AIRWAY MANAGEMENT IN EMERGENCIES - PART 10 doc

Postintubation care in the elderly • Successful airway management should not detract from the recognition that even with a secured airway, the elderly patient remains fragile and prone t

• An alternative intubation technique should

be considered, if “best look” laryngoscopy

and the use of an adjunct such as a bougie

or fiberoptic stylet has failed A change to

a longer, or differently shaped (e.g.,

straight or levering tip) blade may be of

use in selected patients Alternative

device use should consider operator

experience and the likelihood of success

It may be more appropriate to temporize

by proceeding to a rescue EGD in lieu of

using an unfamiliar alternative technique,

when “best look” laryngoscopy has failed

after two or three attempts

D Postintubation care in the elderly

• Successful airway management should

not detract from the recognition that even

with a secured airway, the elderly patient

remains fragile and prone to

cerebrovas-cular and cardiac catastrophe Airway

management is only the first step in

pro-viding the critically ill elderly patient an

opportunity to return to meaningful life

The aging heart, brain, and kidney need

optimal oxygenation and perfusion if

they are to survive

Most aspects of airway management at the

extremes of life are similar to those needed for

the older child and non-elderly adult

How-ever, the clinician must be cognizant of the

anatomic and physiologic differences which

may be encountered, with the resultant need

to prepare for difficulty and adjust drug dosing

appropriately

REFERENCES

1 Patel R, Lenczyk M, Hannallah RS, et al Age and

the onset of desaturation in apnoeic children Can.

2002.

4 Zelicof-Paul A, Smith-Lockridge A, Schnadower D,

et al Controversies in rapid sequence intubation

in children Curr Opin Pediatr 2005;17(3):

355–362.

5 2005 AHA Guidelines for CPR and ECC Part 12.

Pediatric Advanced Life Support Circulation.

7 Goldmann K Recent developments in airway

man-agement of the paediatric patient Curr Opin Anaesthesiol 2006;19(3):278–284.

8 O’Donnell CP, Kamlin CO, Davis PG, et al tracheal intubation attempts during neonatal resus- citation: success rates, duration, and adverse effects.

11 Fisher QA, Tunkel DE Lightwand intubation of

infants and children J Clin Anesth 1997;9(4):

275–279.

12 Bortone L, Ingelmo PM, De Ninno G, et al Randomized controlled trial comparing the laryngeal tube and the laryngeal mask in

pediatric patients Paediatr Anaesth 2006;16(3):

15 Iserson KV Withholding and withdrawing medical

treatment: an emergency medicine perspective.

Ann Emerg Med 1996;28(1):51–54.

16 Birnbaumer D, Marx JA, Hockberger RS, et al The

Elder Patient Rosen’s Emergency Medicine:

Con-cepts and Clinical Practice Vol 5th: CV Mosby;

2002:2485.

17 John AD, Sieber FE Age associated issues:

geri-atrics Anesthesiol Clin North America 2004;22(1):

Chapter 19

Prehospital Airway Management Considerations

• Ensuring scene safety

• Attention to oxygenation, ventilation, andblood pressure

• Recognizing the potential for cervical spineinjury, and taking appropriate precautions

• Being ready for the unexpected, such as iting or seizure

vom-• Ruling out reversible causes of coma, such ashypoglycemia or drug toxicity

• Making decisions about appropriate on-sceneinterventions prior to transport

Without doubt, airway management skillsare necessary in the prehospital setting, withearly support of oxygenation and ventilationfor the acutely ill However, whether this isachieved by bag-mask ventilation (BMV) or tra-cheal intubation depends on a number of fac-tors, including, most immediately, anticipatedtime and type of transport Local EmergencyMedical Services (EMS) jurisdictions may alsohave established algorithms or protocols.The general approach to airway management

in the prehospital environment should follow

the same principles already espoused in this

text Appropriate airway management decisionsrequire consideration of:

Emergency airway management should be

performed by a skilled clinician In this book,

the term “clinician” has included both

physi-cian and nonphysiphysi-cian health-care providers

Depending on the setting, paramedics, nurse

practitioners, and respiratory technicians may

be expected to independently manage patients

with acute airway emergencies As long as they

possess the appropriate knowledge base and

procedural skills, this is entirely appropriate

The practice of airway management should be

defined by educational and competency-based

䉴 Case 19.1

A 20-year-old male was ejected as the result

of a high-speed rollover motor vehicle crash

(MVC), on a rural highway When the

para-medics arrived on the scene, they were faced

with a hypotensive patient who was breathing

spontaneously, but with a Glasgow Coma

Scale (GCS) of 8, and a clenched jaw The

crew had given a “ten minute head’s up”

prior to their arrival at the local emergency

department At that time, they reported vital

signs of BP 90/75, HR 100, RR 20, and SaO 2

98% on a nonrebreathing face mask

Copyright © 2008 by The McGraw-Hill Companies, Inc Click here for terms of use

• Clinician factors (knowledge base, psychomotor

skills, equipment, and the availability of trained

assistants)

• Higher acuity (obtain/maintain an airway,

and/or correction of gas exchange) versus

lower acuity (airway protection and/or

pre-dicted clinical deterioration) indications for

tracheal intubation

• Patient assessment (anatomy, physiology,

cooperation, and time).

䉴CLINICIAN FACTORS

Prehospital care providers with acute airway

management responsibilities should have a

cog-nitive level of understanding comparable to that

of clinicians staffing the emergency department

(ED) They must understand the indications and

contraindications for advanced airway

manage-ment, including tracheal intubation Providers

should be comfortable in performing an airway

assessment and predicting difficulty They

should be able to choose a safe and effective

method to manage the patient’s airway, have

the procedural skills to competently perform it,

and have an approach to difficult situations

The education of prehospital providers must

also be realistic and should reflect their practice

mandate For example, knowledge of

rapid-sequence intubation (RSI) drug pharmacology

should be included only if it is within their scope

of practice Their procedural skill set will be

similarly guided In an ideal world, training

objectives for attaining and maintaining

proce-dural skills in BMV or endotracheal intubation

would be identical for all individuals, regardless

of their professional designation In practice,

for the prehospital provider, the logistics of

attaining and maintaining these competencies

are often difficult, with the practical pressures

of equipment availability, cost, and the sheer

volume of trainees posing a problem Medical

directors must understand these limitations

when designing educational and continuous

quality improvement (CQI) programs, or when

designing protocols for prehospital airwaymanagement providers Pragmatically, NorthAmerican standards of prehospital care ofteninclude a higher level of cognitive and skillstraining in airway management if the providerswork in an air ambulance program, or as part

of a dedicated ground-based critical care port team

trans-䉴PREHOSPITAL INDICATIONS FORADVANCED AIRWAY

MANAGEMENT

“Advanced” airway management in the context

of prehospital practice refers primarily to trachealintubation However, in some EMS settings,advanced airway management involves the use

of an extraglottic device (EGD) such as theCombitube or Laryngeal Mask Airway (LMA) Ingeneral, however, the indications for trachealintubation are as previously discussed in thistext: to obtain or maintain an airway; correctgas exchange, protect the airway against aspi-ration of gastric contents, or for predicted clinicaldeterioration However, it is important to under-stand that each of these indications represents avery different scenario The high acuity, apneic(e.g., cardiac arrest) patient requires an imme-diate, “crash” airway A patient hypoxic fromrespiratory failure due to congestive heartfailure (CHF) may also be higher acuity andrequire tracheal intubation, but can often besafely temporized during transport A headinjured patient with a GCS of 8 and an SaO2

of 98% may well require intubation for airwayprotection, but with less urgency for the interven-tion Predicted clinical deterioration is a similarlylower acuity indication for intubation

䉴PATIENT ASSESSMENT The three components of patient assessmentdiscussed in Chap 11—that is, airway anatomy,system physiology, and patient cooperation arevery relevant to the prehospital provider

However, a fourth variable must be emphasized

in the assessment of the patient in a prehospital

setting, and this is time Simply put, when is it

better to attempt definitive airway management

on the scene, and when is it better to wait?

