Of all the scenarios used in higher anaesthetic training interviews, the call from a remote site with a failed intubation is the most reliable, because it tests everything a senior trainee must do: lead a crisis by phone, decide, go, manage a team you do not know, and handle the aftermath. This guide is about answering it well.
The stem
You are the senior anaesthetic trainee on call. A junior calls from the emergency department, or the cardiac catheter laboratory, or the radiology suite, with a failed intubation and saturations falling. What do you do?
Then, as you arrive: the surgical airway has been attempted and has failed. What now?
The first minute on the phone
The assessors are scoring whether you can lead from a distance. Say what you would say to the junior, in order: declare the emergency, get help in the room (the second anaesthetist, the ODP, the arrest team if needed), optimise what can be optimised (oxygenation by whatever route is working, position, the airway adjuncts), and move down the difficult airway algorithm with them while you travel. Tell them you are coming and how long it will take. Tell them to call the consultant too. Then go.
Candidates lose marks by spending the first minute asking questions. The junior needs instructions, not a history.
On arrival
Take over calmly, confirm where the team is in the algorithm, and assess what is working. If oxygenation is possible by any route, use it and buy time. If it is not, the decision is the front of neck access, and it is yours. Say that you would do it, how, and who would help. The scenario is designed to reach this point and the assessors want to hear a decision, not a further call for help.
The failed surgical airway
The assessors' second stage is the surgical airway that has failed. This is the hardest moment in the specialty and the answer is to keep going: reassess the attempt, try again with a different technique or a different operator, continue oxygenation attempts by every other route, and have someone call the surgeon who can do a tracheostomy and the consultant if they are not already there. Say that you would not stop. Say what you would do if the patient arrested.
The team
Throughout, say how you would run the room: allocate roles, name the person keeping time, keep the noise down, use closed loop communication. A remote site team may be unfamiliar with airway emergencies, so your instructions need to be simple and specific.
Afterwards
The assessors always ask. The patient's immediate care and transfer to intensive care. The family, with honesty and the duty of candour if there has been harm. The team: a debrief, support for the junior who made the first attempts, and support for yourself. The reporting: the incident system, NAP style reporting, the morbidity and mortality meeting. The learning: what the department would change about remote site cover, equipment and training. Say that you would speak to the consultant about all of it.
The probes
- The consultant is twenty minutes away. Do you wait?
- The ODP says they are not confident with front of neck access.
- The junior is in tears afterwards.
- What would you want the department to change?
Each has an answer: you do not wait when the patient is hypoxic; you do the procedure yourself with the ODP assisting on what they can do; you support the junior without blame and make sure they are not left alone with it; the department reviews remote site equipment, the difficult airway trolley, the training of the staff there and the escalation pathway.
What the assessors score
Leadership by phone, a decision made when the algorithm demands it, persistence when the first attempts fail, team management in an unfamiliar environment, honest and structured aftermath, and reflection. The common failures are asking questions instead of giving instructions, deferring the front of neck decision to someone who is not there, and having nothing to say about the aftermath.
Practising
Talk the scenario through aloud as a phone call, then as the arrival, then as the failed surgical airway, with someone throwing the probes. Do the same for the obstetric and the paediatric variants. Then do it again, because on the day it will be delivered quickly and probed hard.