Abstract
Performing a stressful task under pressure is challenging. Strategies to optimise our training must focus on learning a skill correctly, and then practising that skill deliberately to avoid compromising that performance in the cauldron of the clinical environment. This chapter discusses ways of learning and training better: the techniques are based on practical strategies employed in anaesthesia, but developed primarily from practical cognitive psychology, elite sport and the military. It involves taking a skill, practising it until it becomes a habit and over time making it part of normal behaviour. The philosophy is simple (but difficult to apply): control what you can control and always do your best. The best summary of this strategy is: learn it right, practise it right, perform it right.
Basic Principles
Control what you can
Learn it right
Practise it right
Perform it right
You are called to intensive care to assist with a patient who has been extubated prematurely. Before admission the patient was known to be a difficult intubation. You are faced with a severely hypoxic patient that your colleague (despite being intimately associated with the difficult airway guidelines) is unable to oxygenate. You wonder if you had approached your airway training differently 10 years before whether your management and skills in this case would have been different.
‘In theory, there is no difference between theory and practice. In practice, there is.’
Airway skills at their simplest are designed to ensure delivery of oxygen from a source to the patient’s lungs. The skills discussed below are theoretically easy to perform, but because of time constraints and the effect of stress caused by the significant effect of hypoxia on a patient, these skills may not be performed at their best, and a very high level of skill performance is required to optimally manage your patient during a crisis.
In order to learn any skill, it is useful to understand, to an extent, how our mind work, in terms of learning, teaching and performance. If we consider the limitations of working memory to be of the order of approximately four components or blocks of information then the learning, practice and performance of a skill needs to be focussed on not overloading the working memory.
The simplest model of the mind (from an idea by Willingham, see Figure 35.1) considers the working memory as a bottle neck between the skill you are trying to learn, teach or perform and your long-term memory. Long-term memory is huge but in order for it to be useful in any given attempt at performance of the skill, it is important that the skill that is being learnt is taught properly (i.e. learn it right), is practised properly (i.e. practise it right), so that ultimately it can be performed correctly (i.e. perform it right). In order to achieve this, it is important to focus on learning what has been called the inflexible content or inflexible knowledge of whatever one is trying to learn. The relevant inflexible content needs to be carefully considered, particularly in the arena of teaching airway skills, because of the significant negative effect of stress on the performance of that basic skill.
If we consider a systematic approach to solving the problem of which airway skills should be learnt and how to learn them, it is useful to consider five prescriptive principles as described by Merrill in 2002:
1. Learners are engaged in performing real-life tasks or solving real-world problems (the practice is context-specific training)
2. Existing knowledge is activated as a foundation for new knowledge (draw on what the learner already knows)
3. New knowledge is demonstrated to the learner (coaching)
4. New knowledge is applied by the learner (deliberate practice)
5. New knowledge is integrated into the learner’s world (the learner moves from practice to performance)
In this fashion, the learner moves from learning to practice to practice under pressure to performance to performance under pressure. Making training real enhances the likelihood of the performance being successful. In view of the potential overload on the working memory it can be useful to divide the learning of a skill into learning a series of subskills.
Ergonomics (See Figure 35.2)
For each of the various airway skills discussed, the importance of considering ergonomics is part of successful outcome, e.g. position for laryngoscopy or face mask anaesthesia, performing an awake flexible optic intubation etc. Additionally, as Ericsson states (see Further Reading) the principles of deliberate practice will lead to improved performance.
Figure 35.2 Ergonomics of awake flexible optical bronchoscope (FOB)-guided intubation.
Principles of Deliberate Practice
1. Establish a (reachable) specific goal. Vague overall performance targets like ‘succeed’ or ‘get better’ won’t cut it.
2. Focus on improvement during practice. It must be intense, uninterrupted and repetitive (‘drilling’). Not particularly pleasant, but highly rewarding.
3. You must receive immediate feedback on your performance. Without it, you cannot figure out what you need to modify or how close you are to achieving your specific goal.
4. You must get out of your comfort zone, constantly attempting things that are just out of reach.
5. It is arduous cognitively and physically (Figure 35.3).
Figure 35.3 Demonstrating flexible optical bronchoscope (FOB) set-up using an iPad as a monitor. To enhance the stress on performance and evaluate situation awareness while focussed on an FOB-guided intubation. A similar technique can be used for other airway skills, but care should be taken if used for the cannot intubate, cannot oxygenate situation.
Which Airway Skills Should Be Learnt?
Ideally one would like to focus on becoming competent moving to mastery with the aim of becoming an expert over years of practice in the following skills. It is unrealistic to expect to become an expert in all airway skills, but certain skills have a higher priority.
Assessment and planning airway management
Maintenance of the airway and anaesthesia with bag valve mask
Supraglottic airway insertion
Laryngoscopy (both direct and video) and tracheal tube insertion
Flexible optic intubation
Extubation
With additional training for one rescue technique for the cannot intubate, cannot oxygenate situation (see current Difficult Airway Society (DAS) material for a worked example).
Specific more complex techniques (e.g. jet ventilation) should only be used by clinicians who are experienced in those techniques. Additionally, the introduction of an awareness of human factors (decision making, communication, stress management, situation awareness, fixation error) can be introduced as part of real-life task training and learning, once the basic skill is mastered.
If we look at learning these skills it becomes obvious that there are more than four components of information that need to be learned to fit into that working memory box. It is useful to divide the skills themselves into subskills and structure the learning material in such a way that you maximise the function of the working memory model.
Specific Inflexible Components for the Following Components of Airway Skills: Assessment
Assessment of the airway is important because it determines what specific airway skill is likely to be successful. There are a variety of assessment techniques: Mallampati, neck movement, Wilson, thyromental distance (see Chapter 5) – these are used in order to plan and decide which particular airway technique can or should be used, and what the relevant backup plans are (see Chapter 4). The complexity of this planning, appropriate decision making and performance is also important to address and should be simplified wherever possible (e.g. the Vortex approach). These decisions are important because if you start a procedure with the wrong decision leading to the wrong technique, it does not matter how skilful the individual is, the success of the airway procedure is likely to be compromised.
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