Written text from the Fearless FONA manuscript. – Unknown Author (Narrated by Victor Lau)
Essential Elements
Acknowledge Your Humanity: Embrace Human Factors
In a World Health Organization position paper, the section on human factors recognizes the universal nature of human fallibility.
A Fearless FONA mindset begins with a simple but essential truth: we are all human, fallible, limited, and prone to error. High-stakes situations don’t eliminate these realities; they magnify them. Striving for perfection may feel noble, but the myth that errors disappear simply because you care more or work harder is just that: a myth. That belief fosters unrealistic expectations, fuels anxiety, and ultimately undermines performance.
Instead, adopt a FONA approach that embraces the reality of human factors.
Human factors refer to the environmental, organizational, and psychological influences that shape how people perform under pressure. These include fatigue, stress, task complexity, cognitive overload, communication failures, and the natural limitations of memory, attention, and perception. Recognizing human factors reminds us that even the most skilled clinicians can make critical errors, not from ignorance, but from the conditions in which they’re required to act.
Embracing human factors means confronting these truths head-on. It involves leveraging cognitive and procedural strengths, anticipating common failure points, and building systems, habits, and environments that support dependable performance in moments of crisis. It means designing checklists, workflows, and training that align with how humans actually function, not how we wish we did.
A Fearless FONA mindset isn’t about being flawless; it’s about being prepared, adaptable, and anchored in reality. When we account for how humans really think, decide, and perform under pressure, we build the confidence and clarity needed to act decisively when it matters most.
Review of Human Factors
There are many human factors that impact the performance of FONA. If you want to make the cut in a moment of need before your patient suffers from critical hypoxia, you must address them. Here’s a list of the important ones you need to be aware of.
You Need to Rethink Failure
Essential Elements
When failure doesn’t kill patients. Hesitation does.
When an airway starts to unravel, the technical problem is only part of what’s happening. The more dangerous shift is internal. A missed tube doesn’t just register as a clinical event; it lands somewhere deeper. It raises questions you don’t say out loud. Was that a mistake? Should I try again? Am I about to lose this airway?
That moment matters more than most people realize. Because while you’re sorting through those questions, time is passing, oxygen is falling, and the situation is evolving whether you’re ready or not.
The Trap of Failure
What happens when failure begins to take on the wrong meaning?
We tend to treat failure as a judgment. A verdict on skill, on competence, on identity. And once it’s framed that way, everything slows down. You hesitate. You second-guess. You stay committed to a plan that isn’t working, not because it’s the right move, but because walking away from it feels like admitting defeat. That’s the trap.
How Fear of Failure Keeps Us From Acting
On March 4th, 1933, Franklin D. Roosevelt addressed a nation gripped by economic despair and spoke these immortal words:
“The only thing we have to fear is fear itself.”
He named the real threat: not poverty or hardship, but the paralyzing force of fear. When fear governs our response, we lose our ability to act decisively. The same principle applies to crisis airway management.
To cultivate a Fearless FONA mindset, we must begin by asking: “What is my psychological and emotional relationship to failure?”
This is not a theoretical question. In airway management, what happens next if intubation fails? More crucially, what happens inside you? For many clinicians, fear extends beyond patient outcomes—it cuts into identity. Did I fail as a provider? Am I not good enough? These internal narratives can paralyze us when clarity and decisive action are most needed.
If fear of failure keeps us from taking the next step—asking for help, moving to a surgical airway, or simply acknowledging that something isn’t working—we’ve already lost. One thing is certain: if a fear of failure keeps us from taking effective action, then we are truly defeated. That’s why reframing failure is central to a Fearless FONA mindset. Failure is not a verdict on who you are; it’s a challenge to navigate. It’s not the end of the story; it’s the opening of a new chapter.
The Important Truth
A Failure to Intubate Is Not a Personal Failure
DO NOT internalize that failure. Instead, see failure as a signal that the current strategy is not achieving the goal. Nothing more. Nothing less. But if you misread that signal, if you stay in the same loop of repeated attempts and incremental adjustments, you start trading time for hope. And in airway management, that’s a losing exchange.
