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Checklists: Simple but Overlooked Solution to Airway Complexities

Braude, Darren MD, EMT-P

Emergency Medicine News: May 2008 - Volume 30 - Issue 5 - p 16
doi: 10.1097/01.EEM.0000319592.77170.52
The Emergency Airway

Dr. Braude is an associate professor of emergency medicine at the University of New Mexico School of Medicine, the medical director of PHI Air Medical of New Mexico, both in Albuquerque, a co-director of the Emergency Airway Training Program at the University of New Mexico, and a co-director of the National Procedural Sedation Course (



I was working a flight shift last year when I noticed something, something routine but nonetheless noteworthy. We had just dropped a patient off at the hospital, and were about ready to return to our base. I was secured in my seat waiting for takeoff, casually observing the pilot run through his preflight checklist. Despite the fact that he had probably done similar routine takeoffs in this very same aircraft at this same helipad hundreds of times, he was meticulous.

Most of us take this for granted. We expect our pilots to use their checklists. We would feel less safe if they didn't. If you saw your pilot throw away her checklist as you boarded your next airline flight, would you stay on the plane?

The similarities to airway management in the ED could not be more glaring. Here we perform critical tasks (but not necessarily perform routinely) in a hectic environment, yet I have rarely, if ever, seen a physician use a checklist, although many probably have one in their pocket. Granted, some airway situations unfold way too quickly for a checklist.

The same is true for an engine failure in a helicopter. In these cases, you need to act from instinct. Most ED airway situations are more analogous to a routine takeoff than an engine failure, yet these are often the cases that go awry. I would guess that most bad airway outcomes do not occur with crash airways but with relatively routine ones, the ones most amenable to use of a checklist.

Since my observation last year, I have been suggesting to paramedics, flight crews, residents, and attending physicians that they carry and use a checklist whenever possible for rapid sequence intubations. The very word “sequence” suggests a series of steps that must be executed in a critical order, the perfect situation for a checklist. While I do not have any objective data, it appears to me that things run more smoothly and fewer steps are forgotten when residents actually use the checklist. Unfortunately, I still forget to remind them as often as I actually remember; it is difficult to retrain an old dog.

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Overcoming Stigma

Of course, there is a stigma to be overcome. Much like the perception that use of an alternative airway is somehow a failure, use of a checklist may give the uninitiated the appearance that the user is a novice. Both misperceptions can be overcome with education. Moreover, nothing gives one the appearance of being a novice like an airway gone bad. And really, are we trying to look good for our colleagues or do the right thing for our patients? Imagine a culture, like aviation, where it was the failure to use an available resource such as a checklist that looked bad to our colleagues.

Atul Gawande, MD, recently wrote about checklists for the Annals of Medicine series in the March 12 New Yorker. Dr. Gawande draws an interesting comparison with the U.S. Army Air Corps' experience with a crash of a B-17 prototype in 1935. Human error was determined to be the cause, specifically forgetting to release a flight control brake, which was in turn due to the increased complexity of these “new” aircraft that they were trying to fly the “old way” — that is, without a checklist.

In fact, checklists had yet to be introduced to aviation. Dr. Gawande noted, “Medicine today has entered its B-17 phase. Substantial parts of what hospitals do — most notably, intensive care — are not too complex for clinicians to carry them out reliably from memory alone. ICU life support has become too much medicine for one person to fly.”

There is actually a rudimentary body of literature examining the role of checklists in health care. One excellent review is by Hales and Pronovost (J Crit Care 2006;21:231), who stated, “Although pilots are expected to use professional judgment and critical thinking skills, they are provided with tools to aid them in recalling the masses of catalogued information at the appropriate time. If pilots are not expected to recall from memory each crucial step of their complex tasks, why is this required of clinicians who are also responsible for the lives of others?” I don't have a good answer.

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Airway 911: Rapid Sequence Intubation

  • Pre-oxygenate 100% 02 (no PPV unless hypoxic).
  • Place continuous recording pulse oximeter.
  • ▪ Not on same arm as BP cuff.
  • Protect c-spine manually (if indicated) with jaw thrust.
  • Pressure to cricoid (if PPV or when meds pushed).
  • Ponder.
  • ▪ Is this a code/near code? Attempt without RSI.
  • ▪ Does this patient really need to be intubated?
  • ▪ What is my flight time? Can I do this on route?
    • Are there other options to RSI? RSA? Awake?
    • Will this patient be difficult to intubate or bag?
    • Consult with patient, family, and physicians.
  • Prepare equipment/people.
    • Draw up all meds (RSI & postintubation).
    • Scope, blade, two tubes, stylette “straight to cuff” <35°.
    • Suction.
    • BVM and oral/nasal airways.
    • Capnography.
    • Means to secure tube.
    • Bougie.
    • Back-up airway: LMA, Combitube, or King.
    • Assignments (spine/jaw thrust, cricoid/ELM, meds, tube, sats).
  • Position patient: Sniffing routine if not in c-spine.
    • Ramped if obese: ear and sternal notch same level.
    • Hyperelevation of head if difficult airway.
  • Paralyze & induce.
    • Etomidate 0.3 mg/kg.
    • Rocuronium 1 mg/kg.
  • Pass tube with direct visualization/ELM.
  • Postintubation management.
    • Inflate balloon.
    • Confirm with ETCO2 and secure tube.
    • Replace cervical collar if indicated.
    • Ongoing sedation and analgesia +/− paralysis.
    • Midazolam 0.05 mg/kg if adequate BP.
    • Fentanyl 1 mcg/kg.
© 2008 Lippincott Williams & Wilkins, Inc.