Bougie Use in the Field
Objective: Use an introducer (bougie) the way you were trained — feel tracheal rings, railroad the tube, and stop if hold-up is absent and the view is gone.
Why This Is Hard
The epiglottis is a rim and the hole is not obvious. Crews poke, hope, and inflate a cuff in the esophagus. DAS difficult-airway pathways include an introducer as a change of tool, not as infinite extra time.
- Have the bougie in your hand before the look, not in the outside pocket of the airway bag.
- Railroad the tube without losing the bougie depth. Someone holds it.
- Confirm with waveform. Clicks are a clue, not a substitute for EtCO₂.
Field Rules (Education)
- Feel: tracheal rings (“clicks”) and hold-up at the carina are teaching signs you are in trachea. Esophagus is quiet and keeps going.
- Railroad: leave the bougie, pass the tube, then remove the bougie. Rotate the tube if it hangs on the arytenoids.
- One change: bougie after a failed tube pass is a new plan. Repeating the same look with the same blade is not.
- SGA still exists: AHA 2025 ALS accepts an SGA as an advanced airway in adult arrest if the tube is not happening.
Field Pitfalls
- Shoving until you create a false passage.
- Calling clicks without ever seeing or confirming EtCO₂.
- Leaving the bougie on the bench because “this one will be easy.”
Practice
60-second drill
Partner: (1) Grade 2b view, bougie clicks, tube will not pass; (2) no clicks, bougie keeps going; (3) arrest, two failed looks. Next tool.
Related: Difficult Airway, FONA.
Sources & Further Study
Named guidelines for further study. They are not clinical orders and do not replace your protocol or medical direction.
- NASEMSO National Model EMS Clinical Guidelines (2022) — U.S. EMS model language; protocol still wins
- Difficult Airway Society guidelines hub — introducer as a change of technique, not endless attempts
- AHA 2025 Part 9: Adult ALS — limit peri-intubation hypoxia; SGA is acceptable
Education only. Apply learning within your protocols and medical direction. This is not clinical care guidance.
Check Your Understanding
Street decisions from this lesson only. After you check, the key is highlighted. Education practice — not a certification exam.