Trending Topics

ESD11 clinical spotlight: Airway quality initiatives

Novel use of video laryngoscopy with recording capability to improve clinical oversight in EMS airway management


Increasing emergency department data suggests that video laryngoscopy should be first line for emergent airway management.


By Casey Patrick, MD, FAEMS; Jordan Anderson, Dustin Yates, Pandora Peckne, Dana Hogue and Brandi Richardson

Paralytic-assisted airway management is a high-risk prehospital procedure. Increasing emergency department data suggests that video laryngoscopy should be first line for emergent airway management. Historically, EMS airway registries and data collection have been limited to post-procedural forms and chart/monitor review, which leaves a “black box” around what the prehospital clinician actually visualizes during the procedure. Prehospital utilization of video laryngoscopy (VL) with recording capability allows significantly greater insight into the chronology, choices, and obstacles encountered during paramedic intubations.

Staffed by around 300 paramedics and supported by multiple regional first-responder organizations, Harris County ESD11 Mobile Healthcare (ESD11 MHC) is a publicly funded 911 provider covering about 170 square miles just north of Houston. ESD11 MHC answers more than 60,000 calls a year.


ESD11 MHC has only existed for approximately two years and came online as a true startup EMS agency. So, a comprehensive airway management quality review program has been a focus from service conception. We absorbed paramedics from local, national and international locations with a tight educational timeline prior to initiating patient care. Due to these uncommon and restrictive constraints, our clinical team prioritized the ability to review all intubations to allow active re-education and paramedic feedback.

The UEScope video laryngoscope was chosen due to its auto-recording capability. Our team also elected to task the clinical and logistics teams with retrieving, reviewing and archiving the video files. These were not the responsibility of the treating paramedic, nor were they linked to the chart. With all the start-up considerations, additional hurdles to providing patient care were consciously avoided. Airway videos were deemed a part of the protected quality process for educational and feedback purposes only and not ultimately linked to the patient care record. We realize there may be varying approaches to these decisions based on service-specific needs and leadership.

Lessons learned

Those with channeled blade backgrounds will take slightly longer on the uptake. Paramedics who arrived at ESD11 from services with channeled blade utilization needed additional training to develop adequate UEScope dexterity.

Stress the “50/50 view.” Throughout the history of direct laryngoscopy, our holy grail has been the 100% POGO view. However, when using any variant of hyperangulated blade geometry, a “50/50 View” is often ideal. Half of the VL screen should be epiglottis and half vocal cords. This potentially counterintuitive position allows easier passage of the bougie and ETT through the cords.

First … do no harm. ESD11 elected to remove metal/rigid stylets from the airway supplies after reviewing multiple video files with the stylet tip protruding past the endotracheal tube. This led to the addition of a malleable bougie with a copper insert, allowing hyper-angulated geometry to be maintained during the entire intubation attempt.

Quality review keys

As with any new technology, terminology and descriptors evolve and develop as the product gains user experience. Weingart et al. recently addressed this issue related to VL laryngoscopy recordings by describing 13 common errors consistently noted in emergency department airway quality review [2]. Our quality team has noted six especially common EMS errors that warrant mention and consistent educational emphasis and review:

  1. Midline
  2. Anatomy
  3. Suction
  4. Bougie
  5. Tube
  6. Camera

Maintenance of midline insertion seems quite apparent, but many intubation attempts were much more difficult due to offset blade insertion. This must be a constant focus for paramedics throughout the procedural attempt. Recognition of anatomy is also key. This starts with the tongue and rapidly progresses to the epiglottis, concluding with visualization of the vocal cords prior to bougie/tube insertion. Suction use should occur early, and liberally as excess gastric or pulmonary fluid can foul the camera quickly.

VL4 (1).png

“Paralytic-assisted airway management is a high-risk prehospital procedure,” writes Patrick.


Passage of the bougie and the endotracheal tube (ETT) through the vocal cords is not a given, even with an excellent glottic view. The tube can hang up on the arytenoids and the bougie on the first tracheal ring. Both barriers can be countered with a 90-degree twist. Additionally, if the glottic structures are still too anterior, external manual laryngeal manipulation can help better align airway structures for ETT/bougie passage.

