Most clinicians involved in patient transport will agree that establishing a definitive airway on any patient who needs it is best performed before departure. This holds for all modes of transport but has even more relevance when transporting patients by air. Unfortunately, the decision to intubate a patient before a flight is often complex and the patient’s clinical course unpredictable. We describe a case where airway management took place mid-flight on an international air ambulance mission and look at how the medical crew was prepared for the scenario through simulation. Practice makes perfect: emergency airway management at 40,000ft

First, a bit of background about the context of this case. Our service, Air Rescue Africa, mostly does long-distance international retrievals across the African continent. Because of the long travel times with the patient and the challenging environment we operate in, there has always been an emphasis on meticulous patient assessment and optimal stabilization before departure from the referring facility. We believe that patient safety is improved through attention to detail and a sharp focus on evidence-based medicine. An important part of this approach is the appreciation of the value and relevance of high-fidelity simulation and training.

We have various initiatives supporting this sentiment, one of them being our monthly training days where the medical crew gets the opportunity to take part in training and simulation, through which various aspects of retrieval and transfer medicine are addressed practically. For the month of November 2023, this training revolved around highacuity, low-occurrence (HALO) procedures. Included were many procedures/scenarios not frequently encountered in everyday practice. Airway management in-flight was also part of the training day and simulated in teams of two in the back of the aircraft.

Patient transfer

About a week after this training day, we were tasked with a case out of a central African country. The patient was a middleaged man diagnosed with severe malaria due to an impaired level of consciousness (Glasgow Coma Scale 10/15) and an acute kidney injury. Because of the limited medical capabilities at the facility that the patient presented to, he underwent a domestic movement by air the night before to a different facility for an upgrade in care. The report indicated that this movement was without complications and that the patient’s condition had since stabilized and gradually started improving, including his level of consciousness.

Upon the arrival of our medical crew, a thorough assessment of the patient followed, and he was deemed fit to fly. At the time it was concluded that establishing a definitive airway was not indicated. Further measures to improve the safety of the transfer were undertaken and included ultrasound-guided insertion of an arterial line for invasive blood pressure monitoring, and initiation of end-tidal CO₂ through nasal prongs (ETCO₂). Following was an uneventful drive of about 40 minutes by ground ambulance to the airport. The patient was loaded successfully into the Hawker 800XP air ambulance and prepared for takeoff.

Intubation was done using video laryngoscopy, successful on the first attempt with no drop in oxygen saturation or blood pressure

Shortly after takeoff, the patient became increasingly restless and agitated, despite all potential causes being systematically considered and addressed. It became clear that, to ensure the safe execution of the mission, appropriate sedation would be required and, considering the patient’s overall condition, securing the airway was now necessary. Preparations were made, which included measures for optimal preand apneic oxygenation. To facilitate that, a delayed sequence intubation approach was followed with medication that was ready to

use in pre-filled syringes. Intubation was done using video laryngoscopy, successful on the first attempt with no drop in oxygen saturation or blood pressure. Correct placement was confirmed using ETCO₂ and clinical exam. Adequate post-intubation sedation was initiated by a continuous infusion. The patient remained stable for the remainder of the flight and was safely handed over to the receiving facility in Johannesburg, South Africa.

Discussion

There are many components of this case worth discussing, but, for this forum, two will be focused on.

Firstly, one might argue that this patient should have been intubated at the referring facility already. Although certainly true, the consideration thereof is not always straightforward. During the debrief of the case, the medical crew did acknowledge that there was perhaps a ‘gut feeling’ that it would have been necessary. However, a handover that a domestic medevac the night before went well without any complications, and reports that the patient’s condition was improving predisposed the crew to decide that airway management was not indicated. Was this maybe a classic example of a framing bias creeping into decision-making? In hindsight, everything seems to be much clearer, but we all know what the problem with hindsight is. To their credit, the crew did set a ‘rally point’ by stating that, upon arrival at the airport after the 40-minute drive in the ambulance, the patient would have been reassessed for the need to escalate the airway management strategy. This was indeed done and, at that point, there was still no need to intervene.

Secondly, there is an argument to be made that this case is nothing special, nor is it unique, because it is expected that flight crew should be able to successfully manage all common emergencies in-flight, including emergency airway management. Although true, this should never be taken for granted, and we believe there should be a culture within the organization that promotes the ability of the medical crew to perform optimally in all circumstances. This is where training and simulation comes in. Would this airway management event in-flight have been so well controlled and well executed if it hadn’t been for the specific training on this a week before? Considering the skill and the experience of the flight crew involved I would like to say yes, but this is where we need to be aware of our enemy in medicine called complacency. It has been well established that high-fidelity simulation and training contribute significantly to performing any emergency procedure under pressure, so no doubt exists that simulating this scenario not long before the actual case had a positive impact on the outcome. At the very least, the crew had the benefit of tapping into some muscle memory to free up cognitive bandwidth.

This is where we need to be aware of our enemy in medicine called complacency

Cases like the one discussed not only provide us with the opportunity to reflect on our clinical practice but also the chance to see how we can strengthen and improve our system. For us, this reinforced the need for and importance of training together in teams to ensure optimal outcomes for our patients.