FOAMEd review of intubation checklist research

Hi folks

You might have heard Tim Leeuwenberg and I had a debate regarding checklists and airway experts

His side of the debate is well summarised here on his excellent blog

I must say he debated very well and was the clear audience favourite. When Cliff Reid polled the expert panel on their opinion, here were the results.

Did they use airway checklists?
Dr Richard Levitan = NO
Dr Keith Greenland = NO
Dr Scott Weingart = YES

Anyway I was surprised since the debate that an Article in Press in the American Journal of EM came out on perintubation checklists!
Here it is

Impact of checklists on peri-intubation care in ED trauma patients

Key points about the study:
- retrospective, before and after analysis
-underpowered to show outcome differences
- RSI rates significantly more post checklist
- no significant difference in intubation attempts nor success
-no significant difference in haemdynamics nor oxygen desaturation rates with use of checklist
- Mix of anaesthesia and EM docs prior to CL , then 99% EM docs doing intubations post CL so potential confounder

I sent out a call to FOAMEd airway folks to review the is what they said!

Hi Minh

First glance:
Not clear when CL was used – either pre, during or post RSI
“CL” may have positive influence on post-intubation sedation, but underpowered to see if effects on LOS/mortality etc
Looks more like an audit of activity in a unit than a proper challenge-response checklist in a tightly-coupled procedure by trained personnel
Will cogitate and get back to you – unless want to share comments via G+?
Stil think the question of CL use is best answered by experts in human factors, not airway…perhaps ask James French too?
More importantly, is your wife allowing you to engage in another CL debate after the last fracas?
Cheers mate
Tim Leeuwenburg
Kangaroo Island
Twitter @KangarooBeach
And now from Dr Yen Chow in Canada!
I agree with Tim. 

I would argue that their intervention does not appear to be designed as a checklist to be used at the time of intubation, whether pre-intubation or immediately post intubation. The form appears to be designed as a quality audit form. The checklist items appear to be optional and are not challenge-response. The authors also agree that they cannot tell if the providers only used a portion or all of the form.  The “checklist” does not appear to engage the team in what the approach might be nor plan for failure. Given these design issues, it is highly suspect that this was used as an intubation checklist which in most practitioners’ minds would occur before intubation. It also leads me to wonder what was the education on the use of the “checklist” as well?

The effect of more RSI and more postintubation sedation observed after introduction of this audit might be attributed to an observer effect of the study itself.
Dr Yen Chow


Then this from Dr Peter Fritz, Melbourne

Hi Guys, 

Not much of airway/intubation checklist IMHO.
Lots of stuff missing
  • no mention of team
  • no mention of plan A
  • no mention of plan B/C/D etc
  • no mention of patient, equipment, optimisations etc
Not sure if this paper adds much to what we know about checklists in critical care.
Thinking about my favourite quote from The Checklist Manifesto: How to get things right by Gawande is:
“The checklist gets the dumb stuff out of the way, the routines your brain shouldn’t have to occupy itself with and lets it rise above to focus on the hard stuff ( i.e. Where should we land?)”
This checklist doesn’t do that.
Then the usual essay from Dr Nicholas Chrimes, Melbourne
Agree with all the previous comments. Overall this is a flawed “checklist” and a flawed study. A few specific points:

  • There is a major change in practice coincident with the introduction of the checklist with 1/3 of intubations being performed by anesthesiologists pre-checklist compared with almost 100% by EP’s post checklist. This kind of confounder would seem to make the impact of the checklist on the outcomes listed uninterpretable. Subgroup analysis of the EM vs anaesth data might have sorted this out but other than for the “increased RSI” outcome, this info has not been provided. Thus it may be that there were major changes in outcomes from the checklist within these groups that were negated overall by the concomitant change in the nature of the airway provider. This issue isn’t mentioned at all in the “limitations of the study” section.
  • There’s no definition of what a checklist is (I agree with Tim, what they’ve provided looks more like an audit tool), how it was used or how staff were trained to use it. The structure of the CL, timing of implementation and the nature of the training provided is crucial to the ability of a CL to have an impact. I’m not convinced they’ve properly implemented it or that it even constitutes what we would call a checklist.
  • Not only do we not know when the “checklist” was used the “intention to treat” format means that there’s no data provided that tells us if the checklist was EVER used. The discussion seems to imply that it was used but how often, when and to what extent is unclear. The reason many metrics showed no change might reflect the fact that the checklist was never used – or was used after the fact. I understand this is the point of “intention to treat” but it would have been nice to get some sense of whether the failure to produce a change in some of their outcome measures was due to failure to use the checklist.
  • I’m not sure their outcome measures are the right ones. Many of the metrics they’re looking don’t seem to be the sorts of things we are intending to address with checklists (eg. BP/HR changes, length of ED stay, days on a ventilator, etc). Given we all know that despite doing everything poorly it is still possible to have a reasonable outcome, I think assessment of CL’s requires more outcomes that assess process rather than outcome. For example if cricoid was intended but forgotten, the suction not connected or the spare laryngoscope not working – most of the time these things won’t matter anyway (especially the cricoid I hear you all say!). Assessment of checklists need to measure preparedness to deal with rare events, not just the outcomes – as without this if the rare event doesn’t occur with sufficient frequency during the study, no impact will be detected anyway). 
  • It’s also not clear what they’re defining as an “RSI” (PreOx? Use of sux? Use of cricoid? Mode of administration of drugs?) and thus whether this is significant. The fact that their RSI rate was only 75% pre-checklist seems a bit odd to me if the alternative was something other than a “modified RSI” and would seem to indicate an underlying education problem.  Again recognising that a patient needs RSI and remembering to implement it is not typically what you’d envisage a checklist being used for. It’s hard to see how this (their only positive finding) could be attributed to the checklist provided. 
To be blunt, I have to say that this study adds nothing to our understanding of the ability of checklists to impact on patient care.
Then Dr Richard Levitan, who needs no introduction.
well said by all; checklists “sexy” –but getting them right, useful, short, and actionable…aye, there’s the rub!

and they’re just one part of over engineering controls–i.e. make tools easily accessible, have things that work passively, deploy back-up/safety things in tandem, etc…..which just got me thinking—another beautiful thing about NO DESAT—it’s already in place before the missed attempt….i.e. its deployed in moment of calm, without operator having to remember it in crisis


Richard M. Levitan, MD
Airway Cam Tech., Inc.;
610-639-7706 (cell)
610-341-9560 (voice); 610-341-1866 (fax)
PO BOX 337 Wayne PA 19087

Practical Emergency Airway Course:

20 cadavers – Incredible imaging
Real tissue & Practical Approach
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Jackson Lake Lodge (WY) and Millennium Hilton (NYC)
And finally from Dr John Vassiliadis, Sydney
Dear all,

Happy Easter,
sorry for the delay in replying.. was busy with family things…
I agree with the comments already made, I think this was simply an audit of what they did and what effect having EM physicians have made to their department.
I think from what they have written you can not differentiate EM influence from their very basic checklist….
No discussion of how they came up with the checklist and how they agreed upon it  and how it was enforced.
Very small study.. not convinced it add anything to the debate.


Filed under: airway, FOAMEd, Online critical airway training Tagged: airway, checklists, FOAMed, review


This is not cricoid pressure. Courtesy of Richard Levitan

This is not cricoid pressure. Courtesy of Richard Levitan

CP poll 2014


Composite result of Yes and Sometimes = 41%!

Clearly at least amongst those who voted, there is division as to the role of cricoid pressure in RSI. Some think its standard, many do not.


Take home message : read the literature, understand the research and evidence. Be aware of what is considered standard and good practice in general amongst your peers and teachers. Make a decision for the patient before you , taking all this into account. Be true to that and we can figure out the rest later.



Filed under: airway, Emergency anaesthesia, Emergency medicine and critical care, FOAMEd, Online critical airway training Tagged: 2014, cricoid, poll, results, survey

Making endotracheal intubation easy and successful, particularly in unexpected difficult airway


Hey Folks

First, please take the Cricoid Pressure Poll 2014 here.

Second this month is a glorious FOAMEd airway month with this fantastic full text ,open access article in the International Journal of Injury and Critical Illness Science

  1. Making endotracheal intubation easy and successful, particularly in unexpected difficult airway



Filed under: airway, Emergency anaesthesia, Emergency medicine and critical care, FOAMEd, Online critical airway training Tagged: difficult, easier, endotracheal, intubation



Hey Folks

First, please take the Cricoid Pressure Poll 2014 here.

