Psychology of the Difficult Airway

Rich Levitan, pioneer in airway management, talks about operator stress response in the difficult airway. Referenced in this discussion: The laryngeal handshake,  books On Combat and Warrior Mindset. Rich offers several courses including the one of a kind Practical Emergency Airway Management Course and the Advanced Airway Endoscopy Course in Yellowstone.

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Psychology of Intubation: The Fourth Plane (

Interested in a truly unique CME experience? Join Rich Levitan, Scott Weingart, Matt Dawson, Mike Mallin, Andy Sloas and me December 6-8, 2014 for a 5 star, all inclusive vacation in Cabo San Lucas and earn your CME credits in style. The 2014 Cabo CME Retreat will focus on the newest emergency medical practices and technologies in the areas of ultrasound and airway medicine. Our lineup of leading emergency doctors and medical speakers will present at Secret’s Resort, the newest all inclusive luxury resort in San Jose del Cabo. Secrets Puerto Los Cabos Golf & Spa Resort boasts five gourmet restaurants, incredible views, infinity pools, and world renowned golf courses designed by Greg Norman and Jack Nicklaus. At this limited-access retreat, you will experience a CME conference unlike any other.

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  1. CJ

    Wow, great podcast with great pearls. My favorite Levitanism is definitely the Beauty to Death ratio.

    I would like to share a viewpoint and my thoughts on this subject. It may be old news to you though I did not specifically note it in the podcast and I apologize in advance for the ranting. I trained for the Olympics and failed and part of my path was an undergraduate major of exercise science, emphasis--motor control and learning. During my studies I was training 4-6 hours most days and coaching my sport another 4 hours or so also most days. This meant a lot of direct application of the principles I was reading about in myself and in others. My sport was taekwondo, and while not as glamorous as a fighter pilot or army ranger, my opponents wanted to knock out my teeth. I think that the comparisons that we make to fighter pilots, combat medics, general pilots, etc. are fascinating and exciting. They can be helpful qualitative models for us. However, I do not think that only such sensational comparisons have the insight to be useful and informative in medicine. The application of what I learned benefited the athletes I coached greatly and allowed them to perform well under great pressure. I was more successful as a coach than a fighter myself.

    I feel that simulation medicine and research, whether ACLS or airway related are dancing around a subject and implementing some common sense elements of it without actually realizing the depth of knowledge and mountain of literature that exists and that could help us describe and fine tune what we research or teach and understand how best we can train for success and peak performance in the ED. The field of motor control and learning, a subfield of psychology and an integral part of exercise science training, as well as sport psychology itself has been asking the question about how to perform when it really counts for upwards of 40 years or more at this point and I feel like we are in some ways reinventing a wheel. In the podcast Dr. Levitan noted some comparison to his chosen sports but I think the literature about performance in sport has even more to offer. While some of the concepts from the field of motor control and learning are common sensical there is, nevertheless, often fascinating and illuminating data behind these concepts and well worth perusing for anyone involved in teaching procedures or resuscitations.

    As a first example, the number of cognitive variables that one must consider affects reaction time. If you are choosing between two possibilities you will make your final decision faster than if you are choosing between 6. This is common sense, but the data demonstrating and proving this is fascinating. This is one reason that simpler can be better and plays out in both a macro and micro form--observable both in big slow decisions, like which of the many back up airway options will be selected next, and also in faster fine motor decisions like how you adjust your angles and depth during DL.

    A description of the “principle of specificity”, first coined in 1973 was given regarding the approach to the airway course cadavers and experience. Creating a realistic feel and appearance is important! The principle of specificity and the literature describing it from every angle essentially states that if you want to perform something well, the practice and preparation should approximate the real deal as closely as possible. This is why Peyton Manning did not play catch with his receivers before the super bowl. He wore pads, ran EXACTLY the plays they wanted scripted against the Hawks in as realistic a simulation as possible. Unfortunately, Coach Fox did not confer with me before the super bowl and mistakenly decided that the super bowl, as he remembered it, was not that loud, therefore, he chose not to use simulated crowd noise in practice the week before the big game. While the super bowl may be tame during offensive snaps overall, the first minutes of one is louder and crazier than even a seahawks home game. On the first snap of the game crowd noise created an error on the snap and the ball sailed out of the endzone for a safety giving the seahawks an instant lead and a mental edge that was never recovered from. They did not adhere to the principle of specificity in practice. This principle is the reason I cringe every time I hear an award is handed out for taking medical students to the art museum to work on their perception or whatever the heck else they think that activity might enhance. If you want to be perceptive when looking at art, look at art. If you want to be perceptive when looking at humans, look at humans. Preferably sick ones.

    There are numerous additional concepts that can further help to optimize training. The frequency, timing and form of feedback are among many important contributors to improvements in performance. Not all feedback is created equal. The concepts of memory, transfer, retention, Fitt’s Law and schema theory are also enlightening. The concept of memory is one of my favorites. What is 34 + 27?


    What is 34 + 27?


    Easier the second and third time? If you repeat the same thing over and over you are not reaccessing the part of your brain where the skill resides and are not therefore reinforcing that skill but rather just remembering. Clever studies have demonstrated that this is true whether the skill is math, kicking someone in the head or otherwise. This is why you should do one DL, one surgical airway, one fiberoptic, etc. when in the airway lab and avoid doing the same maneuver more than once or twice in a row (depending on your interpretation of the memory in skill acquisition literature).

    Finally, sport psychology and training to achieve peak performance in stressful situations, like when your opponent is trying to knock you unconscious has been studied in sport since the Soviet Union decided embarrasing the US in the Olympics would be an inspirational thing to do. I think that concepts such as peak performance, hyperfocus and flow as described by Csikszentmihalyi in 1975 can be very valuable to simulation and learning in medicine. “Reinterpretations of Csíkszentmihályi’s flow process exist to improve performance in areas as diverse as business, piano improvisation, sport psychology, computer programming, and standup comedy.” Maybe medicine is next in line…

    My hope would be that leaders in simulation medicine of all types could learn from these established concepts and avoid the time sink of reinventing certain wheels.

    Thanks Dr. Orman for your oustanding podcasts and I look forward to my next airway lab!

  2. Jenny

    Great airway talk. I think we have all felt like a deer in the headlights, when we didn’t have a plan and things started going down. Dr. Levitan, what is your advice to EM residents who may have a difficult airway algorithm from our sim/airway course when your attending jumps in and wants you to follow their difficult airway path -- how do you not become a deer in the headlights when you have a plan and then your attendings algorithm for difficult airways is different than yours? Thanks a million.

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