This post is unique as it is a submission in the

Second Great EMS What-if-We’re-Wrong-a-Thon.

In this blogging event, a group of EMS bloggers play devil’s advocates with themselves. It’s not because they like to pick fights with themselves. Rather they seek humility via an unusual process.

Entrenched in something so deep that one can’t imagine it any other way? That’s just the thing Brandon Oto, coordinator of the What-if-We’re-Wrong-a-Thon, challenged us to question.

In the post that follows, I attempt to convince myself that video laryngoscopy is superior to direct laryngoscopy. Having only used direct laryngoscopy, I have been slow to accept that it could (or should) be done any other way. I’ve had success with direct laryngoscopy and simply haven’t seen the need to impose technology onto the process.

A pitch for Video Laryngoscopy (to myself):

Video laryngoscopy should be used for all first-attempts at placing endotracheal tubes in the out-of-hospital environment.

Until recently, video laryngoscopy (VL) has primarily been used only after attempts at direct laryngoscopy (DL) have failed.

VL has been a tool for saving an airway when DL fails. So, why not use VL from the beginning?

So why are we resistant to switch to VL?

Technology can fail, but we have a backup plan.

Worry 1: Technology can fail.

Technology can fail on DL as well. DL depends on working batteries and bulbs. Paramedics mitigate these risks by checking their laryngoscopes and carrying extra batteries and bulbs. And so it can go with the video laryngoscope. Risks exist and steps are taken to mitigate those risks with redundancies as we always have with our clunky, stainless steel, pre-1950s, laryngoscopes. Additionally, esophageal airways sit proudly in the tool box as an option anytime attempts at endotracheal intubation fail. We have a plan b, c, and heck, even d when it comes to airway management.

Worry 2: The view is easily obscured when fluids contact the camera.

This is the most legitimate concern I’ve heard. In order to mitigate this, medics are learning to suction well prior to introducing their blade. Check out this technique of aggressive suction to prevent obscuring the camera.

Honestly, if the fluids are flowing faster than suction can keep up, DL may be a better choice here. And yet with direct laryngoscopy, as blood or vomitus soil the airway in this copious way, we are still looking for bubbles at best.

Worry 3: Because there are different kinds of video laryngoscopes, it is hard to educate the technique to a standard.

I wonder if the same was said for Macintosh and Miller blades when they were introduced. Did they wonder if people would not be able to toggle between the two “technologies?” Having educated paramedics on techniques for both curved and straight blades, I’ve seen first hand that they have the capacity to differentiate techniques for the tool in their hand.

Worry 4: If a medic only performs video laryngoscopy, they will forget how to intubate with a direct laryngoscope.

Paramedics don’t have sufficient number of field intubations to maintain reliable proficiency in either VL or DL. To compensate for this, they practice on manikins and cadavers. Using field intubations as a mechanism to maintain proficiency is a fallacy from the start. The skills can only be maintained via repetitions on a manikin where both VL and DL can be reinforced.

Now that we’ve gotten some worries eased, let’s look at how

absolutely great it is

to be an intubator in the age of video laryngoscopy.

Take these representative pictures for starters.

Not bad:

View via Direct Laryngoscopy

Now compare that to this gorgeous image:

View via Video Laryngoscopy


And if that’s not good enough, add on that you and your partner can simultaneously view the procedure.

Intubator: “Confirming those are the cords”

Partner: “Yep, those are the cords.”

Throw in the ability to take a picture or video to document the passing of the ETT between the cords and that’s a heck of a pitch.

Nice pictures but is there any evidence to support that VL is better than DL?


Jarvis, JL, et al. EMS Intubation Improves with King Vision Video Laryngoscopy. Prehospital Emegency Care. 2015;19(4):482-9.

In this out-of-hospital study, there is significant improvement of both overall success and first-pass success using video laryngoscopy as compared to direct laryngoscopy.

Link to podcast discussing this study

My notes from the PHARM (Prehospital and Retrieval Medicine) Podcast


This study shows impressive results. If these are replicated, it looks fairly clear that Video Laryngoscopy is an intubation game-changer much the way capnography has been.

This concludes my pitch to myself. Perhaps you think about VL differently now as well. Or maybe you were already there with video laryngoscopy but there is another topic that you are absolutely certain you are right about. Don’t be so sure. Go have a little argue with yourself first.

Other entries in the Second Great EMS What-if-We’re-Wrong-a-Thon cover topics like community paramedicine and emergency response times. I applaud these authors for a job well done.





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