# No airway



## EMTIsee (Oct 29, 2014)

Recently we responded to a call with two I's and one basic. Cardiac arrest with CPR in progress 5 min prior to EMS arrival. Regular intubation was attempted twice unsuccessfully, followed by the combitube. we attempted four combitubes, unsuccessfully despite our attempts. The pt. had vomited requiring suction; improper placement of tube made vomit keep coming. Packing the air way full of vomit and blood "reason for failed further intubation. Finally an oral airway was placed and a BVM used. Pt. got little to no air. All other protocols for cardiac arrest where fallowed. Pt. was shocked with no success, and sadly didn't make it. What did we do wrong with this call?


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## CodeBru1984 (Oct 29, 2014)

Your post is kind of confusing in regards to the exact sequence of airway management attempts. Did you attempt endotracheal intubation right off the bat, or did you attempt to use a BLS airway first. Either way, I would have utilized a BLS airway (OPA) first and foremost, and possibly considered utilizing a supraglotic airway (King LT-D) if I felt it could benefit my patient. I cannot really armchair quarterback this call however as I wasn't there.


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## Chris07 (Oct 29, 2014)

So it took you 2 failed intubations and four failed combitube attempts before you went to a BLS airway? How much time elapsed?

Maybe we do it differently here, but BLS airway management is the first thing we do. Then as everything else gets done we start thinking about an advanced airway. The fact that you went straight for an advanced airway is not what really bugs me, but it's the fact it took the time of 6 attempts to finally fall back on a BLS airway technique.


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## EMTIsee (Oct 29, 2014)

CodeBru1984 said:


> Your post is kind of confusing in regards to the exact sequence of airway management attempts. Did you attempt endotracheal intubation right off the bat, or did you attempt to use a BLS airway first. Either way, I would have utilized a BLS airway (OPA) first and foremost, and possibly considered utilizing a supraglotic airway (King LT-D) if I felt it could benefit my patient. I cannot really armchair quarterback this call however as I wasn't there.


I am sorry for being unclear on the sequence. The BVM,(OPA) was being used first,  the advanced methods where then used. The number of attempts for the advanced methods where done because of vomit. In between the attempts a BVM (OPA) was used to keep some ventilation. The other I was doing Io, drugs,and shock. The EMT-B did compression's. The ambulance was driven By another units partner that arrived after we did.


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## EMTIsee (Oct 29, 2014)

Chris07 said:


> So it took you 2 failed intubations and four failed combitube attempts before you went to a BLS airway? How much time elapsed?
> 
> Maybe we do it differently here, but BLS airway management is the first thing we do. Then as everything else gets done we start thinking about an advanced airway. The fact that you went straight for an advanced airway is not what really bugs me, but it's the fact it took the time of 6 attempts to finally fall back on a BLS airway technique.



I felt the BLS airway technique was not working. It was pushing vomit out the nose. Please tell any tips that will help me provide better care in the future.


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## Chris07 (Oct 29, 2014)

EMTIsee said:


> I am sorry for being unclear on the sequence. The BVM,(OPA) was being used first,  the advanced methods where then used.


Ok, that's kind of important since the way the original post was written made it sound like you went for an advanced right off the bat and tried 6 times before even attempting to use BLS airway techniques.



EMTIsee said:


> I felt the BLS airway technique was not working. It was pushing vomit out the nose.


How well was suctioning being done? How often?
I mean it can get messy that's why good aggressive suctioning is really important.
Like @CodeBru1984 said, none of us were there so it's really hard to give decent feedback.


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## EMTIsee (Oct 29, 2014)

Chris07 said:


> Ok, that's kind of important since the way the original post was written made it sound like you went for an advanced right off the bat and tried 6 times before even attempting to use BLS airway techniques.
> 
> 
> How well was suctioning being done? How often?
> ...


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## NomadicMedic (Oct 29, 2014)

EMTIsee said:


> What did we do wrong with this call?



You didn't effectively manage the airway. At all. Seems pretty straightforward.

Tell us why you had so much difficulty with the BIAD. 4 unsuccessful combitube attempts should result in remediation.


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## EMTIsee (Oct 29, 2014)

DEmedic said:


> You didn't effectively manage the airway. At all. Seems pretty straightforward.
> 
> Tell us why you had so much difficulty with the BIAD. 4 unsuccessful combitube attempts should result in remediation.


.               The trouble was caused by the the tubes. Becoming clogged.


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## OnceAnEMT (Oct 29, 2014)

EMTIsee said:


> .               The trouble was caused by the the tubes. Becoming clogged.



