ER Basics for Rookies

When the decision is made to intubate in the ED, time is short, stress is high, and errors are costly. The difference between a smooth intubation and a dangerous delay often comes down to how well you prepared your equipment. For rookie doctors, having a mental (or written) checklist is a lifesaver. This article lays out a comprehensive, step-by-step equipment checklist that aligns with current emergency airway guidelines, but keeps things simple and practical for the realities of the ED.

Why a Checklist Matters

• Cognitive overload is the norm during resuscitation; a checklist reduces mistakes.
• It ensures backup devices are ready, not just the first plan.
• It promotes team communication: nurses and residents know exactly what to prepare.
• It saves lives when the airway becomes unexpectedly difficult.

Aviation, trauma, and emergency medicine all share one principle: checklists save lives.

The SOAP-ME Framework (The Core Airway Checklist)

The widely used SOAP-ME mnemonic is an easy way to structure airway preparation. Each letter covers a category of essential equipment and setup:

S – Suction

• Yankauer suction catheter connected and working.
• Backup suction (soft catheter).
• Test it before starting; a clogged or nonfunctioning suction device during massive secretions or blood is a rookie nightmare.

Pro tip: Place suction in the patient’s mouth before induction to ensure it actually works and is within reach.

O – Oxygen

• Oxygen source ON and functioning.
• Non-rebreather mask or high-flow nasal cannula for preoxygenation.
• Bag-valve-mask (BVM) with PEEP valve attached.
• Nasal cannula for apneic oxygenation.

Pro tip: Always check that your oxygen tubing is connected to the wall source (not the air outlet!)—a surprisingly common mistake on night shifts.

A – Airway Equipment

• Primary device: endotracheal tube (ETT), correct size, cuff tested, stylet pre-shaped (“hockey stick” bend).
• Secondary device: one size smaller and one size larger ETT ready.
• Backup device: supraglottic airway (LMA/i-gel) of appropriate size.
• Adjuncts: oropharyngeal airway, nasopharyngeal airway, bougie.
• Definitive backup: surgical airway kit (cricothyrotomy).

Pro tip: Have the tube depth marked (e.g., “22 at the teeth for average adult male”) before starting—saves fumbling afterward.

P – Pharmacology

• Induction agent: ketamine, etomidate, or propofol drawn up and labeled.
• Paralytic agent: rocuronium or succinylcholine ready in a separate syringe.
• Rescue drugs: push-dose vasopressors (phenylephrine, epinephrine), atropine (for pediatrics), analgesia/sedation for post-intubation care.

Pro tip: Label your syringes clearly; in the chaos of an airway, drug swaps are a real risk.

M – Monitors

• Continuous pulse oximetry.
• Cardiac monitor/ECG leads attached.
• Blood pressure cuff cycling automatically.
• Capnography (EtCO₂)—gold standard confirmation after intubation.

Pro tip: Place EtCO₂ tubing before intubation so it’s ready to confirm tube placement instantly.

E – Equipment (Extra/Everything Else)

• Laryngoscope handle with fresh batteries.
• Blades: video laryngoscope (VL) and direct laryngoscope (DL) options.
• Backup blades of different sizes.
• GlideScope or other VL screen powered on and functional.
• Cricothyrotomy set opened and within reach.

Pro tip: Always turn on the VL monitor before induction—you don’t want a black screen after paralysis.

Expanded “Real-World” Checklist

Beyond SOAP-ME, experienced airway managers add layers for safety:

1. Positioning gear
   • Head-elevated laryngoscopy position (HELP) pillow or blankets.
   • Ramping for obese patients.
2. Ventilation supplies
   • BVM with appropriate mask size.
   • PEEP valve attached.
   • In-line viral filter (post-COVID standard in many EDs).
3. Confirmation tools
   • Capnography is mandatory.
   • Ultrasound probe nearby (in case of doubt, lung sliding check).
   • CXR post-procedure if time allows.
4. Sedation & analgesia setup
   • Propofol or midazolam for ongoing sedation.
   • Fentanyl, morphine, or ketamine infusion for analgesia.

Common Rookie Mistakes

• Forgetting suction—blood and vomit will ruin your first-pass attempt.
• Not checking the cuff—leaks can be catastrophic.
• Wrong-sized mask for BVM—results in ineffective preoxygenation.
• No backup tube ready—if the first fails, you lose time.
• Forgetting post-intubation sedation—paralyzed but awake patients are a major rookie error.

A Practical Pre-Intubation Huddle

Before induction, call a 30-second team pause:

• “We are performing RSI.”
• “Plan A: Video laryngoscopy with bougie.”
• “Plan B: Supraglottic airway.”
• “Plan C: Surgical airway—kit is open.”
• “Drugs drawn: ketamine 100, roc 100.”
• “Suction is working, monitors are on, oxygen ready.”

This creates shared mental models and prevents silent disasters.

Quick-Reference Table

Take-Home Message

A well-prepared airway is a safe airway. Rookies should commit SOAP-ME to memory, but also practice laying out every piece of equipment in order before touching the patient. Airway success in the ED is not luck—it’s preparation.