Second this month is a glorious FOAMEd airway month with these fantastic full text ,open access articles in the International Journal of Injury and Critical Illness Science

They published an entire online symposium on airway management!

  2. Rapid-sequence intubation and cricoid pressure
  3. Airway management in cervical spine injury
  4. Advances in prehospital airway management
  5. Pediatric airway management
  6. Surgical Airway
  7. Extraglottic airway devices: A review



Filed under: airway, Emergency anaesthesia, Emergency medicine and critical care, FOAMEd, Online critical airway training Tagged: 2014, airway, symposium


Filed under: airway, Emergency anaesthesia, FOAMEd, Online critical airway training Tagged: 2014, cricoid, poll, pressure

Prehospital airway management : training, governance and evidence

Photo courtesy of Dr Nicholas Chrimes

Prehospital Airway management

Training and competency

There exists no uniform international standard as to what constitutes the minimum level of training and competency deemed necessary to provide safe and effective prehospital airway management. The differences between various countries as to what is considered standard training and which professional background should provide prehospital airway management is telling. When such significant differences exist between multiple providers across different countries, the only logical conclusion must be that there exists no best practice standard.

Predominantly European nations espouse the belief that the dedicated medical specialist doctor with anaesthetic and specific prehospital training is the preferred provider of advanced airway management or as the Scandinavian Society for Anaesthesia and Intensive 2008 published guidelines on Prehospital Airway management cite “Anaesthetic training and routine in anaesthesia and neuromuscular blockade is necessary for most of the techniques in the treatment of patients with airway reflexes” Provocatively they state “Other physicians, as well as paramedics and other EMS personnel, are recommended the lateral trauma recovery position as a basic intervention combined with assisted mask-ventilation in trauma patients. When performing advanced cardiopulmonary resuscitation, we recommend that non-anaesthesiologists primarily use a supraglottic airway device” .

French, German and British prehospital and retrieval services have taken a very similar stance on this issue of the standard training of the prehospital provider of advanced airway management. The reader should note however, the difference in approach to this in North America where flight nurses and paramedics are routinely training and credentialed to provide the full range of prehospital airway interventions including use of neuromuscular blocking agents to facilitate securing of the airway. The level of training is variable with no national standard for advanced airway management. One aeromedical service mandates flight paramedics must maintain a log book demonstrating at least one prehospital tracheal intubation per month over a year and failure to do so dictates a mandatory upskilling session in the operating room under anaesthetic specialist supervision of a minimum number of intubations.
In Australia, most prehospital advanced airway management is conducted using a prehospital doctor from a background in anaesthesia, emergency medicine or critical care. In general the widely held belief in prehospital and retrieval services in Australasia , is that a minimum experience in hospital based anaesthesia training is required in order to provide safe prehospital advanced airway management. There is once again no agreed standard nationally but one retrieval credentialing standard used in Queensland mandates at least a 6 month anaesthetic experience for retrieval doctors in that state. However in the state of Victoria, the intensive care paramedic system, does train and credential paramedics with the capacity to provider prehospital advanced airway management.
One question the reader should always bear in mind when considering the training and competency standards for a prehospital airway provider is where and what should such training consist of. Is a purely hospital based initial and subsequent refresher program sufficient for the needs of the prehospital and retrieval practitioner? If as the Europeans suggest, anaesthetic training is fundamental then does this adequately address the competencies for a surgical airway in the prehospital setting when a hospital anaesthetist is predicted to encounter one surgical airway scenario in a whole career? Hospital anaesthesia has become a routinely safe process, mainly through the strategy of risk mitigation and the elective application of increasingly sophisticated techniques. To transpose such a hospital based elective strategy into the arena of prehospital and retrieval medicine can not only be challenging but inappropriate at times. Prehospital airway training should emphasise the safe and skilled use of a limited range of simple but effective techniques using a small set of equipment. One small study in North America found that the the Commission on Accreditation of Medical Transport Systems (CAMTS) initial and maintenance intubation training standards on 12 flight nurse novice intubators over a 1-year period did maintain simulated difficult airway intubation success rates. These require a minimum of one successful intubation per 3 months on a live, cadaveric or mannequin based patient.

