Here is a statistic that should make every ATLS candidate sit up. Traumatic airway obstruction was the second-leading cause of preventable death on the battlefield during Operations Iraqi Freedom and Enduring Freedom. And when clinicians reached for the last-ditch procedure designed to fix it, the emergency surgical airway, a retrospective analysis found that up to one in three prehospital cricothyroidotomies failed.
Not one in thirty. One in three.
Research presented last week at the 2026 Military Health System Research Symposium (MHSRS) in Kissimmee, Florida, offers an uncomfortable explanation for part of that failure rate, and it has nothing to do with the patient. It has to do with the plastic neck you practiced on.
The study: smooth plastic builds false confidence
A team from the Uniformed Services University of the Health Sciences, funded through the Tri-Service Nursing Research Program and led by U.S. Army Lt. Col. Andrea Hall, put a simple question to 33 military nurse anesthesia students. Does the training model change the clinician?
Students performed cricothyroidotomy on two kinds of model. The first was the familiar commercial task trainer: clean, smooth, dry, with landmarks you could find with your eyes shut. The second was a custom 3D-printed model built with layered tissue and fluid-filled channels that bleed when you cut them.
The results split in a way that should worry anyone who has ever felt reassured by a fast run on a mannequin:
On the easy model, students were faster. About 33 seconds faster, and they rated their own confidence slightly higher.
Students knew the easy model was fake. They rated the 3D-printed version more realistic and preferred it by close to two to one.
The order of training mattered more than anything else. Students who learned on the realistic model first succeeded 97 percent of the time overall. Students who started on the simple task trainer succeeded only 84 percent of the time.
Read that last point again. Same students, same procedure, same total training time. A thirteen-point swing in success, decided by which model they met first.
The investigators' conclusion was blunt: an emphasis on speed, measured on a model with exaggerated landmarks and no blood, may be actively counterproductive for building a skill that has to survive contact with real anatomy. Fast on plastic is not the same as competent on a neck.
What ATLS actually asks of you
This is where the research and the ATLS Course Manual line up almost word for word, because the manual has already anticipated the psychology of this moment.
The manual is clear that a surgical or incisional airway is indicated when oxygenation cannot be achieved by face mask, laryngeal mask, or intubation, the situation it names cannot intubate, cannot oxygenate. It is equally clear that this is not a technique to perform casually, and that training, practice, and teamwork are what give a clinician the confidence to do it promptly (Chapter 4, pp. 57–58).
Three specific instructions in Chapter 4 deserve highlighting, because each one is a direct answer to the failure modes the MHSRS study exposed.
1. Prepare the kit after the first failed attempt, not the third
The manual states that after the first unsuccessful intubation attempt, another team member prepares the surgical airway equipment. It also says that any team member can and should announce the cannot intubate, cannot oxygenate situation out loud, and that delay in performing the incisional airway can be catastrophic. The related principle from the chapter summary: the first attempt at intubation is the optimal attempt, and identical repeated attempts are unlikely to succeed. Change the operator or change the technique.
2. Once you start, you finish
The manual explicitly warns the clinician not to be dissuaded by the significant bleeding and air spray that follow the incision, and states that once commenced, the procedure must be completed despite obstacles. That sentence exists precisely because bleeding is the thing a dry task trainer cannot teach you to ignore. This is the point the MHSRS work makes empirically.
3. The technique is deliberately low-tech
ATLS chose its cricothyroidotomy technique for simplicity, speed, success rate, and the absence of specialized instruments. Minimum kit is a scalpel, ideally a size 10 or 15 blade, and an endotracheal tube of roughly size 6.0. A bougie helps and is usually already in the intubation kit. The sequence, condensed (Chapter 4, pp. 57–59, Figures 4-13 and 4-14):
Assistant maintains manual cervical motion restriction; front of the collar comes off.
Nondominant hand performs the laryngeal handshake, stabilizes the larynx, retracts tissue, and stays there. It does not let go, and it helps tamponade bleeding.
Vertical midline skin incision, roughly 3–5 cm, from thyroid cartilage down to cricoid cartilage. Vertical and midline because that is how you avoid the larger midline vessels, and because it can be extended either way if your landmarks are deeper than you hoped.
Blunt or sharp dissection to the cricothyroid membrane, palpating frequently to stay midline.
Transverse incision through the membrane, using a transverse motion rather than an up-and-down sawing motion, to protect the posterior tracheal wall.
Remove the scalpel. Insert the non-blade end of the handle and rotate to dilate. Using the blunt end is what stops you lacerating the back wall of the trachea.
Fingertip confirms a hollow rigid tube. Pass a bougie alongside the handle if you have one.
Endotracheal tube in, advanced only until the balloon sits fully within the trachea, so you do not end up in a mainstem bronchus.
- Inflate, ventilate, confirm with sustained end-tidal CO2 and bilateral breath sounds, then suture the tube to the skin.
Note what the manual does not say. It does not give you a target time. It gives you a sequence, and it tells you to finish it.
Three exam traps hiding in this topic
Post-test items on the surgical airway tend to cluster around the same handful of discriminators. If you can answer these three cleanly, you are in good shape:
Vertical skin, transverse membrane. Candidates reliably reverse these. Vertical for the skin (avoids midline vessels, extendable), transverse for the membrane (protects the posterior wall).
Age matters. Surgical cricothyroidotomy is rarely performed in infants or young children. It becomes reasonable in older children in whom the cricothyroid membrane is easily palpable, usually by around age 12. Below that, needle cricothyroidotomy with jet insufflation is the temporizing move, and it oxygenates without ventilating, so hypercarbia is progressive and the clock is running (Chapter 11, p. 176).
- Confirmation is not optional. Sustained exhaled CO2, defined in the manual as present over at least seven breaths, is the standard. A chest radiograph cannot exclude an esophageal intubation.
The takeaway
The MHSRS finding is really about what a training model teaches you to expect. A dry, smooth, bloodless neck teaches you that the landmarks will be obvious and the field will be clean. Real necks are neither. The ATLS manual has been telling candidates this in plain language for years, in the sentence about not being dissuaded by significant bleeding and air spray, and in the instruction that once you start, you finish.
Now there is data suggesting that where you first learned the procedure may still be shaping your success rate long afterward. If your only exposure to a surgical airway is a task trainer and a stopwatch, the honest question to ask before your next shift is not how fast you were. It is what you are expecting to see when you cut.