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My Affective Failure as an EMS Medical Director

Anyone who has been through paramedic school in the past decade has probably heard of the cognitive (knowledge), psychomotor (skills) and affective (attitude) learning domains. These categories help guide how learners are assessed throughout school. While the cognitive and psychomotor domains focus respectively on the learner’s clinical knowledge and ability to perform skills, the affective domain has been less straightforward to nail down. When most people think of the affective domain, they think about bedside manner, whether you were respectful to the patient’s family and whether you acted professionally.

Today, many medic schools assess affective performance by having students fill out reflection surveys on their perceived effort. Clinical rotations assess this domain by answering questions around whether the student dressed appropriately and acted professional with patients.

While all of these are important to being a respected clinican, we’re missing out on something equally important - what does the clinician value when providing patient care.

At first glance this also seems fairly straight forward. People are generally trying to do right for the patient and provide the best clinical care possible. However, when it comes to airway management I think our affective domain enters into a death match with our cognitive domain. Let me elaborate.

There are a few things about endotracheal intubation (ETI) that our cognitive domain should know to be true based on multiple research papers:

  1. Multiple airway attempts decrease neurologic intact survival in cardiac arrest patients1

  2. BVM, supraglottics (SGA) and ETI are all reasonable airway solutions for cardiac arrest patients if the right training and quality improvement processes are put in place.2

  3. ETI is not better than a supraglottic airway for patients in cardiac arrest. It may be equally as good or potentially more harmful.3,4

  4. We all want patients to live (don’t think I need a reference here!)

Even though people know these facts to be true, when it comes to the affective domain of airway management, these are some of the comments I hear from EM physicians and EMS clinicians alike:

  1. I failed the intubation. We settled for a SGA

  2. It took us four attempts but we finally got the ET!

  3. Getting the ETI is a badge of honor.

When I consider the facts from above and statements from below, you can see there’s a clear disconnect between what the research (cognitive domain) tells us and what we openly value about airway management (affective domain). When we know that all of these airways are equal, why do we care so much about ETI? We should be talking about patient survival because of solid airway management. I truly believe that in their heart of hearts, everyone continues to try to do right for patients. No one is consciously being malicious to patients when making these statements or thinking these thoughts. I’ve had them from time to time myself when at the bedside or after a challenging airway. So if people are trying to do the right thing why do these statements that provide insight to our airway management values have such disconnect from the science? To me, this is from the way we teach and send messages to providers about airway management.

  • How much time in your medic program was spent on ETI vs SGAs? While ETI is a harder skill, there probably shouldn’t be as big of a gap in skill requirements for graduation. What about BVM? Doing this effectively is also a challenging skill.

  • Did you spend time intubating mannequins upside down and in oddly confined spaces? Looking back, would an SGA have been a dozen times easier and faster way to manage that airway?

  • What’s your airway management algorithm? Were you taught a “right airway for the right patient” approach or “attempt ETI first?”

Airway Management Algorithms

When I was a new medical director, I wanted to build confidence in my medic’s decision to do a cricothyroidotomy. While this was multifaceted and included different types of training, one aspect was a new airway management algorithm that helped provide some clear guidance on when a cric should be done. Referencing some difficult airway algorithms from the airway literature, this is what I landed on:

^Paramedic can repeat x1 if the reason for missed Endotracheal Intubation is identified and easily solved. Minimize ETI attempts to 3 amongst all paramedics.

Special Considerations:

  • Ventilate the patient between attempts to raise SpO2.

  • Clinical judgement may dictate crews to start at different places in the algorithm.


A few years later, as I sit and reflect on this guideline, I can see it’s riddled with affective errors and not setting my paramedics up for success in airway management:

  1. The word “failure” shouldn’t be so prevalent. Getting any sort of airway in a patient should be viewed as a success. In particular, missing an ETI shouldn’t be viewed as a “failure.”

  2. While there is a little note about allowing people to start wherever in the sequence they deem appropriate, the flow of the diagram significantly de-emphasizes this point. A “right airway for the right patient” mentality should bring this concept front and center, not making it an after thought in the notes.

  3. Labeling things Plan A, B, etc.. implies that some plans are better than others

How do I stand for a “right airway for the right patient” message with a guideline that doesn’t support this approach?

This guideline is due for a change and I’d love your help. Take a few minutes to reflect on what airway management means to you and redesign this treatment guideline.

Share it on twitter and tag myself (@EMtgDO) and @FOAMfrat and join the affective airway management discussion.

The words we use matter when teaching new medics and discussing the best way to manage airways. Not realizing this point is an affective failure that most of us could probably use to improve upon.

1. Murphy DL. Fewer tracheal intubation attempts are associated with improved neurologically intact survival following out-of-hospital cardiac arrest. R E S U S C I T A T I O N. 2021;(167):8.

2. Carlson JN, Colella MR, Daya MR, et al. Prehospital Cardiac Arrest Airway Management: An NAEMSP Position Statement and Resource Document. Prehospital Emergency Care. 2022;26(sup1):54-63. doi:10.1080/10903127.2021.1971349

3. Benger JR, Kirby K, Black S, et al. Effect of a Strategy of a Supraglottic Airway Device vs Tracheal Intubation During Out-of-Hospital Cardiac Arrest on Functional Outcome: The AIRWAYS-2 Randomized Clinical Trial. JAMA. 2018;320(8):779. doi:10.1001/jama.2018.11597

4. Wang HE, Schmicker RH, Daya MR, et al. Effect of a Strategy of Initial Laryngeal Tube Insertion vs Endotracheal Intubation on 72-Hour Survival in Adults With Out-of-Hospital Cardiac Arrest: A Randomized Clinical Trial. JAMA. 2018;320(8):769. doi:10.1001/jama.2018.7044


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