Competency in this area should be demonstrable by the successful application of such skills in varying conditions common to the prehospital setting , in either simulation based assessment format or directly supervised real world cases. What is clear when examining the prehospital airway research is that lecture and mannikin based training alone is insufficient for not only initial airway training but ongoing maintenance of skills. One suggested training strategy by Dr Levitan, a prominent emergency airway researcher, is to begin with the least risky training using internet based and video anatomy teaching, then progress to mannikin training to allow repeated safe practice. The next stage involves attending ear, nose and throat outpatient clinics to review and examine live anatomy and pathology. Following on from this is experience in an elective ENT surgical list as an observer and/or assistant, allowing review of surgical airway techniques and anatomy to occur as well as laryngeal inspection. Supervised supraglottic airway techniques and orotracheal intubation in elective anaesthetic attachment is the next step in the training. After this, the level of risk in the training is increased into supervised airway management in the ED or ICU, where the likely patients encountered in the prehospital setting will be seen. Finally the ultimate level of airway training is in supervised real world airway interventions and decision making in the prehospital and retrieval settings. This method of training is very structured and goal oriented unlike the traditional view of a minimum time spent in anaesthetic training, where goals are often not predetermined nor specific to the needs of the prehospital provider. Ongoing research and clinical audit of prehospital airway management will help us decide eventually what is the best practice approach to training and competency.

Clinical Governance
Any emergency service that aims to field providers competent in prehospital airway management should have a system of credentialing, regular clinical audit and quality review of airway skills.
Credentialling is the process whereby an individual’s past experience and training are formally verified and considered against a range of criteria that the organisation deems essential to adequately perform a given task or set of tasks. For example in Queensland, retrieval medicine credentialing requires that full scope of unsupervised practice, at least 6 months of anaesthetic training as proof of adequate airway skills attainment. Clinical audit is the process whereby regular reviews of airway procedures on given cases, usually chosen at random or fitting set criteria for audit ( all tracheal intubation cases for example), occurs in a systematic manner. Audit aims to set a minimum standard of care in airway management in the prehospital setting by judging the performance of a given airway intervention against set agreed criteria, usually in a retrospective fashion. For example, if tracheal intubation was performed, was end tidal capnography used to confirm correct placement? Systems that use mandatory procedural checklists for airway interventions are able to effectively perform clinical audit as the checklists can be used to determine if a standardised approach was conducted. Quality review and assurance is the process whereby a given performance of an intervention is judged to meet minimum standards of safety and peer review. It is a global assessment of not only the outcomes of the procedure but the decision making process and contingency planning for common complications. For example the emergency airway literature has cited factors such as number of intubation attempts and overall success of intubation as some criteria to judge overall quality of prehospital airway care. These are by no means the only significant factors to consider in quality review. The San Diego RSI trial of paramedic provided intubation demonstrated high rates of significant  hypoxia and hyperventilation during the airway interventions with an overall worse outcome in the treatment group. The Melbourne MICA RSI trial for head injured patients showed a significant increase in cardiac arrest in the prehospital RSI treatment group ,possibly due to the use of RSI drugs in hypotensive patients. Therefore it is important in quality review of prehospital airway management to look at a global assessment of the airway intervention from decision making and preparation right through to post intubation care and monitoring.

