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Anyone Can Intubate
or Not
Teaching & Learning Airway
Management the Antifragile Way
George Kovacs MD MHPE FRCPC
Professor...
2
@kovacsgj
AIMEairway.ca
4
5
6
355
Anyone Can Intubate!!
16
Successful Airway
Management
First Pass
Success
Success…
• 90 % FPS
• >90 % sat
• >90 mm Hg
• <90 sec
Becoming Successful
Competence
Context
Confidence
Conscientiousness
Competence
Context
Confidence
Conscientiousness
Avoiding Failure ?
Competence
Program
Practice
Feedback
Competence/Performance
Do
Show how
Know how
Know
Miller GE. The assessment of clinical skills/competence/performance. Acad...
Does
Competence
Performance
How Much Practice
“The greats weren’t great cause at birth they
could paint. The greats were great cause they
painted a lot.”
Practice- How often?
Math 101
• Owning the airway?
Math 101
• 75,000 Patient visits
• 500 ETI’s/year
• 9 shifts/day
• 15 shifts/month
• 2-3 resusc area/month
• How many tube...
during laryngoscopy is supported by the findings of
Nouruzi-Sedeh et al., who found that the main diffi-
culty for novices w...
The pursuit & consequence
of the search for easy…
1stAttemptSuccessRates
0
25
50
75
100
Sackles 2011 Mosier 2013 Kory 2013 Michalideu 2014 Lee 2014 Silverberg 2014 Sakles 2...
1stAttemptSuccessRates
0
25
50
75
100
Sackles 2011 Mosier 2013 Kory 2013 Michalideu 2014 Lee 2014 Silverberg 2014 Sakles 2...
Tell me what you see?
Do you see the posterior
cartridges?
Competence
Context
Confidence
Conscientiousness
Context: materials
5 Faces
Context
7,000,000,000
43
High Acuity Low Opportunity
Challenge
Petrosoniak & Hicks. Current opinion in Anaesthesiology. 2013
High Acuity
Low Opport...
Opportunities… Overlearn
Opportunities… Overlearn
Context: environment
High
Stakes
These are your vitals
Times of stress
Challenge Threat
Grossman & Christensen. On Combat 2008
Don’t avoid failure
…be antifragile
High Acuity Low Opportunity
Challenge
Petrosoniak & Hicks. Current opinion in Anaesthesiology. 2013
High Acuity
Low Opport...
System 1 training
Learn as Many/Execute as 1
Incrementalization
8
- The “secret “ of competence in crisis is to break down...
System 1 training:
Avoid Insanity
I can’t see %$^&!!!
System 1 training:
Cued Response
• Epiglottoscopy
• Valleculoscopy
• Laryngoscopy
• Intubation
AIMEairway.ca: SMACC Byte- ...
Cued Response:
Psychomotor rehearsal
EVLI
Learn as Many/Execute as 1
Best Look DL&I
Cued Response:
Psychomotor rehearsal
Learn as Many/Execute as 1
Competence
Context
Confidence
Conscientiousness
Confidence
“we all got plans, til you get
punched in the mouth”
Confidence
Number Needed to be…
Confident
Confidence
Experience
Confidence
Good judgment is the
result of experience and
experience the result of
bad judgment
Conscientiousness
Competence
Confidence
Context
64
… work ethically
Conscientiousness
It’s not about you
Its about the patient
67
Conscientiousness
… work ethic
68
Conscientiousness
… work ethic
69
Conscientiousness
Doing
Knowing
… work ethic
Plan A
Plan CPlan B
Airway Tool Box
Do
Know
Plan A
Plan CPlan B
Airway Tool Box
Do
Know
Fear of Failure
Competence
Context
Confidence
Conscientiousness
Anybody can intubate
Anybody can intubate
Competence
Context
Confidence
Conscientiousness
Anyone can intubate
Thank You