Which shouldn't be an issue (just a geyser) if the combitube is being placed correctly. In all seriousness, were the balloons being inflated at all?

All of the above said, further difficulties would be avoided be thorough, quality suctioning. People don't just continuously vomit; they either finish or it manages to stay down.


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## EMTIsee (Oct 29, 2014)

Grimes said:


> Which shouldn't be an issue (just a geyser) if the combitube is being placed correctly. In all seriousness, were the balloons being inflated at all?
> 
> All of the above said, further difficulties would be avoided be thorough, quality suctioning. People don't just continuously vomit; they either finish or it manages to stay down.


Yes balloons where inflated all the way.


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## NomadicMedic (Oct 29, 2014)

EMTIsee said:


> Yes balloons where inflated all the way.



If you had multiple intubation attempts followed by FOUR unsuccessful BIAD attempts, you're in need of retraining. Sorry to be blunt, but there it is. 

Managing a nasty airway is difficult on the best of days, but blaming the equipment or the patient's presentation for your failure is the coward's way out. 

Admit that you were ill prepared to manage that airway and get some additional training. SLAM is a great airway workshop that's offered around the country. Some time with a great instructor and a puke filled airway manakin will give you a better appreciation for how to really get on top of those crummy airway calls.


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## EMTIsee (Oct 29, 2014)

Thank you, Yes I have come to terms with the facts. I was ill prepared and under experienced for the airway. I will DEFIANTLY, get more training for this. Excellent patient care is my top priority.


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## VFlutter (Oct 30, 2014)

Do you guys not have NG/OG tubes?


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## Christopher (Oct 30, 2014)

DEmedic said:


> If you had multiple intubation attempts followed by FOUR unsuccessful BIAD attempts, you're in need of retraining. Sorry to be blunt, but there it is.



Retraining how? And on what? Did they not follow an algorithm appropriately? Or are you saying an inability to ventilate by any means is a failure in training? What recourse do EMT/AEMTs have when BLS and ILS airways fail? They can't cut to air.

Let's say they continued chest compressions throughout this whole ordeal while working to secure an airway.

Is it so hard to believe that suctioning would fail to clear an airway? Yankeurs aren't exactly known as the best means of clearing true emesis.



DEmedic said:


> Managing a nasty airway is difficult on the best of days, but blaming the equipment or the patient's presentation for your failure is the coward's way out.



Coward's way out? A combitube is the biggest piece of sh*t I've ever seen (besides an EOA). I'd blame that every day of the week and twice on Sunday.



DEmedic said:


> Admit that you were ill prepared to manage that airway and get some additional training. SLAM is a great airway workshop that's offered around the country. Some time with a great instructor and a puke filled airway manakin will give you a better appreciation for how to really get on top of those crummy airway calls.



Ill prepared for this airway? Yes. Ill prepared to manage any airway is a bit overblown. Find for me a crowd of EMS providers and I'll show you a crowd of folks statistically likely to be poor at managing airways. The sole constructive bit I've seen in this thread is the advice to take an airway workshop or to practice removing emesis from a mannequin.

No need to dog pile on the person for coming here and asking what they could have done different/better.


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## Christopher (Oct 30, 2014)

EMTIsee said:


> Recently we responded to a call with two I's and one basic. Cardiac arrest with CPR in progress 5 min prior to EMS arrival. Regular intubation was attempted twice unsuccessfully, followed by the combitube. we attempted four combitubes, unsuccessfully despite our attempts. The pt. had vomited requiring suction; improper placement of tube made vomit keep coming. Packing the air way full of vomit and blood "reason for failed further intubation. Finally an oral airway was placed and a BVM used. Pt. got little to no air. All other protocols for cardiac arrest where fallowed. Pt. was shocked with no success, and sadly didn't make it. What did we do wrong with this call?



The trick to a failing airway is to have a good plan for what to do next. In cases where you have an obstructed airway due to emesis your plan needs to be "remove the obstruction". If you have multiple crews there try and get multiple suction units. If they're in cardiac arrest, get some fingers in there and get to scooping. Your Yankeur will not keep up, believe me. You can also take the tip off and just use the plain ole suction tubing. You can also use a meconium aspirator and an 8.5mm tube to make a massive suction tube if necessary.

If your combitube is continually failing due to emesis, try advancing it a bit further than usual in the hopes of really seating it well in the esophagus. Check for lung sounds over each tube, when you've identified the tube that is flowing from the esophagus pump up its balloon and then kink off that tube/tape it down. Suction the other tube, confirm ventilation w/ capno and lung sounds. You can even place the suction tubing directly to the extra tube. Ultimately in these cases you need that esophagus occluded or the vomit tide stemmed.