Lastly, it is imperative that clinicians leave the camera in place through the completion of the attempt to allow visual confirmation to accompany continuous waveform capnography, the gold standard for definitive ETT confirmation.

Data and Future Aims: ESD11 VL with Recording Capability Quality Initiative

Our objective was to describe the airway timing along with contamination degree, suction use, and first-pass success (FPS) rates in a single, high-volume, urban, ground-based EMS agency. This cohort study investigated all adult ESD11 patients who underwent VL from Jan. 15, 2022, to June 1, 2023. A delayed sequence intubation protocol utilizing ketamine and rocuronium with the preferred cardiac arrest airway being a supraglottic device and VL as a backup was in place throughout the study period. Video recording was automatic and did not require paramedic action. An attempt was defined as the laryngoscope blade passing through the teeth. Attempts for tube verification, along with missing and uninterpretable data, were excluded. Standard demographics, airway contamination grade (clear, light, moderate, severe, or obstructed), suction use, time in the airway, and FPS were calculated.

What we found

A total of 115 video files were initially reviewed. 11/115 (10%) were excluded (5 = tube verification, 5 = uninterpretable data, and one missing data file). Eighty patients, resulting in 104 video files, were included in the final analysis. Patients had an average age of 61 years (19-91) and had a slight male predominance, 45/80 (56%). Most airways, 75/104 (72%), were clear or had only light contamination. Nineteen/104 (18%) and 6/104 (6%) were moderately or severely contaminated, respectively. Three/104 (3%) were obstructed entirely. Twenty-three/104 (22%) cases utilized suction. The median overall time in the airway was 43 seconds, with a 37 and 52-second median for successful and unsuccessful attempts. FPS was achieved in 56/80 (70%) of cases.


In this cohort, paramedic median airway time was less than one minute, less than one-quarter were significantly soiled, and suction was used appropriately. Additionally, prehospital VL with recording capability allows for increased clinical oversight, more accurate data collection, and specific paramedic skill feedback. Limitations include the retrospective nature and single agency data source.

Summary points

  1. “50/50 view” necessity should be a critical educational foundation.
  2. Our experience with a rigid stylet has been poor, leading to a transition to a malleable bougie option only.
  3. Feedback and education are difficult without a common language/taxonomy.
  4. Primary EMS errors occur related to off-midline initiation, lack of suction, missed anatomy, bougie and/or tube introduction problems, or early camera retraction.
  5. Data capture, insightful analysis and course correction are vital to any quality initiative.

Watch for more: On-Demand Webinar: Plan C: Navigating the difficult airway


  1. Prekker ME, Driver BE, Trent SA, et al; DEVICE Investigators and the Pragmatic Critical Care Research Group. Video versus Direct Laryngoscopy for Tracheal Intubation of Critically Ill Adults. N Engl J Med. 2023 Aug 3;389(5):418-429.
  2. Weingart SD, Barnicle RN, Janke A, et al; Resuscitationists Research Group. A taxonomy of key performance errors for emergency intubation. Am J Emerg Med. 2023 Nov;73:137-144.

About the authors

Casey Patrick is the medical director for Harris County ESD 11 Mobile Healthcare and assistant medical director for the Montgomery County Hospital District EMS in greater Houston.

Jordan Anderson is the chief of quality at ESD11 Mobile Healthcare

Dustin Yates is the professional development manager ESD11 Mobile Healthcare.

Pandora Peckne is the clinical practice manager ESD11 Mobile Healthcare.

Dana Hogue is a quality coordinator at ESD11 Mobile Healthcare.

Brandi Richardson is an education coordinator ESD11 Mobile Healthcare.

Dr. Casey Patrick is medical director for Harris County ESD11 Mobile Healthcare and assistant medical director for the Montgomery County Hospital District EMS service in Greater Houston, where he helped develop and produces the MCHD Paramedic Podcast. Dr. Patrick is board certified in both Emergency and EMS Medicine and works as a community emergency physician in multiple states. Additionally, he is an active member of the Texas NAEMSP State chapter and the national association, and serves as an EMS1 Editorial Advisory Board member.