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The search for guiding principles is an appealing one.

From Plato’s Republic to Miyamoto Mushashi’s Book of Five Rings, there is a long history of attempts to distill elements of our common human experience like justice, power, love into aphorisms that can become touchstones as we move through the world. I once read a book by Graham Greene called The 48 Laws of Power and afterwards felt like each of the laws was a simple insight not only into the application of power but more importantly how not to fall victim to it.

Over my course of emergency airway training I’ve noticed a set of principles emerge that keep me out of trouble; guide me in my practice, and inform how I teach others. I’ve always liked the format of the aphorism and so have decided to start placing the ones I like that are specific to emergency airway here. Let’s see what number we get to!

the first law

This is far and away the most important law and is the guiding principle of all emergency airway practice. This may seem obvious, but in the time critical and stressful environment of the rapidly evolving airway emergency it is often hard to maintain focus on this goal. Human factors and a desire to skip over this first law in order to do other desirable actions like “place the tube” can overwhelm your judgement. To avoid these errors it’s important to make this first law the foundation of all your training. Build your strategy around this one law and it will serve you well.

the second law

Law one is difficult because most of the time it involves intense pressure and stress. That is why law number two is breathe. First responders rigorously begin with a survey of scene safety because they are no good to any potential victim if they are incapacitated on arrival. So too you need to acknowledge the stress and take a deep breath. When tensions rise do it again, and then again… Calming the mind through breathing is fundamental to our nature and will keep you in the game.

the third law

My wife often has to restrain me in the kitchen. “Don’t embellish” she says. In the same way your emergency airway skills should honor simplicity: learn what you need and add nothing you don’t. It is better to have total mastery of a simple set of airway fundamentals than to have a mish mash of half-baked techniques. Honor simplicity also understands the environment in which we practice: where every additional layer of complexity offers diminishing returns for rapid and effective action.

By JOnathan St George MD

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