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.

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.

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.

“Well,” one of your colleagues says, “we had one person genuinely shot and dying of hypovolemic shock. We had one fellow who just got swept up in the pandemonium of the shoot-out, and then we had the kid with a separate thing going on.”

Another student says, “So we needed to get blood and full resuscitation to the one guy, just support the airway on the other guy, and just move the kid to another place so the ENTs could fish out that peanut from his ear.”

“So,” the first educator asks, “it looked pretty much like you guys divided yourselves up pretty productively. Anything else you did well?”

At this point, the educator stands up, goes to a white board, grabs a marker, and writes a large “T” with a “+” sign above the left column and a “delta” sign above the right column.

He says, “This is a ‘+, delta’ discussion. We talk about what we did right – the ‘+’ side, and what we’d do differently – the ‘delta’ column.”

“We’re so geared to flagellating ourselves, to beating ourselves up, that we often forget to note what we did right,” he says, “And we learn from what we did right as much as by what we did wrong.”

After a few minutes, we flesh out our “+, delta” columns.

“To understand better what happened, why don’t we see what happened?” the first educator asks.

Everyone groans. The thought of having your sins splashed in front of the whole world in living color is a little daunting.

Roll tape, and oh my God but the camera does indeed throw an extra 10 pounds on you.

No matter how “in control” you might have thought you were, the tape shows just how random and maniacal you actually do look. Overlaid vital sign screens show stuff you simply didn’t notice. A minute of asystole before you do anything.

Table 2-1 The +/Delta System

Plus	Delta
Divided up well Assessed airways right away Got blood right away

Didn’t check EKG

Couldn’t handle mother

Didn’t ask for help early

“How did I miss that?”

Lots of repetition. Missed communications. Random motion more reminiscent of a lost Hansel and Gretel than of trained clinicians.

The second educator speaks, “We’ve found the videotape to be as valuable to us as it is to the golf instructor. People literally say, ‘I didn’t do that,’ when the tape clearly shows them doing just that.”

“It’s like the dashboard cam on COPS,” the first educator says.

“We’re busted,” one of your co-simulatees says.

“Ah,” the first educator says, “it’s worth revisiting an important point here about the entire simulator mindset. Your reaction is natural: ‘You caught us, we screwed up, pin the tail on the donkey.’”

“We’re not here to pin the tail on the donkey. We are here to see:

What was your mindset?

What actions proceeded from your mindset?

What resulted from those actions?

How did you assess the results?

What did you do with that assessment?”

“In other words, we’re back to “Every event is a mystery to be solved, not a crime to be punished.”

The educator goes on with a bunch of “mysteries to be solved.” The goal in each one is to discover the thinking behind the event, rather than the event itself. If you uncover the thinking and can correct the thinking, you can change the behavior that results from the thinking. You discover the root of the problem, so you can prevent further problems.

“As we try to understand what happened in there,” the second educator says, “we need to look at what was going through your heads.”

“What movie was playing in our heads?” the first instructor says.

“Yes!”

I speak up, “Well, I was going through the ‘ABC’s.’ Someone’s shot, make sure the airway’s OK, get volume access, treat the deadly stuff first.”

Another person says, “Pneumothorax, blood loss, tamponade. All the stuff that kills you fast.”

“Torn viscus, torn aorta.”

In the “clinical” arena, most of us feel in our “element.”

“And how do you decide who should handle the screaming mother in that situation?” the second educator asks.

At this point, the actor who played the mother joins in, “Look, this is my baby, and he got this peanut in his ear and is screaming bloody murder. I’m trying to keep the baby calm, and all these people come rushing in, and now they’re screaming too. I just moved here from Portugal so I can’t understand anybody.” The actor “respects her character” and voices what “movie was playing in her head” during her scenario.

At this point, clinicians tend to clam up. Whereas you zip off clinical stuff (pneumothorax, blood loss, airway management), you screech to a halt in the “behavioral” area.

And here you have a MAJOR POINT OF INSTRUCTION IN THE SIMULATOR! Most of us are good at clinical things, as we do them every day. We replace blood, treat bronchospasm, intubate. But we rarely practice the behavioral things so critical in an emergency.

