In my own career and from watching hundreds of colleagues, residents, and other clinical staff, I am convinced that job performance, competence, and satisfaction are intertwined. The clinicians who are the most competent are the most content, the most calm under fire, and the best at communicating with patients and coworkers. They have made peace with the job and its demands—and it reflects in all of their interactions. It shows on their face and in every aspect of their practice.
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ACEP Now: Vol 37 – No 08 – August 2018, ACEP Now: Vol 38 – No 07 – July 2019Through 20 years of monthly cadaveric courses focused on airway procedural education, I now know that “expertise” is not an accident. Being good at a task comes through practice and, more important, through mastering an incrementalized, engineered approach to the task. “Incrementalization” is a term I use to describe breaking down complex tasks into smaller tasks. Especially under stressful situations, it is critical that operators approach complex tasks in small, well-rehearsed, well-designed steps. The steps must be achievable (operators envision themselves successfully completing each step) and believable (operators believe the steps will work). Our procedures should be “engineered”—designed step-wise—to maximize success, patient safety, and operator confidence.
In my previous Airway columns, I have advocated a step-wise approach to oxygenation, laryngoscopy, and the emergent surgical airway. I now embrace an equally incrementalized approach to every procedure I perform, including even routine ones that I used to take for granted. I engineer the tiny steps of suturing the vermillion border in a ketamized child—how I hold instruments, rest my hands and elbows, and use loupes. (You don’t use loupes? How many plastic surgeons have you seen not use loupes?)
I take a similarly detailed approached to cardioversion: position the patient’s head to 40–45 degrees; provide nasal oxygenation; divide propofol into four syringes of 50 mg each (never in a single syringe); talk to the patients while slowly administering the drug, squeezing the chest as they relax (note: towels are placed over anterior chest pads).
The Cunningham Technique
A few years ago—before my “conversion” to incrementalization—I heard about the Cunningham technique.1 This remarkable drug-free approach to anterior shoulder reduction by a single operator was developed by Australian physician Neil Cunningham, MBBS. There are some great videos on YouTube showing the procedure.
My initial success with the technique was marginal, however, and even though it has become widely known, many clinicians have reported mixed results to me.
My performance success with the Cunningham technique changed markedly after incrementalizing the procedure. I now usually perform it with a nurse or ED technician as an assistant.
Here’s my two-person incrementalized Cunningham technique (see Figure 1):
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6 Responses to “Incrementalization of the Cunningham Technique for Anterior Shoulder Reduction”
July 28, 2019
Frank FowerSounds wonderful, and Works Good.
I have been using the same Incriminating Engineering Since 1993 : though : I Call it Baby Steps
I have one Extra Step here : I massage the scapula and Trapezius while I am taking the patient about how to straighten and square their shoulders: then push the Tip
Lower Scapular Angle Medialy towards The Vertebral Column : then go to the front to sit and Proceed
Most of the Times: its Already Reduced : pain free
No Meds.
FrankFower MD, FACEP
July 28, 2019
Jeffrey FreemanLike most shoulder reduction techniques, an experienced operator has learned subtle improvements that improve their success in their hands. These incremental improvements are rarely published (as are few of the subtle clues to better procedures – hence the better outcomes for ‘experts’). Thanks for publishing these – there’s no question that a fast Cunningham expertly done is one of the easiest ways to put in a shoulder. I agree with the xray comments as well.
[I’m waiting for incrementalization of fecal impaction, chart documentation and getting out early….]
July 28, 2019
DAVID O JONESTried many times and it never works
July 29, 2019
Curtis Henderson, PhD, DO, FACEPThank you.
I have practice incrementalization unwittingly for decades of practice; I always called it superstition! I realized long ago if , after a few times of success, I engage a particular mindset (focus), set up exactly the same way and performed a procedure in a similar way , my success would continue. This would include laceration repair, LPs, intubation, procedural sedation, closed thoracostomy, fracture/dislocation reduction and the other many complicated intense actions we do. There is virtually no exception to this approach, but it takes time to learn this and to proceed with style and finesse. This article is pointed in its conclusions. I have not tried the Cunningham approach, but I will.
Regards
June 27, 2020
Marna GreenbergThe trick is to have the person assisting on the patient’s posterior to press gently medially on the lower scapular angle (it is really this that does the most , and similar to scapular manipulation reductions just doing it sitting up instead of prone)
October 20, 2020
Matt DiStefanoLike all things, the devil is the in details. You need to understand the anatomy, trust the process, and be patient. We have a case series that we’ll publish in 2021 of 183 shoulder reductions, 62% of which were accomplished via Cunningham technique. Rich you can contact me through casted.ca if you want to chat.