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Trick of the Trade: Difficult intubation — making lemonade out of lemons

Michelle Lin, MD |


IPoolBloodn many cases of massive GI bleeding, airway control is essential. During endotracheal intubation, suction sometimes just isn’t adequate enough to allow to get a good view of the vocal cords. The pool of blood keeps re-accumulating faster than you can suction. You think you see an arytenoid, pointing you in the direction of the trachea, and so you slide the endotracheal tube in.

Unfortunately, when you bag the patient, you realize that you are in the esophagus.


Trick of the Trade: Difficult Intubation

Leave the esophageal tube in. Reattempt endotracheal intubation.

“When life gives you lemons, make lemonade.”


If the endotracheal tube is in the esophagus, do NOT take it out! You have just created a conduit to remove further bleeding from the field. Take another look with Yankauer suction. Reattempt your intubation with a second tube. Do this as soon as you recognize an esophageal intubation to reduce the patient’s risk for oxygen desaturation.


  1. Be sure that the esophageal tube is turned away from the providers to avoid being splashed with blood.
  2. Have an assistant suction the proximal port of the esophageal tube when blood starts pouring out of it.

Thanks to Dr. Marianne Haughey and Dr. Peter Gruber (Jacobi Medical Center) for sharing this tip. Quick thinking!

Image source 1


Author information

Michelle Lin, MD

ALiEM Founder and CEO
Professor and Digital Innovation Lab Director
Department of Emergency Medicine
University of California, San Francisco

The post Trick of the Trade: Difficult intubation — making lemonade out of lemons appeared first on ALiEM.

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