I recently showed a patient his trachea through his trach tube. He flipped the scope over and looked in the eyepiece; he greatly appreciated viewing his own trachea for the first time in his life! It convinced him the trach was in position, the reason he came to the ED in the first place. He followed up as an outpatient with his otolaryngologist.

Finally, there are the cases where a tube cannot be inserted through the mouth, and it must go through either the nose or the neck. In the “surgically inevitable airway,” for those patients who will get a surgical airway because of significant pathology (not quickly reversible) of the oropharynx, it makes sense to go through the neck first if you’re forced to intervene. However, in patients with angioedema or Ludwig’s who may be much improved within a day or two, the nasal route with endoscopic guidance is worth trying. Understand, however, when attempting to intubate these patients, the backup, immediate default plan is to cut the neck. Have them marked, have a tray open and ready, and discuss the possibility with patients and staff so if cutting is required, it’s no surprise, and you are cognitively and physically ready. These types of patients will likely be impossible to rescue by passive oxygenation, mask, or supraglottic ventilation.

There are two other factors changing the rules and enabling, or requiring, emergency physicians to pick up endoscopes. First, there’s no logistical or financial excuse not to have scopes in the ED. There are now single-use disposable endoscopes (AMBU aScope) and sterile endoscopic sheaths (Medtronic EndoSheath) to put over short and long scopes. These eliminate the need to have scopes sent out of the department for cleaning or repair. Some endoscopes also attach directly to our video laryngoscope monitors (Storz).

The second new reason to embrace endoscopy of the airway is that otolaryngology coverage is declining. More and more, we are at risk of having to manage these cases ourselves. We are becoming one of only a few specialties remaining that is made of “proceduralists,” like acute care surgeons in trauma or critical care physicians in some venues.

We cannot run from our fears in this job. It is better to run at them, expanding our skills set, to the do the best for our patients and make better decisions. In the long run, as you gain confidence and eliminate fear, you will last longer in the challenging environment of emergency medicine. The need for endoscopic skills may be infrequent; the benefit of knowing how to do it, priceless.