‘Why tomorrow’s patient needs a digital NHS’

On February 22, I had the honour of compèring an event that brought together NHS leaders, senior clinicians and digital entrepreneurs – .

It was the one-year summit of DigitalHealth.London, an organisation (funded in large part by NHS England) designed to accelerate the uptake of digital technology in the NHS.

The event sizzled with excitement and ambition. Conference delegates were talking about the future of the NHS in positive, expansive terms with an up-beat chirpiness that starkly contrasts the doom-and-gloom-ridden water cooler discussions currently reigning supreme across UK hospitals. The air of possibility and optimism was utterly infectious. I had a great time.

I am a now a fully-fledged digital health believer, and adoption of new technologies discussed at the event can’t come soon enough in my opinion. Interventional virtual reality? Artificial intelligence-augmented clinical decision-making? Healthcare provision to every human being on Earth via smartphones? Yes please.

I met some great people, including the inspirational Molly Watt (one of the most accomplished public speakers I’ve heard; if you haven’t heard her story, check out her website – phenomenal stuff), director of digital experience at NHS England Juliet Bauer, and the amazing Dr. Keith Grimes – a GP from Eastbourne and digital health evangelist, whose work I have admired for a while now. He gave a typically superb talk on the application of virtual reality in medicine, and has since written an insightful blog post reflecting on the artificial intelligence panel discussion. Watch this space for a future collaboration between Keith and I.

DigitalHealth.London have put together a neat full write-up, and produced a couple of beautifully shot videos of the summit, which I happen to feature in! Here they are:

Needless to say, you can count on some future blog posts exploring digital transformation in healthcare!

Thank you DigitalHealth.London (in particular James Somauroo, Yinka Makinde, Rebekah Tailor, and Hannah Harniess) for inviting me to be involved in your fantastic event.

It’s a great time to be a doctor.


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‘My Mental Toughness Manifesto’ Part 2: PRACTICE

Screen Shot 2017-03-06 at 15.55.21

In MMTM Part 1, two-step cognitive appraisals were explained. This process dictates whether one enters a challenged or threatened mindset in the event where an immediate performance is required under acute stress.

Feeling challenged, of course, is one of the two chief components of a mentally tough individual.

“I am 100% committed”

“I feel challenged”

In this post, we will explore principles which must be incorporated in one’s ‘practice‘ (i.e. training) regime, to increase a sense of confidence in one’s skillset. The confident individual will always be more likely to appraise a scenario as challenging as opposed to threatening.

Paradigm shift alert: When practicing, specific skill development must be prioritised over knowledge-base widening. This, of course, sharply contrasts with the traditional approach to medical training. New theoretical concepts seem less abstract and will always be absorbed more rapidly when they fit into the mental scaffolding built by focusing on skill development.

In an ideal world, all clinicians, across the spectrum of specific role and geographic location, would get regular high-fidelity simulation training sessions, supervised by master educators. Of course, this isn’t feasible in even the richest healthcare systems; and the reality is that all types of supervised training (other than weekly death-by-PowerPoint didactic teaching) become increasingly rare the more senior you become.

Therefore, one must take ownership over one’s own practice, and be relentless in the pursuit of ultimate confidence in one’s skillset. This will be achieved through immersiondeliberate practice, and visualisation.


“Discipline equals freedom”

Jocko Willink, Navy SEAL Commander

My definition of professional ‘immersion’ is regular engagement with one’s craft outside of working hours. The abundance of free online medical education (FOAMed) resources makes this process exceptionally easy and enjoyable. With availability/access to excellent content no longer an issue (unlike the olden days where you had to sift through dusty textbooks, and YouTube hadn’t yet been invented), the only obstacle standing in the way of adequate immersion is having the discipline to allocate time to it.

Too often, clinicians assume they are advancing their expertise, and fine-tuning performance standards, purely by attending work – clocking in and clocking out, going through the motions on the shop floor, and then completely disengaging during free time. This is occupational autopilot. And it is dangerous.

