Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.

You’re an anesthesiologist. You’ve lost the airway on your obese anesthetized gynecology patient, your multiple attempts to intubate the trachea have failed, you cannot mask ventilate the patient, and insertion of a laryngeal mask airway did not help. Your patient’s skin and lips are purple and you are terrified. What do you do?

  1. Call a surgeon stat to do a tracheostomy
  2. Ask the gynecologist to cut an airway into the patient’s neck
  3. Keep trying to intubate the trachea yourself
  4. Insert a needle into the cricothyroid membrane, and begin jet ventilation
  5. Cut an airway into the neck yourself.

A study in the October 2019 issue of Anesthesiology showed that when a “can’t intubate, can’t oxygenate” crisis occurred, there were delays finding someone prepared to cut a surgical airway into the front of the neck in time to save the patient’s life. The study looked at malpractice closed claims and found: 1) Outcomes remained poor in malpractice closed claims related to difficult tracheal intubation; 2) The incidence of brain damage or death at induction of anesthesia was 5.5 times greater in the years 2000 – 2012 than in the years 1993 – 1999; 3) Inadequate planning and judgement errors contributed to the bad outcomes; and 4) Delays in placing a surgical airway during “can’t intubate, can’t oxygenate” emergencies were a major issue.

A closed claims study is akin to a large mortality and morbidity (M & M) conference. A closed claims study tells us which complications led to malpractice settlements. Each malpractice closed claim marks a negligent practice which caused an adverse outcome.

I’d like to focus on one specific aspect of this important study: anesthesiologists need to lose their reluctance to cut a surgical airway into a patient’s neck in a “can’t intubate, can’t oxygenate” airway emergency. A surgical airway is an invasive airway via the front of the patient’s neck into their trachea. Waiting for a surgeon to cut a surgical airway, or fearing to cut a surgical airway yourself, could cost your patient his or her life. Delay or failure in placing a surgical airway was described in 10 of the specific 12 cases listed in the Appendix of this Anesthesiology closed claims study, as follows:

Case 1: “Eventually a surgical airway was performed after the patient arrested.”

Case 2: “A surgical airway was performed after the patient arrested.”

Case 3: “The surgeon was called to the room to perform an emergency surgical airway, but there were not any instruments available in the room. The patient sustained anoxic brain injury and later died.”

Case 4: “Ventilation was difficult and the patient arrested. The surgeon arrived and attempted to perform an emergency surgical airway, at which time the anesthesiologist successfully intubated the patient’s trachea as the hematoma was drained. The patient was resuscitated but later died of anoxic brain damage.”

Case 5: “The anesthesiologist asked the surgeon to perform an emergency cricothyrotomy. However, the surgeon insisted that an electrocautery to be set up first. Nine minutes after cardiac arrest, a surgical airway was secured by the surgeon. The patient was resuscitated but remained in a persistent vegetative state.”

Case 6: “An ear-nose-throat surgeon was called to perform a surgical airway, who suggested a supraglottic airway be inserted instead. After the supraglottic airway was placed, the patient became impossible to ventilate and went into cardiac arrest. The surgical airway was placed with some difficulty. The patient sustained severe hypoxic brain and died.”

Case 8: “The surgeon performed a cricothyrotomy after the patient had marked bradycardia and hypotension.”

Case 10: “A surgeon was called to place a cricothyrotomy. The patient was resuscitated but had severe anoxic brain damage and died.”

Case 11: “Multiple intubation attempts and supraglottic airway insertion were made for more than an hour before a surgical airway was performed. At that time, the patient was asystolic and had a tension pneumothorax. The patient died.”

Case 12: “The patient had a hypoxic cardiac arrest. The surgeon arrived 22 min after induction and secured an emergency surgical airway. The patient was resuscitated but sustained hypoxic brain damage requiring assistance with activities of daily living.”

It’s tragic that 10 of the 12 listed cases involved delayed or failed front of neck access to the airway. In an editorial in the same issue of Anesthesiology, authors Takashi and Hillman wrote, “Decision to provide a surgical airway was frequently delayed by repeated attempts at tracheal intubation, anesthesia care providers being hesitant to initiate surgical procedures, or surgeons being reluctant to perform tracheostomy or simply not available.”

The American Society of Anesthesiologists Difficult Airway Algorithm, shown below, clearly describes invasive airway (i.e. surgical airway) access via the front of the neck when attempts to intubate the trachea and oxygenate the patient both fail.

