About Graham E. Snyder, MD, FACEP

Medical Director, Medical Simulation Center
WakeMed Health and Hospitals;
Associate Program Director
Department of Emergency Medicine
University of North Carolina at Chapel Hill

How I Educate: Graham Snyder, MD

This week’s How I Educate post features Dr. Graham Snyder, the Associate Program Director at the University of North Carolina and Director of Education for WakeMed Health and Hospitals. Dr. Snyder spends approximately 90% of his shifts with learners which include emergency medicine residents, off-service residents, and medical students. He describes his practice environment as a Level 1 trauma center that sees 125,000 patients annually. Below he shares with us his approach to teaching learners on shift. 

Name 3 words that describe a teaching shift with you.

Practically Academic, Comradery, Rejuvenating

What delivery methods do use when teaching on shift?

YouTube, just-in-time sim task-training, observation and feedback of the resident teaching the student.

What learning theory best describes your approach to teaching?

Cognitive learning

What is one thing (if nothing else) that you hope to instill in those you teach?

Love and an appreciation of the honor of caring for patients in their time of need.

How do you balance your flow with on-shift teaching? Does this come at the expense of your documentation?

Yes. I hire a scribe to offset time for patient discussions. 

What is your method for reviewing learners’ notes and how do you provide feedback on documentation?

On-shift. By asking them socratically how different parties, consultants, PMD’s, lawyers, and the patients themselves would interpret their documentation in the event that their diagnosis is correct…or if it was completely wrong.

Do you feel departmental flow and metrics adversely affect teaching? What is your approach to excelling at both?

It’s a fine balance. Much like showing compassion and patient counseling, teaching is a corner that could be cut but I choose not to. I also preferentially pick up patients myself that are low yield so I do not need to spend time listening to presentations where I anticipate little teaching opportunity.

It can be difficult to sit back and let senior learners struggle what is your approach to not taking over prematurely?

As a life-long learner and a simulation lab director, I am continually developing my airway and procedural skills in general. I focus particularly on managing learners who are having challenges in completing procedures and this allows me to continue teaching, even when they are struggling while avoiding putting patients at risk.

Do you start a teaching shift with certain objectives or develop them as a shift unfolds?

If the residency leadership team has identified a weakness during our monthly reviews, I make that weakness the goal of the shift. Otherwise, I try to huddle with the resident at the start of the shift to see what they have self-identified as a learning goal.

Do you typically see patients before or after they are presented to you?

After unless I “discover” an interesting patient of my own that I intended to see alone but is just so fascinating that I send the resident in redundantly.

How do you boost morale amongst learners on shift?

I like to both say the words and physically, “take a moment” and point out the countless great wins we have every day: recognition of subtle EKG changes, transforming a terrified patient into a calm one, early recognition and resuscitation of a deadly disease, and force them to not overlook the victories, that can so easily get overshadowed by the frustrations.

How do you provide learners feedback?

On shift, after shift, written and verbal.

Are there any resources you use regularly with learners to educate during a shift?

Up to Date, EM-RAP, and YouTube.

What are your three favorite topics to teach during a shift?

Difficult airways, excited delirium, and ultrasound of the hypotensive patient.

Who are three other educators you’d like to answer these questions?

Jerry Hoffman and Gary Greenwald


How I Educate Series logo

Read other How I Educate posts for more tips on how to approach on-shift teaching.


Trick of the Trade: A “Fiberbougie” through a supraglottic airway device (King tube)

king tubeResuscitation before intubation is a critical construct in modern emergency medicine. The prevention of peri-intubation arrest by correcting pre-intubation hypoxia, hypotension, and acidosis is often easier said than done. Worse yet, the intubation process itself, especially if difficult, can worsen hypoxia and hypotension which is often unrecoverable [1, 2] Supraglottic devices, such as a King Airway or laryngeal mask airway, can be placed quickly, and they effectively oxygenate and ventilate patients with a high degree of success [3]. Unfortunately, when the King (or similar device) is exchanged for an endotracheal tube, success is far from guaranteed. Ideally the King could be blindly changed over a tube exchanger however it is quite easy to lose the airway completely during this process. We describe a potentially safer and more effective alternative.

Trick of the Trade

After a patient is stabilized after initial resuscitation, the supraglottic King airway device should be exchanged. A disposable, single-patient-use bronchoscope can serve as a bougie-like guide.

equipment fiberbougie king

Equipment Needed

  • Disposable bronchoscope
  • Endotracheal tube
  • 50 mL syringe
  • Laryngoscope (video or direct)
  • Trauma shears
  • Suction
  • Capnography

fiberbougie through supraglottic device king airway

Left: Demonstrating the technique inserting a single-use bronchoscope through a supraglottic King tube in a simulation patient. Right: Corresponding view of the vocal cords through the King side port in a real patient.

Description of the Trick

  1. Insert a disposable bronchoscope through the airway port of the King airway
  2. Guide the bronchoscope to exit through the side port of the King and into the trachea until you approach the carina
  3. Cut the disposable bronchoscope at the level of the handle, leaving a “fiberbougie” in the trachea above the carina
  4. Remove the King airway over the cut fiberscope in a modified Seldinger technique while suctioning airway
  5. Insert the endotracheal tube over the “fiberbougie”
  6. Use video or direct laryngoscopy to visualize the tube sliding over the “fiberbougie” into cords
  7. Confirm placement with capnography and/or with direct visualization and x-ray

bronch bougie equipment

Insertion of the endotracheal tube over the “fiberbougie” with video laryngoscopy confirmation with a simulation patient. The inset image was captured from a Glidescope on a real patient during the exchange.


Video Tutorial of the Fiberbougie Technique to Exchange a King Tube




  1. April MD, Arana A, Reynolds JC, et al. Peri-intubation cardiac arrest in the Emergency Department: A National Emergency Airway Registry (NEAR) study. Resuscitation. 2021;162:403-411. doi:10.1016/j.resuscitation.2021.02.039. PMID 33684505
  2. Russotto V, Tassistro E, Myatra SN, et al. Peri-intubation Cardiovascular Collapse in Critically Ill Patients: Insights from the INTUBE Study [published online ahead of print, 2022 May 10]. Am J Respir Crit Care Med. 2022. doi:10.1164/rccm.202111-2575OC. PMID 35536310
  3. Burns JB Jr, Branson R, Barnes SL, Tsuei BJ. Emergency airway placement by EMS providers: comparison between the King LT supralaryngeal airway and endotracheal intubation. Prehosp Disaster Med. 2010;25(1):92-95. doi:10.1017/s1049023x00007743. PMID 20405470 

IDEA Series: Pre-recorded Video Simulation Series for Residency Conference

During medical simulation, the inherent unpredictability of learners’ performances and decisions can make it challenging to consistently achieve desired learning objectives. The amount learned and the errors made can vary wildly between groups. Paradoxically, a stellar student can minimize the learning for the other providers if he or she takes over and effortlessly completes the case. Likewise, the visceral impact of seeing a case go horribly wrong can have tremendous teaching value.1

In addition to these challenges, the COVID-19 pandemic has introduced additional barriers to medical simulation training; physical distancing measures have resulted in limited or canceled simulation activities for most emergency medicine residency programs.


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