The Psychologically Difficult Airway SAM Atlanta 2016
Thanks for the great feedback from my talk at the Society for Airway Management Meeting in Atlanta. Here is a link to the slides.
Heres an excerpt from the chapter entitled Human Factors in Emergency Airway Management from our upcoming 3rd edition of our textbook.
Emergency Airway Management: Psychological Barriers and Human Factors
 Successful airway management requires an integration of knowledge and procedural skills with a range of non-technical skills that are referred to as human factors. Human factors analysis seeks to understand the capabilities of human performance – performance that is affected by factors including stress, ego, fatigue, cognitive biases, errors in perception, estimation, communication, and numerous others
Managing a difficult airway will inevitably be emotional and produce feelings of anxiety and may lead to a dysfunctional self-preservation response and a resultant negative outcome. In managing a critically ill patient with an unanticipated difficult airway, the clinician may persist with their laryngoscopy attempt despite the sounding alarms of rapidly falling saturations. There are numerous reasons that may explain the clinician’s actions (or inactions). It is usually, however, not a lack of knowledge and in fact the clinician may be too aware of the evidence supporting first attempt success to the point that the technical imperative for success supersedes the clinical priority of oxygen delivery (outcome bias). Socio-evaluative stress from fear of failure and/or condemnation from an observing gallery of team members can be a powerful influence on decision making.
Stress is truly measured by the “eye of the beholder” as a mismatch between the clinician’s assessment of whether they have the personal and environmental resources to meet the demands of a given scenario. When the resources are assessed as sufficient to meet demands, the situation is deemed a challenge and the stress is functional and often beneficial. If resources are appraised to be insufficient to meet the demands then a threat is perceived and the resultant distress may become dysfunctional with adverse outcomes.(LeBlanc, 2009)
Like many physiological compensatory mechanisms, the beneficial effects wane at a certain point. As stress response continues, an individual can experience deleterious effects. This non-linear relationship was first explored by Robert Yerkes and John Dodson in 1908 (Their finding demonstrated that, as the level of stress increased, performance improved up to a point of optimal performance. However, after that point, addition stress caused performance to deteriorate.(Yerkes & Dodson, 1908)
Confidence is a challenging balance between having too much and too little. Having a physical presence in the way you present yourself has the potential to positively affect your performance and that of your teams.(Carney, Cuddy, & Yap, 2010) An active, confident and appropriately vocal and engaging leader is more likely to have team members contribute than someone who is quiet, seemingly uncomfortable and speaks without authority. This assumes that the content of their easily heard words represents competent decision making.
The problem is, however, that the relationship between confidence and competence is non linear.(Pezeshki, 2015)(Kruger & Dunning, 1999) In a series of experiments by the now famed authors Dunning and Kruger, they found that unskilled individuals often remain unaware of their incompetence despite being presented feedback on their poor performance.
Competence The key to attaining skill competence is performing what Ericsson terms deliberate practice, which involves repetitive practice with feedback within an educational context. (K. Ericsson, Krampe, & Tesch-Römer, 1993) For laryngoscopy data has varied from 50-100 procedures required to become acceptably competent.(Buis, Maissan, Hoeks, Klimek, & Stolker, 2015)(Cortellazzi et al., 2015)(Je et al., 2013) However, these numbers may apply only to the “normal patient.” What about the difficult airway? One size does not fit all and we know that “n” (the number of cases) will vary according to the individual, the skill in question and the context.
Context and opportunities present a major challenge when it comes to learning life-saving and relatively uncommon procedures. While non-anesthetist, acute care clinicians need to be skilled in managing the toughest of airways, the intubation rate per clinical hour for a practicing individual may be quite low (1-3/month/MD, 0-1/6 months/Paramedic). This low clinical exposure rate is often further affected by the presence of multiple learners in need of intubation experience. For cricothyrotomies, many clinicians will never have the opportunity to perform one. This high-acuity, low-prevalence gap is where simulation has come to play a major role.
Simulation has the potential to distance unhelpful affective components from the learning process. Its effectiveness in part depends on its ability to reproduce a relevant patient care-related stress. Performance anxiety related to socio-evaluative stress, in contrast, is not a fostering substitute for managing patients in a crisis scenario. Simulation without the undesirable anxieties of learning on a real patient is important for the initial phases deliberate practice. The implied “permission to fail” enables learning to proceed under more optimal conditions. How to use failure to facilitate learning and improve outcomes is somewhat controversial.
Airway Adverse Events and Clinical Decision-Making Bias Awareness and concern regarding medical error has increased over recent years. The language and terminology describing error, adverse events, and complications is at times confusing, but collectively describes patient safety issues. To improve patient outcomes, it is helpful to understand why things “go bad.” clinical decision-making can be complicated and is subject to various biases that may lead to unintended outcomes. Croskerry has described the many potential clinical decision-making failures that occur in the emergency setting.(P Croskerry, 2002) Many of these are applicable to airway management:
Playing the odds. Depending on the volume and staffing of an emergency department, a clinician’s need to perform emergency airway management may be relatively infrequent. This may happen in a small-volume centre due to a small likelihood of a patient presenting sick enough to require airway management during any one shift, or in a large centre, by expecting a more experienced colleague to be nearby. However, just because the procedure in question is rarely required of a clinician does not circumvent the expectation to be competent in its execution.