• The patient described in Case 19–1 clearly

represents a critically ill, head-injured

trauma patient who is hemodynamically

compromised.

• He will be immobilized in a cervical collar

and has clenched teeth, which may make

direct laryngoscopy difficult Conversely, his

patent airway and stable SaO 2 create a lower

acuity need for immediate tracheal

intuba-tion.

• If this patient is relatively close to the trauma

center, then it may be advisable to transport

while monitoring the patient’s spontaneous

ventilations and oxygenation status

• If transport with assisted BMV is required,

attention to good technique is important, to

avoid gastric insufflation Otherwise,

regur-gitation could occur, potentially leading to

aspiration and a difficult mask ventilation

scenario.

• In contrast, if the same patient did not have

clenched teeth, had marginal oxygen

satu-ration (SaO 2 <90%) despite assisted BMV,

and was 40 minutes from a trauma center,

then an intubation attempt could be

con-sidered, if provider skills and protocols

allowed.

In either scenario, both “airway protection”

and “predicted clinical deterioration” are

legiti-mate but lower acuity indications for intubation

However, the chosen approach in the

prehos-pital setting will also be based on the added

issue of transport time A short transport time,

combined with a predicted difficult airway and

a lower acuity indication for intubation, favors

skillful BMV en route to the ED, where

defini-tive airway management can occur Training of

prehospital personnel must thus emphasize that

optimal airway management does not always

equate to tracheal intubation In other words,

the technical imperative of “getting the tube” should not overshadow the outcome impera-

tive of maintaining adequate gas exchange.

TRACHEAL INTUBATION

In general, the choices to facilitate tracheal bation (RSI; non-RSI [i.e., “awake” or deep seda-tion] and 1º surgical) in the prehospital settingare similar to those used in-hospital Realisti-cally, most ground EMS systems are limited bytraining and maintenance of competence issues

intu-to non-RSI intubation choices and/or EGDs such

as the LMA or Combitube.1Non-RSI choices fortracheal intubation span the spectrum from truly

“awake” to an intubation facilitated by deepsedation The dangers of deep sedation to facil-itate intubation are just as relevant in the pre-hospital arena as they are in-hospital In fact,the use of sedative agents to facilitate airwaymanagement in the prehospital setting parallelsthe history of their use in the ED Rightly orwrongly in the prehospital arena, familiarity withusing drugs such as diazepam and morphine inthe context of symptom relief has allowed for agradual acceptance of their use to facilitate intu-bation using deep sedation

Cardiac arrest is the clinical context for up

to two-thirds of all tracheal intubations in a ical ground EMS system.2 For these patients,there is generally no requirement for pharma-cologic adjuncts to facilitate intubation Theremainder of the EMS patient cohort requiringairway management tends to be evenly splitamong respiratory failure, nontraumatic centralnervous system (CNS) conditions, trauma, andshock states In general, helicopter EmergencyMedical Services (HEMS) operations do notrespond to primary cardiac arrest victims and,therefore, deal with a patient population of sim-ilar complexity to that in the ED With thisclearly different patient population, and moremanageable provider numbers, educational

support is more feasible, which in turn has

allowed many HEMS programs to introduce RSI

as a safe management option for use by their

crews

The evidence in the EMS literature supporting

the use of RSI is scant,3,4save for some very specific

circumstances For ground EMS systems, several

well-conducted studies have consistently shown

worsened, or insignificant differences in

out-come in traumatic brain injury patients when

prehospital RSI is used to facilitate endotracheal

intubation.5–8 Head injury was deliberately

chosen in these studies, as previous studies had

suggested that optimal and timely oxygenation

of these patients improved outcomes.9However,

despite the lack of efficacy of RSI demonstrated

in ground-based EMS systems, a distinct pattern

of improved outcomes has in fact emerged in

the subpopulation of those patients where air

medical transport had been utilized.8,10–13 It

would thus appear that the key to improved

outcomes lies in the initial training and maintenance

of competence programs (addressing bothcognitive and procedural skills components) forprehospital providers, with particular attention

to the avoidance of transient hypoxia and/orhyperventilation.14–16

Given this evidence, a well-prepared HEMSprogram could use an approach to tracheal intu-bation algorithm similar to that previouslypresented (see Chap.11, Fig 11–3) in this text

However, a prehospital ground system not using

RSI may require a different approach, as shown

in Fig 19–1

DIFFICULT AIRWAYThe procedural skills required for successfulBMV and laryngoscopy and intubation are thesame for all providers However, the environmentalcontext of the prehospital setting adds an addi-tional layer of complexity to airway management

Figure 19–1 Approach to airway management for prehospital ground systems.

