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providers consistently underestimated how often their patients response, the cognitive load of the initial evaluation decreases.
desaturated during intubation attempts. 30 ERADs are relatively simple, and simplicity can be key to im-
proving performance under stress. 34,35 Less neurological energy
Discussion is required which addresses the issue of low working memory
under stress. 29,47,48 Second, the specific cue-driven (e.g., inabil-
Review of Cognitive Behavioral Adaptation ity to visualize the glottis during laryngoscopy) response cir-
Human beings naturally develop strategies that consciously cumvents the need to triage tasks and avoids perseveration on
and unconsciously allow them to cope with perceived stress. ineffective or incorrect tasks because the programmed action
In the field of human factors engineering, this is referred to as removes the necessity of cognitive processes.
strategic control. 3
The field of human factors engineering has proposed the util-
One such strategy is called “resource recruitment.” This sub- ity of “adaptive automation.” These are technologies (auto-
optimal adaptation entails working faster or harder (recruit- matic system surveillance or monitoring) or techniques that
ing more cognitive or physical effort) to quickly achieve an decrease the cognitive load on humans during times when
outcome. While speed increases, accuracy suffers; techniques workload or psychological stresses are increased. These sys-
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are often error-prone. Another strategy is the removal of an tems offload cognitive processes to allow the human brain to
offending stressor, such as silencing an alarm or asking a bois- focus on the most critical decisions. In a sense, ERADs are
terous family member to leave. While an effective intervention, behavioral correlates of “adaptive automation.” They reduce
this is not often feasible. decision-making and cognitive processing to pre-determined,
evidence-based, virtually automatic fixed actions patterns for
Perhaps more effective is strategic adaptation. This includes specific circumstances.
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cognitive or behavioral techniques that have been developed
to cope with certain situations. Heuristics or simplified de- An ERAD Example Applied to Airway Management:
cision-making tools can, in some situations, be effective at Response to Difficult Laryngoscopy
quickly and accurately completing a task. 31–33 Over time, as Many investigations have tried to perfect laryngoscopy, but
individuals gain valuable experience, feedback, and deliberate research advancement has been complicated by factors such
practice, the repertoire of tools can be refined, leading to en- as varying classifications of a “difficult” airway,” the individ-
hanced performance under stress. 9,13,19,22,23 ual managing the airway, or the device used. Orebaugh et al.
performed a retrospective review of emergency department
Organizational approaches have been designed to improve airway management and concluded that the success rate of
decision-making and skills performance in high-stress envi- managing “difficult” airways was between 1 and 30%.
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ronments with the concept of strategic adaptation. For exam- However they did not use a specific definition, stating that
ple, simplified decision trees and concise algorithms are more difficult airway can be defined in several ways. Anesthesiol-

effective in situations with time pressure. 34,35 Digital displays ogists managing airways outside of the operating room (OR)
that reduce visual clutter and only provide salient informa- identified an incidence of 10.3% difficult airways (defined as
tion seem to buffer the deteriorating effects of stress. Concise Cormack-Lehane Grade III or IV view) in Martin et al.’s retro-
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posters that reduce the need to visually search for informa- spective review. Other authors suggested that in the OR, the
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tion and guide attention to key information are likewise effec- rates are somewhat lower: approximately 6%, using a hospital
tive. 3,37 Other adaptations include cognitive off-loading tools specific scoring system for ability to perform direct laryngos-
such as emergency checklists, weight-based tape drug refer- copy. The NEAR III study investigators reported high rates

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ences, or smart phone applications. 38–43 of effective airway management in 18 emergency departments
across the United States, Canada, and Australia. However, they
Finally, a key aspect of strategic adaptation is the develop- noted that first pass success rates varied over the course of
ment of automaticity. Often referred to colloquially as “mus- data collection from 80–86%. Thus, while the precise inci-
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cle memory,” these psychomotor skills can be performed with dence of difficult airways is unknown, it is reasonable to con-
few demands on cognitive resources. 44,45 Furthermore, when clude that it impacts clinical care.
trained correctly, these skills can be executed quickly and al-
most effortlessly under times of exceptionally high cognitive The occurrence of difficult airways, the time-sensitive and
demand and psychological stress. 46 stressful nature of emergent airway management, and the
evidence-based methods to enhance success make airway man-
Proposed Solution: Emergency Reflex Action Drills agement a prime opportunity for implementation of an ERAD,
ERADs are goal-oriented, pre-planned responses to specific as suggested by Kovacs et al. 54–66 During direct laryngoscopy, if
situations that may arise during care. They are designed to the operator encounters a Grade III or Grade IV view, Kovacs
overcome the significant stress and time constraints present et al recommends a series of quick, empiric maneuvers:
during an acute incident. Specifically, ERADs fill a gap in the
spectrum of cognitive off-loading and performance-enhancing 1. Occipital Lift: Increasing the elevation of the head and opti-
tools in stressful situations. They take into account available mizing sniffing position has demonstrated, both in anesthesia
cognitive science and clinical literature to address situations and emergency medicine literature, significant improvement
that are not amenable to other tools (e.g., checklists, refer- in glottic opening visualization and intubation. 55–58
ences, or applications) because of the extremely time-sensitive 2. External Laryngeal Manipulation: External manipulation
nature of the situation and need for immediate intervention. of the laryngeal structures (or “bimanual laryngoscopy”)
by both experienced and novice operators has demon-
ERADs take advantage of two important human factors strated optimized glottis view. 59–62 This technique is per-
concepts. First, by creating a reflexive, programmed motor formed by the person intubating using the right hand to

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