Page 58 - JSOM Spring 2023

manipulate the larynx to a position that provides a better (a) high-fidelity simulations with verbalized thought pro-
view. An assistant can then hold the larynx in this position cesses and debriefings, (b) video recordings of performance
or it may maintain position spontaneously as the intuba- to be reviewed for QA/QI, (c) videos of an expert perfor-
tion is completed. mance with frequent pauses allowing for participants to
3. Bougie: Using a bougie, as compared to a traditional stylet decide their next move then instantly getting feedback by
and endotracheal tube demonstrates improved first-pass continuing the tape, and (d) visualization and verbaliza-
success. 63–65 tion of steps of a case. Each of these methods requires a
4. Scoop: Using a curved blade (Macintosh), inching the tip highly skilled instructor to provide evaluation to individu-
from the vallecula to underneath the epiglottis and lifting als. Research suggests it is worth the investment; military
to fully expose the larynx like the technique applied with a pilots who had incorporated specific emergency scenarios
straight blade (Miller) can optimize the glottic view. 66 in simulation training performed better when that situa-
tion arose in a real flight. 69, 70 It is important to emphasize
The simplistic nature of this ERAD can be reinforced with that the goal is to train with the ERAD in such a way
an easy mantra: head-neck-hands, in which “head” refers to that during the real event, the clinician simply executes the
elevation of the occiput, “neck” applies to external laryngeal skills quickly and efficiently with little to no demand on
manipulation, and “hands” encompasses the final tactile steps: cognitive resources.
using the bougie and scooping the epiglottis. The power of
the ERAD lies in its ability to create an automatic process ERADs may have a place in all stages of medical education.
response. Neuroscience research suggests that stimuli can be- Initial education of all entry level medical professionals is crit-
come a primer to elicit a developed automatic motor response. ical because these practitioners have less experience, but may
The effect of the primer relies on attention, intention, and be equally likely to encounter time sensitive medical emergen-
the circumstances just before the primer. 67,68 By creating and cies, which makes them subject to higher cognitive loads and
3
practicing with an ERAD, one can program a response to the levels of acute stress when faced with novel situations. Clin-
stimuli of a critical scenario or high-stakes procedure to cogni- ically appropriate, nearly automatic responses to these situa-
tively offload and act rapidly. tions might be beneficial. There is also a benefit to including
ERADs in continuing education because spaced repetition can

improve retention and ingrain skills, and deliberate practice
Application and Implementation
can contribute to expertise. 69, 71,72 This continuing education
The above example refers specifically to airway management. might take the form of annual or biannual medical refreshers
The fundamental concepts of ERAD development can be or in more frequent, less formal monthly, weekly, or even daily
broadly applied to other situations such as uncontrolled junc- skills training events. From a military or tactical team perspec-
tional hemorrhage, traumatic cardiac arrest, and other emer- tive they can be practiced regularly at the unit level, particu-
gencies. Steps to create a successful ERAD can be simplified larly in scenario-based tactical training, drills on the range, or
into three main tasks: (1) identifying prospective events, (2) larger full mission profiles.
creating steps, and (3) teaching personnel.
Limitations
(1) Identifying Prospective Events: Because the goal is improv- The concept of ERADs is based on principles that have been
ing the response to high-acuity situations or procedures, established in the realms of cognitive psychology, neurosci-
asking colleagues what type of call or circumstance makes ence, and human factors engineering. Developing similar
them nervous can be enlightening. Emergency clinicians concepts in other high-risk occupations has demonstrated ben-
have a strong perspective into time-critical scenarios, and efits. 22,23 However, this concept has yet to be tested to demon-
an ERAD could help reduce that stress. Another option is strate any clear benefit in the clinical environment, specifically
utilizing quality assurance (QA) / quality improvement (QI) in patient-centered outcomes. Furthermore, the concept of
data to identify procedures with a low success rate. A dis- developing ERADs for these time-critical situations is funda-
crepancy may exist between performance in lower-stakes mentally predicated on establishing automaticity of individual
cases and higher acuity ones. Perhaps simple procedures tasks. Developing this automaticity requires regular, focused
are missed within the chaos of a priority case; it would be practice. 69
prudent to specifically target data from critical calls.
(2) Creating Steps: As explored above, it is possible to capital- Conclusion
ize on the brain’s automation system. To maximize char-
acteristics of attention, utilize a catchphrase or rhyme. To Stress, resulting from the confluence of multiple factors, is
capture intention, create obvious step-by-step simplistic intrinsic to providing care to critically ill or injured patients.
actions. Finally, to ensure cue-driven activity, always prac- The toll on providers’ cognitive faculties and technical skills is
tice the ERAD after the associated stimulus. well documented. The concept of ERADs is based on existing
(3) Teaching Personnel: Ericsson explored the idea of the ac- cognitive psychology and human factors evidence combined
quisition and maintenance of expertise and reported the with available clinical data as it pertains to certain procedures.
importance of deliberate practice, defined as repeated be- Implementation of ERADs may facilitate more effective per-
havior of specific tasks geared towards improvement in formance of crucial actions during resuscitation.
an environment that allows for detailed, immediate feed-
69
back. When examined in studies, experts are better at Funding
chunking large amounts of information to quickly assess, None.
and even anticipate, their next action due to their care-
69
ful analysis and learned pattern recognition. In medical Disclosures
practice, this deliberate practice could be executed with: None.
56 | JSOM Volume 23, Edition 1 / Spring 2023