Screen Shot 2017-03-14 at 20.33.35Occupational autopilot predisposes clinicians to flounder during a crisis because the mind stiffens when seldom fed new information. For example, the disengaged anaesthetist who rarely ventures far from uncomplicated elective orthopaedics will be flummoxed by the surprise grade 4 intubation. Despite being entirely competent enough to weather the storm, he/she will fall easily into the clutches of the threat mindset and spectacularly fail the patient in that rare moment, largely because of their lack of engagement with the broader landscape of their chosen pursuit.

The ability to think laterally, employ techniques that might be ‘rusty’ or never performed before (e.g. surgical cricothyroidotomy), and trust one’s own clinical judgement, can only occur seamlessly if you have adequately immersed yourself in the educational resources and evolving narrative of your vocation.

Of course, immersion in specific resources to improve an isolated skill is crucial if weakness is identified (a principle of ‘deliberate practice’ – see below). But it’s the habitual (daily) general immersion, with no specific agenda, that is a key characteristic of the dedicated professional whose identity is embedded in his or her craft. Immersion isn’t a training methodology – it is a lifestyle decision. It ensures currency is maintained, and nurtures a fertile cognitive environment, mandatory for yielding the acrobatics and improvisation required during a crisis.

Deliberate Practice

“Skill is only developed by hours and hours of beating on your craft.”

Will Smith, actor

Deliberate practice describes a common set of principles which should form the framework of every training session [1].

Every time you practice, your sole mission is to improve. You should constantly be asking yourself the question: “How can I do this better?”.

A specific component of a chosen skill is isolated – one that you are poor at or can’t do – and then subjected to specific training exercises and repetitions (‘drilling’).

The core principles of deliberate practice:

  1. specific, measurable goal must be established for the session. Vague overall performance targets like ‘succeed’ or ‘get better’ mean nothing.
  2. Be maximally focused on improvement during practice. It must be intense and uninterrupted. Put your electronic device away.
  3. Receive immediate feedback on your performance. Without it, you won’t be able to figure out what you need to modify or how close you are to achieving your goal.
  4. Exit your comfort zone. Push yourself to the edge of what you are capable of. Don’t be afraid of failure – it signposts the path to progression.

IdScreen Shot 2017-03-14 at 20.35.09eally, a supervisor should be present to guide training, and give immediate feedback. When this isn’t available (which will be most of the time for the majority of clinicians), video footage of the skill being performed/taught is a decent substitute. You can compare your own repetitions to the video subject, and ‘self-police’ your training progress. The plethora of FOAMed video content makes this comfortably achievable.

Human nature dictates that we gravitate towards training skills that we are already proficient at, and neglect areas outside our comfort zone. Why? It’s much more satisfying to feel like you are ‘nailing’ something. DO NOT be enticed into that trap – the significant gains exist where there is most discomfort and least enjoyment. What is enjoyable, is the feeling that you are moving forward and advancing your overall proficiency.

Regular re-visiting of skills that have laid dormant for a while (either in practice or in the field) is essential for avoiding skill fade. This habitual ‘spaced repetition’ deeply embeds a skillset into our mental scaffolding, and makes it far more likely to be retrievable under acute, severe stress.

Here is a previous blog which covers deliberate practice in a little more detail.


“In my view, the answer is to use the highest fidelity simulator in the universe – the human brain”

Cliff Reid, Emergency Physician, Sydney HEMS

Despite it being our most powerful and adaptive weapon, we routinely fail to utilise our brain as a training gadget. When physically practicing, our minds are engaged, but (naturally) we conceptualise the process as being entirely external. Our conscious focus is largely zoned in on body positioning or equipment handling, making it easy to forget our brain is the anatomical structure in the driving seat.


Visualisation (or ‘mental practice’/’mental rehearsal’/’imagery’) is the process of consciously playing a mental ‘video’ of a task or scenario from the perspective of one’s own eyes. In other words, one thinks about doing something, step by step. Despite no physical engagement, one is activating the very same neural circuitry as when performing the skill for real, and if done effectively, it reinforces skill-related mental scaffolding, just like deliberate practice [2, 3]. It enhances clarity and speed of thought during the moment of truth.

