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.

Through 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):

1. Raise bed height so the patient is slightly elevated relative to your seated position facing them—their relaxed forearm needs to be resting (horizontally) on your shoulder. If the right shoulder is dislocated, the patient will rest the right arm on your right shoulder.
2. Have the patient relax the right arm onto your right shoulder.
3. Ask the patient to shrug their shoulders backward, to push out the chest, straighten the back, and keep both shoulders even. The patient should lift their head up. One way to describe the correct position is to position the shoulders and back as they would be in a wall sit (description courtesy of my colleague Amy F. Lucas, PA).
4. Ask the patient to breath slowly in and out, focusing on relaxing their muscles and rotating their shoulders backward.
5. Your left hand massages the patient’s deltoid and biceps.
6. Your right hand applies gentle straight downward traction to the elbow while adducting it against the patient’s side. This should not exceed five pounds of downward force.
7. The second operator goes behind the patient, helping them rotate the shoulders backward, keeping the shoulders square, and massaging the right and left trapezius.

When done properly, patients are amazed how easy and fast this reduction technique can be. No drugs, no sedation, no IVs. I usually have patients reduced before registration is complete. The paperwork takes longer than the reduction itself!

This is such a gentle technique that I do not routinely X-ray patients before reduction, assuming the patient is cognitively intact, the injury is obviously isolated, and the mechanism of injury is unlikely to have caused a fracture. I rarely do pre-reduction films for the recurrent dislocator.

There are times when the Cunningham technique won’t work. You can expect difficulty with very obese patients. Some patients are too anxious or are in too much distress to relax and assist with positioning. In general, reductions are more difficult in patients with delayed presentations; I usually use medication in these cases and obtain pre-reduction films. I rarely combine medication with the Cunningham technique. However, if needed, an intra-articular injection of 20 cc of lidocaine beneath the acromion can be effective enough to avoid the need for sedation while permitting a more forceful manipulation technique.

The Technique’s Many Benefits

Deploying the Cunningham technique has exponentially positive effects. It dramatically lessens length of stay and minimizes use of departmental resources. I believe that the gentle massaging of the patient has a significant analgesic effect. Coordinating your efforts with the second operator (nurse or technician) makes the procedure go more smoothly. It is great for team building, allowing others to participate in a successful procedure.

Incrementalizing your procedures so you perform better can translate into positive effects on your job perception. It can lower stress because you are operating well within your comfort zone due to an approach that favors small, achievable, and believable steps. It allows you to transmit confidence and reassurance to the patient. Patients greatly appreciate the reassurance and acknowledge that your expertise allows you to take good care of them.

What I love about incrementalization is that takes me away from tedious tasks, like running sedation checklists and getting unnecessary radiographs. I am happier in my job—and better at it—since I started engineering and incrementalizing my practice. It even allows me to be present for the patients themselves. If you embrace incrementalization, I believe you’ll find your own ways to improve your practice and thereby even your own wellness. In the meantime, start with the incrementalized two-person Cunningham—it’s awesome! 

Reference

1. Cunningham N. A new drug free technique for reducing anterior shoulder dislocations. Emerg Med (Fremantle). 2003;15(5-6):521-524.