Airway Dogmalysis #2: Get Real

A colleague of mine jogged up to me before a course once, rather excitedly, he grabbed my arm and jogged me into the lab to see none other than Fred the Head taped to the bottom of a desk. “Man, we are gonna ‘mess’ with them.” He said with a dubious grin. When asked “why” his reply was a predictable “so we can make it hard, and it will totally mess with their heads.” Mind you, there were still students having trouble with the basic skill of intubation and the process of airway management. After all, they had only been doing it for a couple of weeks. I was perplexed by not only my colleague’s attitude toward the training (almost as if they were not supposed to be successful), but their motivations for training that day seemed centered around anything but enhancing the student’s capability, capacity, or confidence… Since when was it our job as instructors to screw with our students?

The Caveat:

I make one caveat with this type of training situation:  If an instructor sets up the lab with these types of situations to aid in the development of shoot/no shoot (intubate or not intubate) decision making or alternative airway management techniques (SGAs, crics); I 1000% support and encourage this. When they are encouraged to use ALL of their tools (and teammates) to manage an airway they will develop better mental models so that they can respond more effectively to challenging situations in the field. They obviously need the experiences in simulation to develop those decision making skills.

But forcing intubation as the right answer in all of these situations is too much too soon and really it is just the wrong way to go about it. There is no good evidentiary support for no-win, over the top scenario training. McCarthy et al published a paper in the JSOM (Journal of Special Operations Medicine) that highlights how over the top, unrealistic training actually does very little to build the student’s capability or capacity for a skill. In fact, it can do just the opposite or worse. Worse would be the student is now the primary operator attempting to intubate a patient when it is either not safe for them or the patient, because that’s how they were taught. Keep it simple, reinforce good habits, and don’t botch the debrief. But don’t take it too far the other direction where the focus is on fun and entertainment. The same problems exists there… just because they enjoyed it does not mean they are walking away with an improved skill set.

Training should be tough and challenging, for everyone, otherwise it is just skills demonstration that offers little (if any) value to the trainee. The training should be hard enough to expose the weaknesses in the operator’s skill set, followed by a deep and thorough debrief, followed by enough reps to train out the mistakes or poor mental models. But beware of taking it too far over the top with stressors and simulation fidelity. This leads to frustration and anxiety instead of confidence and capacity for the skill. Stress is good in training, but it has to be applied intentionally (i.e. with a good reason) and carefully (so as to avoid triggering anxiety and maladaptive stress responses). It also has to be applied at the right time in the student’s development. A novice intubator has little to gain from being stressed out by lights, fog, and a confined space within which to operate if they cannot perform the basic skills basically well. There is a step-wise approach to this that the military uses to great effect called: crawl, walk, run. The student is taken through progressively complex iterations of training, only advancing once they have met the standard of the lower level training.

As an instructor, you have to ask yourself a few things when you are setting up these simulations/scenarios:

•   Have I seen this situation in real life? (Do I have a meaningful lesson learned to offer the students as a result)
•   Would I make this same decision in the field? (Would I do what I am forcing them to do in this training event in real life)
•   What, specifically, do they need to walk away with from this training? (Why are they doing this event)

Asking these questions will keep the instructor and the training grounded in reality and ensures that the student actually benefits from the training. Again, I do advocate for the shoot/no shoot type of decision making puzzles for students, but I would work to avoid putting the student into a situation where they are funneled to an inevitable intubation in a situation that falls outside the realm of realism. If you are on the fence about it, bounce ideas off of fellow instructors and see what they say and ask them what decision they would make.

My good buddy and I discuss this and other topics in this episode of the Alert Medic 1 Podcast:

Horn GT, Bowling F, Lowe DE, Parimore JG, Stagliano DR, Studer NM. Manikin Human-Patient Simulator Training. J Spec Oper Med. 2017 Summer;17(2):89-95. doi: 10.55460/0SE6-Q7TF. PMID: 28599039.

Petersen CD, Rush SC, Gallo I, Dalere B, Staak BP, Moore L, Kerr W, Chandler M, Smith W. Optimization of Simulation and Moulage in Military-Related Medical Training. J Spec Oper Med. 2017 Fall;17(3):74-80. doi: 10.55460/X6BB-TZ0C. PMID: 28910473.

McCarthy J, Lauria MJ, Fisher AD. A Lost Opportunity: The Use of Unorthodox Training Methods for Prehospital Trauma Care. J Spec Oper Med. 2022 Sep 19;22(3):29-35. doi: 10.55460/AQU3-F0UP. PMID: 35862849.