Much like the concept of mental toughness itself, visualisation can get routinely dismissed as a vague, abstract, somewhat hippyish concept, with little scientific credibility. If that is your opinion, you are sorely mistaken and missing a huge opportunity. The evidence-base is abundant across a wide spectrum of human endeavour, with perhaps the most high profile examples found in the results-driven world of elite sport [4, 5, 6]. Desperate for the edge over equally motivated competition, you would be hard pushed to find an upper echelon-worthy individual or team not dedicating a considerable portion of their training schedule to mental practice. Put simply, it is considered pivotal to producing the goods by folk who earn their living making us say ‘WOW’. When the Federers, Mcilroys, and Bradys of this world consider it indispensable, then frontline healthcare, an equally performance-centric game, should be paying attention.

Vivid realism is crucial for the process to be effective. You need to feel it as well as see it. The PETLEPP mnemonic is a useful guide [7]:

Physical – What are you holding? What are you wearing? What are you smelling?
Environment – What are your surroundings? It is essential to imagine yourself in the environment where you will be performing (i.e. your usual workplace).
Type –Imagery must be specific to your role and responsibility.
Timing – Given the time critical nature of acute care, imagery must take place in ‘real time’.
Learning – Content should evolve with learning. The cognitions and feelings experienced will change as the individual improves.
Emotion – Imagine yourself acutely stressed, but in the challenge mindset. Total ‘calm’ is not realistic and, therefore, not useful.
Perspective – Feel and see from your own perspective (i.e through your own ‘eyes’).

The unique selling point of visualisation when compared to other practice modalities is its malleability. Using your imagination to conjure up potential curveballs and banana skins is a very effective method for finely sharpening routine skills and processes where there may be a tendency to get complacent. Play the ‘what if’ game:

“What if I had to perform an RSI on a 300kg patient with a receding chin? What extra precautions should I take?”

“What if whilst I was putting in a right IJV central line, the patient became hypotensive and the oxygen saturations dropped to 70%? What should my next steps be?”

“What if I was the trauma team leader for a penetrating chest trauma case and suddenly the patient lost output?”

It’s also a perfect strategy for shoring up one’s procedural routine for exceptionally rare events, such as the emergency thoracotomy or perimortem Caesarian section. Procedures like that would be uneconomical, and logistically impossible, to repetitively practice on mannikins/cadavers. Regular and structured mental practice is therefore a must for emergency providers who genuinely want to be able to tackle everything thrown at them. It is impossible to predict what is coming through the resus doors, but when you have seen it all in the simulation lab between your ears, you will be ready.

This technique isn’t limited to skills training; it can be applied on a broader, more personal level as well. It can galvanise the spirit, and ignite the passion for positively affecting the world through your job – a trait abundant in all of us deep down. Regularly visualise yourself returning home at the end of a shift, mission, or deployment with that beautiful sense of victory and euphoria that washes over when you know you’ve performed well. See yourself overcoming every obstacle thrown at you on duty, and always able to access clarity of thought, and the best of your ability, when it really counts.

Capture yourself in the career trajectory exactly as you have always dreamed it, regardless of how far away you currently feel. If you have the imagination to dream, and the courage to believe that your vision is possible, it will make you hungrier to strive for it. Every training session will be laced with boundless intent, and in time, your mental movie will become a reality.


Effective practice is about building confidence, so that when a performance is required, the challenge mindset is achieved.

Immersion in your craft safeguards against occupational autopilot, and fosters a healthy cognitive environment for high performance.

When training specifics, fully embracing the principles of deliberate practice is the only gateway to expert-level skills.

Visualisation, when maximally vivid and performed in a structured fashion, can prepare you for anything. Never underestimate the training-tool that is your mind.

Building mental toughness isn’t easy, but your patients deserve it. No-one will do it for you. Get after it.


