In my own career and from watching hundreds of colleagues, residents, and other clinical staff, I am convinced that job performance, competence, and satisfaction are intertwined. The clinicians who are the most competent are the most content, the most calm under fire, and the best at communicating with patients and coworkers. They have made peace with the job and its demands—and it reflects in all of their interactions. It shows on their face and in every aspect of their practice.
Through 20 years of monthly cadaveric courses focused on airway procedural education, I now know that “expertise” is not an accident. Being good at a task comes through practice and, more important, through mastering an incrementalized, engineered approach to the task. “Incrementalization” is a term I use to describe breaking down complex tasks into smaller tasks. Especially under stressful situations, it is critical that operators approach complex tasks in small, well-rehearsed, well-designed steps. The steps must be achievable (operators envision themselves successfully completing each step) and believable (operators believe the steps will work). Our procedures should be “engineered”—designed step-wise—to maximize success, patient safety, and operator confidence.
In my previous Airway columns, I have advocated a step-wise approach to oxygenation, laryngoscopy, and the emergent surgical airway. I now embrace an equally incrementalized approach to every procedure I perform, including even routine ones that I used to take for granted. I engineer the tiny steps of suturing the vermillion border in a ketamized child—how I hold instruments, rest my hands and elbows, and use loupes. (You don’t use loupes? How many plastic surgeons have you seen not use loupes?)
I take a similarly detailed approached to cardioversion: position the patient’s head to 40–45 degrees; provide nasal oxygenation; divide propofol into four syringes of 50 mg each (never in a single syringe); talk to the patients while slowly administering the drug, squeezing the chest as they relax (note: towels are placed over anterior chest pads).
The Cunningham Technique
A few years ago—before my “conversion” to incrementalization—I heard about the Cunningham technique.1 This remarkable drug-free approach to anterior shoulder reduction by a single operator was developed by Australian physician Neil Cunningham, MBBS. There are some great videos on YouTube showing the procedure.
My initial success with the technique was marginal, however, and even though it has become widely known, many clinicians have reported mixed results to me.
My performance success with the Cunningham technique changed markedly after incrementalizing the procedure. I now usually perform it with a nurse or ED technician as an assistant.
Here’s my two-person incrementalized Cunningham technique (see Figure 1):