What Failure Actually Means
The only definition of failure that actually matters in this moment is simple: you are not effectively oxygenating the patient.
Not how many attempts you’ve made. Not whether you almost had it. Not whether a different blade or angle might work. If oxygen is not being restored, the plan has failed. And once you accept that, the objective becomes clear. You are no longer trying to prove that you can intubate. You are trying to restore oxygen as quickly and reliably as possible.
That shift is everything.
The Critical Shift
Rewiring Your Response
If you want to change how you perform under pressure, you have to change how you interpret failure.
That starts by naming the fear. Not ignoring it, not pushing it aside—naming it. Fear thrives when it stays vague and unspoken. It grows in silence and uncertainty. But once you bring it into the open and examine it directly, it loses much of its control.
What you begin to see is that failure isn’t moral. It isn’t personal. And it isn’t permanent. It’s part of the terrain. Something you will encounter if you do this work long enough.
And in that terrain, the goal is not perfection. It’s the ability to recover, to redirect, and to stay ready for what comes next.
Because this is where clinicians get into trouble. Not because they lack technical skill, but because they stay committed to the wrong objective for too long. They chase the tube when they should be chasing oxygen. They persist when they should pivot. And the delay that follows is often what determines the outcome.
You Can Think Differently
Regarding our relationship with the failed airway, remember that a failed airway does not signal defeat. It merely identifies a problem, one that can lead to the right path and an easy and effective solution.
What does that look like in practice?
- Preparing ourselves emotionally, not just technically, for difficult airways
- Creating cultures where naming a failed attempt is met with clarity, not shame
- Viewing the move to front-of-neck access not as a defeat, but as decisive, life-saving care
- Embracing practice—deliberate, immersive, and ongoing—as our antidote to paralysis.
Rethinking failure doesn’t make it comfortable. But it does make us capable.
And that’s the beginning of fearlessness.
The Trained Response
The way out of that pattern is not more knowledge. It’s a trained response.
You have to learn to recognize the moment when things are no longer working, to say it out loud so the team can align with you, and to change course without hesitation. This isn’t about abandoning effort; it’s about redirecting it. Decisively. Early enough that you still have time to act on that decision.
Say It Early
Language plays a critical role here. Silence allows ambiguity to persist. Clear words cut through it. When you say that the airway is failing and that oxygenation is not being achieved, you are not escalating emotionally; you are clarifying reality. You are giving the team a shared understanding of the situation and permission to move forward.
FONA Is Not Failure
FONA Is Not Failure
And sometimes, moving forward means moving to the neck.
This is where the final misconception needs to be confronted directly. Front-of-neck access is not what happens when everything has gone wrong. It is what happens when you recognize early that something is going wrong and you choose the most direct path to fixing it. It is not a last resort born of failure. It is a decisive intervention based on an accurate assessment.
That distinction matters. Because if FONA feels like a failure, you will delay it. And if you delay it, you may miss the window where it can still make a difference.
Train the Transition
What you are really training for is not just the procedure itself, but the transition. The ability to let go of one plan and commit fully to another without hesitation or regret. That is a cognitive skill as much as a technical one, and it has to be practiced deliberately.
Because in a real airway emergency, you won’t rise to the occasion. You will fall back on what you have trained yourself to do.
Deep Cuts
Explore a little more.
Words Matter
Speaking of naming fears—words matter. What we call things shapes how we feel about them and how we act in critical moments. And let’s be honest: calling an inability to intubate a “failed airway” might be one of the most damaging labels we use. Who wants to be associated with failure?
Intubation is an intricate, high-stakes skill. It requires advanced tools like a fiberoptic scope or video laryngoscope, a deep understanding of spatial relationships in airway anatomy, and the precision to guide a tube past multiple structures to a small—and sometimes moving—target. When it doesn’t go as planned, it’s not a personal failure. It’s a reflection of just how complex the task really is.
Now compare that to the surgical airway. It’s fast. It’s direct. It provides immediate access to the trachea. So why does it carry such emotional weight? Why is it perceived as a last resort or a mark of defeat? Somewhere along the way, we gave it a fearsome name—and an even more intimidating reputation.
But what if we simply called it what it is?