Overconfidence bias. To quote Mark Twain, “Good judgment comes from experience, and experience comes from bad judgment.” After junior clinicians perform their first five RSIs without encountering difficulty, it is understandable how overconfidence may breed complacency and risk-taking behavior. However, as more experienced clinicians can attest, it is only a matter of time until the less experienced and overconfident clinician will be “humbled” by encountering a bad outcome.
Omission bias. “First do no harm” is usually a safe adage for clinicians to heed. It may be appropriate advice for an inexperienced clinician, to avoid getting in over his or her head. However, consider a failed airway situation in a critically ill patient, where intubation attempts were unsuccessful, failed oxygenation ensued in spite of EGD placement, and the patient died. Failure to attempt to “rescue” the patient by performing a cricothyrotomy would be considered an error of omission. In general, it is human nature to feel more comfortable with a negative patient outcome having omitted a potentially life-saving procedure, than to experience a similar negative outcome having performed an unfamiliar procedure.
Outcome bias. The goal of airway management is to optimize patient outcomes by maintaining adequate gas exchange. This can be achieved by multiple means, be it BMV, placement of an SGA, or tracheal intubation. “Getting the tube” should never alone be considered a successful outcome, especially if it comes at the price of hypoxemia during its placement.
Fixation error. Einstein defined insanity as “doing the same thing over and over again and expecting different results.”(Einstein, n.d.) The most common response to difficulty is to repeat the action that has already failed. This is counterproductive – unless something is done differently, as with the use of a tracheal tube introducer during a second attempt at direct laryngoscopy. Simply repeating the same action is unlikely to succeed, may harm the patient, and tends to narrow the clinician’s focus (fixation error) in such a way that the appropriate course of action (e.g., calling for help, and placing an EGD) is overlooked.
Multiple alternative bias. The suddenly increasing array of airway equipment has created “device confusion,” whereby the clinician may make an inappropriate choice to employ a particular airway device. The choice of device should reflect not only equipment availability and clinician experience, but also an understanding of the clinical situation. Reaching for a video laryngoscope is inappropriate in a failed oxygenation situation. Rather, an EGD should be placed while preparing to move on to a cricothyrotomy. As previously discussed in Chap. 12, there are “you have time” and “you have no time” pathways and devices.
Conflict avoidance. In caring for a patient it, is critical to keep patient care interests a priority. Sometimes this means asking for help. Avoiding calling a colleague or consultant for fear of conflict related to a previous adversarial interaction or for fear of being viewed as incompetent can have dangerous clinical consequences. Making the choice to perform an RSI on a stab wound to the neck with subcutaneous emphysema because you feel inexperienced in performing an awake intubation is another example of playing the odds. If, however, your choice relates to avoiding conflict with a consultant, you are putting your personal sense of safety and interests ahead of the patient’s.
Addressing Human Factor Challenges Despite the challenges that Human Factors present to emergency airway management, certain strategies can be applied to compensate for our innately-human shortcomings. Dr. Clifford Reid has suggested these issues can generally be organized into four categories: self, team, environment/equipment, and patient.
Self. Law enforcement, the military and athletics are examples of high-stakes occupations that teach psychological skills to improve performance under stress. As other professions have done, a comprehensive set of Performance-Enhancing Psychological Skills (PEPS) can be specifically adapted to resuscitation and emergency airway management.
The airway team. Emergency airway management success requires a team effort. The cognitive effects of stress on individuals may be compounded or compensated by other team members. Attention narrowing creates a potential series of silos with a loss of central authority and lack of communication. The critical features of effective teams include:
Clear leadership with assigned roles and responsibilities using closed-loop communication:
“Annie, you’re on airway. Let’s start with HFNO using prongs and BVM with a PEEP valve; don’t bag for now. Tom, start an IV in the right antecubital fossa and tell me when the 500 cc bolus is running.”
An ability to adapt and adjust roles and resources:
“Joan, move to the head of the bed to help Bob with 2-hand bag mask ventilation, and,Tom, looks like it’s a tough IV. Move to a tibial IO.”
Adaption and reallocation of resources, which requires effective situation awareness and can be checked by recruiting input from team members:
“IO looks to be running well. We’re going to have to move on to do an RSI. Tom, can you prepare 100 mg of ketamine and 100 mg of rocuronium please? Annie, what’s your assessment of the airway?”
Use of checkpoints to stop, think, and reassure yourself and the team is key when thrown into a complex, high-stakes scenario. Use of a checklist may be helpful:
“Before we go ahead, let’s review. Annie, tell me tour plan A,B and C. Tom, you’re pushing the drugs, giving us 15-second time updates and watching the monitors. Annie, Tom, are you OK with this plan? Do you have any questions?”
After a failed plan regroup, checkpoints are perhaps even more important:
“Annie, that’s OK. The patient’s easy to bag. Sats are stable, we have time. What did you see?”
Environment/Equipment. “Geography is destiny” they say. Intubation success rates will differ based on clinician experience, patient condition, and environment. First-pass success rates are higher in the OR than in the emergency department, which in turn are higher than the prehospital setting.
Patient. Ultimately, our ability to influence patient outcomes is determined by our actions and, perhaps more importantly, our decisions. Algorithms are often binary, “difficult or not,” but in the real world there are many shades of grey. Making the best decision for the patient may not be the best for the clinician as per the situation where an awake intubation is indicated, but the clinician may be biased to perform an RSI as that’s what they are most comfortable with.
Thanks for the great feedback from my talk at the Society for Airway Management Meeting in Atlanta. Here is a link to the slides. 