Here’s the number that should terrify you:
Miss your first intubation attempt and your patient’s risk of adverse events increases sevenfold.
By the third attempt, you’re approaching a 100% rate of complications.
And here’s what makes it worse—those failures aren’t happening because you don’t know your anatomy. They’re not happening because you didn’t study hard enough or haven’t logged enough tube time.
Yes, those things matter.
But even expert clinicians fail in predictable ways.
David Olvera spent 20+ years in EMS and critical care leading national research on why we crash at high-stakes procedures. His work on challenge-response checklists reveals something uncomfortable:
Your expertise doesn’t protect you from error.
Your willpower doesn’t overcome human cognitive limits under pressure.
Systems do.
This is the gap Loud & Clear exists to fill—the space between clinical knowledge and operational execution. Between knowing exactly what to do and actually doing it when your hands are shaking and the patient is crashing.
Let’s build the system that makes airway success inevitable.
The Human Factors Problem: Why Smart People Make Dumb Mistakes
David’s research started with a personal story.
His partner is a type-1 diabetic. She managed her condition for over 20 years—expert-level knowledge, daily execution, complete mastery of insulin administration.
One evening after a long restaurant shift, she came home, reached into the fridge, and grabbed her insulin.
She grabbed the wrong type.
Hours later, she was seizing with a blood sugar of 24.
Twenty-plus years of expertise.
Daily practice.
Complete knowledge.
And she still made a catastrophic error.
This isn’t unique.
The B-17 bomber—one of the most advanced aircraft of its time—crashed on its test flight because expert pilots forgot to release a single lock.
They weren’t rookies.
They were the best.
This is human factors.
The invisible variables that turn experts into people who make critical mistakes under pressure, fatigue, distraction, and chaos.
You walk into an intubation call carrying personal stress. Maybe you had a bad morning. Maybe you’re exhausted. Maybe your brain is overloaded.
And suddenly:
• You skip a step
• You miss equipment
• You assume something is ready
This isn’t a character flaw. This is neuroscience.
The solution isn’t “try harder.”
The solution is systems.
The Challenge-Response System: Why Three People Beat Two
David’s research proved something surprising:
Checklists don’t slow you down. They speed you up.
But only when used correctly.
The key is a challenge-response checklist with three people.
Person 1 – Operator: Performs the intubation
Person 2 – Confirmer: Verifies each step
Person 3 – Reader: Reads the checklist (anyone who can read)
Example:
“Oxygen at 15 liters?”
“Confirmed, 15 liters.”
“Suction assembled and tested?”
“Confirmed, suction working.”
Why does this work for experienced medics?
Because tunnel vision makes you skip steps.
Your brain fills in gaps that aren’t actually complete.
The third person isn’t in tunnel vision. They read exactly what’s written.
A doctor in Thailand used this system during a chaotic airway in an unfamiliar hospital.
He stopped the room.
Ran the checklist.
Succeeded.
Not because he didn’t know what to do.
Because the system forced execution.
David’s research showed challenge-response checklists reduced intubation time by preventing “I forgot” moments.
The Dump Kit: Visual Checklists That Work in the Dark
The second system: Dump Kits
Learned from Australian HEMS teams.
Dump your airway bag onto a laminated layout.
Every item goes in the same spot. Every time.
Example layout:
BVM – Top left
Supraglottic – Top right
ETT/Bougie – Center
Laryngoscope – Bottom center
Your hands learn where things are.
No searching.
No guessing.
When it’s dark, loud, or moving, muscle memory takes over.
A dump kit is a visual checklist.
If something is missing, you see it instantly.
Systems eliminate variability. Consistency creates excellence.
The HEAVEN Criteria: Six Warning Signs That Predict Failure
David’s team analyzed five years of intubation data and identified six predictors of failure.
They created the acronym HEAVEN.
H – Hypoxemia: Low oxygen before attempt
E – Extreme size: Obesity or pediatric patients
A – Anatomic disruption: Trauma, burns, tumors
V – Vomit/blood/fluids: Obstructed view
E – Exsanguination: Hemorrhagic shock
N – Neck mobility: Limited movement
These are warning signs.
They tell you to adjust before you fail.
Examples:
• Hypoxemia → aggressive pre-oxygenation
• Limited neck → video laryngoscopy
• Vomit → SALAD technique
HEAVEN doesn’t tell you if to intubate.
It tells you how to succeed.
Remember:
First-attempt failure increases adverse events by 700%.
Building Systems That Think for You
You will face chaos.
That’s the job.
But you don’t have to rely on willpower.
You can rely on systems.
1. Build a Challenge-Response Checklist
Create a laminated airway checklist.
Use it every time.
Tell your reader:
“Read it line-by-line. Don’t skip.”
2. Organize Equipment the Same Way Every Time
Create your dump kit layout.
Photograph it.
Train with it.
Repetition builds reliability.
3. Apply HEAVEN Before Every Attempt
Make it automatic.
See warning signs?
Change approach.
Do it before you fail.
4. When Chaos Hits, Stop and Reset
Stopping feels slow.
Rushing without systems is slower.
Pause.
Reset.
Run the checklist.
5. Train Your Team on the System
Everyone needs to know their role.
Reader reads.
Confirmer confirms.
Operator performs.
Excellence is built together.
6. Review Every Intubation
Ask:
What worked?
What failed?
What was skipped?
Systems improve only when reviewed.
The Bottom Line: Systems Beat Willpower Every Time
You’re skilled.
You’re trained.
You’re capable.
And you’re still human.
Humans fail under pressure.
The question isn’t intelligence.
The question is systems.
David’s partner grabbed the wrong insulin.
B-17 pilots missed a lock.
Experts still fail.
Systems don’t.
So:
Build the checklist.
Create the dump kit.
Learn HEAVEN.
Train your team.
Run it every time.
Because under pressure:
You won’t rise to the occasion.
You’ll fall to the level of your systems.
Build them now.
Practice them early.
Trust them when it counts.
That’s operational excellence.
That’s how you stop the 700% increase in harm.
That’s how you become the paramedic who doesn’t just know what to do—
But does it when it matters most.
Want help building these systems?
Check out the Paramedic Confidence Builder program at emspodcast.com/program. Learn how to build checklists, organize equipment, and perform under pressure
Here’s the airway checklist that pairs with this topic and helps you apply it in real calls:
👉 https://www.airmedandrescue.com/latest/long-read/medical-insight-latest-tools-ensure-successful-first-pass-intubation