Anyone Can Intubate, or Not: Teaching airway skills the antifragile way
Anyone Can Intubate, or Not: Teaching airway skills the antifragile way
Anyone Can Intubate, or Not: Teaching airway skills the antifragile way
Anyone Can Intubate, or Not: Teaching airway skills the antifragile way
Anyone Can Intubate, or Not: Teaching airway skills the antifragile way
Anyone Can Intubate, or Not: Teaching airway skills the antifragile way
Anyone Can Intubate, or Not: Teaching airway skills the antifragile way
Anyone Can Intubate, or Not: Teaching airway skills the antifragile way
Anyone Can Intubate, or Not: Teaching airway skills the antifragile way
Anyone Can Intubate, or Not: Teaching airway skills the antifragile way
Anyone Can Intubate, or Not: Teaching airway skills the antifragile way
Anyone Can Intubate, or Not: Teaching airway skills the antifragile way
Anyone Can Intubate, or Not: Teaching airway skills the antifragile way
Anyone Can Intubate, or Not: Teaching airway skills the antifragile way
Anyone Can Intubate, or Not: Teaching airway skills the antifragile way
Anyone Can Intubate, or Not: Teaching airway skills the antifragile way
Anyone Can Intubate, or Not: Teaching airway skills the antifragile way
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Anyone Can Intubate, or Not: Teaching airway skills the antifragile way

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Becoming competent in airway management requires good decision making and and technical skills. Ultimately what matters is how your clinical performance impacts patient outcomes. For this we need to have a clear understanding of what defines success ensuring that its more than just 'getting the tube'. Come to this talk and you'll experience a Canadian take on Guinness, adventure sports, flying a plane and how other factors including failure influence airway management outcomes.

Published in: Health & Medicine

Anyone Can Intubate, or Not: Teaching airway skills the antifragile way

  1. 1. Anyone Can Intubate or Not Teaching & Learning Airway Management the Antifragile Way George Kovacs MD MHPE FRCPC Professor, Departments of Emergency Medicine, Anaesthesia Medical Neuroscience & Division of Medical Education Dalhousie University, Halifax Nova Scotia gkovacs@dal.ca @kovacsgj AIMEairway.ca
  2. 2. 2 @kovacsgj AIMEairway.ca
  3. 3. 4
  4. 4. 5
  5. 5. 6
  6. 6. 355
  7. 7. Anyone Can Intubate!!
  8. 8. 16 Successful Airway Management
  9. 9. First Pass Success
  10. 10. Success… • 90 % FPS • >90 % sat • >90 mm Hg • <90 sec
  11. 11. Becoming Successful Competence Context Confidence Conscientiousness
  12. 12. Competence Context Confidence Conscientiousness Avoiding Failure ?
  13. 13. Competence Program Practice Feedback
  14. 14. Competence/Performance Do Show how Know how Know Miller GE. The assessment of clinical skills/competence/performance. Acad Med.1990
  15. 15. Does Competence Performance
  16. 16. How Much Practice
  17. 17. “The greats weren’t great cause at birth they could paint. The greats were great cause they painted a lot.”
  18. 18. Practice- How often?
  19. 19. Math 101 • Owning the airway?
  20. 20. Math 101 • 75,000 Patient visits • 500 ETI’s/year • 9 shifts/day • 15 shifts/month • 2-3 resusc area/month • How many tubes?
  21. 21. during laryngoscopy is supported by the findings of Nouruzi-Sedeh et al., who found that the main diffi- culty for novices was in obtaining a good laryngeal view within 120 s [12]. In addition, Aziz et al. found a 65% incidence of failure involving inadequate laryngeal views in a observational study of 2004 GlideScope intubations [23]. The findings of this study are limited in that it includes a small number of individuals in a single institution, with the possibility that the findings may not generalise to other institutions. However, the large number of intubations studied, the statistical homoge- neity of subjects/case difficulty and the gradual pro- 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 0 20 40 60 80 100 Probabilityofoptimalintubation Experience Figure 1 The probability of optimal intubation pre- dicted by mixed-effects logistic regression model. Cortellazzi et al. | GlideScopeâ tracheal intubation expertise Anaesthesia 2014 75? >100? Resuscitation xxx (2015) xxx–xxx Contents lists available at ScienceDirect Resuscitation journal homepage: www.elsevier.com/locate/resuscitation Review article Defining the learning curve for endotracheal intubation using direct laryngoscopy: A systematic reviewଝ,ଝଝ Maria L. Buis∗Q1 , Iscander M. Maissan, Sanne E. Hoeks, Markus Klimek, Robert J. Stolker Department of Anaesthesiology, Erasmus University Medical Centre, Office H-1286, ’s-Gravendijkwal 230, 3015 CE Rotterdam, The NetherlandsQ2 a r t i c l e i n f o Article history: Received 31 July 2015 Received in revised form 4 November 2015 Accepted 11 November 2015 Keywords: Learning curve Direct laryngoscopy Intubation a b s t r a c t More than two failed intubation attempts and failed endotracheal intubations (ETIs) are associated with severe complications and death. The aim of this review was to determine the number of ETIs a health care provider in training needs to perform to achieve proficiency within two attempts. A systematic search of the literature was conducted covering the time frame of January 1990 through July 2014. We identified 13 studies with a total of 1462 students who had attempted to intubate 19,108 patients. This review shows that in mostly elective circumstances, at least 50 ETIs with no more than two intubation attempts need to be performed to reach a success rate of at least 90%. However, the evidence is heterogeneous, and the incidence of difficult airways in non-elective settings is up to 20 times higher compared to elective settings. Taking this factor into account, training should include a variety of exposures and should probably exceed 50 ETIs to successfully serve the most vulnerable patients. © 2015 Published by Elsevier Ireland Ltd. Introduction Q3 Failed intubation is the most frequently reported complica- tion in airway management according to a recent British survey.1,2 Numerous (>2) attempts and failed endotracheal intubations (ETIs) are associated with oxygen desaturation, arrhythmias, cardiac arrest, brain damage, and mortality.3–6 The most critical patients deserve the best-skilled health care providers, and the more experienced the physician, the higher the chance of a successful intubation.7 As for all manual skills, ETI is subject to a learning curve.8 ETI skills should be developed in a structured training pro- gramme, which is especially relevant for those who intubate in non-elective or emergency settings where the incidence of a dif- ficult or failed intubation is up to 20 times higher than in the elective setting.3 In the Netherlands, training programmes for non- anaesthesiologists who perform ETIs currently do not require a minimum number of completed ETIs.9 The aim of the present study was to provide a systematic review of the literature on the learning curve for ETIs. Because direct ଝ A Spanish translated version of the abstract of this article appears as Appendix in the final online version at http://dx.doi.org/10.1016/j.resuscitation.2015.11.005. ଝଝ This review was presented at the Dutch Anaesthesiology Congress, May 29, 2015, Maastricht, The Netherlands. ∗ Corresponding author. E-mail address: m.buis@erasmusmc.nl (M.L. Buis). laryngoscopy (DL) is the most widely used technique pre-hospital and in-hospital, we reviewed the learning curves for this proce- dure. We specifically aimed to identify the number of ETIs a novice intubator must perform to achieve proficiency with this procedure, defined as successfully intubating within two attempts. Methods Study selection This review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) state- ment. A search of the literature (January 1990–July 2014) was performed using EMBASE, MEDLINE, Web of Science, Cochrane Central Register of Controlled Trials (CENTRAL), and PubMed. The following keywords were used for the search: ‘intubation’, ‘learn- ing curve’, and ‘laryngoscopy’. The search was limited by excluding the keywords ‘videolaryngoscopy’ and ‘paediatrics’. The full elec- tronic searches can be found in Appendix A. In addition, we hand searched the reference sections of all articles that were selected for review. Inclusion criteria were English-language only, human studies only, DL as the sole procedure, novice participants or number of previously performed intubations clearly identifiable, and speci- fied quantification of the success rate learning curve for ETI. Studies were excluded if they had been conducted in a simulation labora- tory, were limited to paediatric patients only, involved ETI using a 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 40-80? Bernhard et al. 2012 Acta Anaesthesiologica Scandinavica Cortellazzi et al. 2015 Anaesthesia
  22. 22. The pursuit & consequence of the search for easy…
  23. 23. 1stAttemptSuccessRates 0 25 50 75 100 Sackles 2011 Mosier 2013 Kory 2013 Michalideu 2014 Lee 2014 Silverberg 2014 Sakles 2014 Hypes 2016 Total VL DL 68% 80% Total ~2500 in each DL & VL In pursuit of easy… VL is better…
  24. 24. 1stAttemptSuccessRates 0 25 50 75 100 Sackles 2011 Mosier 2013 Kory 2013 Michalideu 2014 Lee 2014 Silverberg 2014 Sakles 2014 Hypes 2016 Total VL DL 68% 80% 17,000 Registry PatientsDL 84% In pursuit of easy… VL is better than bad DL
  25. 25. Tell me what you see?
  26. 26. Do you see the posterior cartridges?
  27. 27. Competence Context Confidence Conscientiousness Context: materials
  28. 28. 5 Faces Context
  29. 29. 7,000,000,000
  30. 30. 43
  31. 31. High Acuity Low Opportunity Challenge Petrosoniak & Hicks. Current opinion in Anaesthesiology. 2013 High Acuity Low Opportunity Low Acuity Low Opportunity High Acuity High Opportunity Low Acuity High Opportunity Opportunity Acuity Sim Zone Overlearn
  32. 32. Opportunities… Overlearn
  33. 33. Opportunities… Overlearn
  34. 34. Context: environment High Stakes
  35. 35. These are your vitals
  36. 36. Times of stress Challenge Threat
  37. 37. Grossman & Christensen. On Combat 2008
  38. 38. Don’t avoid failure …be antifragile
  39. 39. High Acuity Low Opportunity Challenge Petrosoniak & Hicks. Current opinion in Anaesthesiology. 2013 High Acuity Low Opportunity Low Acuity Low Opportunity High Acuity High Opportunity Low Acuity High Opportunity Opportunity Acuity Sim Zone Overlearn System 1 training
  40. 40. System 1 training Learn as Many/Execute as 1 Incrementalization 8 - The “secret “ of competence in crisis is to break down the challenge into smaller parts, and then incrementalize it into its smallest, most fundamental components. - Operators should master a regimented series of best-practice steps that are small, reliable, and reproducible. Expertise is the ability to do each task well, transforming incrementalized steps into one fluid, apparently easy, and effortless movement. - Slow is smooth and smooth is fast. Rushing deteriorates performance.  Multi-tasking is a myth. - Procedures should be engineered for crisis performance, by flattening the slope, and lightening the load. - Slope: Incrementalization - Load: Cognition
  41. 41. System 1 training: Avoid Insanity I can’t see %$^&!!!
  42. 42. System 1 training: Cued Response • Epiglottoscopy • Valleculoscopy • Laryngoscopy • Intubation AIMEairway.ca: SMACC Byte- Airway Management Kata Epiglottis only response
  43. 43. Cued Response: Psychomotor rehearsal EVLI Learn as Many/Execute as 1
  44. 44. Best Look DL&I Cued Response: Psychomotor rehearsal Learn as Many/Execute as 1
  45. 45. Competence Context Confidence Conscientiousness Confidence
  46. 46. “we all got plans, til you get punched in the mouth” Confidence
  47. 47. Number Needed to be… Confident
  48. 48. Confidence Experience Confidence
  49. 49. Good judgment is the result of experience and experience the result of bad judgment
  50. 50. Conscientiousness Competence Confidence Context
  51. 51. 64 … work ethically Conscientiousness
  52. 52. It’s not about you
  53. 53. Its about the patient
  54. 54. 67 Conscientiousness … work ethic
  55. 55. 68 Conscientiousness … work ethic
  56. 56. 69 Conscientiousness Doing Knowing … work ethic
  57. 57. Plan A Plan CPlan B Airway Tool Box Do Know
  58. 58. Plan A Plan CPlan B Airway Tool Box Do Know
  59. 59. Fear of Failure Competence Context Confidence Conscientiousness
  60. 60. Anybody can intubate
  61. 61. Anybody can intubate Competence Context Confidence Conscientiousness
  62. 62. Anyone can intubate
  63. 63. Thank You

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