Evidence base for prehospital airway management
Whilst this may seem a surprising area to be considered controversial, the reader should try to answer a simple question first before proceeding.
“What are the sentinel studies demonstrating a clear benefit in prehospital intubation and/or rapid sequence induction of anaesthesia for the trauma patient or the critically ill patient?”
Unfortunately this question cannot be simply answered as such studies do not exist. Some readers may argue that there is no point in trying to answer this question as tracheal intubation and rapid sequence induction are considered standard of care in hospital settings for critically ill and injured patients. Therefore the logic demands that if its good enough in hospital, so be it for prehospital settings. Many attempts to prove this in research have failed to demonstrate a clear benefit for trauma patients. In the traumatic head injury group, some studies demonstrate an advantage to prehospital intubation but many studies do not as well. The Paramedic MICA RSI trial in Victoria, Australia was one randomised controlled trial examining the benefit of rapid sequence induction and intubation for head injured patients. At 6 month outcome, there was a small significant advantage in neurologic condition in the prehospital RSI group. Unfortunately there was a significant increase in cardiac arrests in the prehospital RSI group, albeit no overall increase in mortality between control and treatment groups. The other RCT trial was in a paediatric population, and tracheal intubation without use of drugs was performed by paramedics who had limited training(5). This failed to demonstrate any benefit to prehospital intubation compared to bag/valve face mask ventilation.
Along the way in this debate has been the line of arguement that only doctors should be performing prehospital RSI as allegedly paramedics do not have enough experience to do this safely. Certainly published research out of Europe and UK have demonstrated a much higher claimed success rate for prehospital RSI with little complications when performed by senior prehospital doctors compared with paramedics. The San Diego RSI trial added more cold water into the arguement in favour of prehospital RSI by demonstrating a clear survival disadvantage for head injured patients undergoing paramedic led prehospital RSI. Careflight NSW Head Injury Retrieval Trial has been collecting randomised data examining this issue of the benefit of prehospital RSI by a helicopter borne critical care physician in the head injured patient compared to paramedic led road ambulance care. The HIRT trial was the largest RCT trial of its type in the world and failed to show a significant difference in mortality outcome benefit between the two groups. It was plagued with methodologic issues such as treatment crossover.
So where does the truth lie for prehospital airway management? The evidence suggests that the experience and training of the prehospital provider performing RSI and intubation does make a difference in minimising complications. Therefore regardless of the background of the retrieval provider, it seems common sense looking at the evidence to ensure they have adequate initial training and ongoing maintenance of their airway and anaesthetic skills. What this means in real terms is difficult to say as once again the evidence base into this area of “sufficient airway training and ongoing skills maintenance” is scant. One study out of the London HEMS retrieval service indicates that at least 6 months of formal hospital anaesthetics training is required to achieve a sufficiently high intubation success rate. Other published articles stipulate a minimum of at least one retrieval intubation per month to maintain skills or an initial successful completion of 57 intubations to achieve a intubation success rate of greater than 90%.It is the author’s opinion that prehospital RSI should be beneficial in most critically ill and injured patients when performed by providers who are experienced and maintain high level of skills maintenance and case volume. To become good at prehospital RSI you probably need to be doing it at least several times a week, with a well rehearsed prehospital team/assistant , working from a well trained standard operating procedure with a standard setup of drugs , monitoring and airway equipment. If you work in a retrieval service that does not provide sufficient volume of prehospital RSI cases, then unless you are maintaining your airway skills elsewhere such as hospital work, you are likely to suffer significant airway deskilling to the point of becoming substandard competency within a short period of time. Whilst your emergency airway skills will never reduce to the level of a novice, it seems fool hardy thinking to assume you will be as competent as a provider who is performing prehospital RSI 3-4 times more often than you are! Sports and human factors research clearly demonstrates this.
The obvious alternative question to consider in this topic is whether tracheal intubation is absolutely necessary for all critically ill and injured patients? Certainly the cardiac arrest research in the last 10 years has demonstrated consistently worse outcomes in arrested patients who were intubated compared with controls. The latest international resuscitation guidelines stipulate that a laryngeal mask airway is considered an advanced airway equal to a cuffed tracheal tube for the purposes of advanced life support. This issue has received virtually no attention in the anaesthetic or critical care research field apart from some case reports in the use of laryngeal mask airway for transport ventilation of neonates and in the failed intubation scenario for a trauma patient on retrieval. The author has published a prehospital intubation audit in which 3 cases of failed intubation were all successfully managed and transported using a laryngeal mask airway. Uncuffed paediatric tracheal tubes are in many services still considered standard of care for emergency intubation but what they offer for airway protection compared to the laryngeal mask airway, in particular the older Proseals or newer paediatric LMA Supremes, both with gastric drainage ports, is difficult to say and indeed prove. May there come a day in retrieval medicine whereby the paradigm in airway management has shifted to a focus on oxygenation instead of intubation, using RSI to insert primarily a supraglottic airway device such as a LMA and if oxygenation and ventilation are adequate then transporting with said device in situ? In 2014 the UK Faculty of Prehospital Care issued a consensus statement on the technique of PALM, pharmacologic assisted laryngeal mask, advising that this was a reasonable approach for providers who were not credentialled for RSI. It seems unlikely that this will replace endotracheal intubation as the gold standard prehospital airway but it certainly opens up the discussion as to what constitutes prehospital airway management and how what is best , will depend on the situation, provider and the patient.

