My friend and all-around incredible guy, Rich Levitan, speaking on the Surgical Airway.
Update:
- See here for the EMCrit take on Surgical Airway
-
Subsequent to publication of the podcast, Rich Levitan received this letter:
Rich,
I met you about 4 years ago and we had talked about airway training as you can see in the email below. First off I would like to thank you for your presentation at SOMA (or SOMSA) 2013. It was enlightening for me and I appreciated the discussion.
I am writing you about an airway lecture that you gave in a 2014 conference which was subsequently posted on EMCrit as podcast 119. Although the lecture was excellent, I would like to bring two small inconsistencies about the video portion to your attention:
1) Just for the sake of clarity, the soldiers featured in the video were actually from the 101st airborne, which is a conventional airborne unit staged out of Ft Campbell KY and they were performing operations in Afghanistan. These are not Special Forces soldiers and in fact, are not affiliated with Special Operations at all. The medics in the video received entry level medical training at Ft Sam Houston, home to AMMED. The scope of their training is relatively narrow in comparison to that of the Special Operations Medic.
The majority of Special Operations medics are more familiar with the cricothyrotomy procedure and are competent/confident enough to perform it when the injury pattern dictates the need. In fact, the majority of the cricothyrotomies performed at the point of injury, in combat, are performed by SOF Medics and not by conventional medics. This is not to take away from the amazing work that Dr Bob Mabry has done with the entry level training at Ft Sam.
2) The injured soldier in the video is actually an Afghan soldier working alongside American Troops. This is not one of their buddies. This is not to say that bonds never get formed between American Troops and the members of the local population because they certainly do, but a safe assumption here might be that the provider and the casualty do not even know each other’s names.
I don’t know why I am so compelled to address this, maybe it is a little bit of foolish pride in my Special Forces lineage but nevertheless being a man of science I am sure you desire the same level of accuracy in medicine as you do in all things.
Thank you again for all the support, hard work and passion you bring to emergency medicine!
Rich Levitan's New Advanced Airway and Endoscopy Course
http://www.ceme.org/advanced-
Additional New Information
More on EMCrit
- Podcast 70 – Airway Management with Rich Levitan(Opens in a new browser tab)
- 10 Pearls from the Levitan Airway Course(Opens in a new browser tab)
- EMCrit 131 – Cricothyrotomy – Cut to Air: Emergency Surgical Airway
Additional Resources
You Need an EMCrit Membership to see this content. Login here if you already have one.
Professor
Nassau University Medical Center
No conflicts of interest (coi).
- EMCrit 396 – Some Philosophy of Surgical Airways (Crics) and What to Do When the Doom is Lower Down (Central Airway Obstruction) - March 7, 2025
- EMCrit 395 – Stellate Ganglion Block – Not Whether, but When? - February 23, 2025
- EMCrit 394 – CV-EMCrit – Inotrope Basics Part 2 – Specific Scenarios - February 7, 2025
Fascinating – by a process of convergent evolution, I use and teach exactly the same hand positioning and stabaisation as Rich!
Looking forward to sitting on the Airway Q&A with you chaps at SMACC
-John
Same with me, I heard him lecture and I’m like, “Shite, only took me 10 years to figure that out.”
awesome stuff! I have seen Richard give this lecture several times and each time he comes up with new useful advice!
About the scalpel bougie, we can chat about this at SMACCGOLD Airway forum. I dont think its as clear cut as we would like to believe ( excuse the nonintended pun!)
having done 7 scalpel-finger-bougies in real patients, I can say it is exactly that clear cut, but only if folks understand how to wield the tools in the way described. Variants can go horribly awry. What Rich describes as the cartilaginous cage is the key (excuse the alliteration).
Scott,the key is in the finger as part of the scalpel finger bougie technique. Variants can and do go horribly wrong. a common technique taught here is scalpel bougie with no finger use for tracheal lumen ID. it is, as Richard describes in his lecture..make a hole, keep scalpel in position and past the bougie! problem is false passage of bougie!
this paper by Griggs and Paix describe scalpel finger technique predominantly
http://onlinelibrary.wiley.com/doi/10.1111/j.1742-6723.2011.01510.x/abstract
think I just said that, brother. hence Scalpel-FINGER-bougie. If you don’t feel the cage, you are not where you think you are.