I'm a big fan of planning for failure, and use the Vortex approach as my mental model. You are going to have failures, and these are not the end of the world. You're not a horrible person, you're probably not even horrible at your job. EMS lacks the necessary training and education to effectively manage the multitude of situations we find ourselves in. The best thing you can do is (1) identify the problem, (2) acknowledge the problem, and (3) work to fix the problem. Guess what, you're here asking for advice so you're already going down that road.

I'm sorry you got torn a new one for attempting to come out better for your patients next time.


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## NomadicMedic (Oct 30, 2014)

Christopher said:


> Retraining how? And on what? Did they not follow an algorithm appropriately? Or are you saying an inability to ventilate by any means is a failure in training? What recourse do EMT/AEMTs have when BLS and ILS airways fail? They can't cut to air.



I'm saying that SIX failed airway attempts is piss poor patient care anyway you slice it. Do you think that cramming a combi tube in on attempt number 3 is going to deliver any different results than the first 2 failed attempts? If your answer is yes, you need retraining. (Do you think trauma from repeated CombiTube insertion attempts might have been what "packed the airway full of blood..."?)



> Is it so hard to believe that suctioning would fail to clear an airway? Yankeurs aren't exactly known as the best means of clearing true emesis.



As I said, managing a messy airway is difficult, but certainly not impossible. Did they truly AGGRESSIVELY, CONTINUOUSLY suction? I don't know, and neither do you. Can this person place an OG/NG tube? However, from the description, they seemed WAY more focused on obtaining an advanced airway than actually MANAGING the patient. An airway course, as I mentioned, would have taught some triucks like using a merconium aspirator and how to suction a misplaced tube while leaving it in place. 



> Coward's way out? A combitube is the biggest piece of sh*t I've ever seen (besides an EOA). I'd blame that every day of the week and twice on Sunday.



Did you ever hear the expression, "Blame it on the rain?" Not my fault. The equipment was didn't work. Not my fault, the airway was clogged with puke. Not my fault, the trachea was really anterior. Not my fault, the tube must have moved. Not my fault... and on and on. Guess what? It's the FAULT OF THE PROVIDER. It's our job to manage these patients. Not only the ones with a dry, Class I Mallampati... but the puke filled, difficult to ventilate patients too.



> Ill prepared for this airway? Yes. Ill prepared to manage any airway is a bit overblown. Find for me a crowd of EMS providers and I'll show you a crowd of folks statistically likely to be poor at managing airways. The sole constructive bit I've seen in this thread is the advice to take an airway workshop or to practice removing emesis from a mannequin.



Don't be obtuse. The advise in this thread is take an airway course and own the issue. The OP couldn't manage the airway. It's plain and simple. And you know as well as I do, the agencies that provide continuing education on airway management have statistically higher first pass intubation success rates. Education is the key...


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## Christopher (Oct 30, 2014)

DEmedic said:


> Don't be obtuse. The advise in this thread is take an airway course and own the issue. The OP couldn't manage the airway. It's plain and simple. And you know as well as I do, the agencies that provide continuing education on airway management have statistically higher first pass intubation success rates. Education is the key...


Berating folks on the internet is the strangest form of education I've ever seen.


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## Carlos Danger (Oct 30, 2014)

You don't know what you don't know.....and you can only do what you know how to do. 

This is exactly what happens when you tube the goose and ventilate it, or use a BVM to insufflate the belly. Unfortunately, this type of scenario is not at all uncommon and is exactly why there is so much discussion about the state of prehospital airway management.


In this scenario:

The harsh reality is, suction won't always keep up with these vomit volcanoes, especially the portable units. Increasing the diameter of the suction device by replacing the Yankauer with an ETT may help, but often it won't because the tubing diameter hasn't changed, and you haven't actually increased the suction any. It's worth a try I suppose, but I wouldn't hang my hat on it. Also, OG tubes don't help much either when things are that bad - they are even smaller than suction tubing.

If the patient were not in cardiac arrest in thus in need of continuous chest compressions, the best thing to do is simply turn them onto their side into the recovery (or "lateral recumbent") position and suction them that way....unfortunately you didn't have that option in this case.

Use two suctions.....one held by an assistant, the other by the operator who is trying to secure the airway....use 3 if you have them. 

Cric pressure is worth a try as an attempt to slow the emesis, but it probably won't help much. 

