You are intubating a critically ill patient. The first intubation attempt fails and the patient experiences rapid oxygen desaturation. The respiratory therapist tries to ventilate the patient but air leaks out around the mask with each breath. The chest does not rise and the saturation is dropping.


What is the problem?

Sometimes the problem is an insufficient seal around the mouth but more often the problem is soft tissue obstruction. We intubate supine. The tongue occludes the airway. The air follows the path of least resistance, which is out the face, leaking around the mask.


What are the choices of grip?

  1. One handed grip, aka C or CE grip (generally acknowledged to be less optimal).
  2. Classic two handed grip – taking the problematic one handed grip, and doing it with the other hand too. Similar to the grip you would have if holding a soda can.
  3. Jaw thrust grip – similar to the grip you would have if lifting a gurney or plank, thumbs on top, fingers below doing the work of lifting. Or if you will, taking your soda can and dumping it out forward.


Some studies say CE grip or jaw thrust grip are equally effective. So why do you say jaw thrust is better?

Most of the time airway resistance (A) is lower than mask resistance (M). Anything will work in that situation. What really matters is what happens when A is greater than M. That isn’t addressed in most of these studies.


What happens when A is higher than M?

When airway resistance is higher than mask resistance, the operator grips harder to raise mask pressure. The fingers often compress the submandibular space. This presses the tongue against the posterior airway, and raises airway pressure further. The harder you grip, the more you close off the airway.


What is a better way?


The best way to grip the mask is to press the mask to the face with the thumbs pointing forward. The fingers then fit over the angle of the jaw. If you want more pressure, you pull the fingers, which not only increases the seal pressure but also performs a jaw thrust maneuver. It pulls the tongue off of the palate.


Is there anything else that will help?


Place two nasal trumpets and an oral airway. Whether you have great technique or bad technique this will help. Don’t be afraid to “waste” some plastic here. I suspect that nasal trumpets also improve the effectiveness of apneic oxygenation via high flow rate nasal cannula.


Back to the case. You put the thumbs pointing forward on the mask and pull jaw thrust with digits 2-5. The leak is gone and the patient is re-oxygenated before your second attempt.



-Use the jaw thrust mask grip technique for ventilation

-Good mask ventilation is a crucial airway skill. Invest in it.

-If you are have ANY trouble, place nasal and oral airways


Suggested references:

Efficacy of facemask ventilation techniques in novice providers.

Gerstein NS, Carey MC, Braude DA, Tawil I, Petersen TR, Deriy L, Anderson MS.

J Clin Anesth. 2013;25:193-7



A patient presents to the emergency department on a 5150 hold. He is yelling and straining against police restraints. Of course you will use medications but also want to try calming him down through bedside interaction.


The human mind, unhinged by disease and drugs and high emotions, needs simple, calm communication that is easy to understand. Talk to the patient in a story format. Introduce the characters and organize it chronologically (past, present, future). Make it very clear that they are safe, and you are on their side.



Hi Mr. ____, I am Dr. ____. My job is to help people who are sick or hurt get better.”



“You are here because somebody called 911. They could tell something was wrong. When the police evaluated you they determined something was wrong also.”



“My job is to make you better. I am going to be talking to you and doing a physical examination.”



“When we are done we will determine the best treatments and the best place for you to continue to get better.”



You will be safe here and you will be treated with respect.”

” Everything we do will be in your ultimate best interest.



“Just as I promise to keep you safe and treat you with respect, I expect you to do the same for my staff.”



To get started I would like to calm you down with a medication. That can be through a shot or a pill. If you are willing to take the pill you can choose that. The medicine will calm you and make it easier for us to talk.”



“I know you will be safer if you get some medication. We are going to give you the shot and 4 people will hold you down. They will not hurt you. They are to keep you from hurting yourself and anyone else. When it is done I will talk to you some more.”



Go back to being therapeutic right away so the patient is reassured.

“Are you feeling better after the shot? I want to talk to you about what to expect going forward.”



“What are you most concerned about?”

“What would you most like to see accomplished today?”


How does your emergency department treat the patient with psychosis? This is a stress test for genuine patient-centeredness. If you can be sincerely non-judgmental with them, it reminds everyone that we are serious about our caring culture.



