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Paramedics are dispatched to a patient with respiratory distress who is noted to have swelling and pain involving the submental tissues that began within the last 24 hours. He has been suffering from a tooth infection and was recently placed on penicillin and advised to see a dentist for an extraction. The crew arrives to find the gentleman with trismus and drooling. His vital signs are BP 136/84 mmHg, pulse 110/min, RR 26/min, SpO₂ 97% on room air. The EMS clinicians assess the patient’s airway and elect to perform RSI. They are concerned that he will not be able to protect his airway for the 20 minute transport to the emergency department. The crew prepares medications and paralyzes the patient. They are unable to advance a 4 Macintosh blade into the patient’s mouth, and switch to a 3 Miller. Over three more attempts they note significant swelling in the airway, have difficulty identifying structures, and cannot clearly visualize the vocal cords. They place an endotracheal tube but quickly remove it when it does not return EtCO₂. They are forced to abandon the attempts when the patient’s oxygen saturation falls to 60% and he becomes bradycardic. They place a SGA and are able ventilate and to recover the patient’s oxygen saturation.

The medical director reviews the case and re‐educates the crew on the following points. 1) Given the patient’s ability to protect his own airway it may have been better to manage the patient conservatively, keeping him upright with humidified oxygen and suction (know when not to intubate). 2) When it is clear that there will be a difficult airway, ask for additional resources including, perhaps, a second unit, supervisor, EMS physician, or critical care team (call for help). 3) Intubation attempts should be discontinued if they are not likely to be successful. The conditions of the intubation (positioning, equipment, or clinician) should be changed after a failed attempt. 4) The backup plan should be discussed prior to the attempt and prepared for implementation. The crew recreated this scenario in a high‐fidelity simulation to review alternative actions that could have resulted in a better outcome. The simulation included multiple iterations of the scenario and debriefing to discuss the points noted above. The scenario was then used to build a simulation demonstrating and evaluating decision making for all the paramedics in the service during the following year’s education sessions.