Every emergency physician remembers their first few intubations—the nerves, the adrenaline, the shaky hands. For rookies, airway management is both exhilarating and terrifying. But certain mistakes happen over and over again in the ED. The good news? Almost all of them are preventable with awareness, preparation, and practice.
This guide outlines the most frequent rookie errors during intubation and offers practical strategies to avoid them.
1. Poor Preparation: “Just Grab the Tube and Go”
The mistake: Rookies sometimes think intubation is all about the moment you put the laryngoscope in the mouth. They forget that 90% of airway success happens before drugs are pushed.
Examples of poor prep:
- No suction set up.
- Tube cuff not tested.
- Wrong-sized mask for BVM.
- VL screen not turned on.
How to avoid it:
- Use the SOAP-ME checklist every single time.
- Lay out your backup devices (supraglottic airway, bougie, cric kit).
- Call a quick airway huddle: state Plan A, Plan B, Plan C aloud before induction.
2. Inadequate Preoxygenation
The mistake: Skipping or rushing preoxygenation. Rookies often sedate and paralyze patients without maximizing oxygen reserves, leading to rapid desaturation.
Why it matters: Critically ill patients desaturate much faster than elective OR patients—sometimes within seconds.
How to avoid it:
- Give 3–5 minutes of oxygen via NRB or HFNC if time allows.
- Add nasal cannula for apneic oxygenation.
- For severe hypoxemia, use NIPPV preoxygenation.
- Always start in a semi-Fowler or ramped position if possible.
3. Bad Positioning
The mistake: Flat positioning with no head elevation, especially in obese or trauma patients. This makes laryngoscopy harder and worsens oxygenation.
How to avoid it:
- Elevate the head so the ear is at the level of the sternal notch.
- Use blankets, pillows, or a commercial ramp.
- In trauma with c-spine immobilization, still use head-elevated supine.
4. Over-Reliance on Mallampati
The mistake: Trying to force a Mallampati view in a crashing patient. It wastes time and doesn’t predict ED intubation difficulty reliably.
How to avoid it:
- Use LEMON + MOANS to rapidly predict difficulty.
- Always have a backup airway device, regardless of how the patient “looks.”
5. Incorrect Laryngoscope Technique
The mistake:
- Using the laryngoscope as a lever on the teeth.
- Inserting too deep and missing the epiglottis.
- Poor blade angle with VL.
How to avoid it:
- Remember: lift, don’t lever. Motion should be upward and forward.
- With VL, keep the screen in view but don’t forget to use standard technique—look into the mouth first, then at the screen.
- Practice hand positioning in simulation labs.
6. Neglecting the Bougie
The mistake: Many rookies don’t use the bougie early enough. They attempt multiple intubations with stylet alone, wasting time.
How to avoid it:
- Have the bougie on the table for every intubation.
- Use it for Cormack-Lehane grade II or worse views.
- Practice the tactile “tracheal click” and “hold-up” feel in training.
7. Forgetting Confirmation
The mistake: Assuming the tube is in just because it “looked right.” In emergencies, esophageal intubation is a deadly pitfall.
How to avoid it:
- Always use waveform capnography as gold standard.
- Secondary checks: chest rise, bilateral breath sounds, fogging, ultrasound if needed.
- No EtCO₂ waveform? Assume esophageal until proven otherwise.
8. No Post-Intubation Sedation
The mistake: Paralyzing and intubating the patient, then forgetting to sedate. This leads to the dreaded scenario of a patient who is paralyzed but awake.
How to avoid it:
- Prepare post-intubation sedation and analgesia before induction.
- Examples: propofol or midazolam for sedation; fentanyl, morphine, or ketamine for analgesia.
- Reassess frequently to avoid under- or over-sedation.
9. Too Many Attempts
The mistake: Rookies often keep trying again and again, making hypoxemia worse.
How to avoid it:
- Stick to the “two attempts per operator” rule.
- If two attempts fail, switch to another strategy, operator, or device.
- Always have a clear escalation plan (SGA, cric).
10. Communication Failures
The mistake: Not verbalizing the plan, leaving the team guessing.
How to avoid it:
- Before RSI, call out:
- “Plan A: VL with bougie.”
- “Plan B: LMA.”
- “Plan C: Cricothyrotomy.”
- Assign roles: who pushes drugs, who does BVM, who monitors vitals.
Rookie Pearls
- Airway management is a team sport—never do it in isolation.
- Confidence comes from preparation, not bravado.
- Simulation is the safest place to make mistakes—seek it out.
Take-Home Message
Rookies don’t fail because they don’t know how to insert a tube—they fail because of preparation gaps, poor positioning, and lack of backup planning. By recognizing these common mistakes, you can avoid them, build confidence, and improve patient safety from your very first shift.
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