PAC:SCAPEExhibit 02 / Reframe
PAC:SCAPE // EXHIBIT 02 // Human factors

The Human Element

This Gallery makes the human response visible: fallibility, fear, stress, performance, and the team structures that keep hesitation from deciding the next action.

Exhibit premisePressure changes the person before it changes the procedure.
Play firstWritten text from the Fearless FONA manuscript. – Unknown Author (Narrated by Victor Lau)
Human factors film
QR arrival // Start hereBegin here before exploring the Gallery or entering the Practice Studio.After the film: explore the Gallery ↓
Exhibit 02

Continue through the Gallery.

Follow the Rooms in sequence. Enter the Practice Studio when the idea is ready to become an action with cards, objects, or equipment.

Gallery routeExplore the GallerySix Rooms establish the argument before practice.Interactive visitEnter the Practice StudioPractice regulation before attention narrows.
Gallery 02Rooms

Prepare for human limits.

Fatigue, stress, task overload, and communication failures can interrupt a familiar response. Prepare the language, equipment, and team roles for those conditions.

Human factors background

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.

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.

A meditating monk surrounded by elements representing human factors that impact performance under pressure, including stress, cognitive load, distractions, and fatigue, with a backdrop of a heartbeat graphic and various performance metrics.
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.

An illustrated infographic titled 'The Hidden Barriers to Fona Success' outlining human factors that impede decisive action, with a list of nine barriers including loss of situational awareness, cognitive overload under pressure, and lack of practice and procedural confidence.
Room 01

You Need to Rethink Failure

A missed intubation can draw attention toward another attempt. Keep the objective in view: restoring oxygenation.

Rethink your relationship to failure: prepare to recognize when the plan needs to change.

The Trap of Failure

Treat an unsuccessful attempt as information about the current plan. Notice when fear of personal failure makes changing course harder.

The Important Truth

Failure to intubate is not a personal verdict. If oxygenation is not being restored, reassess the strategy rather than repeating it in hope.

A stylized illustration of a martial artist resembling Bruce Lee, posed in a fighting stance with one hand raised and the other clenched. The background features an ancient Asian landscape and includes quotes from Bruce Lee about defeat and success.

The Critical Shift

Name the fear before the crisis. Rehearse asking for help, acknowledging an unsuccessful attempt, and moving to the next plan with the team.

  • 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.

The Trained Response

Recognize that the plan is not working. Say it aloud so the team shares the problem and can act on the next plan.

FONA Is Not Failure

When indicated, FONA is a route to restoring oxygenation. Rehearse the decision and team transition as deliberately as the procedure.

A serene monk sitting on a rock overlooking a mountain landscape, with an inspirational quote about failure and oxygenation displayed prominently.
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.

Words Matter study: reason through fear of an unsuccessful airway attempt.

“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?

EXIT STUDY
A serene illustration of a monk sitting in meditation on a mountain, with a visual representation of a brain emitting positive thoughts like 'Rewire,' 'Refocus,' 'Release,' and 'Let Go,' while negative thoughts such as 'Fear,' 'Doubt,' and 'Regret' dissipate into the background.
Critical Understanding poster reframing a failed airway as a direct airway and emphasizing decisive FONA action.
Room 02

The CICO Scenario

Excerpts from the restored portions of the Fearless FONA manuscript – unknown author (Narrated by Victor Lau).

Critical Language

“Can’t intubate, can’t oxygenate” names the problem and calls the team to action. Use clear, shared language during escalation.

A graphic with the title 'CLEAR LANGUAGE' emphasizes the importance of using clear communication to foster a fearless mindset. The text explains that understanding terms like 'CICO' helps everyone know what to do next. The background features a serene landscape with silhouettes of individuals.

The Key Terms

Know what CICO and FONA mean before the crisis. Use the definitions below to establish a shared mental model.

Text graphic on failed airway management emphasizing the importance of maintaining oxygen delivery with various airway techniques, featuring a serene silhouette figure against a mountain backdrop.

Visit the Critical Language Compendium for more information on this and other important airway terminology.

An educational graphic on CICO (Can't Intubate, Can't Oxygenate), describing it as a critical airway emergency that requires immediate surgical intervention.

The Trigger for Action

When intubation fails and adequate oxygenation cannot be delivered through face-mask ventilation or a supraglottic airway, declare CICO and transition to FONA. Do not wait for critical hypoxia.

The Key Concept

The goal is oxygenation. The CICO declaration should trigger the team’s rehearsed response without an avoidable communication delay.

An illustration depicting an hourglass and a silhouetted figure standing on a cliff. The text reads, 'After three minutes without oxygen, hypoxic brain injury begins.'
EXIT STUDY

Use the agreed declaration to give the team one clear understanding of the airway crisis. Rehearse the response before it is needed.

An hourglass symbolizing the passage of time with the phrase 'TIME = BRAIN' prominently displayed above a tranquil landscape featuring mountains and a sunset, and a figure standing contemplatively in front of it.
Room 03

Real Stories of FONA

An illustrated educational poster featuring two figures in conversation, one an older teacher and the other a younger student. The teacher shares a story about a critical moment in airway management, emphasizing the importance of hearing the right moment. The text on the poster includes the phrases 'First airway. I froze.' and 'This is CICO.' along with a QR code for more information.