-Explain their care like a story. Introduce yourself and explain the past (how they got here), present (what you are doing now) and future.

-Everything you do is ultimately in their best interest (say that!)

-Reassure their safety first, and respect, and require them to abide by it also.

-Stay therapeutic before, during, and after conflict



Verbal De-escalation of the Agitated Patient: Consensus Statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup.

Richmond JS, Berlin JS, Fishkind AB, Holloman GH Jr, Zeller SL, Wilson MP, Rifai MA, Ng AT. West J Emerg Med. 2012 Feb;13(1):17-25.


A patient presents with a recurrent anterior shoulder dislocation. Milch fails but Spaso works. The next month she is back and the procedure feels different, with more resistance. This time Spaso fails and Milch works. Same shoulder, so what is different? Why did the efficacy reverse?


Milch’s 1938 article started with a question: why do some reductions seem impossible and then under general anesthesia they become very easy, almost going in spontaneously? It was the muscle and tendon opposition, he concluded, so his technique focused on putting the patient in the muscle neutral position overhead (hanging from a limb position). The various shoulder muscles would share equal stress and equal angles.


Milch’s idea has probably not yet been fully fulfilled – it was the idea that shoulder reduction is not about overcoming force but about untangling the humeral head from the adjacent muscles, tendons, and soft-tissues. That was the same idea that inspired Kocher.


We have all had the tough shoulder that would not go in with technique A, but after trying technique B, a second attempt with A yielded an effortless reduction. There seems to be an unlocking of the soft structures that occurs.


Now as to the unlocking. I suspect there is advantage in the difficult shoulder to running through a variety of techniques. Ideally we would know which soft structures are causing the locking, but the literature lacks consensus and I do not know to resolve that. So I run though a variety of techniques.


This is reductionistic but you can think of all techniques as the application of external rotation in different positions.


Kocher is external rotation in the adducted humerus, as are all the derivative techniques.


Milch is external rotation in the abducted elevated humerus (technically he advocated doing the external rotation on the way up).


Spaso is external rotation in the forward flexed shoulder.


Back to the bedside. Its your next shoulder attempt. The shoulder is locked in internal rotation. Your goal is to get it into external rotation. You try Kocher but there is too much resistance to external rotation. You laterally abduct to Milch and you came close but did not fully reduce the shoulder. Finally, you perform forward flexion (Spaso) which also does not work. You then go back to Kocher, which this time was successful.


Take Home Points:

-The obstruction to shoulder reduction is not bone position but soft structures

-The obstruction can apparently be unlocked through applying external rotation in various positions through the range of motion

-If your favorite technique does not work, range the shoulder, externally rotate, and try it again.

Check out medicalclassics.com for more on Milch. If the link does not work, here is the location.  https://medicalclassics.com/2016/09/05/1938-milchs-shoulder-reduction-techniqueabduction-external-rotation-and-pulsion/



The Kocher technique, one of the oldest and most popular techniques, was developed for the subcoracoid anterior dislocation. Review Neil Cunningham’s resources at shoulderdislocation.net for insight on this, as well as his translation of the original Kocher article.


The goal of Kocher’s method, which was worked out on cadavers in 1870, is to roll the greater trochanter of the humeral head on the glenoid rim. It might have been named the “shoulder rim roll.” Here are the steps:


1) Adduct the elbow all the way to get the greater trochanter right next to the glenoid rim.

2) Externally rotate to roll the greater trochanter on the glenoid rim.

3) Forward flex the shoulder (sagittal plane) to tip the humeral head back toward the socket.

4) Internally rotate to complete the reduction.


Kocher’s words:

“Pressing the arm bent at the elbow towards the body, turning outward until resistance is felt, lifting of the outwardly rotated upper arm in the sagittal plane as far as possible, and finally slowly turning it inward” (translation by Cunningham)



The subglenoid dislocation will not be resolved with the Kocher technique because the external rotation phase will not latch onto anything. Kocher himself in his article specified that this was for subcoracoid dislocations, and said “the more therefore the head has departed from the coracoid process toward the interior … the less can be expected from the method.”



-Make sure you fully adduct the elbow first.