You can also press on the abdomen (NOT while doing cric pressure) to try to expel most of the stomach contents quickly, and THEN suction aggressively and place an OG to minimize pressurizing the gut further during mask ventilation. 

Blindly intubate the esophagus with the largest ETT you have and use it to divert some of the vomitus. 

If you can place the patient in fairly steep trendelenburg while doing these maneuvers, it may help minimize aspiration.
Bigger picture:

DEmedic is correct that you need more training. It's definitely not just you, it's the vast majority of us; it's to your credit that you recognize it. Take a course, read about airway management, practice as much as you can.

Christopher is right, too - you need to approach airway management with a systematic plan that you have practiced over and over and over on manikins. I also like the Vortex approach that he mentioned, but really any simple, systematic approach is much better than just winging it.

I personally feel strongly that the newer LMA's (ProSeal, Supreme; my favorite is the Air-Q) are far better than the Combitube (and probably the King).....if you can talk your company into investing in those, it would probably be an improvement.

The best approach to airway management in cardiac arrest for non-expert intubators, IMO, is to drop an LMA and then an OG tube (and place it to suction) during continuous compressions, and then ventilate with low pressures, synchronized as well as you can with the compression. This won't work in everyone, but it will in many and will probably greatly reduce vomiting during airway management and reduce interruptions in compression. At that point you can then intubate through the LMA, if you need to. Now, if you are really the shiznit with a laryngoscope and a tube and you can consistently place tubes in one attempt with compressions ongoing, then great. But if we are being honest, there aren't many of us who can do that.


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## Brandon O (Oct 31, 2014)

Christopher said:


> Berating folks on the internet is the strangest form of education I've ever seen.



One of my biggest frustration as a new provider was when I turned to the Web, which I'd always relied on for self-education - -  and which did have a large community of EMS professionals - - but whenever I asked a question, I'd get long diatribes from grumpy medics about the sorry state of our training, yet no actual answers. In other words, people really like to point out what's missing but don't want to take the time to fix it. 

Obviously in an ideal world these things would be taught more systemically and universally, but it's not an ideal world (as I suspect we all know) and until then motivated learners should be helped, not told to read a book or whatever (at least not without recommending the book!).


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## SeeNoMore (Nov 4, 2014)

I am always grateful for advice from other EMS folks but I don't worry about the harshness of criticism. In my mind it should not matter. I should be my own harshest critic. This does not mean giving up when a mistake is made. All of us have made errors or realized there was an area of our practice that could be improved.  Try to be as agressive and comprehensive with your education as possible. It is far better to avoid a bad call by education than be forced into learning from your mistakes.


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## DesertMedic66 (Nov 4, 2014)

That's why I always carry a wet shop vacuum and a silver spoon on these types of calls.


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## Kevinf (Nov 4, 2014)

I'm with Jeff on this one. EMS is taught to be afraid of suctioning. I'm sure I'm not the only one to get the "no more than 15 seconds and don't go too deep" lecture in class. And unless your patient is able to close their lips around the suction tip to create a seal, the suction units are not going to be terribly effective regardless. Any device that increases the efficacy of suctioning is welcome in my book.


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## jwk (Nov 8, 2014)

Chase said:


> Do you guys not have NG/OG tubes?


For what? (in this particular case)


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## VFlutter (Nov 8, 2014)

jwk said:


> For what? (in this particular case)



Decompress the stomach and place it on continuous suction.


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## PFDEMT (Nov 22, 2014)

DEmedic said:


> I'm saying that SIX failed airway attempts is piss poor patient care anyway you slice it. Do you think that cramming a combi tube in on attempt number 3 is going to deliver any different results than the first 2 failed attempts? If your answer is yes, you need retraining. (Do you think trauma from repeated CombiTube insertion attempts might have been what "packed the airway full of blood..."?)
> 
> 
> 
> ...








*IM WITH THIS GUY!!!!         ^^^^^^^^^^^^^^*


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## jwk (Nov 22, 2014)

Kevinf said:


> I'm with Jeff on this one. EMS is taught to be afraid of suctioning. I'm sure I'm not the only one to get the "*no more than 15 seconds and don't go too deep*" lecture in class. And unless your patient is able to close their lips around the suction tip to create a seal, the suction units are not going to be terribly effective regardless. Any device that increases the efficacy of suctioning is welcome in my book.


??? I think that refers to suctioning an ETT, not the oropharynx.


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## jwk (Nov 22, 2014)

Chase said:


> Decompress the stomach and place it on continuous suction.