“Can’t intubate, can’t oxygenate” events are rare, but they do occur with a published incidence of 1 in 50,000 anesthetics, per the fourth national audit project in the United Kingdom.  

The brain can be permanently damaged following episodes in which the brain sees no oxygen for five minutes or longer.

Approaches to front of neck access include either cannula techniques or surgical techniques, with significant differences:

Cannula Technique:

This involves inserting a large bore IV catheter through the cricothyroid membrane.

Because the lumen of a 14-gauge IV catheter is small, ventilation requires a high-pressure jet oxygen delivery system. In a publication from 2016, the failure rate with cannula techniques was 42% in “can’t intubate, can’t oxygenate” emergencies. Failure can occur because of kinking, malposition, or displacement of the needle/cannula. Because of the high failure rates, use of the cannula technique is discouraged.

Surgical Technique:

Most surgeons are trained to perform tracheostomies during their residencies, but when a “can’t intubate, can’t oxygenate” emergency occurs, tracheostomy is not the preferred procedure.

Tracheostomy – tube is inserted between tracheal rings

  Cricothyroidotomy, a technique which is faster and requires less surgical skill, can be performed by anesthesiologists, and is the preferred procedure.

In a cricothyroidotomy, the cricothyroid membrane is divided by a surgical incision made with a wide scalpel (#10 scalpel).

a cricothyrotomy is inserted in the cricothyroid space, cephalic to the trachea

Using the scalpel, bougie, tube (SBT) technique,

a bougie is inserted into the trachea through the incision. A lubricated 6.0 mm cuffed endotracheal tube is advanced over the bougie into the trachea, and the bougie is removed as demonstrated in this video link: 

This technique has been specifically endorsed in the United Kingdom in the algorithm from their Difficult Airway Society.  The British Difficult Airway Society guideline for a Can’t Intubate, Can’t Oxygenate crisis follows: 

How to train anesthesiologists to perform SBT cricothyroidotomy:

Are anesthesiologists trained to perform cricothyroidotomy? Not really. Even though the procedure is the last safety valve on the Difficult Airway Algorithm, most anesthesiologists have minimal or no experience in this life-saving procedure. How can we train anesthesiologists to perform cricothyroidotomies? 

In my residency in the 1980s we were trained to do cricothyroid injections of cocaine prior to awake fiberoptic intubation procedures. Each resident performed dozens of these injections, and I became extremely comfortable locating and piercing the cricothyroid membrane with a needle. In 35 years and 25,000+ anesthetics, I’ve never needed to place a surgical airway through that same membrane, but I feel confident I could do so with the scalpel, bougie, tube technique. 

The problem is that most anesthesiologists have never had to perform this front of neck access procedure on a patient. The stakes are high, because there is little time for failure. After several minutes of “can’t intubate, can’t oxygenate,” someone needs to take a scalpel to the cricothyroid membrane. That someone can and often should be the anesthesiologist.

In the October 2013 American Society of Anesthesiologists Monitor we read, “Perhaps the most important problem encountered in “can’t intubate, can’t oxygenate”  is a delay in recognition or institution of emergency airway management. . . . While someone clearly needs to make the decision to obtain a surgical airway, both the surgeons and the anesthesiologist may feel uncomfortable in this role. Retrospective studies, including closed claims analysis, demonstrate that most patients are already in cardiac arrest before emergency invasive airway attempts are performed. While decisive and timely action is clearly needed, the decision to pursue a surgical airway is not an easy one; . . . In fact, there is little legal risk from a surgical airway attempt – no matter how messy – if the patient survives, but enormous liability if the procedure is not attempted.”

In a study from Great Britain, 104 anaesthetists received a structured training session on performing cricothyrotomy. These anaesthetists then took part individually in a simulated “can’t intubate, can’t oxygenate” event using simulation and airway models, to evaluate how well they could perform front‐of‐neck access techniques. First‐pass tracheal tube placement was obtained in 101 out of the 104 cricothyroidotomies (p = 0.31). They concluded that anaesthetists can be trained to perform surgical front of neck access to an acceptable level of competence and speed via simulator training

What needs to happen? Anesthesiology residents need to be trained to do front of neck access, and they need to be trained not to delay if the procedure is indicated. This training needs to be a requirement for all anesthesia professionals. Mid-career anesthesiologists pay for weekend Continuing Medical Education courses on subjects such as ultrasound-directed regional blocks or transesphogeal echocardiography. While these topics are important, they are not life-saving skills such as front of neck access. Anesthesiologists in training, practicing anesthesiologists, and Certified Registered Nurse Anesthetists (CRNAs) must receive hands-on education on performing front of neck access, as well as the reasoning behind not delaying the procedure. 