-Avoid traction, which is what creates the need for sedation(Chitgopar Injury 2005).

-Avoid sedation. This is the best way to avoid too much force. Kocher’s method excluded the use of force. Perpendicular forces of opposing muscles can lead to fracture. If you get resistance, use another technique.



-Kocher’s shoulder reduction was originally intended for subcoracoid dislocations, not for subglenoid.

-Do not use force with Kocher’s method.



shoulderdislocation.net (see the lectures and translation of the original Kocher article)

Chitgopkar SD, Khan M. Painless reduction of anterior shoulder dislocation by Kocher’s method. Injury. 2005;36:1182-4.


A patient presents with a scalp hematoma from a remote fall. When you press on it, it feels very soft but is not swollen. You are confused, and order a CT, which shows complete lysis of the bone,. Further workup suggests metastatic renal cell carcinoma. The patient is avoidant on history and keeps explaining away the findings and concerns. Hours later, while he is awaiting a bed upstairs, he reveals that a year ago his doctor suspected renal cell carcinoma but he refused a workup.


This patient suffers from denial. Whether that is a perfect term is debatable. In this case it is severe but so often denial seems to overlap with avoidance, perhaps even procrastination. It is at times the unwillingness to address an unpleasant reality. In medicine all too often we judge “denial” as a break with reality but we need to understand it as a human experience. Denial is the way some patients try to grasp onto hope. Go read Arthur Miller’s Death of a Salesman if you want a literary exploration of denial and hope.


We shouldn’t always oppose denial. Don’t argue over code status. If they want to be full code don’t gripe about them at the nurse’s station. They are dying. If knowing they will get 30 minutes of CPR in the end gives them comfort then let them have that consolation. If the patient-centered reasons aren’t enough, remember that practicing code situations only makes you better at it.


The literature is accumulating articles portraying denial as a positive thing. Denial mitigates terror and allows patients to continue to function. But in the emergency department we sometimes see patients at an earlier stage, where denial gets in the way of potentially curative treatment. So what should we do?


Accentuate the positive

Without distorting the truth, emphasize the safety and efficacy of your recommendations.


Build a relationship of trust by genuinely connecting as people

Spend some time getting to know them as people. Share anecdotes of those who have had good experiences, which not only illustrates safety but also displays your connection to patients. As emergency physicians we will not get long-term rapport, so build it for your consultants, whose expertise and caring we should commend to the patient (assuming we can do so truthfully).


Tools of persuasion – allowing an “out” lowers the cost of an “in”

Finally, point out that they can always choose to stop treatment later. That way they can say yes without feeling stuck. By giving them an “out” you are lowering the cost of going “in.”


Ultimately, denial is their choice. We will not be able to convince everyone to face the unpleasant reality but we should use the skills and techniques that best address their frame of feeling.


Take Home Points:

-Denial is often a way for the patient to have hope

-Give such patients hope through emphasizing the positives of treatment

-Connect on a genuine, human level

-Remind them they can change their minds later


Anecdote 1:Don’t call it a seizure, start CPR

Resident: Hey, remember that patient in room 7 with the heart attack? Now he’s having a seizure!

You: That is not a seizure, let’s start CPR!

(the patient survives, and receives emergent catheterization opening a blocked vessel)


Cardiac arrest is often accompanied by jerking movements. The cartoons of the 1940s understood this. Bugs Bunny would typically do a few good jerking leg kicks prior to faking death with Elmer Fudd, Yosemite Sam, etc. If the setting is more appropriate for cardiac arrest, check pulses first.


This is probably not substantially different from convulsive syncope but I will describe that separately:


Anecdote 2: Don’t call it a seizure, refer to cardiology

“we never figured out why the Brugada syndrome patient had a seizure” –someone who should know better


Blood bank studies show that about 10% of syncope events are accompanied by a convulsion. These can look like epileptic generalized tonic clonic seizures. The differences are:

Pre-ictal: what were the setting, the symptoms, and the signs, before the event. An aura suggests a seizure. Standing in church suggests syncope. Alcohol withdrawal suggests seizure, etc.

