Medical Education, Airway

Pay No Attention to the Intern Behind the Curtain: Tips for Success on Your Anesthesia Rotation

Endotracheal intubation is one of the most high-stakes and critical procedures we as emergency physicians perform; one study found that 4.2% of emergency department intubations resulted in a cardiac arrest.1

It is now standard for most emergency medicine residents to learn this skill in the operating room under the guidance of anesthesiologists and certified registered nurse anesthetists (CRNAs). Because there are fundamental differences between airway management under emergent and elective settings, it is easy for an EM resident to become flustered and perhaps even frustrated while working in these environments. This article will summarize some tips and tricks for EM interns which can be used to maximize their experience on their anesthesia rotation.

Recognize and appreciate the differences between anesthesiology and EM
It doesn’t take long to realize that anesthesiologists are generally much more cautious than emergency physicians. Many EM trainees, myself included, have been perplexed when told we should “probably just watch this one” when a patient in the OR was undergoing a rapid sequence intubation (essentially the only means of performing intubation in the emergency setting). While this difference in attitudes may be attributable to the personalities attracted to each specialty, it is important to recognize that the history of anesthesiology is also a contributor.

While undergoing anesthesia today is very safe, this has not always been the case. A landmark study published in 1954 by Beecher and Todd found that anesthesia-related deaths occurred in 64 out of every 100,000 procedures.2 At that time, this was more than twice the mortality associated with polio in the United States. In the decades since, intense research efforts in the field of anesthesiology have reduced the mortality risk of anesthesia from 1 death per 1000 operations in the 1940s to 1 in 10,000 in the 1970s, and then to 1 in 100,000 in the 1990s and early 2000s.3 These numbers help put into perspective the heavy emphasis on patient safety in the field of anesthesia, which has led to clearly better patient outcomes. With that in mind, it seems perfectly reasonable that an anesthesiologist would be wary around EM residents fresh out of medical school with only a few intubations under their belt. While you will likely find some anesthesiologists who are very patient with learners, don’t take it personally if you are (gently) shoved aside during an intubation attempt in the operating room.

I’ve found one of the best ways to gain the trust of anesthesiologists is to clearly communicate with the supervising physician or CRNA. Richard Levitan, a leading expert on emergency airway management, describes the “mystique of direct laryngoscopy.”4 While thought to be a relatively straightforward procedure, given the inherent limitations of direct laryngoscopy (only the operator has a clear view of what the laryngoscope reveals), trainees are often restricted to learning this technique via “trial and error” as more experienced supervisors are limited in their ability to coach them through troubleshooting maneuvers when the glottis cannot be visualized.

I’ve found that clearly verbalizing what I see during intubation goes a long way toward mitigating these limitations. During each intubation attempt, I systematically call out each airway structure I see as I advance my blade in the patient's mouth: “I see lips, I see teeth, I see tongue, I see soft palate, I see uvula, I see tonsils, I see epiglottis… and I see cords.” I’ve found this strategy to put my supervisors at ease and make them more willing to allow me extra time to troubleshoot when I am unable to obtain an adequate view of the vocal folds. In addition, I believe this methodical and deliberate identification of airway structures has aided me in orienting myself during my more difficult intubations in the Emergency Department.

Now that I am about halfway through my 3-year residency, I have performed more than 100 intubations. However, if you include every intubation I’ve rehearsed in my head, that number would be around 10 times higher.

Visualization is a popular strategy employed by many athletes (including legends such as Muhammad Ali and Billie Jean King), though its effectiveness is not limited to sports. This technique translates to any motor skill or procedure, including intubation. One study showed that performing mental exercises of finger abduction (with no physical exercise) increased finger strength by 35%, compared to no increase in the control group.5 When it comes to skill acquisition, the power of the mind can go a long way.

Be the anesthesiologist!
Scott Weingart of the EMCrit podcast says in the show's inaugural episode that emergency physicians should “stop thinking like a surgeon and start thinking like an anesthesiologist.”6 His point is that EM doctors should be able to perform any task in their department without the help of auxiliary staff (eg setting up a BiPAP machine, adjusting drip rates on IV infusion pumps, placing OG tubes, etc). I wholeheartedly agree with this sentiment. While nurses, emergency technicians, and respiratory therapists are vital members of our team, we as emergency clinicians should be self-sufficient resuscitationists. One of the best ways to learn the skills necessary to be one is alongside anesthesiologists.

While it is easy to fall into the mindset that an anesthesia rotation is meant to “get your numbers,” it is crucial to realize that there is much more to proper airway management than placing the “tube in the hole.” Evaluating an airway, properly positioning a patient, performing bag-valve-mask ventilation, and placing a supraglottic airway are all indispensable skills that can and should be learned in the operating room under the guidance of an airway expert. In addition to airway management, the OR is a great setting to learn how to set up and adjust IV infusion pumps, place peripheral IVs (without ultrasound), and even attach a patient to the monitors. I’ve found that displaying an interest in learning all of these skills, as opposed to solely focusing on intubation, goes a long way toward earning the trust of anesthesiologists.

It’s OK if you miss
In the popular children’s show Adventure Time, Jake the Dog shares a salient piece of wisdom: “Dude, suckin’ at something is the first step to being sorta good at something!” I’ve found few other quotes to be as relevant to airway management, and medicine in general.

While emergency intubation has been shown to be highly successful,7 achieving a high success rate takes time. One study found the success rate of anesthesia residents to be below 50% within the first 10 intubation attempts, and a mean of 57 intubation attempts was required to reach a 90% success rate.8 Moreover, 18% of the residents required assistance even after 80 intubation attempts. So if you find yourself floundering during your first week, rest assured that you will improve. What’s more, even the best of us will encounter an airway we have difficulty with, even after we are considered to be “competent.” When it comes to airway management, humility is key. Success is not final, and failure is not fatal.

Airway management is a crucial skill for emergency physicians. While you may encounter ups and downs during your anesthesia rotation, have patience and faith in your training. With deliberate practice and dedication, you too will master this essential and esoteric skill.


  1. Heffner AC, Swords DS, Neale MN, Jones AE. Incidence and factors associated with cardiac arrest complicating emergency airway management. Resuscitation. 2013;84(11):1500-1504. doi:10.1016/j.resuscitation.2013.07.022.
  2. Beecher HK, Todd DP. A study of the deaths associated with anesthesia and surgery: based on a study of 599, 548 anesthesias in ten institutions 1948-1952, inclusive. Ann Surg. 1954;140(1):2-35. doi:10.1097/00000658-195407000-00001
  3. Li G, Warner M, Lang BH, Huang L, Sun LS. Epidemiology of anesthesia-related mortality in the United States, 1999-2005. Anesthesiology. 2009;110(4):759-765. doi:10.1097/aln.0b013e31819b5bdc
  4. Levitan RM. The mystique of direct laryngoscopy. Respir Care. 2007;52(1):21-23.
  5. Ranganathan VK, Siemionow V, Liu JZ, Sahgal V, Yue GH. From mental power to muscle power--gaining strength by using the mind. Neuropsychologia. 2004;42(7):944-956. doi:10.1016/j.neuropsychologia.2003.11.018
  6. Scott Weingart, MD FCCM. EMCrit Podcast 1 – Sympathetic Crashing Acute Pulmonary Edema (SCAPE). EMCrit Blog. Published on April 25, 2009. Accessed on March 10th 2021. Available at [].
  7. Brown 3rd CA, Bair AE, Pallin DJ, Walls RM, NI Investigators. Techniques, success, and adverse events of emergency department adult intubations. Ann Emerg Med 2015;65:363–70, e1.
  8. Konrad C, Schüpfer G, Wietlisbach M, Gerber H. Learning manual skills in anesthesiology: Is there a recommended number of cases for anesthetic procedures?. Anesth Analg. 1998;86(3):635-639.

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