I have long questioned the utility of airway algorithms and their relevance to emergency airways. This notion that if we just memorize X, Y, and Z, we will magically perform better has not been borne out by my own efforts to improve my practice or made me more comfortable with my job.

In my opinion, airway algorithms add significant cognitive burden. The burden of multitasking procedural performance while simultaneously trying to remember a complex algorithm can imbalance the operator’s psyche, adding to the perceived demand of the situation. This precipitates increased operator stress and, in turn, degrades crisis performance. Ironically, in true crisis, the burden of trying to remember an algorithm—although intended to give cognitive assistance—can backfire dramatically. We know from clinical experience that real cases frequently do not fit neatly into the boxes and arrows. While we seek a guide, a hand to lead us through the challenge, as I see it, algorithms fail to light the way.

Watching clinicians for more than three decades and reflecting on my two decades of procedural education, I now recognize a common mindset of those who do well in crisis. I believe I have improved my own performance and become more comfortable with the challenging and humbling job of emergency physician by not focusing on comprehensive algorithms or the big picture.

I now entirely focus on the next step. That is the “secret.”

One Step at a Time

Master clinicians, who walk into complete chaos with a smile, maintain their cool, and inspire confidence from the team, do not worry about everything. They have insight into the priorities of the situation. They take small incremental steps, fixing one problem, then the next, until it’s clear they have command and control of the situation, making forward progress in the face of great challenge.

Operating “in the zone” is not about struggling to do everything at once; it is the exact opposite. A lightness of being, an unburdening of mental load, “just doing, not trying”—this is the inside secret of those in all areas of life who perform mightily in the face of enormous stress and terrific challenge.

We have all seen novice clinicians struggling in a crisis situation, overthinking and trying to figure out what is the right thing to do. Conversely, experienced clinicians calmly and with relaxed focus are able to just perform. Those with the least experience and knowledge are struggling with performance while assuming complex cognitive burden. Master clinicians, who have the most experience and knowledge, have no cognitive burden and just glide through performance.

In my prior columns I have enumerated an incrementalized approach to oxygenation, laryngoscopy, and surgical airways. All of these procedures are just assembled tiny little steps, deliberately engineered to be achievable and believable. The best clinicians engineer their practice—it is not just they are skilled and experienced. Having deliberately engineered their performance into small, simple, reproducible, and reliable steps, they have lowered the task complexity. This improves the balance of perceived ability to perceived demand, lowering stress and improving confidence and performance. Without the adrenaline surge flowing through their body, they can see and hear better. Their voice stays calm; their pulse, low. They have more situational awareness and think better. Master clinicians do better (especially in the most stressful of situations) because they have engineered their practice to actually be simpler and easier. Difficult tasks have been compartmentalized and incrementalized (and practiced over and over again). The small steps flow into a muscle-memorized, smooth process done without struggle or desperation.

The secret to procedural performance is compartmentalization, incrementalization, and repetitive practice.

But there is a big-picture component that master clinicians do have in mind. It is not an expansive detailed algorithm for every possible scenario—rather it is a clear insight into the fundamental priorities of the situation.