You’re an anesthesiologist or a CRNA. What should you do now?

  1. Familiarize yourself with the anatomy of the cricothyroid membrane on each of your patients.
  2. Have a scalpel, bougie, tube kit containing a #10 scalpel, a bougie, and a #6 cuffed endotracheal tube included with each difficult airway cart at each facility you anesthetize at.
  3. I now carry a scalpel, bougie, tube kit in my briefcase which I take with me every day at work. In the current model of private practice in California, where we work at multiple different freestanding surgery centers and surgeon offices, this is a reliable means to assure that I have front of neck access equipment with me wherever I anesthetize patients.
  4. Review and rehearse the anatomy and skills necessary to perform front of neck surgical cricothyroidotomy.
  5. Work to avoid “can’t intubate, can’t oxygenate” events. Evaluate each airway prior to surgery. If a significant concern exists regarding a difficult intubation, a difficult mask ventilation, or difficult front of neck access, use your judgment and perform an awake intubation. Securing an airway prior to anesthesia induction is a reliable way to avoid “can’t intubate, can’t oxygenate” disasters.

The closed claims study on difficult tracheal intubation in the October 2019 issue of Anesthesiology should serve as a bellwether for our profession. The practices of waiting for surgeons to arrive to do front of neck access, or of anesthesiologists delaying front of neck access in a “can’t intubate, can’t oxygenate” emergency must cease. Emergency front of neck access must be a core skill that all anesthesiologists are both willing and able to perform when a patient is turning purple before their eyes. 

We owe it to our patients to be ready to save their lives.


The most popular posts for laypeople on The Anesthesia Consultant include:
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Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.

At weddings you’ll often hear a Bible verse that reads, “And now these three remain: faith, hope and love. But the greatest of these is love.” (1 Corinthians 13:13) A parallel verse in the bible of acute care medicine would read, “Emergencies are managed by airway, breathing, and circulation. But the greatest of these is airway.” The objective of this column is to help you avoid airway lawsuits.


Every health care professional learns the mantra of airway-breathing-circulation. Anesthesiologists are the undisputed champions of airway management. This column is to alert you that avoiding even one airway disaster during your career is vital.

Following my first deposition in a medical-legal case years ago, I was descending in the elevator and a man in a suit asked me what I was doing in the building that day. I told him I’d just testified as an expert witness. He asked me what my specialty was, and I told him I was an anesthesiologist. The whistled through his teeth and smirked. “Anesthesia,” he said, “Huge settlements!”

I’ve consulted on many medical malpractice cases which involved death or brain damage, and airway mishaps were the most common etiology. It’s possible for death or brain damage to occur secondary to cardiac problems (e.g. shock due to heart attacks or hypovolemia), or breathing problems (e.g. acute bronchospasm or a tension pneumothorax), but most deaths or brain damage involved airway problems. Included are failed intubations of the trachea, cannot-intubate-cannot-ventilate situations, botched tracheostomies, inadvertent or premature extubations, aspiration of gastric contents into unprotected airways, or airways lost during sedation by non-anesthesia professionals.

Google the keywords “anesthesia malpractice settlement,” and you’ll find multiple high-profile anesthesia closed claims, most of them related to airway disasters. Examples from such a Google search include:

  1. The Chicago Daily Law Bulletin featured a multimillion-dollar verdict secured by the family of a woman who died after being improperly anesthetized for hip surgery. The anesthesiologist settled prior to trial, resulting in the family being awarded a total of $11.475 million for medical negligence. The 61-year-old mother and wife was hospitalized in Chicago for elective hip replacement surgery.  Because of a prior bad experience with the insertion of a breathing tube for general anesthesia, she requested a spinal anesthetic. Her anesthesiologist had trouble inserting a needle for the spinal anesthesia, so he went ahead with general anesthesia. The anesthesiologist was then unable, after several attempts, to insert the breathing tube. He planned to breathe for her through a mask and let her wake up to breathe on her own.  A second anesthesiologist came into the room and decided to attempt the intubation. He tried but was also unsuccessful. Finally, a third anesthesiologist came into the operating room and tried inserting the breathing tube several times. He too was unsuccessful. All of the attempts at inserting the tube caused the tissues in her airway to swell shut, blocking off oxygen and causing cardiac arrest. She suffered severe brain damage and died.
  2. $20 Million Verdict Reached in Medical Malpractice Lawsuit Against Anesthesiologist. A jury returned a $20 million verdict in an anesthesia medical malpractice lawsuit filed by the family of a woman who died during surgery when bile entered her lungs. The wrongful death lawsuit alleged that the anesthetists failed to identify that the victim had risk factors for breathing fluid into her lungs, despite the information being available in her medical record. The victim was preparing to receive exploratory surgery to determine the cause of severe stomach pains when she received the anesthesia. Once anesthetized, she began breathing bile into her lungs. She then later died. The jury awarded $20 million in favor of the plaintiff.
  3. A $35 million medical malpractice settlement was matched by only one other as the largest settlement for a malpractice case in Illinois, and the most ever paid by the County of Cook for a settlement of a personal injury case. The client, a 28-year-old woman, suffered severe brain damage from the deprivation of oxygen resulting from the failure of an anesthesiologist to properly secure an intubation tube. The client, immediately following the occurrence, was in a persistent vegetative state from which the likelihood of recovery was virtually nil. Miraculously, she regained much of her cognitive functioning, although still suffering from significant physiological deficits requiring attendant care for the rest of her life.
  4. Anesthesia Death Results in $2 Million Settlement: 36-Year-Old Man Dies From Anesthesia Mishap Following Elective Hernia Repair Surgery. The plaintiff’s decedent was a 36-year-old man who died secondary to respiratory complications following an elective hernia repair. During the pre-operative anesthesia evaluation, the defendant noted the patient had never been intubated and had required a tracheostomy for a previous surgery. The defendant decided to administer general endotracheal anesthesia with rapid sequence induction. The surgery itself was without incident. Following extubation, the patient began to have difficulty breathing. The patient desaturated. The surgeon was called back to the OR to perform  a tracheostomy, however, there was no improvement in the patient’s oxygenation and he continued to have asystole. Subsequently, he went into respiratory arrest and coded. The code and CPR were unsuccessful, and the patient was pronounced dead.

Per Miller’s Anesthesia, failure to secure a patent airway can result in hypoxic brain injury or death in only a few minutes. Analysis of the American Society of Anesthesiologists (ASA) Closed Claims Project database shows that the development of an airway emergency increases the odds of death or brain damage by 15-fold. Although the proportion of claims attributable to airway-related complications has decreased over the past thirty years since the adoption of pulse oximetry, end-tidal-CO2 monitoring, and the ASA Difficult Airway Algorithm, airway complications are still the second-most common cause of malpractice claims. (Miller’s Anesthesia, Chapter 55, Management of the Adult Airway, 2014).

In 2005, in the ASA-published Management of the Difficult Airway: A Closed Claims Analysis (Petersen GN, et al, Anesthesiology 2005; 103:33–9), the authors examined 179 claims for difficult airway management between 1985 and 1999. The timing of the difficult airway claims was: 67% upon induction, 15% during surgery, 12% at extubation, and 5% during recovery. Death or brain damage during induction of anesthesia decreased 35% in 1993–1999 compared with 1985–1992, but death or brain damage from difficult airway management during the maintenance, emergence, and recovery periods did not decrease during this second period. There is no denominator to compare with the numerator of the number of closed claims, so the prevalence of airway disasters was unknown.

Awake intubation is touted as the best strategy for elective management of the difficult airway for surgical patients. Fiberoptic scope intubation of the trachea in an awake, spontaneously ventilating patient is the gold standard for the management of the difficult airway. (Miller’s Anesthesia, Chapter 55, Management of the Adult Airway, 2014). Awake intubation is a useful tool to avert airway disaster on the oral anesthesiology board examination. Dr. Michael Champeau, one of my partners, has been an American Board of Anesthesiology Senior Examiner for over two decades. He tells me that oral board examinees choose awake intubation for nearly every difficult airway. This is wise–it’s hard to harm a patient who is awake and breathing on their own. Is the same strategy as easily implemented outside of the examination room? In actual clinical practice, an awake intubation may be a tougher sell. Awake intubations are time-consuming, require patience and understanding from the surgical team, and can be unpleasant to a patient who will be conscious until the endotracheal tube reaches the trachea–an event which can cause marked coughing, gagging, hypertension and tachycardia in an under-anesthetized person. As anesthesia providers, we perform hundreds of asleep intubations per year, and only a very small number of awake intubations. Inertia exists pushing anesthesia providers to go ahead and inject the propofol on most patients, rather than to take the time to topically anesthetize the airway and perform an awake intubation. But if you’ve ever lost the airway on induction and wound up with a “cannot intubate-cannot ventilate” patient, you’ll understand the wisdom in opting for an awake intubation on a difficult airway patient.

