Too much time is dedicated to the acquisition of technique and too little to the preparation of the individual for participation.
–Bruce Lee, martial artist, actor, director
Explore This IssueACEP Now: Vol 33 – No 06 – June 2014
The probability that the total system will perform correctly is the probability that the hardware/ software will perform correctly, times the probability that the operating environment will not degrade the system operation, times the probability that the user will perform correctly. By defining total system this way, human performance is identified as a component of the system.
–FAA System Safety Handbook, Chapter 17: Human Factors Principles & Practices (2000)
In many instances, the “difficult airway” is a relative term—relative to the operator. Early in my career, I recall missing an intubation. I panicked and called an anesthesiologist. Picking up the same instrument, she inserted the tracheal tube without difficulty. It would have made me feel much better if she struggled with the tube, but alas, she made it look easy. For some time, I wondered what I did wrong and what she did right.
Twenty years later, I was able to successfully intubate a patient in whom anesthesia missed the tube. The patient was shot in the central box; anesthesia had placed a tube, but by direct visualization of the lungs (thoracotomy in progress), it was clear the tube was not in the trachea. I picked up the same laryngoscope, came down the tongue, suctioned the mouth, identified the epiglottis, and intubated the patient as if it were easy.
Looking back on my multidecade obsession with the techniques of airway management, I realize in hindsight how much the individual’s mindset is critical to successful performance in crisis.
Proper techniques are essential: patient positioning, the mechanics of mouth opening, epiglottoscopy (finding the epiglottis before making any attempt to expose the larynx), understanding the subtleties of epiglottis elevation, knowing laryngeal anatomy (even when partially viewed), and the nuances of tube insertion.
The operator’s mindset, however, is what allows for the proper application of techniques in the moment of crisis. It is one thing to know how something should be done but quite another to actually then pull it off in the real life-and-death, high-pressure situation. Related to the ultimate stress—fear—the Spartan commander Brasidas observed: “Fear makes men forget, and skill which cannot fight is useless.”
Fear Is the Mind Killer
We each have a genetic disposition to handle stress. Looking back at my initial years in emergency medicine, I now understand that my inherent adrenaline response made it very difficult for me to perform well. I got too stressed, and the adrenaline dump that ensued made it very difficult for me.