A Treatise On Marksmanship


“So how many intubations have you done?” asked Retired Surgeon.

“More than you’ve done in the past twenty years,” came my good-natured retort. “Maybe more than you’ve done, period. After all, you had the gas passers to do your airway procedures for you.”

“Seriously, how many?” he pressed.

The question stumped me, I’ll admit. I never really kept count, other than during my paramedic training, when I was required to.

“Probably a couple hundred?” I ventured a guess. “Maybe a handful more? I’ve been a medic for thirteen years. I did thirty-four tubes during my anesthesia rotations in medic school. I worked in rural EMS for ten years, but I averaged a tube a month for the first three years I worked at Mom and Pop EMS, and that was back in the days when our run volume was a third of what it is today. I did two or three tubes a month at Big City EMS.”

“So how do you compare your level of expertise with, say, an anesthesiologist or CRNA with a few thousand tubes?”

“Well first of all, I don’t compare my experience level to theirs,” I explained. “But I will say that I’m more accustomed to working in, shall we say, austere environments than your typical anesthesiologist or CRNA. Besides, experience on live patients isn’t all it’s cracked up to be.”

Yeah, that last sentence garnered a raised eyebrow from Retired Surgeon, too. I know what you’re thinking:

Does Ambulance Driver actually mean that you can become proficient at endotracheal intubation by practicing solely on a manikin?


Yeah, that is what I’m saying, at least to the extent that constant manikin practice builds the hand-eye coordination and muscle memory necessary to develop the skill of hitting this target:


See, here’s the thang. Hitting this target consistently is really no different fundamentally than punching holes in paper or knocking over steel plates with your projectile weapon of choice. Laryngoscopy even shares some common elements with the shooting arts; grip, sight picture, etc.

Heck, you can even consider a laryngoscope a weapon, in the sense that when used correctly, it can save a life, and when used by the unskilled or foolhardy, it can also kill someone.

Regular manikin practice with that laryngoscope and endotracheal tube is akin to range practice with your firearm. You practice the fundamental skill set in a set of controlled conditions, and you build those psychomotor skills until they become an unconscious reflex. If you have to think about it, you haven’t practiced enough.

Mastering the skill is easy enough, if your end goal is simply slipping a tube between those two pearly white vocal cords under ideal conditions. Heck, my friend Gary once dressed a janitor in scrubs, gave him some rudimentary instruction in endotracheal intubation over the lunch hour, and then set him to teaching medical residents and nurses how to intubate.

And they never had a clue that their ACLS airway management module was taught by the guy who mops the floors.

Edit: Turns out Gary used a kitchen worker, not the janitor. So, the doctors and nurses in that class were taught to intubate by the lady who makes the sloppy joes and that weird hospital Jello with the fruit chunks in it. Apparently, if you take off the hairnet and slap on a surgical cap, a short order cook can can easily pass for an anesthesiologist. Comforting, ain’t it?

That’s how easy the skill is to master, yet I constantly encounter people who mythologize the ability to effectively wield a laryngoscope.

This manikin practice has to have a purpose, though. You have to be critical of your performance. Every marksman worth his salt wants to hit the bullseye on every shot.

When you’re a new shooter, just getting all the rounds in the black is a thrill. After a while though, you naturally want to tighten those groups.

Sadly though, hitting the bullseye (glottic opening) on an airway manikin is easily done even with piss-poor technique. All too many paramedics think they’ve achieved mastery at this point, only to find out that a tough tube on a real patient exposes flaws in their technique they never knew they had. You have to practice how to deal with clenched teeth, blood, vomit, and laryngospasm. All of these things can be simulated on a manikin.

You don’t want your first encounter with these things to be in a muddy ditch somewhere, with someone’s life on the line. To do so is akin to going to the range very day and shooting your carry sidearm, yet never practicing drawing it in a hurry. The ability to punch very small groups in a classic duelist’s stance won’t do you much good if your weapon is on your hip when you encounter the knife-wielding thug on a dimly lit street.

I’m not saying however, that practice alone is sufficient. It’s not. But experience is not going to magically increase your hand-eye coordination or your psychomotor skills.

Experience will teach you the mindset.

One of my favorite authors, W.E.B. Griffin, wrote in his books that the only marksmanship medal that counts is the Combat Infantry Badge – the one you earn when your target is shooting back at you.

LawDog wrote an excellent set of posts on the combat mindset. The airway mindset is no different. Constant practice may hone your skills, but only real-life experience teaches you how to effectively utilize those skills when the feces have struck the thermal agitator.

The question then becomes, how much experience is required to develop that mindset? Is it two hundred tubes, or two thousand? Personally, I think it depends upon the attitude and learning curve of the individual.

People who hold up x number
of successful intubations as the defining measure of proficiency fail to consider the mindset of the person holding the scope. It’s as ludicrous as saying a cop has to be in a shootout every single day in order to be proficient with his sidearm. It’s as laughable as saying a soldier must be in a firefight every day to stay sharp.

For me, the most important part of the airway mindset came about a hundred tubes in. I learned that the most important thing about airway management is knowing how to secure an airway without resorting to the tube. As a result, the number of times I’ve chosen to intubate people has actually gone down, because I have other, less invasive tools in the toolbox now.

It’s not about numbers. It’s about learning from your experiences.

I know a few medics with twenty years of experience. I know a lot more with one year of experience, twenty times.

The same holds true for anesthesiologists and CRNAs. Some have two thousand tubes under their belt. Many others have twenty tubes, repeated a hundred times.

P.S. I got the tube that precipitated this conversation, after Retired Surgeon had tried several times and failed. I’m also convinced that, had he let me handle things from the beginning, the tube might not have been necessary in the first place.

Browse by Category