I refer you to Chapter 55 of Miller’s Anesthesia for a detailed treatise on the assessment and management of airways, which is beyond the scope of this column. In addition to the reading of Chapter 55, I offer the following clinical pearls based on my 30 years of practice and my experience at reviewing malpractice cases involving airway tragedies:

  1. Become skilled at assessing each patient’s airway prior to anesthesia induction. Pertinent information may be in the old chart or the patient’s oral history as well as in the physical examination. Red flags include: previous reports of difficulty passing a breathing tube, a previous tracheostomy scar, morbid obesity, a full beard, a receding mandible, inability to fully open the mouth, rigidity of the cervical spine, airway tumors or masses, or congenital airway deformities.
  2. Learn the ASA Difficult Algorithm and be prepared to follow it. (…/ASAHQ/…/standards-guidelines/practice-guidelines-for- management-of-the-difficult-airway.pdf‎).
  3. Become skilled with all critical airway skills, particularly mask ventilation, standard laryngoscopy, video laryngoscopy, placement of a laryngeal mask airway (LMA), fiberoptic intubation through an LMA, and awake fiberoptic laryngoscopy.
  4. Read the airway strategy recommended in the Appendix to Richard Jaffe’s Anesthesiologist’s Manual of Surgical Procedures, an approach which utilizes a cascade of the three critical skills of (A)standard laryngoscopy, (B)video laryngoscopy, and (C)fiberoptic intubation through an LMA. For a concise summary of this approach read my column Avoiding Airway Disasters in Anesthesia (
  5. If you seriously ponder whether awake intubation is indicated, you probably should perform one. You don’t want to wind up with a hypoxic patient, anesthetized and paralyzed, who you can neither intubate nor ventilate.
  6. If you’re concerned about a difficult intubation or a difficult mask ventilation, get help before you begin the case. Enlist a second anesthesia provider to assist you with the induction/intubation.
  7. Take great care when you remove an airway tube on any patient with a difficult airway. Don’t extubate until vital signs are normal, the patient is awake, the patient opens their eyes, and the patient is demonstrating effective spontaneous respirations. An airway that was routine at the beginning of a surgery may be compromised at the end of surgery, due to head and neck edema, airway bleeding, or swollen airway structures, e.g. due to a long anesthetic with a prolonged time in Trendelenburg position.
  8. If you’re a non-anesthesia professional administering conscious sedation, never administer a general anesthetic sedative such as propofol. A combination of narcotic and benzodiazepines can be easily reversed by the antagonists naloxone and flumazenil if oversedation occurs. There is no reversal for propofol. Airway compromise from oversedation due to propofol must be managed by mask ventilation by an airway expert.

In its 1999 report, To Err Is Human:  Building a Safer Health System, the Institute of Medicine recognized anesthesiology as the only medical profession to reduce medical errors and increase patient safety. With the pulse oximeter, end-tidal-CO2 monitor, a myriad of airway devices, and the Difficult Airway Algorithm, the practice of anesthesia in the twenty-first century is safer than ever before. Let’s keep it that way.

Faith, hope, and love. The greatest of these is love.

Airway, breathing, and circulation. The greatest of these is airway. Your patient’s airway.


The most popular posts for laypeople on The Anesthesia Consultant include:

How Long Will It Take To Wake Up From General Anesthesia?

Why Did Take Me So Long To Wake From General Anesthesia?

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?


The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

12 Important Things to Know as You Near the End of Your Anesthesia Training

Should You Cancel Surgery For a Blood Pressure = 178/108?

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?





Published in September 2017:  The second edition of THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.


In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.

Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.

Nuanced characterization and crafty details help this debut soar.

Click on the image below to reach the Amazon link to The Doctor and Mr. Dylan:


Learn more about Rick Novak’s fiction writing at by clicking on the picture below: