If you read this all the way to the bottom you are either going to be really appreciative or really upset with me. You will find that there is no link to a store that is selling a silver bullet solution that promises to enhance your patient outcomes in airway management and/or reduce the risk of the procedure in the prehospital environment.
I can guarantee you that 100% of your organizations already own everything you need to achieve this goal and implement the changes that will enable the best possible outcomes (within the right contexts). The most difficult change that will need to occur is a shift in mindset of how your organization will approach airway management moving forward.
SPOILER ALERT: this is easily one of the most difficult aspects of airway management. Influencing individual clinicians to alter their approach to anything, and particularly in airway management, is exponentially difficult…but it can be done. Attacking mindsets is key. Notice that I said attack mindsets, not people, not behaviors…mindsets. The mindset is key. Mindsets are FREE! They cost the organization nothing to change, but easily it is the most difficult thing to change. You will not policy or discipline your way to outstanding clinical results.
Successful airway management in prehospital medicine begins and ends with organizational culture. Culture is what leads when the boss isn’t looking, and a great organizational culture is like having 300 extra supervisors that you do not have to pay for. It is not policies or guidelines, believe it or not. Let’s focus for this first part on just that: organizational culture surrounding airway management.
ACTIONS follow MINDSETS
Better mindsets lead to more effective actions.
Tim Kite lays this out very nicely (in my opinion). For those who do not know, Tim Kite was the brainchild behind the culture shift at Ohio State University (pardon me: THE Ohio State University) when he partnered with then Coach Urban Meyer in 2014. We all witnessed what a dramatic shift in the culture did for that team. Check out Coach Meyer’s book Above the Line for a deeper dive on that season.
The core of that culture shift was all about mindset, and one that is easily extrapolated to shifting the mindset of our clinicians:
Belief → Behavior → Outcome
What we believe about our team, a concept, our abilities, etc. determines our actions (how we behave), and the actions we take (good and bad) determine the outcome. The stronger the belief, the more consistent the performance over time, and the harder it will be to modify that behavior as a leader.
In the absence of quality education, supported by evidence, a mindset shift in airway management will likely not happen. If the education cannot modify what they currently believe about how they execute on it, you will waste your time chasing an outcome that is inevitably unobtainable.
Suppose the education piece is squared away, but the quality improvement piece is not there. In that case, you will have individuals operating under a false sense of security and likely an inflated belief about their capabilities. Clinicians need the feedback in order to reach their peak operational capacity. Expert feedback provided soon after the encounter is key and essential to a clinician learning what they need to learn about the encounter and modifying their approach as needed.
Anders Ericsson in his book Peak talks about the expert feedback being the key element in performance improvement in any endeavor, especially in medicine. Debriefs that unpack the performance and decisions that were made are a cornerstone in improving the airway management program in your organization. Clinicians need to know what needs to be fixed or how to make a better decision as well as the aspects of the encounter that went well.
Tools, Tactics, and Concepts
“The man who grasps principles can select his own methods. The man who tries methods, ignoring principles, is sure to have trouble.”
– Harrington Emerson
Beware of building a clinician’s mindset about airway management around a tool or technique. Doing so in the absence of providing them with the appropriate context and concepts is a sure way to end up chasing your tail as a clinical leader. Education in airway management must focus on core concepts and principles that have real influence on patient outcomes. It must not be built around a tool.
Building methods and tactics around concepts (preoxygenation, resuscitate before you intubate, etc), will most assuredly provide your clinicians with a plethora of tools from which they can choose and influence outcomes. Building methods and concepts around tactics and tools will create unforeseen holes in their education which will become evident in their actions.
This goes back to the belief, behavior, outcome model. If the education does not correctly influence their belief about what they do, the necessary behaviors will not manifest at the bedside, and the desired outcome will elude them. When clinicians are trained in a method or a tactic that revolves around a single tool, they will operate with the belief that success and/or failure in the procedure will hinge on that tool. This is how organizations can accidentally engineer a single point of failure into their processes that may likely be the crux of their airway management outcome issues.
Conclusion
There are no silver bullets in airway management. If there were, organizations would already own them and the morbidity and mortality in prehospital airway management would have evaporated already.
A solid airway management program begins with solid clinical leadership. The kind of leadership that trains and builds the beliefs that drive the actions/behaviors that generate the best possible outcome in a given set of circumstances. Organizations cannot order a great clinical culture from a medical device distributor, they have to be engineered and built in house and then attached to the hearts and minds of the individual operators that are out on the bloody edge of prehospital medicine.