  1. Peak: Secrets From the New Science of Expertise. Anders Ericsson and Robert Pool.
  2. Weisinger H, Pawliw-Fry JP. Performance Under Pressure. New York, NY: Crown Business.
  3. Mike Lauria. EHPR Part 5: Using Mental Practice and Visualization Exercises by Mike Lauria. EMCrit Blog. Published on February 21, 2017. Accessed on March 13th 2017. Available at [https://emcrit.org/blogpost/ehpr-part-5-using-mental-practice-visualization-exercises-mike-lauria/].
  4. Feltz DL, Landers The effects of mental practice on motor skill learning and performance: A meta- analysis. Journal of Sport Psychology. 1983;5(1):25-57.
  5. Mental Training for Peak Performance. Steven Ungerleider and Nick Bollettieri.
  6. Sports visualisation: how to imagine your way to success. Mark Bailey, The Telegraph.
  7. Holmes PS, Collins DJ. The PETTLEP Approach to Motor Imagery: A Functional Equivalence Model for Sport Psychologists. J Appl Sport Psychol. 2001; 13(1): 60-83.

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‘My Mental Toughness Manifesto’ Part 1: Cognitive Appraisals

Screen Shot 2017-02-10 at 15.50.43It has been an exciting period for me recently. Last month I was at the International Special Training Centre (ISTC) in Pfullendorf, Germany, where I had the honour of speaking to a group of Special Operations Combat Medics in-training from eleven nations across NATO. Staying at the base, meeting the guys, and contributing to their fantastic 26-week course was an unforgettable experience, and without a doubt my most proud achievement to date.

Why me? Last year I blogged/podcasted for St. Emlyn’s about my lively experience working in a South African Township Emergency Department, at Khayelitsha District Hospital. Luckily for me, a course faculty member from the ISTC stumbled across this work and thought I might have something to offer a group of warrior medics.

If you haven’t read the original blog, I would advise that you do before proceeding; the credibility of what follows hinges on its predecessor.

I was tasked with providing a session that tackled human performance optimisation. Through four separate 20-minute lectures, I delivered a package of strategies for ‘Building Mental Toughness’.

This post is a summary of my first lecture at the ISTC, and is the first instalment of a four-post series. My intention is for the series to read as a call-to-arms for frontline healthcare providers to prioritise performance optimisation strategies.

This is my Mental Toughness Manifesto.

What is Mental Toughness?

Roger-Federer-of-Switzerl-007Traditionally, it’s a term synonymous with the sports world. It is therefore often ignored or laughed off as meaningless cliché, particularly by performers in healthcare – a ‘serious’ field. In my opinion, this represents a glaring missed opportunity.

A mentally tough individual is consistently able to produce desirable performances during moments of high stress; an undeniably crucial trait for those operating in high octane environments, not least the resus room, prehospital environment, or the realm of combat.

By accurately identifying the specific components of mental toughness, we can work on strengthening it through focused training and attitude adjustments. During a stressful, high stakes scenario where a performance is immediately required, (having interrogated the literature [1]) I believe you are mentally tough if able to state the following:

“I am 100% committed”

“I feel challenged”

Commitment to one’s overall goal is critical, but should be a foregone conclusion. A trauma team leader, flight paramedic, or special operations combat medic, should be inherently committed to their job because what they do is of indisputable importance – they deal in the currency of human life. Also, they will have had to demonstrate commitment whilst climbing their respective professional ladders, via examination and selection processes. So, the first half of the battle – ‘being 100% committed’ – is the easy bit.

Feeling ‘challenged’, as opposed to feeling threatened by a stressful scenario, is more complicated. This requires confidence in one’s skillset and a feeling of control over one’s emotional arousal.

Cognitive Appraisals

It is imperative to appreciate the nuances of acute stress, and how it influences our physiology and cognition.

When an individual is faced with a situation which threatens an important goal (like staying alive, or keeping someone else alive), an immediate two-step cognitive appraisal takes place [2, 3]:

Sumo final

If personal resources are deemed sufficient to meet the demands of the scenario, the ‘challenge appraisal’ ensues. One feels positively energised (‘pumped up’), there is a sense of high self-esteem, and one will view the situation as an opportunity to capture a victorious moment. It is what athletes call being ‘in the zone’. There is physiological stress via activation of the sympathetic nervous system, but control of task-specific motor skills and cognition remains intact.

If the demands outweigh available resources, a ‘threat appraisal’ takes hold. In addition to the sympathetic nervous system response, the hypothalamic-pituitary (HPA) axis activates, triggering the release of cortisol. This cortisol ‘dump’ is a relic from our days as primal hunter-gatherers. It readies the mind and body for instant, evasive action (like running away from a predator), which is, of course, suboptimal when a skilled and complex performance is immediately required.

