Suction tubing reversal as a dormant failure during airway management

An intubation in the Emergency Department (ED) would never occur without suction set up and tested. However, due to the complexity and inherent failure potential of these devices, even checked suction devices can fail at a crucial juncture. We present a case report of suction that worked properly during pre-intubation preparation, but critically failed due to inappropriate set up. This situation is an example of a dangerous dormant failure that can easily reoccur in any ED.