These are the principles of “crisis resource management”—an entire field of study. (Entire textbooks are written on the subject.) Crisis resource management originally looked at how crises are handled in airline cockpits, nuclear reactors, and the chemical industry. For example, before a plane crash, no one challenged the pilot about how low he was flying (no one stepped back and did a global assessment of the overall flight). At Chernobyl, no one reacted fast enough when the reactor started to overheat (no one knew of other resources available for cooling). In the Bhopal chemical spill, no one took charge of the safety mechanisms (there was no role clarity in the Dow Chemical Company’s safety department).

BOX 2-3 Crisis Resource Management

FIGURE 2-2 Crisis resource management boils down to keeping your eyes peeled. The term itself, crisis resource management, is a little goofy. Crisis has such frightening overtones. The Hindenburg bursting into flames is a crisis. Resource management has all the derring-do of a pony ride at a corner carnival. Running out of paper clips and ordering more is resource management.

Now, the principles of crisis resource management are entering the OR, the ER, and the ICU. We, as doctors, ICU staff, ER personnel, need to know these same principles in a medical emergency.

The first educator writes the principles of crisis resource management on the white board. Then, over the next 10 minutes, we fill in how our scenario demonstrated each of those points.

1. Role clarity

Establish right away who is charge of the entire room, not just one of the beds. We never did that. We broke into three small groups but never had one person in definite charge. One person who got all the information and gave all the orders. Others needed to establish what their role was.

“I’ll take the airway on bed one.”

“I’ll give blood.”

“I’ll assess bed two.”

“I’ll take the kid.”

Without role clarity, the room goes to “chaos theory,” which, truth to tell, is what happened in your scenario.

2. Communication

When the fur starts flying, it’s easy to overload and just start yelling for things. (That’s exactly what you did.) Instead, you should address people directly, better yet, tell them by name, even if you have to grab their ID badge and turn it around so you can see their name. Close the loop in communication. When someone tells you something, repeat it to make sure that you got the right information.

When the first patient coded, you told one of your colleagues, “Start chest compressions,” and right away she said back to you, “Start chest compressions, right?” She closed the loop on your exchange. (In a classic example of not closing the loop, a pilot of a 747 on Tenerife in the Canary Islands started to take off before he had clearance from the tower. His co-pilot said, “We don’t have clearance.” The pilot did not close the loop and acknowledge this critical piece of information. More than 500 people died.)

3. Personnel support

As you were struggling with these three patients in the ER, it didn’t occur to any of you to call for additional people, such as security to take care of the screaming mother. As a rule, it’s good to call for help early if it looks like you’re getting overwhelmed.

Once support arrives, you want to make sure you use the support personnel well. Give them a quick update and tell them what the issues are. In your room, for example, if another physician had come in, you could have said, “We have some gunshot wounds here. Do me a favor and assess the vitals on each of these patients.”

The other thing you want to do is assign people to either a “doing” job or a “thinking” job.

“YOU, squeeze blood into patient number one.”

“YOU, come over here by me, help me straighten out who needs what here. I don’t know what’s going on with the baby.”

4. Manage resources

Blood loss was going to kill the first patient. So get the wheels in motion to get more blood, even O-negative blood in a pinch. That’s priority number one, so get your “doing” people on that right away.

Once you’ve assessed that the other two patients are OK, get them moved out of the room so you can put all your “energy” eggs into the resuscitation basket.

Figure out who can do what for you. The cop can’t intubate, but he can usher the distracting mother away. The anesthesiologist can get you an airway and a big line, so do not ask him (or her) to deliver the blood sample to the lab.

5. Global assessment

A big “no no” in a crisis is fixation. You start along one line of thinking and can absolutely not be shaken from that line of thinking. In an emergency, with a ton of information pouring in, you “clutch at straws”; you grab for the first thing that can make order out of chaos, and you hang onto it.

In your case, there was a shooting, and you saw blood on the sheets. So, damn it, everyone in that room was shot. If you fixated on that, rather than stepping back and thinking coolly and examining the patients individually, you would have placed monster lines in everyone. Including the kid with a peanut in his ear!