Ictal: convulsive syncope is less rhythmic, less symmetrical, and less sustained

Post-ictal: Convulsive syncope patients regain normal arousal within a minute, seizure patients take 10-15 minutes


It isn’t a seizure until you have a diagnosis. It is a convulsion. Apply an appropriate differential that includes convulsive syncope.


Ancedote 3: Don’t call it a seizure, check the temperature

A middle aged patient is waiting to be seen for generalized weakness. The triage RN rushes them out of the waiting room because of a “seizure.” He never lost consciousness and was awake the entire time. Temp is 103 oral. You ultimately diagnose sepsis from pyelonephritis.


Rigors can cause tremendous shaking and can make us worry about seizure. Obviously a seizure can raise the temperature so judgment is required. But don’t automatically assume that a convulsion from sepsis is a seizure. Rigors happen when the temperature is rising, so recheck the temperature.


Anecdote 4: Don’t call it a seizure, educate the family

A patient is here for opioids. The doctor said no. She has a history of developing “seizures” when she does not get narcotics. Now she is screaming loudly and, wait for it…. The RN runs to you announcing a seizure and asks if you will give Ativan. Okay, I admit it, I often give Ativan if I am not sure. One time I went to the patient and said “really, you are having a seizure? Can I see the tongue biting, show me the tongue” and she proceeded to show me her teeth, biting the tongue.


This is tough. Don’t expect the family to understand the difference between seizures and psychogenic convulsions (also known as pseudoseizure). Educate them on the potential for psychogenic causes (but don’t prematurely rule out epilepsy either, unless it is abundantly obvious)



-Our terminology can box us in. Don’t call it a seizure unless you are committing to an epileptic etiology.

-Ask about circumstances before, during, and after the event to identify possible convulsive syncope


We speak of physical diagnosis as if the sign and the suggested diagnosis always match. Often they do, for example when we see acromial step off and suspect anterior shoulder dislocation.


But more often there is ambiguity. Most bedside information is non-specific. For example, tachycardia can mean a lot of different things. Later when we look at everything at once, there is the chance to “put it all together.”


But when will you do that? It is necessary at times to give uninterrupted concentrated thinking to a patient’s symptoms and signs. For example, how about the chronic headache patient who saw the chiropractor for neck pain? When you put it all together you might think of vertebral dissection.


Some call this a “cognitive pause,” others just call it medical decision-making, and others focus on the disruptive effect of interruptions.


Many ED groups routinely expect charting to be done at the end of the shift, after the patients are gone.


But charting is a chance to think critically, to put it all together. And sometimes when we do that early in the visit, it can prompt a “lightbulb” moment where we realize the need to check something else.


I advocate real time charting. The act of creating a chart requires thinking. Why not do that while the patient is still in the ED? I think at the end of the visit just before discharge is okay but even better would be right after seeing the patient. The recitation of the symptoms and signs are most accurate at that time and the “cognitive pause” of thinking through the whole presentation then can happen early, when it can change the workup.


It is simply impossible to do that on all patients on all shifts. But this is something we should try to do. The bottom line is that most historical and physical findings are ambiguous. There needs to be an explicit stage after information collection, which is information “integration.”


Take Home Points

-Complex patients require a “cognitive pause”

-It is hard to do that on a busy shift but real-time charting makes it more possible



Check out Mark Jaben EP Monthly April 2013

To Reduce Medical Errors, Take a Cognitive Pause


A patient a history of COPD presents with shortness of breath. Physical examination shows pursed lip breathing, prolonged exhalation, recruitment of accessory muscles, etc. COPD exacerbation, right?


Hold on. Have a COPD patient jog around the parking lot and they will look just the same. Anything that causes shortness of breath in a COPD patient will accentuate the physical signs of COPD. All those signs mean is that they are either having to breath harder, or deal with secretions.


The GOLD criteria for COPD emphasize a change in sputum character or quantity or dyspnea. A viral URI can do that. So can PE, metabolic acidosis, CHF, etc.


This is why I recommend thinking of COPD as a diagnosis of exclusion. If there are copious secretions then maybe that tells you the origin of the problem. But if it is just shortness of breath, then work it up the same way you would work up any patient with shortness of breath.