Threat appraisals narrow our auditory and visual perception, minimise our mental ‘bandwidth’, increase our sense of fear (via its effect on the amydala), erode our short-term memory (hippocampus), and obliterate our capacity for rational judgement (prefrontal cortex) [4].

Need convincing? Watch the video below for an armchair threat appraisal…

The psychological literature has consistently demonstrated that high serum cortisol is associated with impaired performance, over a wide range of human pursuit [4, 5]. What becomes clear, therefore, is that performance optimisation centres around this two-step cognitive appraisal process. By using strategies to modify one’s perception of the immediate demands and available resources, we can convert threat appraisals to challenge appraisals, and in doing so harness the power of the sympathetic nervous system, avoiding HPA axis-mediated self-sabotage.

I will propose seven strategies, over three phases of the game (the ‘practice’, ‘perform’, and ‘process’ phases) which are designed to favourably modify our perceptions during the cognitive appraisal process. The aim is to build the challenged mindset, resulting in a mentally tougher performer, better equipped for saving lives.

Stay tuned for the next instalment.

Robert Lloyd


  1. Mike Lauria. Imperturbability: William Osler, Resilience, and Redefining Mental Toughness by Mike Lauria. EMCrit Blog. Published on February 3, 2016. Accessed on February 24th 2017. Available at [https://emcrit.org/blogpost/imperturbability-william-osler-resilience-and-redefining-mental-toughness/].
  2. Tomaka, J., Blascovich, J., Kelsey, R. M., & Leitten, C. L. (1993). Subjective, physiological, and behavioral effects of threat and challenge appraisal. Journal of Personality and Social Psychology, 65, 248-260.
  3. LeBlanc, V.R., The effects of acute stress on performance: implications for health professions education. Acad Med, 2009. 84(10 Suppl): p. S25-33.
  4. Scott Weingart. Podcast 177 – Chris Hicks on the Fog of War: Training the Resuscitationist Mindset. EMCrit Blog. Published on July 11, 2016. Accessed on February 24th 2017. Available at [https://emcrit.org/podcasts/chris-hicks-fog-of-war/].
  5. How stress affects your brain – Madhumita Murgia, TED Ed

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Resources for ISTC NSOCM students

Screen Shot 2017-02-10 at 15.50.43This is a post intended for the NSOCM students I presented to at the ISTC last week.

The title of my session was: ‘Practice, Perform, Process': Strategies for Building Mental Toughness.

Here are some of the resources I used to design the session, which I believe will be useful for you guys.


On Combat: The Psychology and Physiology of Deadly Conflict in War and in Peace. Lt. Col. Dave Grossman (2008).

Peak: Secrets from the New Science of Expertise. Anders Ericsson (2016).

Black Box Thinking: The Surprising Truth About Success. Matthew Syed (2015).

Extreme Ownership: How U.S. Navy SEALs Lead and Win. Jocko Willink and Leif Babin (2015)

Blog Posts

Lessons From South Africa – My initial blog post on my time working in South Africa. This has a few of the videos I used for ‘deliberate practice’ embedded (surgical hand ties, tying in chest drains).

An Englishman in South Africa – My St. Emlyn’s blog post on the experience where I focus on my initial extreme acute stress reaction working in Khayelitsha.

Stress Inoculation Training by Mike Lauria (NB for some reason this post isn’t available on the site currently. I’m sure it’ll be back up soon)

Imperturbability: William Osler, Resilience, and Redefining Mental Toughness by Mike Lauria


St. Emlyn’s podcast: An Englishman in South Africa – I describe my experience in Khayelitsha with Professor Simon Carley

Emcrit podcasts:

Rollcage Medic Podcast: Podcast 8 – Decision making in high stakes environments with Mike Lauria

Core EM podcast: Podcast 81.0 – Visualization

SMACC podcast – Shoes, Sex and Secrets: Stress in EMS by Ashley Liebig


FOAMed resources – for the ‘immersion’ process

Here is an excellent explanation of FOAMed.

These are my preferred FOAMed websites:

Some of the above will have a lot of material not relevant to being a combat medic, so be sure to carefully select what is appropriate for you.