Why?  (just trying to get you to think about why you're doing something - BTW I've never dropped an NG/OG during a code)


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## Gurby (Nov 22, 2014)

jwk said:


> ??? I think that refers to suctioning an ETT, not the oropharynx.



OHHHHHHHHHHHHhhhhhhhhhhhhhhh!  They either never specified that during my training, or I forgot about that important detail...



jwk said:


> Why?  (just trying to get you to think about why you're doing something - BTW I've never dropped an NG/OG during a code)



Because we are F terrible at mask ventilation and will likely put a bunch of air into the stomach.


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## gotbeerz001 (Nov 22, 2014)

Gurby said:


> OHHHHHHHHHHHHhhhhhhhhhhhhhhh!  They either never specified that during my training, or I forgot about that important detail...
> 
> 
> 
> Because we are F terrible at mask ventilation and will likely put a bunch of air into the stomach.


So be better. 
It's far preferable to do it right than create additional work-arounds.


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## gotbeerz001 (Nov 22, 2014)

jwk said:


> ??? I think that refers to suctioning an ETT, not the oropharynx.


That refers to the oropharynx using rigid suction (as well), but lets think realistically:
If you have vomitus in the oropharynx, no advanced airway and you hit the 15 second mark... Are you really going to start ventilating again and create an obstruction??

The take-away is to do it right but but don't waste any time doing it.


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## Gurby (Nov 22, 2014)

gotshirtz001 said:


> So be better.
> It's far preferable to do it right than create additional work-arounds.



How in the world do you expect an EMT-B to simply "be better"?

I just finished a week in the OR for medic clinicals, managed ~40 patients under perfectly controlled conditions with an attending anesthesiologist standing over my shoulder telling me what to do, and my airway skills are still poor.  I was talking to a friend of mine who is a 2nd year anesthesia resident about it and he said even mask ventilation is an art and that he still has a lot to learn.  How can you expect an EMT-basic who just learned "make a 'c' and don't squeeze too hard" in class to do a good job?

I think really the only way to improve at this is practice on real patients (or maybe cadavers if that were somehow possible?  dummies just don't cut it...) and feedback from someone who knows what they're doing.  Most EMTs are not going to get much of either of those things.


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## gotbeerz001 (Nov 22, 2014)

^^^ So find opportunities to do that. To make a blanket statement such as "we are F terrible at mask ventilations" is frustrating; we are not all "F terrible" at mask ventilations and if your skills are weak, find a way to improve them. That is what I mean by "be better".

I don't expect an EMT-B to be able to drop an NG tube, either. If you need to use a medic to get any tube, may as well be an ETT.


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## jwk (Nov 22, 2014)

Gurby said:


> OHHHHHHHHHHHHhhhhhhhhhhhhhhh!  They either never specified that during my training, or I forgot about that important detail...
> 
> 
> 
> Because we are F terrible at mask ventilation and will likely put a bunch of air into the stomach.



  So then you're going to try and mask someone with an NG/OG in the way and messing up your seal?


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## Gurby (Nov 22, 2014)

jwk said:


> So then you're going to try and mask someone with an NG/OG in the way and messing up your seal?



Well it sounded good on paper anyways... Maybe the answer truly is just "be better"...


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## gotbeerz001 (Nov 22, 2014)

We can always "be better".


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## Carlos Danger (Nov 22, 2014)

Gurby said:


> *How in the world do you expect an EMT-B to simply "be better"?*
> 
> I just finished a week in the OR for medic clinicals, managed ~40 patients under perfectly controlled conditions with an attending anesthesiologist standing over my shoulder telling me what to do, and my airway skills are still poor.  I was talking to a friend of mine who is a 2nd year anesthesia resident about it and he said even mask ventilation is an art and that he still has a lot to learn.  How can you expect an EMT-basic who just learned "make a 'c' and don't squeeze too hard" in class to do a good job?
> 
> *I think really the only way to improve at this is practice on real patients (or maybe cadavers if that were somehow possible?  dummies just don't cut it...) and feedback from someone who knows what they're doing.  Most EMTs are not going to get much of either of those things.*



I completely agree with this.

Airway management is a skill that takes practice and experience that most of us just don't get enough of in school or after.

We do need to seek opportunities to improve our skills, of course. But as hard as one tries, those opportunities can be really hard to come across. Asking about techniques and tricks ("work arounds", I guess) that might make it easier is entirely legit.

I don't agree that OG tubes are the answer in most cases - nor is stuffing as many airways adjuncts as we can fit, as was asked in the another thread on a similar topic.

But they are both perfectly reasonable questions. Talking about this stuff is part of the process of getting better.


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