I have performed this in anger: there was blood and the patient was receiving chest compressions (PEA from gas trapping as airway occluded). This has implications for resting your hand on the sternum for stabilisation. It was not as technically difficult as I had expected. Finger in the trachea is key for knowing where you are. When I saw the cricothyroid membrane being repaired with three stitches by an ENT surgeon (after formal tracheostomy) I was surprised at how little tissue damage I had caused. When I teach this technique I emphasise the limitations of the models we use and… Read more »
great comment, Tony!
Excellent , detailed and timely info Dr Levitan. We just moved to a different Cric kit and we are reviewing the Adult Surgical airway with our practitioners.
First, let me say thanks for bringing Rich Levitan on. I always enjoy hearing what he has to say and hang on every word as if it was pure gold. I accredit him along with Walls, Murphy, Braude, and Weingart as truly helping me master the airway. With that being said I have to be a little critical of this cric approach. Watching the video of the procedure I saw a few potential procedural fail points and Rich completely miss-state the purpose of using the Bougie. The Bougie is not a magic tool that somehow helps you find the trachea.… Read more »
Ken,
I think you will like my SMACC lecture as I agree on pretty much every point. Awake cric is definitely an option though and ketamine alone is the way to go if you want the pt breathing during the cric (but yes, blood sprays everywhere–PPE)
this is all good commentary so thankyou. To Ken Davis, thankyou but I would suggest that the bougie should not replace the finger ID of the anatomy. Richard is wise and consistent with other experienced teachers in advising use of finger in this procedure. Using bougie to replace the scalpel sounds logical and easy but when your HR is 200 and there is blood everywhere, I know of at least 3 cases where the bougie is passed without a finger check and it goes into the neck tissues. When this happens,by all accounts, it can still feel as if it… Read more »
It was the size of the bougie that was considered unfeasible on the battlefield–at least that was what was mentioned to me when I spoke to Dr. Mabry about the issue. Hold-up was not something Rich was familiar with using when we last debated this, it was the lack of consistency with tracheal ring sensation with the bougie that I believe led to the superior design of the cric key (I have never, in 100’s of uses perceived tracheal rings with a disposable bougie). But hold-up past the notch cannot be a misplaced bougie.
Scott, like I said I am going to try to get these failed cases published as holdup sign was an issue in at least one of them. The problem is how do you know in a true stressful crisis that you pass the bougie pass the notch? sure you can measure but under duress this is going to be difficult to do and to know that you passed the bougie the length you measured it. The feeling tracheal rings with bougie sign is interesting as it shows the variance and unreliability of bougie signs in detecting tracheal placement! You say… Read more »
We’ve discussed this on the comments on your site: New bougie will be built with the distance to sternal notch colored red to avoid having to think–no red and hold-up is 100% confirmation. Able to pass red and finger felt the cage, 100% confirmation even without hold-up. The literature doesn’t put tracheal ring palpation and anywhere near the sens/spec to even suspect it is usable for confirmation. I’m not sure what that has to do with hold-up. The failed cases you mention, which I am eagerly awaiting the publication of, were almost certainly a perception of hold-up in the soft-tissues… Read more »
I have no issue with using bougie as an aid to passage of an airway. My only caution is using it when tracheal lumen is not Identified accurately. I suggest that using bougie holdup as surrogate marker of tracheal lumen is as yet to be proven as a reliable method.
You suggest its a better method but you need to clarify is that to pass an airway or to confirm you are in trachea.
if you are suggesting both, then I would request better proof in the setting of an emergency surgical airway
Awesome talk by Dr. Levitan! I can already tell this is a talk I’ll come back to again and again! I love how he emphasizes the mental part of the procedure and how you need to be ready. From all the fantastic work Levitan’s done, I feel almost heretic to even slightly disagree with the approach he shows. But here goes: I think there are too many instruments there, and not enough emphasis and use of the finger. All the instruments and steps shown are also part of what scares people, and could keep them from cutting the neck. I… Read more »
Exceptional episode.
Any info regarding when Dr Levitan’s Cric-Knife will be available for purchase?
very soon is all I can say. Getting FDA stuff through now, last time I asked him.
Minh, I do see your point with using your finger to identify the tracheal lumen but just as you have few cases of false passage, I have a few of the ET tube heading north effectively causing a complete airway obstruction. I think the Shiley pretty much eliminates this but it got me thinking. Maybe the procedure should be, scalpel, bougie in, finger to palpate the bougie being in the tracheal lumen, tube over bougie. I believe the main point that Dr. Levitan was trying to relay is that we need to be thinking about the cric before we need… Read more »