Introduction/Background The goal of High Fidelity Simulation (HFS) is to convince the participant they are immersed in a real situation. To enable HFS, we employ “Realism” in three parts; first, we insure the problem being simulated is believable (conceptual); next, we take great pain to manipulate the simulation space to appear compellingly real (physical); and finally, we insure that the communication during simulation is reflective of the event being modeled (emotionally contextual).1 Fidelity is the degree to which simulation achieves the objective of “Realism”. Realism seems to be the critical quality that enables effectiveness of High Fidelity Simulation to enable episodic memory & transformational learning. 2-4 Hence, any contribution that enhances realism - be it conceptual, physical, or contextual - is of high value at increasing the probability of HFS event to occur. We present a novel approach to HFS, whereby the integration of the Laerdal Medium Fidelity Airway Management Trainer enables enhanced conceptual and physical realism in airway management scenarios such as the bleeding tonsil, the unexpected aspirating patient and a PA rupture. Methods In all three scenarios, the High Fidelity SimMan 3G manikin is moved down the OR table and fully draped, whereby the Medium Fidelity airway head is the visible part, giving the appearance of a continuous manikin. Case One - The Bleeding Tonsil: Using fake blood loaded in the injection apparatus (see picture), we carefully position the open tip of the suction catheter in the hypopharynx of the airway trainer’s mouth, behind the tonsillar pillar. Under full drapes, a confederate will forcefully inject the fluid into the direct view of the larygoscopist, mimicking a “bleeding tonsil”. Case Two - The Aspiration Scenario: Using the same injection apparatus and fake bile, we know change the catheter tip position to the corner of the mouth. Immediately after induction, a confederate forcefully injects the fluid into the airway, whereby “bile” comes rushing out of the side of the mouth, into the mask, imitating an aspiration event. Case Three - The PA Rupture: After intubating the manikin with a short 8.0 ETT (cut to 26cm), using the same injection apparatus described above, the suction tubing is inserted up the manikin trachea, with the open catheter tip resting just past the elbow of the breathing circuit. In our simulation, when the surgeon either begins to suture in the mitral valve or during a severe protamine reaction, the red tinged fluid is injected forcefully, whereby the breathing circuit is saturated with red “blood”, mimicking a PA rupture. Results: Conclusion The ability to train for airway complications is critical to mastery of the difficult airway. Given the sensitivity to damage of expensive high fidelity equipment, it is often unfeasible to imitate the physical conditions present in certain real life situations, such as pooling blood, projectile vomit or bile, or an ett full of blood. Introducing a medium fidelity head into the HFS environment offers more flexibility to faithfully simulate the characteristic features of these scenarios, thereby enhancing the conceptual and physical realism of the learner.