Psychology of the Difficult Airway

Educational Objectives

The goal of this program is to improve stress management during airway emergencies. After hearing and assimilating this program, the clinician will be better able to:

1. Apply stress management techniques during airway emergencies.

Summary

Stress: flying blind in high-stress scenarios (eg, difficult intubation) tests the physical and mental limits of health care providers; despite all the tools and training available, the mind, which is responsible for problem-solving, communication, and the execution of fine motor tasks, can also fail under stress; a study in England analyzed failed airways by anesthetists and found that cognitive failures were a root cause in 40% of cases; the stress response, triggered by a perceived mismatch between demands and resources, alters physiology; perception is the key element; while stress boosts strength and readiness to flee or fight, it compromises cognition, communication, and fine motor skills, precisely what is needed for delicate procedures

Managing stress: being prepared — time is often the scarcest resource in emergencies; the stress of having only minutes to act magnifies the pressure; preparing ahead of time, knowing what to do in the moment, and debriefing afterward can help mitigate these challenges

Preparation: under stress, skills deteriorate to a baseline level; the goal is to ensure this baseline is sufficient to perform the task; high-acuity, low-occurrence (HALO) tasks (eg, cricothyrotomy, neonatal resuscitation) are not performed often enough to maintain proficiency; simulation is optimal for keeping skills sharp but may not always be available; passive learning (eg, reading textbooks, watching videos) results in minimal retention; literature on cognitive psychology demonstrates that retention requires challenging the brain with recall at spaced, repetitive intervals; the speaker recommends preparing a video playlist of all the HALO procedures one may encounter clinically and reviewing these videos every few months; before watching each video, visualize performing the procedure step by step, challenging yourself with imagined complications; after visualizing, compare your performance with the video; revisit and practice these scenarios regularly to build muscle memory and confidence; “honing tired moves” — a concept coined by Dan Dworkis in the book “The Emergency Mind”; fundamental skills eg, bag-valve-mask ventilation, are often overlooked but vital in a crisis; regularly practicing tired moves ensures effectiveness, even under duress; plan B — incorporating plan B into routine preparation normalizes its use; identifying cricothyrotomy landmarks early and having the necessary equipment ready can save critical seconds; equally important is giving oneself permission to proceed with plan B if needed, as delays in critical decisions often worsen outcomes; self-care, or lack thereof, also affects performance under stress

Execution in the moment: self-talk is a strategy for maintaining composure under stress; it is a proven method for reducing anxiety and enhancing performance; focus only on what matters, ie, offload less important decisions to others when possible; prioritize the basics (airway, breathing, circulation) along with core assessments

Debriefing: important for learning and emotional processing after a high-stakes scenario; it allows teams to analyze what went well and identify areas for improvement; personal debriefing often continues later as the events replay in one’s mind; the physician should be compassionate with themselves during this reflection, acknowledging that difficult outcomes are part of medical practice

Readings

Goldberg MB, Mazzei M, Maher Z, et al. Optimizing performance through stress training - An educational strategy for surgical residents. Am J Surg. 2018;216(3):618-623. doi: 10.1016/j.amjsurg.2017.11.040; Yaribeygi H, Panahi Y, Sahraei H, et al. The impact of stress on body function: a review. EXCLI J. 2017;16:1057-1072. doi: 10.17179/excli2017-480.

Disclosures

For this program members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Zdradzinski was recorded at the 2024 Rocky Mountain Winter Conference, held February 24-28, 2024, in Steamboat Springs, CO, and presented by Well Assembled Meetings. For information about upcoming CME activities from this presenter, please visit https://wellassembled.com/events. Audio Digest thanks the speakers and Well Assembled Meetings for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0.50 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0.50 CE contact hours.

Lecture ID:

EM420504

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.