Also, this list is not exhaustive. There are many more resources out there which you’ll easily find once you start navigating the FOAMed universe. I know that there are several paramedic-led websites which may be particularly useful for combat medics.

If looking for a specific topic, you can utilise GoogleFOAM, where you can search all FOAMed outlets.

Email me with questions

Please feel free to email me at [email protected] with any questions.

I am close to completing a blog post which summarises my 4 presentations, so please look out for that.

Many thanks,
Robert Lloyd

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Assessing Airways in the ED

2414534443_84c035698bI’m an anaesthetic registrar in North East London (@andrewwilko1986). On a daily basis I perform airway assessments. Although not a classic medical school patient examination, it’s an extremely important process. Fortunately it’s very simple, and in this blog I’d like to highlight why it’s important, and some concepts to think about when dealing with a patient that might require a definitive airway in the ED.


One main reason is NAP41. If you’re scratching your head and wondering what NAP4 is then you’re in luck and have the delight of reading it for the very first time after this blog. And PLEASE do, you won’t regret it. It’s a phenomenal audit project investigating the nature of airway management complications across the UK, both in and out of theatre. One of their major conclusions was that ‘poor airway assessment contributes to poor airway outcomes’ and ‘failure to assess the airway is a failure in professional duty’.

The familiar adage ‘failure to prepare is preparing to fail’ couldn’t be more poignant than with the acutely unwell patient that requires intubation.

Now I know that emergency medicine (EM) rapid sequence intubation (RSI) is a hot topic for debate but I want to focus on the step before this that I believe is more important than the person wielding the laryngoscope blade. After all, you can teach a monkey to put a correctly shaped block through a hole.. and presumably put an endotracheal tube into the trachea. Point being: it’s not a difficult psychomotor skill to master.

We know that the incidence of difficult intubation (grade 3 or 4 view) in the ED is up to 7 fold greater than for elective surgical cases, with the percentage of difficult intubations quoted at 8.5% in a large multi-centre prospective study of urban EDs in Scotland2. I’m fully aware that there are significant confounding factors with these figures this but it reinforces the importance of a quality airway assessment allowing us to prepare appropriately.

In ED, when you have a patient requiring an RSI, before you get caught up with the type and dose of induction agent, size of endotracheal tube and laryngoscope blade, DON’T forget the airway assessment!

To assess a patient’s airway we need to have an organised, structured approach and be aware of features that worry us.

The assessment

Like any patient assessment it can be neatly divided into history, examination and investigations. In the ED, I can appreciate that history and investigations are not always available, but that’s OK because the crucial component of an airway assessment is the physical examination. Virtually all of the information is gained visually.

It is made up of multiple single assessments:

  1. Mallampati score (I,II,III,IV)
  2. Mouth opening (>3cm is good)
  3. Thyromental distance (>6.5cm is good)
  4. Dentition
  5. Mandibular protrusion/upper lip bite test
  6. Neck movements

A well described assessment is the Mallampati score (see appendix below) which is simple to perform. However, a large meta-analysis demonstrated ‘only 35% of patients with a difficult intubation were identified as Mallampati III or IV’4. Similarly poor sensitivity/specificity is seen in all single assessments if performed in isolation. So what we must do is utilise an amalgamation of these single tests.

Grouped assessments (see appendix):

  1. WILSON’s score (5 parameters – weight, neck movement, jaw movement, receding mandible, buck teeth)
  2. LEMON (Look, Evaluate, Mallampati, Obstruction, Neck movements)

I personally like to break the airway assessment down into what will be difficult for the given patient;

  1. Difficult BVM = ‘BONES’Beard, Obese, No teeth, Elderly, Sleep apnoea
  2. Difficult larngoscopy = Mouth opening < 3cm or unable to put 3 fingers between inscisors.
  3. Difficult larnygeal view = Inability to align the 3 axis of the airway, see below.
  4. Difficult surgical airway = ‘SHORT’Surgery, Haematoma, Obese, Radiation, Tumour

Predicting difficult laryngeal view


I’m going to concentrate on the issue of a predicted difficult laryngeal view in more detail, because if we identify a problem here then it’s vital we make a contingency plan prior to pushing the drugs (having said that, one should always make a contingency plan even if the airway is predicted to be easy, particularly in the ED).

