The Missing Airway Gauntlet

A gauntlet is synonymous with a specific type of challenge - usually, it’s used to infer a sequence of escalating or difficult challenges. When it comes to training for airway management, you can probably recall a few different types of challenges you’ve faced, such as training with peers prior to check-offs in school or at your monthly in-service. Depending on how these trainings were run, you may have mixed feelings about them. What determines the way you look back on those learning experiences?

You’re probably familiar with the ‘flow state’ diagram or thought process:

The general idea of the ‘flow state’ is that, on one hand, if you overload someone with a challenge that they do not feel prepared to tackle, you’ll push them into anxiety and stress. On the other hand, if you give someone a challenge that is very easy for them, they’ll probably become bored and disengaged. Either one of these extremes will defeat the whole purpose of the training (for the student/trainee to leave feeling more confident and better prepared for future real-world challenges). For example, imagine you’re about to run one of two airway challenges:

1. Insert an NPA into a simple airway manakin.

2. Run a full RSI scenario on a pregnant, hypotensive, hypoxic trauma patient in active labor.

   
   

This is all rather obvious. Giving a student/trainee something ridiculously difficult will stress them out, and something very easy will bore them to tears. The obvious answer, then, is to find a challenge that is in the middle. However, ‘the middle’ is a moving target. How so?

What’s adequately challenging and engaging to them during the first scenario they ever run will not stay the same - they’re always improving and becoming more confident, so they need increasing difficulty to stay engaged (while we try not to tip them over the edge to anxiety and stress). Hitting that moving target of where the student/trainee’s flow state actually is can be a difficult task. However, maybe it’s not as complicated as it sounds.

Finding the Corners of the Box

Having a simple conversation with a student or trainee to assess their current confidence and skill levels is a good starting point. You might try asking them which tasks/procedures they feel as though they could perform without any coaching whatsoever. Their answers might surprise you.

“I’m totally comfortable with NPAs and OPAs but struggle with BVM seal.”

“I can verbally walk through RSI, but if you make me actually draw up meds, I get flustered.”

After determining (what you might call) their ‘baseline,’ ask them which tasks/procedures stress them out, or which they wouldn’t feel comfortable performing on a real patient if they had to right now. You might even show them an RSI checklist and use that as an outline of all the things involved in a complex scenario. This essentially outlines their flow state. You now have a decent idea of what would overly stress or bore them, and you can work between those two, gradually increasing the challenges.

Asking about current ability levels may seem obvious, but at times, trainers may feel that because a student/trainee has a certain number of years under their belt as a provider, has some prior experience, or has taken specific classes, they should be able to perform ‘X’ tasks. This is simply not likely true - expectations do not always meet reality. The good news is that this should be expected and is the whole purpose of training!

Even after roughly identifying their flow state, you might still struggle with how to proceed with a structured and useful learning experience. Returning to our idea of a gauntlet, it’s a series of increasingly difficult challenges. Let’s go through a rough outline.

The Gauntlet

I’ll outline what I think a logical progression is to increase difficulty over time, while not overloading or boring a student. If you have ideas on how to improve this, please comment and share how this could be improved!

Step 1: Basic Foundation

In step 1, you’re walking (not running) through a basic scenario. An RSI checklist should be used for this, where you go through each item with the student under no time constraint, focusing only on accuracy and building confidence in each task.

Step 2: Introducing a realistic challenge

In step 2, there is again likely no time constraint. Active coaching is used to allow them to overcome a challenge they’ve practiced overcoming. Examples might be mixing some push dose pressors, increasing the SPO2 through 2-hand BVM techniques, or leading with suction in a soiled airway (S.A.L.A.D.).

Step 3: Solo Realistic Challenge

Step 3 is very similar to Step 2, but with less instructor intervention. In my opinion, this does not mean letting them fail. Rather, this is more of a ‘phone a friend’ scenario where help is nearby (but only if they make the call). This step should be repeated until they feel confident with the various complications that they encounter.

Step 4: Add Environmental Variability

After the student is comfortable overcoming the complications of step 3, try adding an environmental challenge. Poor lighting, the need to move the patient, confined space, etc. This starts to mimic real-world scenarios and builds confidence that they can take their skills on the go.

Step 5: Full complexity

Step 5 is the first time you present multiple complications and environmental issues to the student simultaneously. The patient may be in a less-than-ideal location, hypoxic, hypotensive, etc. These are difficult scenarios, but the student should feel as though the variables and challenges that they’ll face are ones they’ve prepared for.

Of note, I’ll point out that training is different than activities such as competencies. In these steps I’ve outlined, there is really no room for the student to fail, because you’re building up their confidence and coaching when needed. When it comes to something like a competency for your organization, that is a different scenario. Sooner or later, clinicians must demonstrate competency in situations that mimic real-life practice. Training, however, is the time to make mistakes, build confidence, and experiment (and maybe even have fun).

Conclusion

What’s often ‘missing’ about the airway challenges that we give students and trainees? Finding the flow state of the individual and building confidence through continued success, which enables them to improve after each round of well-defined, increasing levels of difficulty. For some, this may be a concept they’ve never given much thought to, while others have mastered this.

As we conclude, I’ll take a moment to highlight a master at airway training: Jim DuCanto, M.D. I’ve had the pleasure of watching Jim teach many students through the courses we’ve taught together over the years, and no one is better at meeting students where their confidence currently lies than he is. He’s broken down the S.A.L.A.D. procedure into parts and takes the time to show the student how to perform the first part, has them experiment with it, and provides active coaching and positive feedback. Once their confidence is high, he adds the next part, and the next part. By the end of the session, students are S.A.L.A.D. machines, confidently conquering soiled airways with multiple pieces of equipment with ease. I think his success comes from a few key items:

1. Assessing and accepting the student’s current skill set.

2. Providing positive feedback and active coaching where needed.

3. Having a clear outline of increasing difficulty to keep them engaged.

Thanks for reading!

References:

Chernikova, O., Heitzmann, N., Bieg, S., Schill, K., Renkl, A., & Rummel, N. (2020). Simulation-based learning in higher education: A meta-analysis. Review of Educational Research, 90(1), 27-68. https://journals.sagepub.com/doi/full/10.3102/0034654320933544

Heyn, L. G., Lee, S., & McMullan, D. (2023). Exploring facilitation in virtual simulation in nursing education. Nurse Education in Practice, 65, 103553. https://www.sciencedirect.com/science/article/pii/S2772628223001139

Masava, B., Nyoni, C. N., & Botma, Y. (2022). Scaffolding in Health Sciences Education Programmes: An Integrative Review. Medical science educator, 33(1), 255–273. https://doi.org/10.1007/s40670-022-01691-x