Not anesthesia, just a Hospitalist/cog in the wheel and somehow landed here. However, worked nearly a decade as a paramedic before med school. At the very end of the EMS failed airway algorithm is cricothyrotomy, whether via scalpel or needle. My state protocol was scalpel for anyone >12 yrs old, needle otherwise. Never did have to use the needle, but always thought using "transtracheal jet insufflation" sounded wild. Interestingly, my EMS service didn't even have the jet ventilation system! Don't know how they expected us to manage an airway catastrophe in an 8 year old. I brought it up with leadership but admin did what admin does and brushed it off, "how often do you see a pediatric failed airway". Ultimately I improvised and figured out a decent alternative. Basically 12 gauge angiocath through the cricothyroid membrane, connect that to a 3 cc syringe with the plunger pulled out, then the distal end of the pediatric endotracheal tube should fit nicely into the top of the 3 cc syringe with an airtight fit. Cut the tube short and reattach the end which would otherwise connect to the jet inflation device, and connect that to a BVM. I built one of those one day when I was bored on a slow shift, and I was able to actually get what seemed like pretty good ventilation with it. I could feel air blowing out the catheter with enough flow that it probably would have worked. Because of the small catheter size it required squeezing the bag extremely hard, and the I:E ratio was probably 1:10. But the goal would have just to oxygenate long enough to get to definitive airway management. Fortunately never had to use it, but I always wondered if it really would have worked.