Scary Calls, Simple Skills: How EMS Pros Stay Sharp When the Stakes Are High

There is a special kind of terror that hits when you realize the call is real. Not training real. Not “we can pause and reset” real. Real real.

The scariest moments are rarely the flashy ones. They are the moments when something simple becomes complicated, and you have to perform while your brain is screaming “everybody is watching.”

That is also why continuing education matters. Not because you want more letters behind your name, but because you want fewer surprises when the room goes dark, the airway goes weird, and the family is fighting in the living room.

The call that looks routine until it absolutely is not

A residential alarm. Light smoke. Bright sunny day. First floor looks fine. Then you step into the back bedroom and it is pitch black, hot, and you cannot see your hand in front of your face.

That kind of “oh, this is different” moment exists in EMS too.

It is the patient who “just needs clearance” and turns out sick.
It is the choking call that is actually a full arrest with a true obstruction.
It is the airway that should be easy, except the neck is basically immobile from radiation fibrosis and you cannot get a view even with video.

The lesson is not “be scared.” The lesson is “expect the pivot.”

Why the basics matter more than the hero stuff

When providers talk about scary procedures, they often jump straight to the dramatic list: thoracotomy, pericardiocentesis, cric, thoracostomy. Those are intense.

Simple procedures can be the hardest ones.

Intubation is a perfect example. In theory, it is straightforward. In real life, it can get ugly fast. That is why modern airway guidance keeps circling back to physiology, preparation, and having an exit plan that is not “try harder.”

The National Evidence Based Guideline for Prehospital Airway Management emphasizes selecting an airway strategy that fits the patient and situation, and prioritizing oxygenation and ventilation over any single device or technique. (EMS.gov)

Ventilate first, tube second

If you take one thing from this blog, let it be this: the goal is not to intubate. The goal is to ventilate.

That is said out loud in the podcast, and it is one of the most sanity saving reframes you can carry into difficult airway calls. If you can oxygenate and ventilate with BVM, supraglottic airway, or basic adjuncts, you bought time. Time is life, and time is options.

Keep the environment in your plan, not just the patient

Erik, an ER doc points out something that prehospital folks already know in their bones: the environment is not controlled. Sometimes you are intubating on a dining room floor with a crowd that might throw hands. Sometimes the patient’s arm flops off the cot during egress and now the family is furious and escalating. That is not just stress, it is risk.

Your clinical plan has to include scene control, crew roles, and a realistic “load and go” threshold.

Humility is a clinical skill

The most experienced clinicians in the world still get humbled by airways and trauma. In the episode, they tell a story about an airway so difficult that even video laryngoscopy did not save the day, and the case shifted when the wife arrived and stated the patient was DNR.

That kind of moment is why humility matters. Not performative humility. Practical humility.

Practical humility looks like:

• You assume the airway might go sideways
• You have suction ready before you need it
• You assign roles out loud
• You set a time limit on attempts
• You call for help early, not late

NAEMSP also highlights the importance of training, deliberate practice, and maintaining competence, especially for airway skills that may not be used frequently. (NAEMSP)

Three high risk, low frequency moments worth training this month

Here are three scenarios from the episode that are perfect for an EMS continuing education refresh. Each one is scary for the same reason: you may not see it often, but when you do, the clock is not your friend.

Difficult airway and the “cannot intubate, cannot ventilate” path

The episode hits multiple airway realities:

• First intubation anxiety with everyone watching
• The comfort of having a skilled preceptor or attending present
• The nightmare anatomy case, post radiation, fixed position, limited access

Takeaways to build into training:

• Focus on pre oxygenation and apneic oxygenation where appropriate
• Limit attempts and optimize between attempts
• Use a checklist for difficult airway prep
• Treat supraglottic airways as a win when they work
• Rehearse your failed airway plan until it is boring

If you want a deeper evidence base, NAEMSP’s trauma airway position statement reinforces that airway management must be individualized and should focus on adequate oxygenation and ventilation rather than any one intervention. (PubMed)

Difficult airway diagram 

Orbital compartment syndrome and lateral canthotomy

Erik mentions lateral canthotomy as one of those “you could go a whole career and never do it” procedures, until the day you need it twice, immediately, on both eyes.

