Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

The Upside Down, in a Ditch, During a Tornado Intubation

Whenever pathetic intubation success rates are discussed, this complex, almost impossible intubation becomes one of the excuses for the low intubation success rates.

The problem with the example is that we are supposed to assume that intubation is the right thing for this patient.




How hypoxic are we trying to make the patient?

How long are we trying to delay extrication?

If the patient needs an airway right now, why are we messing around with an endotracheal tube, rather than using our heads?

Don’t we have more important things to do that stroke ourselves in public?

This article presents a case in which an air medical flight crew encountered a potentially difficult airway when a trauma patient deteriorated in-flight.[1]

Also a difficult situation.

The crew elected to sedate and paralyze the patient and place a laryngeal mask airway without a prior attempt at direct laryngoscopy and endotracheal intubation.[1]

They didn’t even try?

This is the end of intubation. How are paramedics supposed to have self respect, if one of our own is going to stab us in the back, like this?

We aren’t supposed to be doing what is right for the patient, but doing what is right to make sure that nobody ever takes our tubes away.

How are we going to be able to BS people with the upside down, in a ditch stories?

Sure, they do happen.

Rather than look at them as examples of great intubation skill, we should look at them as demonstrations of a need for remediation.

Next time, we should think about what is best for the patient, rather than what will make a good war story – at least a good war story for people who don’t understand patient care.


An endotracheal tube is not significantly more secure than other airways, nor does it do a great job of keeping detritus out of the lungs.

The term Rapid Sequence Airway (RSA) is coined for this novel approach. This article describes and supports this concept and provides definitions of alternative and failed airways.[1]

One sad part is that this was considered such a novel concept only five years ago.

A much sadder part is that this would still be novel in many places.


[1] Rapid Sequence Airway (RSA)–a novel approach to prehospital airway management.
Braude D, Richards M.
Prehosp Emerg Care. 2007 Apr-Jun;11(2):250-2.
PMID: 17454819 [PubMed – indexed for MEDLINE]