Airway Manifesto Part 4
- Adam LaChappelle
- 2 days ago
- 7 min read
Updated: 2 hours ago
The Case:
“Good morning, Chelsea!” Frank greeted her with a bright smile as she unceremoniously tossed
her backpack onto the floor, the fabric hitting the ground with a soft thud. Chelsea, however,
felt anything but cheerful. She glanced at Frank, feeling as though the only good thing about
this morning was that her hair, at least, was not on fire. “Morning,” she muttered begrudgingly,
her thoughts swirling in a cloud of self-loathing.
“Can you believe Mike, her boyfriend, left the leftovers out again?” she ranted internally.
“That’s so infuriating! Doesn’t he understand that we have just $0.34 in the bank and that payday isn’t until tomorrow? That was supposed to be my lunch, and now it’s popcorn again. I
hope the hospital still has some snacks left.”
Chelsea caught a glimmer of hope as she continued to cross the bay, muttering under her breath about the mask that felt like a suffocating weight. “At least there’s some coffee here,” she thought, heading towards the kitchen.
Suddenly, the tones dropped, interrupting her spiraling thoughts: “M101, respond to 1616
Main St NE for a GSW to the head. Male unresponsive. PD is being dispatched.”
Chelsea, voice tinged with frustration, exclaimed, “How many damn times do I have to tell
dispatch to send a damn wagon and supervisor for critical calls?” Just as she finished her
complaint, the radio crackled again: “M101, be advised EMS4 and Wagon 14 are being added to your call.”
“Finally!” she huffed, feeling a mix of relief and irritation.
The Airway
As they approached the scene, Chelsea’s focus shifted entirely to the task ahead. Abby, riding
on EMS4 today, turned to her and said with a commanding tone, “Chelsea, I need you to take
that airway after I push the drugs.”
“Yeah, I’m on it,” Chelsea replied, steeling herself for the challenge ahead.
“Drugs are in,” Abby announced, and with that, Chelsea readied herself. She grabbed the DL and prepared for her first attempt. But as she looked down the throat of the patient, a wave of
and panic surged through her—blood filled the airway, obscuring her view.
“I need suction!” she shouted, her voice rising above the chaotic backdrop of the emergency
scene. “It’s behind the head!” Frank shouted back, urgency in his voice. “Finally!” Chelsea thought, relief flooding her as she grabbed the suction device. She quickly cleared the airway with fierce determination, her hands moving almost instinctively. As she cleared the blood, Frank began calling out the SpO2 levels. “96, 95, 93, 92, 89, 87, 85, 84, 83, 82, 81, 80.”
Meanwhile, Chelsea remained trapped in her thoughts, plagued by doubt. “All I see is
pink,” she lamented internally, feeling the moment's weight pressing down on her.
“Where’s the epiglottis? Maybe I should back out and attempt again… There!”
Out loud, she declared, “Tube’s in! Phew, glad we got the tube.”
But Frank’s following words cut through her momentary relief: “I can’t get a sat!”
“What do you mean?” Chelsea sniped, a mix of confusion and irritation flashing across her face.
“NO PULSE! Start CPR!” Abby shouted, urgency tinging her voice.
Chelsea dove back in with the laryngoscope without hesitation, determination surging anew.
“Tube’s in; try suctioning the tube!” she ordered as Frank hastily rummaged through the
cabinet for a flexible catheter. As blood clots filled the container, the suction unit roared to life, a chaotic symphony of clattering
and buzzing.
“Pulse Ox is 94%, capno is back, check a pulse,” Chelsea stated, trying to maintain a level head despite the chaos.
“I’ve got a pulse!” Abby shouted, a note of triumph cutting through the tension.
The Debrief
Sitting on the tailgate of the rig, Chelsea felt the weight of the call settle heavily on her
shoulders. Abby approached her, a sympathetic look in her eyes. “Tough airway, huh?”
Holding back tears, Chelsea whispered, “I knew I could do it. I don’t understand what went
wrong.”
“Didn’t you hear Frank stating the sats?” Abby asked gently.
Visibly upset, Chelsea shook her head. “No! When did he say that? How was I supposed to
know I needed to pull out?”
“The sats dropped below 92%,” Abby explained, her voice firm but understanding. “That’s when the protocol states we’re supposed to insert an iGel to reoxygenate.”
“I know what the protocol is; I just didn’t hear Frank,” Chelsea admitted sheepishly, her voice
trembling. “I wish I would have heard; I didn’t want to hurt the patient.”
What Paramedic School Didn’t Teach
Many paramedic schools incorporate some version of stress inoculation—whether intentional
or not. The amplified stress is meant to expose students to real-life scenarios, often
summarized by the phrase “this is real life.” However, this approach frequently leaves students
feeling shame about their performance during high-pressure situations, especially when they
succumb to the effects of stress.
While well-intentioned, merely exposing students to stress does not benefit them and can
potentially harm their development. Educational institutions often skim over wellness while
neglecting the complex nature of stress and the dynamics of nontechnical skills that are
equally important in the field.