Orbital compartment syndrome is time critical. A classic study on traumatic orbital compartment syndrome found visual recovery is best when decompression happens within about 2 hours of injury. (PubMed)

That means EMS and ED teams benefit from shared recognition skills:

• Severe periorbital swelling and proptosis
• Rock hard orbit
• Vision changes if the patient can report them
• Relative afferent pupillary defect when assessable
• Rising intraocular pressure when measurable

Not every EMS system will perform lateral canthotomy, but every EMS clinician can learn to recognize the red flags, communicate urgency, and avoid delays.

Foreign body airway obstruction that turns into cardiac arrest

In the episode, they describe a choking call where nothing would ventilate, nothing would pass, and the team knew it was a true obstruction. They also share the mindset shift a trauma surgeon taught: the patient is already in arrest, so the only direction left is better.

Foreign body airway obstruction is a real contributor to out of hospital arrest, and outcomes are tied to quick intervention. A 2024 study of out of hospital cardiac arrest related to foreign body airway obstruction discusses incidence, interventions, and survival outcomes, and reinforces how critical early action is. (PubMed)

For training, focus on:

• Early recognition of ineffective ventilation during arrest
• Rapid transition to obstruction management steps per protocol
• Team communication so everyone understands why ventilation is failing
• When and how your system approaches emergency front of neck access

Also worth knowing: surgical airway in the setting of OHCA is uncommon and outcomes are generally poor, which is exactly why training and decision making matter so much when it is truly indicated. (PMC)

The team factor: partner skills, closed loop comms, and why you want a safety blanket

One of the best lines in the episode is the idea of the “safety blanket.” New clinicians perform better when they have an experienced person talking them through the steps, but that is also true in reverse. Even experienced clinicians perform better when roles are clear and someone is watching the big picture.

On the fire side, the conversation lands on the importance of having a partner maintain orientation and prevent getting trapped. In structural firefighting, the “two in, two out” concept is designed to ensure teams entering IDLH atmospheres have backup resources ready. (OSHA)

You can borrow that mindset for EMS high risk procedures:

• Two providers focused on the patient
• One provider focused on equipment and meds
• One provider focused on the room, the family, and scene safety
• A plan for what happens if you fail

Closed loop communication and role clarity reduce errors when adrenaline spikes.

Quick training ideas you can do without a fancy sim lab

You do not need a million dollar sim center. You need repetition.

Try these:

• Two minute airway drill: BVM seal, airway adjuncts, suction setup, SGA readiness
• Difficultairway talk through: Say your failed airway pathwayout loud with your partner
• Scene chaos role play: One person plays family drama while you keep communication clean
• Micro refresh on rare skills: Review indications, contraindications, and your system protocol for one rare procedure each week
• After action debrief habit: What went well, what was risky, what do we change next time

Make it normal. Make it routine. That is how scary becomes manageable.

Takeaways you can use on your next shift

• The calls you remember often start out boring
• “Simple” skills can be the hardest under pressure
• The goal is ventilation and oxygenation, not ego
• Humility keeps you ready for the airway that will not cooperate
• Train high risk, low frequency skills in tiny reps, often
• Build a team plan that includes the environment, not just the patient

And if you ever need to remind yourself why you train, remember the moment from the episode where the firefighter says, “this is the real deal” and realizes nobody can just shut it off. That is why we prep.

Because the day you need it, you will really need it.

External references cited:

• National Evidence Based Guideline for Prehospital Airway Management, EMS.gov. (EMS.gov)
• NAEMSP position statement on prehospital airway management training and education. (NAEMSP)
• Sun et al. Traumatic orbital compartment syndrome, decompression timing and visual recovery. (PubMed)
• Wolthers et al. Out of hospital cardiac arrest related to foreign body airway obstruction, incidence and outcomes. (PubMed)
• Humar et al. Cricothyroidotomy in out of hospital cardiac arrest. (PMC)
• OSHA interpretation on two in, two out in IDLH environments. (OSHA)