A respiratory arrest occurs in the intermediate care unit on the surgical ward. The patient is an elderly man in a cervical halo, 3 days after admission and following a motor vehicle crash. Soon after a “code-blue” is called overhead to which both the intensive care unit (ICU) resident and the anesthesia resident respond. Upon arrival, a large number of other health care providers are crowded into the room, including many medical students who were receiving a lecture nearby. The noise level is high, and it is impossible to hear anyone calling out instructions. It is also impossible to tell if someone is leading the resuscitation or preparing for intubation.

Two nurses are taking turns performing chest compressions and a respiratory therapist is performing appropriately slow bag-mask-ventilation. The anesthesia resident goes to the head of the bed. He starts making suggestions: “perhaps we could intubate”; “maybe it’s time for others to take over compressions”; and “I think someone needs to lead this resuscitation.” Unfortunately, nobody picks up on his initial polite hints. As such, he believes he has tried but there is no point trying again. He subsequently becomes silent, and stands at the head of the bed silently hoping somebody will hand him a laryngoscope and an endotracheal tube. The ICU resident goes to the patient’s right groin to insert a central line and shouts for “someone,” “anyone” to get him “the damn equipment.” He is angry when nobody does and starts berating the others for being “lousy teammates.”

A surgical resident arrives at this point and asks if the patient might have a postoperative pulmonary embolus and whether there are contraindications to thrombolysis. He announces that if the patient survives they ought to get “a 12-lead ECG and a bedside echo,” and then he walks away. Meanwhile the nurses performing chest compressions have become exhausted but do not know how to ask for relief. As such they cease compressions and it is 30 seconds before another person takes over.

The anesthesia resident uses this pause in chest compressions to attempt tracheal intubation, but fails. He does not know if anyone has airway skills, so he tries four more times before causing airway bleeding and hence returns to bag-mask-ventilation. The patient has been without a pulse now for 45 minutes. A nurse suggests calling the ICU attending physician. She arrives and finds a Do-Not-Resuscitate order on the chart. At this point resuscitative efforts are ceased and the patient is declared dead. While several of the team members try to leave stating: “well, he was a DNR so it doesn’t matter,” the attending/consultant insists they remain for an immediate debrief. She states that the crisis management skills, and especially the communication skills need to be improved. They agree, but when they request specifics, the intensivist is unsure what to say.

Why Dedicate a Chapter to Communication Skills in the Difficult and Failed Airway?

The above case includes several clinical errors. However, as correctly pointed out by the attending intensivist, the crisis management skills, and especially the communication, were especially poor. In another high-stakes industry, namely aviation, pilots can summarize their job as: “navigate, aviate, and communicate.”¹ Pilots could also argue that they “fly by voice.” All of these suggest that planes are flown as much by communication as by the plane’s controls and instruments.^1–4 Accordingly, airway practitioners managing difficult and failed airways should perhaps learn to “oxygenate; ventilate; communicate” and to “resuscitate by voice.”^2,3 This is because of all the human factor and crisis management skills, the most important appears to be communication.^2–6

This chapter supplements the discussion of human factors and teamwork outlined in Chapter 6. This is because if communication means to “share, join, unite, or make understanding common,”² then, much of what it means to create a good airway team, or is to become a good team communicator.^2–4 However, just as teamwork does not come naturally nor does communication in crisis situations.^2–15 For these reasons, this chapter will focus on practical communication skills that can be applied to the difficult and failed airway. Readers are strongly encouraged to read widely given the importance of this topic. They should also accept that being an expert airway practitioner includes being an expert communicator.^2–4

Many of the ideas contained within this chapter are not native to medicine (or to this author). Instead, as in Chapter 6, these ideas have been translated from other high-consequence low-tolerance professions; most notably aviation. As previously stated, we should not overdo the comparison between aviation and acute care medicine. After all, whereas planes may not take off during significantly inclement weather, the failed airway forces practitioners to routinely “fly into the storm.” However, poor cockpit communication—especially between junior and senior crew—has long been understood to be one of the commonest reasons why mechanically sound planes crash.^3–5 This is mirrored in acute medical crisis (such as the difficult and failed airway) where poor communication is one of the commonest reasons for preventable medical error and preventable death.^3–9 The difference is that medicine has only recently embraced deliberate communication instruction. This chapter is part of a long overdue catch up, and an effort to move beyond terror or hubris when it comes to the difficult and failed airway.