The reasons for difficult laryngeal views are due to an inability to line up the three axes of the airway (laryngeal axis, pharyngeal axis and oral axis) with the line of our vision.

Predictors for difficult laryngeal view includes:

  1. Mallampati grade III or IV
  2. Buck teeth/awkward dentitian
  3. Limited mandibular protrusion/Retrognathia
  4. Short/fat neck = Thyromental distance < 6.5cm
  5. Reduced neck movements (particularly extension) or C-spine immobility.

If you highlight any of these then I recommend that you alert the anaesthetic team, and insist on senior airway supervision for the RSI. I also highly recommend that the primary intubator’s first line laryngoscope blade should be a video laryngoscope. DAS guidelines for RSI suggest that you should have NO more than 3 laryngoscope attempts; therefore, make your first attempt your best attempt!

Unconscious patient?

A landmark paper on ED RSI from Fogg et al in 2012, found that the significant majority (65.4%) are carried out due to patients having low conscious states (GCS <8)3.

Levitan et al (2004) published a retrospective study looking at airway assessments in ED RSI’s, which found that ‘Mallampati scoring, neck mobility testing, and measurement of thyromental distance could have been done in only one third of non-cardiac arrest ED intubations and in none of the rapid sequence intubation failures’5.

This is often the reason given for not formally carrying out an assessment (i.e. patient unable to comply with assessment); however, this is an unacceptable excuse as the majority of airway assessment tests can be performed without patient co-operation. All that’s required, is a modified approach.

To do so, put a pair of gloves on and simply look and feel your way through the assessments; short, fat neck, receding mandible, open mouth and inspect dentition, mobilise the neck (provided no risk of C-spine injury). In my opinion the only one that you definitely can’t do is the Mallampati assessment and I have already explained that it’s fairly poor at identifying the difficult intubation if used as the only method of airway assessment.

Ultimately, if you feel you are unable to perform an adequate airway assessment then the patient should be classed as a predicted difficult airway, and the airway plan should reflect that.

Final thoughts and recommendations

Airway assessment is the cornerstone to preparing for your ED RSI. There is NO excuse for its omission. ‘Failure to assess the airway is a failure in professional duty’.

There is always time to perform an airway assessment.

If a potential difficult airway is identified, ensure you have senior airway support.

Obtain immediate feedback from your own airway assessment even if you aren’t the primary intubator. Guess the suspected Cormack and Lehane grade and see if you were correct in suspecting an easy or difficult view.

Have a low threshold for use of a video laryngoscope with the proviso that you are familiar with the device available in your hospital. If you aren’t, then go and practice. Introduce yourself to a friendly anaesthetic colleague and ask to practice in the calm environment of elective theatre. We will always be eager to teach, as we know that airway management transcends specialty boundaries.


Wilson’s score

0 1 2
Weight (kg) 90 90-110 >110
Neck movement >90 90 <90
Jaw movement >0 0 <0
Receding mandible None Moderate Severe
Buck teeth None Moderate Severe

Total score <5  easy intubation, 5-7moderate intubation, >7 difficult intubation


Look externally – facial trauma, deformity, beard, poor dentition, large tongue etc

Evaluate – 3-3-2 rule of finger breaths. 3 (mouth opening) – 3 (hyoid to chin) – 2 (thyroid to floor of mouth)

Mallampati – (I-IV)






bstruction – soft tissue swelling, trauma to the face or neck, foreign bodies, obesity etc.

Neck movements – restricted


  1. NAP4 – http://www.rcoa.ac.uk/nap4
  2. Graham C et al. Rapid sequence intubation in Scottish urban emergency departments. EMJ 2003;20:3–5.
  3. Fogg T et al. Prospective observational study of the practice of endotracheal intubation in the emergency department of a tertiary hospital in Sydney, Australia. EMA 2012, 24: 617-624.
  4. Lundstrom L et al. Poor prognostic value of the modified Mallampati score: a meta-analysis involving 177 088 patients. BJA. 107 (5)
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