Recommended Reading

R Levitan.The Airway Cam Guide to Intubation and Practical Emergency Airway Management.Airway Cam Technologies Inc, 2004.
A Griffiths, T Lowes, J Henning. Prehospital Anesthesia Handbook. Springer,2010.
Prehospital anaesthesia working party. AAGBI safety guideline Prehospital Anaesthesia. Association of Anaesthetists of Great Britain and Ireland, 2009.

P Berlac et al. Pre-hospital airway management: guidelines from a task force from the Scandinavian Society for Anaesthesiology and Intensive Care Medicine. Acta Anaesthesiol Scand, 2008;52:897-907
F Thomas et al. Difficult Airway Simulator Intubation Success Rates Using Commission on Accreditation of Medical Transport Systems Training Standards. Air Med J, 2011; 30(4):208-215.
Davis et al. The Effect of Paramedic Rapid Sequence Intubation on Outcome in Patients with Severe Traumatic Brain Injury.Journal of Trauma, 2003;54:444-453
Bernard et al. Prehospital Rapid Sequence Intubation Improves Functional Outcome for Patients With Severe Traumatic Brain Injury A Randomized Controlled Trial. Annals of Surgery,2010; 252(6):959-965.
Gausche M, Lewis RJ, Stratton SJ, Haynes BF, Gunter CS, Goodrich, SM, et al. Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome: a controlled clinical trial. JAMA 2000;283:783-90.
T Harris, D Lockey. Success in physician prehospital rapid sequence intubation: what is the effect of base speciality and length of anaesthetic training? Emergency Medicine Journal, 2011;28:225-229 viewed on Tuesday 19th April 2011
Wang et al. Out-of-Hospital Endotracheal Intubation Experience and Patient Outcomes.Annals Emerg Med,2010;55(6):527-537
R Dawes,A Mellor. Prehospital anaesthesia. J R Army Med Corps, 2010;156(4 Suppl 1):S289-294
M Le Cong. Flying doctor emergency airway registry: a 3-year, prospective, observational study of endotracheal intubation by the Queensland Section of the Royal Flying Doctor Service of Australia. Emergency Medicine Journal, 2010 ;Sept 15 published ahead of print
Walls, RM. The emergency airway algorithms. In: Manual of Emergency Airway Management, 3rd edition, Walls, RM, Murphy, MF (Eds), Lippincott Williams and Wilkins, Philadelphia 2008. p.8.
D Braude, M Richards. Rapid Sequence Airway (RSA) – a novel approach to prehospital airway management. Prehosp Emerg Care, 2007;11:250-252
R Mackenzie,J French,S Lewis, A Steel. A pre-hospital emergency anaesthesia pre-procedure checklist. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2009, 17(Suppl 3):O26 viewed on April 19th, 2011
T C Mort. The supraglottic airway in the emergent setting : its changing role outside the operating room. Anesthesiology News Guide to Airway management, McMahon Publishing, 2011 : 59-71
X Combes et al. Unanticipated difficult airway management in the prehospital emergency setting : Prospective validation of an algorithim. Anesth, 2011 ;114 (1):105-110 viewed on April 19th, 2011.
D Ellis, T Harris, D Zideman.Cricoid pressure in emergency department rapid sequence intubations : a risk-benefit analysis. Annals Emerg Med, 2007;50(6):653-665.
T Harris, D Ellis, L Foster, D Lockey. Cricoid pressure and laryngeal manipulation in 402 pre-hospital emergency anaesthetics: essential safety measure or a hindrance to rapid safe intubation? Resuscitation, 2010;81(7):810-816.
Patanwala et al. Comparison of Succinylcholine and Rocuronium for First-attempt Intubation Success in the Emergency Department. Acad Emerg Med, 2011;18:11-14.
Tang et al. Desaturation following rapid sequence induction using succinylcholine vs. rocuronium in overweight patients. Acta Anaesthesiol Scand 2011; 55: 203–208

UK Faculty of Prehospital care PALM consensus statement

Filed under: airway, Emergency anaesthesia, Emergency medicine and critical care, FOAMEd, Online critical airway training Tagged: airway, prehospital