The first topic, the failed airway, is one of those sexy, bread and butter Emergency Medicine subjects that really cool educators who are smarter and funnier, and more experienced than me have covered in rousing talks at cutting edge conferences, on podcasts, and in other great FOAM venues.

The second topic, rebraining, is one you've probably never heard of since I'm sharing it here for the first time. It's about learning. Specifically it's about building the capacity for sustainable learning within our profession and across the arc of our careers.

As physicians, we spend a lot of time building our knowledge base and not much time understanding how to effectively maintain our skills

So the first topic is really the chocolate coating to get you to develop a taste for the second one. Perhaps when I'm done today rebraining will turn out to be the creamy nougat that makes the whole thing worth eating...

Situational Awareness is a military term: it is the ability to identify, process, and comprehend the critical elements of information about what is happening to you and the team with regards to the mission. More simply, it's knowing what is going on around you.

Acute stress (you know) that adrenaline surging through you during the failed airway scenario is a key factor in how well you will perform and will rapidly degrade your situational awareness.

Link to Video: https://youtu.be/djyvLKqAxQc

Impaired Recall.
You may have been able to recite the latest airway textbook chapter and verse on the subway to work, but add the chaotic environment of a crash airway into the mix and suddenly your memory recall isn’t so great.

See what stress can do to your memory?

Link to Video: https://youtu.be/WkFsgU_WLko

Focus Lock.
As the stress mounts the desire to try and succeed with one more attempt at endotracheal intubation becomes a thought that overrides all others. Meanwhile your patient’s oxygen level drops to levels not compatible with life. This is focus lock.

Note insert solutions for this after this slide

Normalcy bias is one of the most common and most dangerous psychological phenomena: when facing a disaster many people underestimate the impending consequences of inaction.

Normalcy bias emerges from the cognitive dissonance of stress. Stress delays the mind's ability to process new information. In a failed airway situation, a physician may be unable to process the warning signs of a crisis, in order to "normalize" the situation they may also seek information to support the belief that the crisis is in fact not happening.

Here is a more complete description of normalcy bias.
Link to Video: https://youtu.be/e7u5_VMjWes

I had to rid myself of the belief that knowing the failed airway algorithm and being comfortable with an emergency cricothyroidotomy procedure was enough to keep me and my patient out of trouble.

I had experienced the effect of stress on my decision making ability first hand and realized that the first step towards a better performance during the next failed airway was acceptance of this fact and devising a strategy around it.

The number one failure in a failed airway that I see is the failure to recognize that the priority has shifted to oxygenation over intubation after intubation attempt(s) have failed.

Link to Video: https://youtu.be/JzlvgtPIof4

- I didn't fail because of my failure to intubate
I came to realize that what was at the heart of my failure was a fundamental misunderstanding of the nature of my failure

One of the first things I like to emphasize when unpacking the concept of rebraining is to highlight the continuing need in our profession to improve our understanding of how the brain learns, so that we can design better tools to help us keep our critical knowledge effective and ready for use.

This quote by Benedict Carey author of "How We Learn" sums up nicely the ethos of rebraining as a strategy. For a longer excerpt, click on the audio button to listen to me reading a key passage from the book.

Changing your mindset of learning from the traditional transfer of knowledge model. The biggest challenge to performing a cognitive reboots that it requires you to think differently about failure. While the process can be hard, it has a silver lining. By doing it you can move from a place where failure is so painful that it is ignored or glossed over to a place where it inspires new, creative thinking about a problem. It becomes the driving engine for improvement and the catalyst for change.

Link to Video: https://youtu.be/o_Ycw0d_Uow

Sometimes when we talk about learning and pedagogy we fall into the language of education and education research because we feel it lend gravitas to what is ultimately a murky subject. Sure we can talk about active vs passive learning, flipped classrooms, blended learning, spaced learning, and all the other terminology in pedagogy today. But let's remember three very practical things. Learning designed for humans must understand how we learn, anticipate our weaknesses and leverage our strengths if it is to be successful.

The Vortex Approach is a great example of an active countermeasure.
http://vortexapproach.org
is a great example of learning designed for humans. More than just a teaching tool, it's creators describe it as a "high stakes cognitive tool" that takes into account not only how the brain learns, but also how it recalls information under stress.

In other words it's designed to anticipate our weaknesses, and leverage our strengths, to help us access critical knowledge when we need it most.

Their great design also shows us the positive impact that placing an emphasis on how we learn (not just what we learn) can have on our clinical care.

What does this mean for the evolution of medical education? It means not teaching to the classroom and leaving learners to work out on their own how to translate that knowledge to the bedside, but creating resources that live and work in real-time and inhabit the space between the classroom and clinical practice.

I don't do education research and I don't believe in grand education philosophies, nor do I have an educational agenda. What I believe is simple, as physician we must inhabit our knowledge.

Once you've gone through this talk come back and watch this scene from The Matrix again. It might be one of the best descriptions of learning challenge ever put to film.

Link to Video: https://youtu.be/zE7PKRjrid4

When we design cognitive tools for humans we understand that words matter: that they are filled with meaning, and therefore consequences, much of it often unintended.

In a failed airway scenario when our judgement is impaired by stress, it is surely possible even probable that the word failure in the failed airway algorithm has played a contributing role in a physician making one, or two, or even more attempts to intubate a hypoxic patient because "failure is not an option".

Put this idea in your sandbox and play with it. Design a better cognitive tool the failed airwa