Stop sniffing, start ramping
I agree completely with the results of the short survey. I direct
readers to the article below which I have found to work superbly in
practice in patients without head or neck trauma. From memory the concept
first appeared as 'ramping up' in an US emergency medicine article, but
the beauty is the simplicity and objectivity of the horizontal line from
the external auditory meatus to suprasternal notch.
The following is my working script for trainees and ambulance paramedics,
being simple enough for all grades of staff to ensure that the patient is
1) Patient supine,
2) Arrange pillows under the head to achieve a horizontal line from the
external auditory meatus to suprasternal notch.
3) If necessary in the very obese be prepared to ramp even more
pillows/blankets under the upper thoracic spine to get the position right.
4) Always have the thumb of the left hand slightly to the left of centre
parallel to the handle (ie off centre, similar to a golf grip).
5) If the anterior upper chest wall obstructs insertion of the
laryngoscope, with the tip of the blade over the mouth, turn the
laryngoscope handle clockwise until the base is approximately over the
acromio-clavicular joint. Gently insert the blade to the right of the
tongue and as the tip moves posteriorly rotate the handle back to a normal
position, gliding clear of the chest wall.
Authors: Jeremy S. Collins; Harry J.M. Lemmens; Jay B. Brodsky; John
G. Brock-Utne; Richard M. Levitan
Source: Obesity Surgery, Volume 14, Number 9, October 2004, pp. 1171-
Publisher: FD Communications Inc.
Competing interests: No competing interests