How Anesthesia Simulation Is Done

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CHAPTER 2 How Anesthesia Simulation Is Done

“I think I killed him. Can I try again?”

—Overheard in the simulator

Nothing like jumping into a medical simulation to see how it works. Here goes. You’ll see how it works from the point of view of a participant.

A CONFERENCE, INTERRUPTED

You are sitting in a conference room. Someone runs into the room, breathless. “There’s been a shootout, we need a hand.”

You and some fellow simulatees get up and head down the hall. You go through a doorway into a white linoleum-tiled room with screens between three gurneys. On each gurney is a Simulator, covered with a blood-spattered blanket. Two of the Simulators are adults, one is an infant. Each has a monitor and an IV attached. A woman is crying out in Portuguese, draping herself over the infant. A cop is trying to pull her off, but she won’t let go. Two people in white coats are standing at the head of each bed. One is mask-ventilating an adult, one is standing, ignoring the patient and pressing buttons on the monitor; no medical person is by the infant. A red light is going off in the corner, and an overhead speaker is saying, “Code Blue, cafeteria. Code Blue, cafeteria.” As you come upon this scene, a man in a white coat asks you where the cafeteria is because he is going to go take care of the code there.

There are seven of you in your simulatee group. You split up, two to the adult beds and three to the infant. Everyone starts yelling

“Get me an intubation kit!”

“Does this monitor work?”

“This is for an adult, this is too big!”

“Get the blood bank on the phone!”

“Suction, suction, where’s the Yankauer?”

“Volume!”

“This is asystole, someone feel a pulse, do you feel a pulse?”

“Forget that, how do we put his head down!”

“This light is out! Get me another one!”

One adult codes and stays dead, despite CPR. One adult starts blinking and talking, despite a flat line. You notice that an electrode has been pulled off. A brief history reveals that this guy just fainted at the scene of the gun battle, had been covered by a bloody blanket, and had ended up in the emergency room by happenstance.

You go over to the baby and try to intubate when the cop says, “Wait, her kid was in here to get a peanut removed from his ear. He didn’t get shot!” Then, on looking back, you notice that there actually isn’t any blood at all on the baby’s blankets, though you could have sworn there had been.

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FIGURE 2-1 Howdy pardner! Come on down to the shootout at the OK Simulator. Jazz up the scenarios with some theatrics and props. It’s fun. Just don’t let the boss know how much fun you’re having or he/she will cut your pay.

After 15 minutes, which seems like 2 hours, an instructor walks in the room and says, “Thank you, doctors, this simulation is over.” You look around the room at your fellow simulatees. You all look like you’ve been driving for hours in a convertible with the top down. As you walk back down the hallway to the conference room, a torrent of babble pours from everyone’s mouth. The instructors walk behind, listening.

“Oh man, can you believe that?”

“I thought everyone was shot!”

“I went right to the airway, but then he talked!”

“With that guy in asystole, do we bother or just bag it?”

“Mass casualty drill, I was thinking, but didn’t they say a lot of people were shot?”

“No, did he actually say that?”

“Who were those people in there? I know the cop was a cop, but the other ones?”

“Med students?”

“Respiratory?”

“Wait, was that guy a cop?”

You are back in the “safe” room, where trickery and chicanery have no place. You are in the debriefing room.

BOX 2-1 Debriefing

• Make sense
• Replay
• Rethink

You sit around in a loose semicircle, with two instructors on opposite sides of the room, facing you but at an angle. Not you versus them; it looks more like a cooperative effort with the instructors “among” you, discussing, rather than a solid phalanx of educators “in front of you,” ready to lecture you naughty, naughty children.

No instructor rushes to start talking. They sit and listen for a few minutes, letting you and your compatriots “decompress.”

“So, how do you think it went?” the first instructor asks.

That opens the floodgates!

“I felt so unsure of myself!”

“I didn’t know the equipment!”

“Was I supposed to take charge? I mean, I don’t even know these people.”

“It’s hard to know where to go first.”

While this is going on, the “actors” in the Simulation walk in and quietly sit down in the room. Of note, they don’t come in smiling and joking and “We gotcha”-ing. They come in the room “in character” and sit down to listen.

This seemingly trivial point is part of the Simulation process. It’s called “respecting the character.” The actors, as the case is discussed, continue to voice their concerns as they arose during the scenario. In other words, the woman crying out over her child explains to you why she was upset and how she viewed the scenario unfolding. The cop explains what was going through his mind. Neither character walks up to you, gives you a high five, and says, “Wasn’t that great? Didn’t I seem like a real cop?” If they did that, it would not “respect the character,” and you would not learn as much from them.

“The emergency room can be a confusing place, can anyone tell me what was happening in there?” the second instructor asks.

The question is open-ended, the kind of question that opens discussion. This questioning period after the event is called the “debriefing” and is the most important aspect of the simulation.

Two truisms:

You do a Simulation in order to do a debriefing.
During the debriefing you make sense of what just happened.

You and your co-learners respond to the scene that just played out:

“Yeah, oh man, was it ever confusing in that ER!”

“Who’s dead, who’s passed out? What’s going on?”

“Blood everywhere.”

“Then you’re thinking ‘everybody’s shot,’ but then I’m new to this ER so I don’t know if they have a trauma bay for the really bad ones or if everyone just gets clumped together or what?”

“Then the EKG thing, I mean, two people flat line and one’s really dead and the other’s just pulled his electrode lead off.”

The first educator speaks up, “I saw three patients with different needs. Can anyone lay out for me who needed what?”

Even in the phrasing of the questions there is “method to the madness.” Questions are phrased to look for “good judgment” on the part of the simulatees. You don’t make a judgmental question, you don’t make a nonjudgmental question; rather, you make a good judgment question.

The following demonstrates the difference between a judgmental, a nonjudgmental, and a good judgment question.

Judgmental (you, the examiner, know what should have been done and state so explicitly): “So you blew it with the EKG electrode and got distracted by the hysterical mother. Shouldn’t you be able to tell the serious from the trivial?”
Nonjudgmental (you, the examiner, know what should have been done, but you cagily keep your judgment to yourself. This is called the “iron fist in the velvet glove” approach.) “So, there’s a flat line and so…?”
Good judgment (you, the examiner, view everything that happened as a “mystery to be solved, not a crime to be punished,” so you phrase your question as a way to tease out what everyone was thinking. You’re not afraid to throw in your own observations. You don’t hide your cards or pretend, blithely, that you are as impartial as a Martian observing from outer space.) “I saw three patients with different needs. Can anyone lay out for me who needed what?”

This last method, the “good judgment” method, is the best way to ask questions during a debriefing.

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