-Think of COPD as a diagnosis of exclusion- consider other causes like CHF, pneumonia, pulmonary embolism

-Be especially vigilant in the COPD patient who presents with shortness of breath and no change in secretions


Morgagni in 1761 described a man who presented with a swelling on the upper part of the sternum (Seats and Causes of Diseases). The skin became thinner and blood began to leak out. The original case describes the patient pulling at his bandages and being “ordered to keep himself still, and to think seriously and piously of his departure from this mortal life, which was very near at hand, and inevitable.” The following day Morgagni describes the lesion bursting. “Nevertheless, he had the presence of mind, (as soon as) he felt the blood gushing forth, not only to commend himself to God, but to take up with his own hands a basin that lay at his bedside; and, as if he had been receiving the blood of another person, put it beneath the gaping tumour, while the attendants immediately ran to him as fast as possible, in whose arms he soon expired.” Post-mortem examination revealed the cause to be an aortic aneurysm.


In the 1955 movie Not as a Stranger Robert Mitchum evaluates his chief of surgery who complained of chest pain. Mitchum listens to the chest (presumably hearing a diastolic murmur), recoils in horror, then checks the bilateral pulses (presumably feeling a pulse deficit), and rushes him off to the operating room.


Before one gets the conclusion that we were better at physical diagnosis then, a contemporary article of that era described the antemortem diagnosis rate of aortic dissection as 11% (Levinson 1950). Hollywood has always exaggerated the abilities of its heroes to overcome the limitations of our real world. One of the leading experts on this disease has said “…difficulty in diagnosis, delayed diagnosis or failure to diagnose are so common as to approach the norm for this disease…” (Elefteriades Cardiology 2008).


Is there anything we can we do at the bedside to improve our history and physical examination?


Full history beats partial history:

Physicians who ask about onset, location, and quality have a better chance at diagnosis. Of patients who turned out to have aortic dissection, when all 3 of those were documented the condition was suspected in 91% of cases. When at least one of those is missing from the chart, the diagnosis was initially suspected in 49%.(Rosman Chest 1998)


Pain that is sudden, severe, or radiating to the back

Sudden and severe pain are present in up to 90% of cases (Klompas JAMA 2002). Radiation to the back occurs in 47-64% of patients (Hiratzka JACC 2010).


Chest pain + neurologic deficits

Other specific findings include migration of pain along the territories of the aorta and new neurological deficits, both present in up to about a quarter of patients (Sullivan Am J Em Med 2000).


Diastolic murmur

It turns out that Robert Mitchum’s approach is still worth doing. A diastolic murmur of aortic regurgitation is a high risk finding, occurring in 45% of patients (Hagan JAMA 2000).


Pulse deficit

A “pulse deficit”, which refers to an absent or asymmetrically weak pulse, occurs in 26%(Pape 2007. Klompas says 31%). Do not bother with blood pressure limb differentials in low risk populations, as it has poor specificity, being found in 19% of chest pain patients without aortic dissection (Singer 1998). Instead, palpate both limbs feeling for a difference.


Although it is beyond the scope of this article, many advocate using d-dimer as a screening test in those with a low (but not zero) probability of disease because it is 97% sensitive and 47% specific, at least in the first 24 hours of disease (Suzuki Circulation 2009). With time that sensitivity goes down and most experts recommend not relying on this test.



-Sudden and severe pain raises your concern for aortic dissection

-Check for pulse deficits and diastolic murmurs

Deep Space Infection of the Neck? Check Range of Motion

A young man presents with a severe sore throat. He was here yesterday and received antibiotics. Today he feels worse. You look in the throat expecting a peritonsillar abscess but the throat looks completely normal, not even erythema.


Now what?


Amidst the busy emergency department practice, sometimes we need a reason to take a second, closer look. Always trust your gut. In this case the patient had severe pain but no erythema. The concerning finding was not the severe sore throat or the normal examination, but the incongruity of both. Is there something deeper going on? What else should you check?


Check range of motion. He can do it but has severe pain, not so much with flexion but definitely with extension. You order a CT scan and it shows a retropharyngeal abscess.


I would have hoped to a review of the physical findings on this condition but they appear to be very limited (odynophagia, trismus, stridor, muffled voice)


Take Home Points:

-Incongruity/anomalous findings get your attention

-Check range of motion for suspected deep space infection of the neck