! I bet you if you surveyed the doctors who actually DID decide to proceed with a surgical airway, most of them would have some background in the fighting arts. Bruce Lee taught : adapt to your opponent! Why persist with techniques that are failing. There are no rules!

    • Thomas D says:

      Yeah, I found it interesting. The decision. How to make it happen. And why it often doesn’t happen. It’s really something I would like to learn more about, as it’s pretty much overlooked in doctor training – but an incredibly important skill. Especially in any field that involves critical patients, but also in everyday work when things seem to be standing still around a patient, and you see the need for an intervention or a change of direction. How to make that happen. I loved your piece on airway kung-fu, and will continue to keep Bruce Lee in mind! Bruce Lee will spice up any teaching session! Almost more so than a rubber chicken.

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