Noncardiac arrest

Patient assessment:

Airway anatomy and physiology transport time

Cardiac arrest

Issues of lighting, weather, scene safety and

location, and the presence of distraught family

members often create unique challenges to the

prehospital care provider

Direct laryngoscopy (DL) remains the most

appropriate approach to tracheal intubation in

the prehospital setting, despite its significant

learning curve Unlike the blind or indirect

visu-alization intubation techniques, DL retains the

advantage of enabling the provider to assess the

oral cavity for presence of foreign material during

the intubation attempt

The approach to the difficult airway in the

prehospital setting is similar to that previously

outlined in this text Difficult tracheal

intuba-tion, once encountered, requires an approach

that employs first attempt “best look”

laryn-goscopy, including the use of external laryngeal

manipulation (ELM) and a bougie A change in

the blade type or length may be useful depending

on the encountered problem The benefit of

repeated attempts at intubation should always

be weighed against the risk of prolonging the

scene time The advisability of proceeding to an

alternative intubation device such as the LMA

Fastrach if laryngoscopic intubation fails is less

clear in the prehospital setting Indeed, failed

intubation in this context might be defined by

two unsuccessful attempts (as opposed to three)

and would usually mean reverting to BMV or an

EGD such as the Combitube or LMA A falling

oxygen saturation after an initial attempt at

laryngoscopy should preclude further attempts

at intubation until the patient’s oxygenation has

been corrected by BMV, EGD or ultimately,

cricothyrotomy

For the paramedic, although the principles

of airway management are the same, the

spec-trum of available equipment may not be as wide

However, prehospital systems considering

an RSI program should have several difficult

airway devices available:

• The bougie is simple, inexpensive, and

proven in the prehospital arena;17 blade

change options should also be available.

• Alternative intubating devices: the LMA

Fas-trach is simple and may provide a reasonableprehospital option;18the Trachlight is a less real-istic option because of skill maintenance issuesand the inability to control environmental light-ing Fiberoptic- or video-based devices may beuseful, but, especially for ground EMS systems,cost often precludes outfitting of entire fleets

• Rescue oxygenation devices: the

Com-bitube has a long track record in prehospitalcare, used as a rescue oxygenation device19

or as a primary airway, especially in the ting of cardiac arrest.20 An LMA can also beused as a primary or rescue device in thissetting.20,21 Newer EGDs such as the KingLTS-D and the LMA ProSeal and Supremelook promising for the prehospital settingdue to their esophageal drainage tubes anddesign features enabling higher ventilatingpressures, if needed However, scientific val-idation of their use in the field is still required

set-• Surgical airway: many EMS systems now

stock needle-guided percutaneous rotomy devices (e.g., the Melker or the PortexPCK), which are relatively simple to use.22Finally, confirmation of correct endotrachealtube (ETT) placement, initially and continu-ously, is vitally important in the chaotic prehos-pital environment, as the consequences of anunrecognized misplaced endotracheal tube arealways devastating The exact number of unrec-ognized esophageal intubations in the prehos-pital setting is uncertain, as many EMS systems

cricothy-do not systematically gather this data Very lowrates are found in systems with specific tubeverification protocols, including end-tidal CO2(ETCO2) monitoring, and ongoing qualityimprovement programs to ensure compliance.23Conversely, unacceptably high rates of esophagealintubation are found when no such protocolsare in place.24

Prehospital care providers can objectivelyconfirm correct placement of the ETT in thesame ways previously discussed in this text:

by visualization of tube going between cords;

use of an ETCO2detector and/or by using a

mechanical esophageal detector device (EDD)

