Review of unusual patient care experiences is a cornerstone of medical education. Each month, the AQI-AIRS Steering Committee abstracts a patient history submitted to the Anesthesia Incident Reporting System (AIRS) and authors a discussion of the safety and human factors challenges involved. Real-life case histories often include multiple clinical decisions, only some of which can be discussed in the space available. Absence of commentary should not be construed as agreement with the clinical decisions described. Feedback regarding this article can be sent by email to Heather Sherman: airs@asahq.org. Report incidents or download the AIRS mobile app at www.aqiairs.org.

Patient undergoing an ORIF of a fracture under general anesthesia. ETT in place. Music being played loud by iPhone cradle/sound system located directly behind anesthesiologist. In between songs, anesthesiologist notices high pressure alarm caused by kinked endotracheal tube that...

You do not currently have access to this content.