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AIRWAY MANAGEMENT needs to be done. What Cormack-Lehane view is seen? If it's a grade 3 or 4, get your bougie and use your airway helper to facili- tate visualization and try again. Have your partner monitor the patient's oxygen satura- tion continually. As long as he's above 90%, you are fine. Kelly: Define the roles of your rescuer posi- tions in the pit crew. For an example, see Table 2. Once RSI/DSI is ready to be performed, all team members shift to their right. The airway assistant moves to patient's right shoulder to assist with intubation by doing external laryngeal manipulation (ELM), lip retraction, holding the bougie, tube and suc- tion, and so forth. The team lead moves to head and intubates. The IV starter moves to left shoulder and calls out EtCO 2 readings, heart rate and SaO 2 readings. Airway management, and especially intu- bation, is a team sport, but over the years the role of those team members has evolved. Long ago the Sellick's maneuver (posterior cricoid pressure) was applied by an assistant to limit gastric distention and facilitate visu- alization of the vocal cords, and that evolved into external laryngeal manipulation. The primary differences between Sellick's and ELM are the structures manipulated and the presence of coaching by the laryngoscopist. In Sellick's maneuver, the assistant simply pressed down on the cricoid cartilage. In ELM, the assistant applied pressure to the thyroid cartilage itself, in response to coach- ing by the laryngoscopist on how much and where to apply pressure. This technique was widely known as BURP (backward, upward, rightward pressure). It was thought that BURP could improve the laryngoscopic view in difficult intubations by at least one Cormack-Lehane grade. In more recent studies, BURP was found to worsen POGO (percentage of glottic open- ing) scores by 35%. In comparison, Sellick's worsened those scores by 29%, and biman- ual laryngeal manipulation worsened the visual POGO score by only 4%. 4 In bimanual laryngoscopy, rather than coaching an assistant in applying the neces- sary external laryngeal manipulation, the laryngoscopist simply applies that pressure himself with his right hand until an optimal view of the glottis is achieved. The assistant then maintains pressure at that location, freeing the laryngoscopist's right hand to place the tube. If the assistant applies lip retraction to the right corner of the patient's mouth with his free hand, the procedure can be even more effective at achieving visualization. Jason: Bimanual laryngoscopy is just one of many reasons to make airway manage- ment a team sport, not only in the perfor- mance phase but in the practice phase. The last place you want to be teaching an EMT bimanual laryngoscopy is when your favor- ite blade and ideal positioning aren't quite giving you the view you need. Even with a top-notch team in place, there are still things that can go wrong. Many of the complications of RSI aren't spe- cific to RSI alone, since they stem from the same places as other intubations: potential for tube dislodgement, insufficient sedation and so on. (On the other hand, some compli- cations are less likely: a paralyzed stomach can't regurgitate.) The worst thing that can happen is not getting an endotracheal tube in. You should be able to avoid this most of the time with excellent airway positioning, as Kelly mentioned, but if you do airways often enough, you'll eventually end up with someone you just can't tube. At that point you have to go to a backup—which could be either a supraglottic airway or a cricothy- roidotomy. This is where your drug choice becomes extremely important. Traditionally, the etomidate/succinyl- choline combination was used because if you failed an airway, you could just bag the patient for a couple of minutes and be back to breathing. That's fine for a semi-elective OR procedure but not really applicable to emergency medical practice; if you could just back off and try something different, you probably shouldn't have done RSI in the first place. That's why I recently switched TABLE 2: PIT CREW ROLES AND POSITIONS Airway assistant Positioned at patient's head, positions airway and begins preoxygenation technique/apneic oxygenation. Team lead Positioned at patient's left shoulder and readies the RSI kit, draws up medications. IV starter Positioned at patient's waist on left side. Obtains vascular access via tibial IO or peripheral IV in the left arm. Gives sedative as soon as vascular access is established (if certifed to push medications). Positions monitor at patient's waist, facing head so all team members can see screen. 54 OCTOBER 2015 | EMSWORLD.com ABOUT THE AUTHORS William E. "Gene" Gandy, JD, LP, has been a paramedic and EMS educator for over 30 years. He has implemented a two-year associate degree paramedic program for a community college, served as both a volunteer and paid paramedic, and practiced in both rural and urban settings and in the offshore oil industry. He lives in Tucson, AZ. Steven "Kelly" Grayson, NREMT-P, CCEMT-P, is a critical care paramedic for Acadian Ambulance in Louisiana. He has spent the past 22 years as a field paramedic, critical care transport paramedic, field supervisor and educator. He is a frequent EMS conference speaker and author of the book En Route: A Paramedic's Stories of Life, Death, and Everything In Between and the popular blog A Day in the Life of an Ambulance Driver. Jason Kodat, MD, EMT-P, has been in EMS for more than 15 years. He has reviewed EMS textbooks and the USFA's EMS Medical Director Handbook, and lectures at regional EMS conferences regularly. He currently works as an emergency physician and associate EMS medical director at hospitals near Pittsburgh, PA.