ETCO2verification of correct ETT placement

has become the standard of care in the EMS

arena.25 The limitations of each of these

tech-niques have been previously discussed

Despite the provider’s quiet sigh of relief

fol-lowing ETCO2 detection, it is what has

hap-pened up to the point of successful tracheal

intubation that will determine patient outcome

Tracheal intubation alone will almost never save

a life, unless it has been done without further

compromising the patient’s condition

Irrespec-tive of the setting in which airway management

occurs, attention must be directed throughout

towards the basics of maintaining oxygenation,

ventilation and perfusion

REFERENCES

1 Wang HE, Davis DP, Wayne MA, et al Prehospital

rapid-sequence intubation—what does the

evi-dence show? Proceedings from the 2004 National

Association of EMS Physicians annual meeting

Pre-hosp Emerg Care 2004;8(4):366–377.

2 Wang HE, Kupas DF, Paris PM, et al Preliminary

experience with a prospective, multi-centered

evaluation of out-of-hospital endotracheal

intuba-tion Resuscitaintuba-tion 2003;58(1): 49–58.

3 Gausche M, Lewis RJ, Stratton SJ, et al Effect of

out-of-hospital pediatric endotracheal intubation

on survival and neurological outcome: a controlled

clinical trial JAMA 2000;283(6):783–790.

4 Wang HE, Yealy DM Out-of-hospital rapid sequence

intubation: is this really the “success” we envisioned?

Ann Emerg Med 2002;40(2):168–171.

5 Bochicchio GV, Ilahi O, Joshi M, et al

Endotra-cheal intubation in the field does not improve

out-come in trauma patients who present without an

acutely lethal traumatic brain injury J Trauma.

2003;54(2):307–311.

6 Davis DP, Hoyt DB, Ochs M, et al The effect of

paramedic rapid sequence intubation on outcome

in patients with severe traumatic brain injury.

suc-agents Am J Emerg Med 1998;16(2):125–127.

11 Murphy-Macabobby M, Marshall WJ, Schneider C,

et al Neuromuscular blockade in aeromedical

air-way management Ann Emerg Med 1992;21(6):

13 Slater EA, Weiss SJ, Ernst AA, et al Preflight versus

en route success and complications of rapid sequence intubation in an air medical service.

J Trauma 1998;45(3):588–592.

14 Davis DP, Douglas DJ, Koenig W, et al tilation following aero-medical rapid sequence intubation may be a deliberate response to hypox-

Prehosp Emerg Care 2007;11(1):1–8.

17 Phelan MP, Moscati R, D’Aprix T, et al Paramedic use of the endotracheal tube introducer in a

difficult airway model Prehosp Emerg Care.

2003;7(2):244–246.

18 Swanson ER, Fosnocht DE, Matthews K, et al parison of the intubating laryngeal mask airway versus laryngoscopy in the Bell 206–L3 EMS heli-

Com-copter Air Med J 2004;23(1):36–39.

19 Davis DP, Valentine C, Ochs M, et al The

Com-bitube as a salvage airway device for paramedic

rapid sequence intubation Ann Emerg Med.

2003;42(5):697–704.

20 Rumball CJ, MacDonald D The PTL, Combitube,

laryngeal mask, and oral airway: a randomized

pre-hospital comparative study of ventilatory device

effectiveness and cost-effectiveness in 470 cases of

cardiorespiratory arrest Prehosp Emerg Care.

1997;1(1):1–10.

21 Hulme J, Perkins GD Critically injured patients,

inaccessible airways, and laryngeal mask airways.

Emerg Med J 2005;22(10):742–744.

22 Keane MF, Brinsfield KH, Dyer KS, et al A

labo-ratory comparison of emergency percutaneous

and surgical cricothyrotomy by prehospital

personnel Prehosp Emerg Care 2004;8(4):

424–426.

23 Bozeman WP, Hexter D, Liang HK, et al Esophageal detector device versus detection of end-tidal carbon dioxide level in emergency intu-

bation Ann Emerg Med 1996;27(5):595–599.