Not exactly a case of volume resuscitation.

So you need to step back. Think. Invite others to think. (You may be “in charge” of the room, but everyone in that room should be thinking.)

Another crucial aspect of global assessment is to verbalize what you are thinking. That lays bare the “current thinking” in the room and invites others to speak up and clarify if they disagree.

“OK folks, we have three people down with gunshot wounds, so we need blood for everyone. Let’s get some lines.”

“Wait, this second guy is OK. No blood on him, and his pulses are strong.”

“Same with the kid, he’s free of blood, is breathing, no trauma here.”

(Good time to re-verbalize, update the room.)

“OK, three people down, need blood and big time resusc in bed one. Basic support for beds two and three until we clear up what’s going on with them.”

That’s global assessment. Ongoing, never static.

“OK, what do we take away from this,” the second educator asks.

The clinical points take a back seat to the behavioral points. That is the exact opposite of how you started … the exact opposite of your usual, clinical orientation. The clinical scene functioned almost like kindling wood in a fire. The clinical scene started things but was not the focus.

“Well,” one colleague says, “we need to talk to each other more clearly.”

“I can see now,” another says, “that you really need to drill code teams on how to do things productively. You can’t just assume everyone will know what to do.”

“It’s hard to not get fixated on one thing,” you say.

You go on for another 10 minutes, pulling “larger” lessons out of your Simulator experience. Then you draw back even farther and try to apply what you learned to your bigger goal, learning the simulation process.

1. Debriefing is the heart of the matter.

2. A good video system aids in the debriefing process.

3. Posters help in the debriefing room. (Posters should emphasize major behavioral points such as role clarity, reassessment, management of resources.)

4. Refrain from “going clinical” right away and falling into a lecture on, for example, how to treat asystole.

5. Focus on the wise words, “It’s not about the dummy, dummy, it’s about you, dummy.”

Here, then, are the major steps of the debriefing in review.

1. Eavesdrop

This is the stage, after the Simulation scenario, where everyone is “unloading” as they walk down the hallway. Skilled educators walk along, keeping their ears open, listening for issues important to the participants. For example, one of the participants says, “What do you do when you’re new to the ER and don’t know where the equipment is?” OK, unfamiliarity with equipment in a new setting is an issue. The educator picks up on that and talks about it during the debriefing. Another participant says, “It’s tough when you’re distracted by a hysterical parent.” OK, dealing with distraught family members is another issue. The educators pick up on that, too, and talk about it during the debriefing.

2. Reactions

You go over the feelings of the participants. No matter how well prepared or educated, anyone gets a little “rattled” by the simulation scenario. That “rattling” is a critical part of the process. To propel learning, you need to create a little emotional “irritant.” For analogies, look to physical exercise: You tear down your muscles a little at the gym, then the muscles repair themselves, and you get bigger muscles. Another analogy is the sand grain that irritates the oyster. Give it enough time, and that irritant turns into a pearl.

BOX 2-4 The Heart of the Matter

• Debriefing

• Video

• Posters

FIGURE 2-3 During a scenario, residents tend to get pretty wound up. They “let loose” in the hallway and “spill their guts” to each other. “Oh man, I didn’t see those ST segments!” “Did you think we needed to transfuse?” The clever instructor takes advantage of these “hallway confessions” to see into the residents’ minds. Here, the instructor is so subtle that you would never guess that he is listening in.

3. Understanding.

Now is when you digest what happened. You try to make sense of that chaos in the ER; you examine what you did and what you were thinking. Understanding the behavioral aspects of a simulation are important. You don’t just focus on the clinical things that were done.

4. Summary.

Review what happened and put things in a larger context. That is, at the end of this particular scenario, draw broader conclusions than just this particular ER. Put the lesson in a big picture of: “What do you do when a lot of people are in trouble, and you have to sort it out?”

BOX 2-5 Steps in debriefing

• Eavesdrop

• Reactions

• Digest

And there you have it, a medical simulation from stem to stern.

Let’s take a step back for a moment and look at the equipment that goes into these simulations.

Simulation In Anesthesia

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A CONFERENCE, INTERRUPTED

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