Author: Joshua Stilley, MD FACEP FAEMS; Medical Director, University of Missouri Ambulance
Editor: Michael DeFilippo, DO FAAEM; Assistant Professor of EM and EMS; Washington University at St. Louis School of Medicine
In aviation, safety is built around the expectation that plans will sometimes need to change. Pilots train not only to execute procedures well, but to recognize early when conditions are no longer favorable and to decisively reset before risk compounds.
Emergency medicine and EMS operate in similarly high-stakes, time-pressured environments. While healthcare has widely adopted aviation-derived frameworks such as Crew Resource Management, many other core aviation mental models remain under-recognized in clinical practice.
Continuing our Aviation Concepts for Emergency Medicine and EMS series, Dr. Joshua Stilley introduces the aviation concept of the go-around and explores how this mindset can be applied to airway management and other high-risk procedures in emergency care. Rather than framing aborted attempts as failure, the go-around emphasizes intentional reassessment, physiological optimization, and patient safety as markers of success.
The Go-Around in Aviation
A “go-around” is a maneuver in aviation where, if something is wrong during the approach to landing, the pilot applies power and climbs, rather than continuing the approach. Several factors can trigger a go-around: another aircraft on the runway (a situation we’re seeing more often at major airports), birds between the aircraft and the airport, changes in conditions like wind or weather, or any number of other factors.
A key aspect of the go-around is that the pilot is not committed to landing. The pilot is only committed to the phase of flight they are currently executing, such as the approach. Anchoring too heavily on landing, when conditions are unsafe, can significantly increase risk, leading to accidents. Multiple aviation incidents demonstrate that the proper application of a go-around is often the safest course of action.
The Go-Around in Healthcare: Intubation
This concept of a go-around can be applied to many areas of healthcare, particularly during intubation attempts. Intubation and landing an aircraft are quite similar in many ways. Both involve specific tasks that must be completed before initiating the procedure, both require skill on the part of the operator, and both carry inherent risks that can lead to catastrophic outcomes. However, in most cases, placing the aircraft on the runway or the endotracheal (ET) tube in the airway is not an absolute necessity at that exact moment. Just as pilots have multiple checkpoints during the approach and landing phases – where they decide whether to continue or go around – clinicians should adopt a similar mindset during intubation.
A go-around during an intubation can happen at various stages. For example, if you’re preparing to intubate but the patient’s vital signs are unstable (e.g., systolic blood pressure < 90 mmHg or oxygen saturation < 93%), you can “go around” early in the process. Similarly, during preoxygenation, if equipment fails or specific tools are unavailable, it may be necessary to abort the attempt and address these issues before proceeding.
During the intubation itself, factors such as poor visualization of the vocal cords, difficulty manipulating equipment, or equipment failure should prompt a go-around. Rather than persisting with a dangerous attempt, clinicians should be prepared to abort, stabilize, and reassess.
Mindset for Success
A critical component of a successful go-around is having the right mindset. In aviation, landing is never guaranteed, and the same should be true for intubation. Too often, I see clinicians fixated on getting the ET tube in the trachea at all costs. This “tunnel vision” can lead to devastating outcomes for the patient. Instead, the mindset should be that we will only proceed with intubation if the conditions are right. To restate, the default outcome of an intubation attempt is not to intubate. Only if conditions are met will we continue, otherwise we will “Go Around”.
In my practice and protocols, this means ensuring physiological benchmarks – such as adequate blood pressure and oxygen saturation – are met, along with criteria like HEAVEN or LEMON, checklist completion, backups ready, time to do the intubation well, and good team communication. Only when these conditions are satisfied should the next step in the procedure be undertaken. The goal is not to complete the intubation but to remain flexible, always ready to go around if necessary. This approach helps maintain a focus on patient safety rather than just the outcome of a procedure.
Options After a Go-Around
After a go-around during intubation, several options are available. These may include resuscitating the patient, identifying errors or issues with the intubation attempt such as positioning (which should have been optimized from the start), or choosing an alternative airway management strategy such an extraglottic device. Just as in aviation, reaching the final destination (successful intubation) is never a guarantee, and we have many tools at our disposal to maintain airway patency, ventilate, and oxygenate the patient.
What other procedures do you think would benefit from a go-around mindset? Comment below.