What Are the Basics of Communication Success and Communication Error?

Our communication shortfalls can be neatly summarized using a quote from Rall and Gaba⁶: “Meant is not said; said is not heard; heard is not understood; understood is not done.” However, it is also important not to oversimplify something as complex as communication. The first insight is that communication is more than just talking. Good communication is a key therapy that aids (or impairs) task execution, bolsters (or stalls) information exchange, and helps (or hinders) relationship building.^2–4 Communication is also more than just what is said. It also includes how it is said and how it is understood.² As a result, nonverbal communication (which includes posture, facial expressions, gestures, and eye contact), as well as paraverbal communication (which includes pacing, tone, volume, and emphasis) are at least as important as verbal communication.^2,3

Understanding communication as verbal, paraverbal, and nonverbal is especially important if there is incongruence between the words used and the facial expression or the tone.^2–4 For example, if we say: “I don’t need your help with this intubation” but in a tone that suggests otherwise then listeners are likely to downplay the verbal in favor of the nonverbal. Alternatively, they may base their response upon prior interactions (i.e., “he never wants help from anyone … no matter what he says”). As such, we need to “say what we mean and mean what we say.” At best, incongruence can increase misinterpretation, at worst it erodes teamwork.^2–4 Congruence is even more important when those involved are unfamiliar, or when the medical situation is novel.^2–4 In addition, practitioners should understand that we really cannot afford to not communicate. Failing to say anything can also send its own unintended message. For example, silence can be variously misinterpreted as lack of concern, unwillingness to work with others or assent.

Aviation made flattening the authority-gradient a priority.⁵ A practical strategy is to teach and model more “horizontal communication.”^2–3 This means that all members of the team are authorized—in fact obligated—to speak up, and to do so clearly, regardless of rank.⁵ Moreover, aviation has mandated “transmitter-orientated” communication (where it is the speaker’s responsibility to be understood), rather than “receiver-orientated” communication (where it is the listener’s responsibility to unravel what was meant).⁵ However, making communication more deliberate means that we also promote active listening.² This requires that we confirm understanding and demand clarification, regardless of seniority or embarrassment. All team members take responsibility for how messages are delivered, received, understood, and carried out.^2–5,8

If we compare communication to a drug, it would be understood to be one of our most potent “therapies.” Similarly, like a drug, communication is not one-size-fits-all, nor a panacea. Like a drug, it should be used in the right dosage at the right time and tailored to the patient’s needs. Like a drug, communication can also be either a “placebo” (i.e., good communication makes things better) or “nocebo” (i.e., bad communication makes things worse).^2–3 Better communication might also decrease litigation and maintain a hospital’s reputation. Regardless, communication is everybody’s business: it should be taught to trainees, expected from practitioners, and supported by administration.^2–4,11

What Are Some Relevant Communication Models, and How Could They be Adapted to the Difficult and Failed Airway?

Shannon and Weaver, working for Bell Laboratories, developed a model for verbal telephone communication. It can still be applied to medicine, decades on.² Simply put, transmitters (i.e., speakers) encode messages, and receivers (i.e., listeners) decode them. However, both must be on the same channel (which in medicine could mean possessing similar situational awareness and emotional states), and there should be minimal interference (which in airway management could mean minimizing chaos, stress, or cognitive bias). They also identified the danger of “channel-overload” (which in airway management warns against communication that is unnecessarily complex). Overload, which often results in indecision, also occurs unless the receiver can filter data into usable information. The practical point is that a skilled practitioner will receive data (“his oxygen saturation is dropping despite bag-mask-ventilation”), but be able to turn this into usable information (“we have a failed airway”).²

Shannon’s communication model has limitations. For example, complex communication also requires meaning (i.e., “we need to do a surgical airway”). Meaning is harder to encode, transmit, and decode, which is why we cannot assume that coworkers have reached the same conclusions as us.² Shannon’s model also describes communication as unidirectional (transmitter to receiver), while medical decision-making is commonly multidirectional, across disciplines and across hierarchies.^2–4,11 Location (i.e., a noisy operating theater or trauma bay) ought not to affect data transmission, but it does affect communication quality, impact, and efficiency. For example, when transmitter and receiver are no longer face-to-face our communication loses important nonverbal cues.² This is why communication while wearing masks is important to practice. It is also why confirming understanding by routinely summarizing and repeating back is an important fail-safe.^2–4,11