Resuscitations are fraught with tension, which makes them all the more complex when clinicians must collaborate to effect positive outcomes. After all, humans are not machines; no single trick, routine, or article can provide a foolproof solution to the challenges faced in the field.
As practitioners and within the broader healthcare organization, what can be done is to
leverage the right tools to empower providers and enable them to deliver quality resuscitation.
Psychological Safety
Like Chelsea, we all navigate many life events and stressors that can amplify or hinder our
performance. The healthcare industry must look seriously at how to support its providers better. It is unacceptable to place the entire burden of wellness on
any single individual. This culture erodes the morale of dedicated professionals who only
want better tools to provide optimal care.
Creating this supportive culture requires more than just a leader implementing a program; it
necessitates individuals taking a stand and initiating change, even if it feels uncomfortable.
Change doesn’t have to come with anyone else’s permission—it can start with one person
taking a small, wobbly step toward becoming a better human, thus fostering a psychologically
safe environment where mistakes can be made and corrected without fear of judgment.
Imagine how it would feel if your supervisor gathered the entire team before a shift and said, "Our environment is dynamic and unpredictable.
While caring for people, I know you will try new things, do good work, ask questions, and make mistakes. I fully expect all those things to happen. I’m not here to judge you, grade you, or evaluate you on your performance. I’m here to provide feedback to help you grow as providers and work alongside you to care for our patients. I believe in your intelligence, capability, and commitment to doing your best while continually improving.” This kind of vulnerability from a leader can help establish an environment where everyone feels safe to make mistakes and learn from them.
The After-Action Airway
During Chelsea’s intubation attempt, she experienced tunnel vision and auditory exclusion—a
normal stress response. While this was on the upper end of the stress spectrum, it is still
common. One effective way to manage such high-stress situations is by consciously bringing down the stress levels, perhaps by taking a deep breath.
Their protocol clearly states that any attempts should be halted when SpO2 levels drop below 92%. Everyone knew this, yet communication remained a significant issue. While well-meaning, Frank’s continuous announcements about the saturation levels became overwhelming, drowning out critical information others on the team needed. The person performing the intubation must maintain focus on the task at hand. This means that monitoring vital signs and resuscitation efforts should be offloaded to other team members to ensure each individual can work efficiently as part of a cohesive team. Implementing a communication plan, such as a sterile cockpit approach, can significantly enhance care delivery during critical incidents. A CRM concept limits communication to only essential, task-relevant information during high-stakes situations. In the context of this call, a more structured approach could have been beneficial. Frank could have been tasked with monitoring the vitals, and using the sterile cockpit, he would wait until the saturation levels hit 92% before saying, “Pull out, insert iGel, sats are 92%.”
This succinct communication would have conveyed Chelsea's critical information,
enabling her to execute the procedure without hesitation. Such clear and focused
exchanges allow task-saturated individuals and teams to perform the crucial tasks necessary for effective resuscitation.
As we navigate the high-stakes world of emergency medical care, it becomes increasingly clear
that the effectiveness of our interventions hinges not just on technical skills but also on the
strength of our communication and teamwork. Chelsea’s experience serves as a poignant
reminder of the profound impact of psychological safety and clear, focused communication
on outcomes during critical situations. By fostering an environment where every team
member feels empowered to speak up, ask questions, and learn from mistakes, we can create a culture of continuous improvement that benefits the providers and the patients
we serve. As we strive to master airway management and other vital skills, let us remember
that collaboration, understanding, and a commitment to shared growth are the cornerstones of
exceptional emergency medical care. In doing so, we honor not only the patients who rely on us in their most vulnerable moments but also ourselves as professionals dedicated to making a
difference in medicine.
Fore, A. M., Sculli, G. L., Albee, D., & Neily, J. (2013). Improving patient safety using the sterile cockpit principle during medication administration: A collaborative, unit-based project.
Journal of Nursing Management, 21(1), 106–111. https://doi.org/10.1111/j.1365-
2834.2012.01410.x
Gleeson, S., Groom, P., & Mercer, S. (2016). Human factors in complex airway management.
BJA Education, 16(6), 191–197. https://doi.org/10.1093/bjaed/mkv045
Kovacs, G., Lauria, M., Law, J., & Croskerry, P. (n.d.). Human Factors and Resuscitation
Psychology in Airway Management. In Airway Management in Emergencies (3rd ed.).
Lauria, M., & Keiler-Green, A. (2018, November 6). COMM CHECK: Sterile Cockpit. EMCrit Project. https://emcrit.org/emcrit/comm-check-sterile-cockpit/
Orasanu, J., & Fischer, U. (1997). Finding Decisions in Natural Environments: The View from the Cockpit (pp. 343–357).
Ornato, J. P., & Peberdy, M. A. (2014). Applying lessons from commercial aviation safety and operations to resuscitation. Resuscitation, 85(2), 173–176.
Schnittker, R., Marshall, S., Horberry, T., & Young, K. L. (2018). Human factors enablers and barriers for successful airway management—An in-depth interview study. Anaesthesia,
73(8), 980–989. https://doi.org/10.1111/anae.14302
-Adam LaChappelle
A paramedic with a heart for design and organization. Owner of The Resuscitation Tailor.
