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The Psychology of the Difficult Airway and How to be Prepared

Michael Macias

You have a crashing patient in front of you that requires an airway. You attending asks you "How many intubations have you done?"  You really want to get an attempt at this airway and you also want to show confidence obviously. You: "Uhhh...3, well actually 4 but I missed one." That wasn't the confidence you were hoping to portray (as your attending stares in that sort of endearing way like what you said was actually sort of cute).

Ok so one last chance to prove yourself and least instill some sort of mild confidence from your attending and/or senior resident. Time to set up for YOUR airway. Remember, always prepare for the worst, think several steps ahead, have a back-up plan and know what drugs you want to give. Dr. Scott Weingart at EMCrit breaks down what you need to know to initiate, plan, and carry out a successful intubation, all in one easy checklist. Read it, this is one checklist that you should run through the hippocampus a few times, maybe even keep it handy in your pocket for reference.

So your all set up for your intubation, your at the head of the bed, DL with a mac blade in hand, glidescope ready as your backup. You can feel your heart palpating in your mouth (its quite an odd sensation), you have an essential tremor, and you actually are trying to remember which hand to hold your laryngoscope in. Is something wrong with you? Maybe, but we won't address that here.

What you do next and how you approach it will determine the rest of your intubation. It may also let you get a second look at the airway if you miss the first attempt rather than getting it snatched away by your senior resident or attending. Be confident, watch the blade as you advance, talk as you go, let everyone know what you see. I came across an excellent discussion by one of the masters of the airway Dr. Rich Levitan, with Dr. Rob Orman on He discusses the psychology of the difficult airway and the mistakes we make with the adrenaline dump we experience. Now he specifically is talking about that 'difficult' airway where you are suspecting to find trouble. However, as an early resident, I think it's fair to assume that any airway may be a difficult one, and we need to be ready, with our same algorithm and fore though for every air airway we encounter. So have a listen and remember next time not to jam your DL blade down your patient's throat without a little personal pep talk.