24 Katz SH, Falk JL Misplaced endotracheal tubes

by paramedics in an urban emergency medical

services system Ann Emerg Med 2001;37(1):32–37.

25 O’Connor RE, Swor RA Verification of endotracheal tube placement following intubation National Association of EMS Physicians Standards and Clinical

Practice Committee Prehosp Emerg Care 1999;

3(3):248–250.

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exposure had not provided them the nity to encounter difficulty and fully engage thethree principal domains of human performance:psychomotor, cognitive, and affective.3

Historically, the maxim of skills acquisition inmedicine has been “see one, do one, and teachone,”1 often on compromised and vulnerablepatients The shortcomings of this approachare immediately obvious, and include adverseeffects on patient safety In an attempt to addressthis problem, training using human patient simu-lators is becoming increasingly common Indeed,most trainees in airway management techniqueswill begin their skills acquisition on a manikin

or airway simulator of some sort

Unfortunately, psychomotor skills transferfrom simulator to human is hampered by issues

of tissue fidelity Although simulators may beanatomically correct, their “tissues” don’t respond

to manipulation in the same way human tissuedoes Thus, while psychomotor skills acquisition

in airway management can begin in the tion environment, it must then be augmented

FACTORS

From a patient safety standpoint, airway

man-agement is a key determinant of patient

out-come In this book, the emphasis has inevitably

fallen on two main areas: procedural skills, and

the knowledge required to safely secure

an airway Prepared with a comprehensive

knowledge of anatomy, physiology, equipment

options, and pharmacology, tracheal intubation

proceeds as a complex integration of visual,

motor, and haptic (i.e., touch feedback) skills

For the patient, a successful intubation will

be one during which the clinician has avoided

significant error However, for the clinician

(as long as it is recognized), error is a necessary

component of learning any procedure.1Failure

and adversity have the potential to make behavior

more robust and adaptive Indeed, recognizing

that errorless practice is an unrealistic goal, the

term “quality assurance” has been replaced by

“continuous quality improvement” (CQI)

In an unpublished study, investigators queried

novice paramedics on their self-perceived

com-petence in laryngoscopic intubation The

para-medics had performed 5, 10, or 20 tracheal

intubations as part of another study seeking

*Personal communication, Orlando Hung, 2006

Copyright © 2008 by The McGraw-Hill Companies, Inc Click here for terms of use

and reinforced in real patients This in turn

pre-sents logistical (where and when to get the

expe-rience) and ethical (whether elective surgical

patients should bear the brunt of such training)

dilemmas Going forward, there is a

signifi-cant need for training programs using airway

management simulators4 of increased fidelity,

coupled with multimedia presentations5 and

expert instructors

Having said this, good psychomotor skills

may not necessarily translate to improved

patient outcomes Although success in airway

management has historically been measured by

whether “they got the tube,” the occurrence of

process-related adverse events, such as

hypoten-sion, hypoxia, or aspiration, are much more

likely to influence patient outcome Fortunately,

simulation can also provide a valuable venue

for improving cognitive decision making and

addressing contextual issues

Spinal reflexes in a transected cord apart, no

behavioral act can be performed without cognitive

input from the brain The cognitive components

required during the acquisition of procedural skills

are those needed for basic learning processes:

intelligence, alertness, attention, and

concentra-tion However, once the skills have been

acquired and are being maintained, a second

cognitive imperative comes into play—that

asso-ciated with clinical decision-making These skills

are vital in deciding when (or when not) to apply

specific airway management strategies Good

decision-making embraces all aspects of the

clin-ical milieu, and involves reasoning that

mini-mizes the potential for harm to the patient.6The

mode of clinical reasoning is important: it may

be intuitive, rapid, heuristic, and recognition

primed (“System 1”); or more analytical,

delib-erate, reasoned, and deductive (“System 2”).7

Sometimes, the situation might call for a blend of

the two It is important to be aware of the

strengths and limitations of each mode.8

“System 1” reasoning will typically impel thedecision maker reflexively toward what is famil-iar and comfortable; it is the rapid cognitive style

