One of the greatest challenges of emergency airway management is managing our own emotions. The "adrenaline rush" we feel when confronted with high stress clinical scenarios can help, or hinder, our performance in those moments. Human performance under situations of extreme psychological stress is a field of inquiry well applied to acute care medicine. Military psychologists have studied both mental and physical performance in soldiers exposed to extreme psychological stress and have described different levels of stress "activation". (Grossman, 2008) Not surprisingly, the neuroendocrine response to a little bit of increased psychological tension increases both cognitive acuity and physical ability. However, this relationship is not linear, and as the level of stress increases, both psychological and physical capabilities decline and eventually fail completely. Have you ever felt "paralysed" with fear or indecision during a stressful resuscitation scenario? It follows that awareness of our psychological state during emergency airway mangement may be as important as which medications we chose and what intubation devices we favor. Ideally, we would welcome the sharpened critical thinking and focus that accompany a modest amount of stress, but we would want to avoid moving too far down the spectrum where stress clouds our decision making and impedes our fine motor skills. Meditation practitioners have long known the calming benefits of breathing exercises for decreasing sympathetic activation. Today, military personnel as well as civilian police and rescue personnel are taught "tactical breathing" as a simple, pragmatic exercise that can be literally done "in the line of fire" in order to regain a psychological state that is compatible with good decision making and optimal execution of motor skills. Simply breathe in counting to four, hold for four seconds, then exhale counting to four. Repeat once, maybe twice. For a soldier or police officer, tactical breathing may save their life. For emergency airway managers, tactical breathing may save our patient's life. So the next time you are faced with a difficult, stressful, emergency airway scenario... remember to breathe.
Mark Vu, MD FRCPC
Anesthesia, Trauma and Resuscitation
Department of Anesthesiology, The Queens Medical Center
Honolulu, Hawaii