Listen for the moment each clinician recognized the need to change course. These accounts describe the human experience of FONA; they are not procedural tutorials.

The Stories

The Quote

Fear and anxiety are part of these accounts. Notice how the clinicians describe hesitation, communication, and the decision to act.

An artistic illustration featuring a tree with anatomical features resembling the human airway, alongside a quote by Ron Walls MD about the experience of a failed airway.
EXIT STUDY
A serene image of a monk sitting on a rocky ledge, gazing at a mountainous landscape. The background features a heartbeat line and motivational phrases: 'Train hard. Know your plan. Don't wait too long.' and 'Fear is normal. Hesitation is dangerous.'
Jamie Lee MD, who collected the clinician FONA stories.

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.

Room 04

Address the Stress

Excerpts from the restored portions of the Fearless FONA manuscript – unknown author (Narrated by Victor Lau).

Stress can disrupt recall, attention, and communication. Study the patterns below, then review the countermeasures.

An illustration depicting a serene figure meditating, surrounded by concepts like uncertainty, hesitation, and team dynamics. The text emphasizes the challenges of performing under pressure in clinical situations.

The Effects of Stress

Recognize three patterns: impaired recall, normalcy bias, and focus lock. Each recording explains one pattern.

Impaired recall study. The recording below explains this stress-related pattern.
Normalcy bias study. The recording below explains this stress-related pattern.
Focus lock study. The recording below explains this stress-related pattern.
Room 05

Performance Training

Techniques to enhance your fona performance

Study the four resources below. Use the Regulate Studio to rehearse with the guided audio.

Box breathing pacing guide: inhale, hold, exhale, hold, for four counts each.
box breathing
  1. Listen to the intro audio 🎧
  2. Use the GIF to practice 🫁
  3. Use it before any procedure
Visualization study. Review the introduction, then rehearse with and without guided audio.
visualization skills
  1. Listen to the intro audio 🎧
  2. Watch the FONA procedure video
  3. Use guided audio to visualize
  4. Then try it without the audio
Positive self-talk study. Write three phrases and practice using them.
Positive self-talk
  1. Listen to the intro audio 🎧
  2. Write down 3 positive self-talk phrases
  3. Practice using them
Trigger phrases study. Choose a trigger phrase and practice using it.
triggers
  1. Listen to the intro audio 🎧
  2. Write down a trigger phrase
  3. Practice using it
Room 06

Team Building

Share the work: name roles, communicate the plan, and ask for help. Rehearse how the team will support the transition to FONA.

Team communication study: ask for help.
It’s not all on you
Team Building study: the work is shared with the team.
EXIT STUDY
Illustration showing the effects of acute stress on performance, including impaired decision-making, narrowed attention, reduced fine motor control, and communication breakdowns. Depicts a serene figure in meditation alongside stress-related imagery, emphasizing the importance of mental strategies, teamwork, and training for effective response under stress.

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.

PAC:SCAPE / EXHIBIT 02 / PRACTICE STUDIO

Use the breathing study to notice a deliberate physiologic response, then reset the device for the next learner.

Continue the ExhibitEnter the Practice Studio
PAC:SCAPE / EXHIBIT 02 / PRACTICE STUDIOOne exercise

Regulate

Practice one deliberate physiologic response before narrowed attention becomes narrowed action.

What you need
Wearable or pulse oximeter · box-breathing guide
First action
Find a stable starting heart rate
Start hereGuided breathing exercise

Listen. Follow the count. Notice the response.

Start the guide. Follow Victor through baseline, four cycles, comparison, and reset.

Audio guide · Victor Lau · 1:45Regulate: four cycles of box breathing
0:00 / –:––
Read the audio transcript

Before you begin, place your wearable or the station pulse oximeter. Let the reading settle. Find a stable starting heart rate. There is nothing to enter or save. Just notice the number.

Settle into a comfortable position. If you become lightheaded at any point, stop and return to normal, comfortable breathing. You will complete four cycles. Each phase lasts four seconds.

For each cycle: inhale for four, hold for four, exhale for four, and hold for four. Complete four cycles, then return to normal breathing.

Let the monitor settle and find a stable post-exercise heart rate. Compare it with your starting rate. A ten-beat-per-minute reduction is a challenge target—not a test, a requirement, or a promised effect.

Remove the pulse oximeter if you used it. Return the device or display to its starting state. The exercise is complete.

  1. 01
    Baseline

    Find a stable starting heart rate.

    Use your own wearable if available or the station pulse oximeter. Do not enter or save the reading here.

  2. 02
    Breathe

    Complete four comfortable cycles.

    Inhale for 4. Hold for 4. Exhale for 4. Hold for 4. Repeat for four cycles.

  3. 03
    Compare

    Find a stable post-exercise rate.

    Notice the response. A 10-bpm reduction is a challenge target, not a test, pass requirement, or promised effect.

Before you leave

Complete the exercise. Reset the device.

Complete attempt

Complete four cycles, compare, and reset.

Reset

Remove the pulse oximeter if used and return the device or display to its starting state.

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