described in the book Blink as “thinking without

thinking.”9It is often algorithmic in nature andmay be achieved through deliberate prepara-tion and rehearsal, in a specific attempt toachieve a stage of “reflexive responsiveness.”Thus, faced with a Cormack-Lehane Grade 3 view,the clinician might “automatically” perform ahead lift (if not contraindicated), external laryn-geal manipulation (ELM) or reach for a bougie.However, without rehearsal and preprogram-ming, this “System 1” type of response may not

be cognitively accessible during times of stress,and the clinician may simply revert to a lowerpattern of untrained behavior: repeated attempts

at direct laryngoscopy

In contrast, stepping back from the immediatepull of the situation to reflect on the wider pic-ture, engage in more analytical thinking, andconsider less obvious consequents is reflective

of “System 2,” and when there is greater tainty, or less predictability, this might be thepreferred course.10 Why did head lift, ELMand the bougie fail? Was it a problem withmanaging the tongue? Would a blade change

uncer-䉴 Case 20.1

Consider a complex patient with a head injury and a Glasgow Coma Score of 8, in a community emergency department The patient was obese, immobilized on a spine board and had significant facial injuries He was hemodynamically stable, with an oxy- gen saturation of 97% Prior to transfer, the attending physician had spoken to a resi- dent at the referral trauma center and had been advised to intubate the patient The attending clinician was a family physician, working alone, whose last tracheal intuba- tion had been performed during a cardiac arrest over a year previously.

be helpful? System 2 decision-making may still

involve reference to an algorithm or

decision-tree, but is less prescribed, requires some degree

of reflection, and the greater use of judgment

Obtaining a colleague for help in a difficult

sit-uation will allow the primary clinician to

emo-tionally and physically “step back” and engage

in this type of thought process

“System 1” thinking (“Glasgow 8, intubate”)

applied to Case 20-1 would not take into account

the complexities of the decisions at hand More

analytical consideration of the risk/benefit ratio

of a relatively inexperienced clinician managing

this patient’s potentially difficult airway, with no

back-up, represents a “System 2” process

Similar considerations apply widely Being

trained to perform a complex act is not an

indi-cation to proceed with it, simply because the

opportunity has arisen In the interest of patient

safety, the benefit of the intervention should

always outweigh the risk of proceeding

Some-times, there is great virtue in reflection, and

recognition of when not to do something:

therein lies the stuff of clinical acumen

The affective state of a clinician refers to his or

her internal emotional milieu Rarely are we in

an affect-neutral state—usually there is a greater

or lesser degree of ongoing confidence, energy,

positivity, hesitation, fear, anger, and negativity

The affective state is highly relevant to both

learning, and subsequent performance in the

clinical arena

• Learning Learning can no sooner proceed

without an appropriate affective state than

it could without cognition With a negative

affect (e.g., that caused by excessive

anxi-ety), or without the desire and motivation

to learn, the learning process is clearly

impoverished and will be adversely

impacted Thus, emotional and cognitive

processes are inextricably related.11

Simulation training has the potential toremove the negative impact of the affectivestate from the learning process Some per-formance anxiety may still occur in a peer-observed situation, or when learning isbeing evaluated, but for the most part theundesirable anxieties of learning on a realpatient have been neutralized The implied

“permission to fail” enables learning to ceed under more optimal conditions

pro-• Clinical Performance The intrinsic

contri-bution of the affective state to the execution

of a psychomotor skill is reflected in theYerkes-Dodson law, which describes theinverted-U relationship between level ofarousal and performance.12Arousal is a phys-iological and psychological state in whichemotion is crucial It raises the level of alert-ness and readiness to act, although too little

or too much can adversely affect performance(Fig 20–1) The corollary of the law is thatthere must exist an optimal level of arousalfor any given task

In the real-life situation, clinician anxietymay result in excessive arousal and com-promised performance For example, during

a rapid-sequence intubation (RSI), a gressively dropping oxygen saturation that

pro-is audibly broadcast to all resuscitation team

Figure 20–1 The Yerkes-Dodson law The relationship between level of arousal and per- formance 12

Arousal

High