Not a failed airway—how about a direct airway?
Or even a simplified airway?
Words won’t change the anatomy. But they can reshape our mindset. And with a name that reflects clarity instead of judgment, maybe we’d all breathe a little easier—and act more decisively—when the time comes.
“Reason can wrestle and overthrow terror.” Euripides (Εὐριπίδης) c. 406 BC
Can we reason through our fear of the failed airway? Euripides thought so. What are we so afraid of that a change in attitude, a little preparation, and some confidence in our training can’t overcome?
The Bottom Line
A failed airway is not a defeat; it’s information. It tells you the current plan isn’t working and that it’s time to change course. If you’re prepared, you can use that signal rather than resist it. That preparation goes beyond technical skill. It means expecting difficulty, speaking failure out loud without hesitation, and recognizing that moving to front-of-neck access is a decisive step toward restoring oxygen, not a loss. When you train this mindset and practice it enough, you don’t freeze in the moment; you act. It won’t make failure comfortable, but it will make you capable, and that’s what allows you to move through fear instead of getting stuck in it.
The CICO Scenario
Excerpts from the restored portions of the Fearless FONA manuscript – unknown author (Narrated by Victor Lau).
Essential Elements
Critical Language
In emergency airway management, critical language refers to the use of standardized, high-clarity phrases that are immediately understood across disciplines and roles. These terms serve a vital function in time-sensitive, high-stakes scenarios where ambiguity can result in costly consequences, including loss of life. One of the most essential of these is “can’t intubate, can’t oxygenate” (CICO).
The CICO declaration is more than a clinical description—it is a call to action. It signals that conventional airway management has failed and that immediate transition to a front-of-neck airway (typically cricothyroidotomy) is now the priority. This language is deliberately unambiguous. It is designed to cut through the noise and cognitive overload that often accompany airway emergencies.
The Key Terms
These two definitions are intertwined and crucial for developing a clear, shared mental model in clinical environments where FONA may occur. They are interrelated and should be terms for which you have a great deal of clarity.
Visit the Critical Language Compendium for more information on this and other important airway terminology.
The Trigger for Action
When intubation fails, and adequate oxygenation cannot be delivered through the other upper airway lifelines (FMV&SAD), it’s time to declare CICO and move quickly to address the situation.
The Key Concept
The reason for this is clear: Time is brain. Poor communication leads to critical delays in FONA performance, and adverse outcomes related to failed airways are often caused by failure to oxygenate, rather than by failure to intubate. When the team declares CICO, a series of well-rehearsed actions should be performed to ensure FONA is completed before critical hypoxia occurs.
The Bottom Line
When should you declare CICO?
The answer is always BEFORE critical hypoxia occurs. The most important thing to remember is that time is brain. Using critical language to declare CICO early, if your best effort(s) fail or you judge that the situation requires the immediate transition to FONA, is the best way to protect your patient from the harm of prolonged hypoxia.
Failure to use clear, standardized terminology during an evolving airway crisis can lead to confusion, delayed escalation, and missed windows for life-saving interventions. That’s why institutions and airway training programs increasingly emphasize the routine practice of critical language alongside procedural skills.
Understanding and appropriately using CICO and other critical phrases is a core competency in emergency airway management. These words are not just descriptions; they are triggers for decisive, coordinated, and potentially life-saving action.
Real Stories of FONA
Essential Elements
The Face of FONA: Personal Stories
Performing a surgical airway is one of the most high-stakes, emotionally charged moments in clinical practice. In this video, experienced clinicians share deeply personal accounts of when they’ve had to perform front-of-neck access (FONA). These aren’t procedural tutorials; they’re raw, honest reflections on what it feels like to make that cut: the hesitation, the silence, the noise, the aftermath.
Hearing directly from those who’ve been there offers something no textbook can: a window into the emotional, psychological, and human realities of managing a can’t-intubate-can’t-oxygenate (CICO) crisis. These stories prepare not just your hands, but your mindset, for the moment that may one day be yours.
The Stories
The Quote
This quote crystallizes the reality that stress and emotions play a role in our ability to perform FONA. Acknowledging this is important, but also understanding that anxiety and fear around FONA are common experiences and that if you have these emotions, you share them with the rest of us. Just knowing this can help lessen that fear. Now, listen to the stories below to complete this section.
The Bottom Line
The people who’ve done FONA carry lessons that every airway clinician needs to hear: it’s terrifying, it’s messy, and it’s unforgettable, but it’s also lifesaving. Their message is clear: train hard, know your plan, and don’t wait too long. The fear is normal, but it doesn’t have to be paralyzing. It’s the hesitation that is dangerous. What stays with you isn’t just the procedure, but the weight of the moment. Learn from those who’ve lived it, because someday, it might be you.
Thanks to Jamie Lee MD @thestrivetofit for collecting this compelling series from real clinicians facing down the can’t intubate, can’t oxygenate reality of a failed airway.
Address the Stress
Excerpts from the restored portions of the Fearless FONA manuscript – unknown author (Narrated by Victor Lau).
Essential Elements
FONA is not complicated. But performing it under pressure is one of the hardest things we ask clinicians to do. Not because of the steps, but because of everything surrounding them—uncertainty, hesitation, team dynamics, and time running out.
In this section, we focus on what real readiness looks like in practice. You’ll learn how stress impacts performance—and how to control it when it matters.
The Effects of Stress
Identify stress-related killers
Stress can undermine performance in specific, predictable ways. Here, we highlight three stress-related pitfalls commonly seen in failed airway scenarios—so you can recognize them in yourself or your team and be better prepared to counteract them when it counts.
Performance Training
Techniques to enhance your fona performance
Here, we give you four techniques you can practice to enhance your performance under pressure and cultivate your Fearless FONA Mindset. Each technique provides you with all the resources for self-guided practice and in-person learning in our performance lab.
box breathing
- Listen to the intro audio 🎧
- Use the GIF to practice 🫁
- Use it before any procedure
visualization skills
- Listen to the intro audio 🎧
- Watch the FONA procedure video
- Use guided audio to visualize
- Then try it without the audio
Positive self-talk
- Listen to the intro audio 🎧
- Write down 3 positive self-talk phrases
- Practice using them
triggers
- Listen to the intro audio 🎧
- Write down a trigger phrase
- Practice using it
Team Building
Lean on Your Team
Teamwork is critical during high-stress, time-sensitive procedures like FONA because no single person can manage everything alone. Effective teamwork ensures clear communication, role clarity, and mutual support, helping to prevent errors, manage stress, and optimize performance. When teams function well, they can adapt quickly, catch mistakes early, and keep the focus on what matters most: saving the patient.
It’s not all on you
Learning to manage stress is essential, but reducing it is also vital. Your team is a valuable resource if you know how to utilize it effectively. Developing techniques for team communication that can support cognitive offloading and improve your bandwidth is part of cultivating a Fearless FONA mindset.
The Bottom Line
Understanding how stress impacts performance is essential when performing high-stakes procedures like FONA. Under acute stress, even skilled clinicians can experience impaired decision-making, narrowed attention, reduced fine motor control, and communication breakdowns. Recognizing these effects allows us to design training, systems, and mental strategies that mitigate stress, preserve performance, and support effective action when every second counts.
Reference – Psychological Skills to Improve Emergency Care
Providers’ Performance Under Stress
Michael J. Lauria, BA, NRP, FP-C*; Isabelle A. Gallo; Lt Col Stephen Rush, MD;
Jason Brooks, PhD, MSc; Rory Spiegel, MD; Scott D. Weingart, MD
More to Explore
Review Article
Why This Article Matters for Airway Safety
Airway management is a high-stakes, high-consequence domain of clinical practice, one where cognitive, environmental, and systemic factors can significantly influence outcomes. In “Human Factors in Airway Management” by Duggan et al., the authors offer a concise yet insightful overview of how human performance principles intersect with airway care.
This article is a valuable resource for clinicians seeking to move beyond technical skills alone and understand the broader factors contributing to safe and reliable airway management. It underscores the importance of anticipating errors, designing resilient systems, and cultivating situational awareness, critical considerations for anyone aiming to improve safety in both routine and high-stress airway scenarios.
What’s Next
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