What Is a Simulator–a Clinical Checklist or a Theater?

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CHAPTER 1 What Is a Simulator–a Clinical Checklist or a Theater?

“Schrodinger’s cat is both alive and dead.”

One of many unfathomable ideas from quantum theory

Jimmy grows up, insists you call him “James” now, although most of the students in his quantum physics class call him “Professor.”

In this most advanced of disciplines, the professor still delivers his lectures the old-fashioned way—white chalk on a blackboard. The students shuffle in, take off their bulky jackets, and set up their laptops to take notes. James had initially resisted this maneuver, and he found the clicking keys irksome; but alas, after a while there was so much clicking it became a kind of white noise, and you tuned it out.

“What does a single electron do when it comes to this sheet of metal with two holes in it?” the professor asks.

No one’s hand goes up. There weren’t any hands free; they were all glued to their keyboards!

James turns around, draws a square representing the sheet of metal, and draws a little dot, the electron, with a little arrow pointing toward the square.

Click, click, click, click, click, click.

(“How are they drawing this picture on their computers?” James thinks. “Notebooks and pens were better for drawing pictures.”)

“Simple,” James explains, “the single, indivisible electron passes through both holes.”

Click, click, click… click. Click, click. Click. Click.

The clicks fade out and the lecture hall gets quiet. Outside, in the distance, the carillon’s bells start playing “Amazing Grace.” Every student’s head lifts up from their laptops as they look at the blackboard.

The single electron passes through both holes.

Now just how the heck can it do that?

A single simulator passes through a couple holes of its own. For a simulator can be viewed as two separate creatures:

A clinical checklist
A theater

But like the elusive and tricky electron, the clinical checklist and the theater inhabit the same simulator experience. Is this as incomprehensible as quantum physics?

No. As the core of this book—the 50 simulator scenarios—show, each scenario has an element of the clinical checklist, and an element of theater—educational theater.

BOX 1-1 What is a Simulator?

• Checklist
• Theater

image

FIGURE 1-1 Our simulation center has a quantum level camera that actually caught this electron in midflight. As you see, the single electron behaves in a curious “dual” manner, going through both holes and remaining a single electron. The simulation center also functions in a curious “dual” manner. Both checklist and theater, the simulation center tests your ability to “go down the list” (give oxygen, start nitro, send a blood gas), as well as your ability to “act in a theater” (interact with others, lead appropriately, communicate clearly).

image

FIGURE 1-2 A. Checklist. In the simulator, you want to make sure that you do each of the “items” on the checklist, just as you would do with a real patient. The checklist is the most common way of grading people on their performance, and you often see a checklist in a simulator study. B. Theater. There are other, more subtle things that go on too. These don’t so readily fit on a checklist. Here, a doctor asks an inappropriate question in front of an awake patient. Not a good thing to do!

For example, you set up a simple scenario for medical students:

INDUCING GENERAL ANESTHESIA IN A ROUTINE PATIENT: CLINICAL CHECKLIST
Check the preop and consent.
Make sure airway equipment, suction, and drugs are ready.
Talk to the patient, reassure them, make sure they are NPO.
Apply routine monitors: EKG, BP cuff, pulse oximeter.
Preoxygenate.
Give induction drugs to induce anesthesia.
Ensure adequate mask ventilation.
Give paralytic drug.
Continue mask ventilation until paralytic agent has worked.
Perform laryngoscopy.
Intubate.
Ensure correct tube placement.
Institute ventilation.
Secure endotracheal tube.
Check vital signs.
Start anesthetic.

You could throw in other steps (sedate prior to induction), or you can take out steps (if a bunch of medical students are standing around, just have them intubate, one after another, so everyone gets to do something). But the idea is the same—you use the simulator as a checklist. You ensure that the student does the right things in the right order.

“Oops,” the instructor corrects, “you just induced, but you forgot to preoxygenate first. Let’s try that again.”

“Nope, nope,” the instructor observes, “you induced anesthesia all right; but if you put that laryngoscope in before you give the paralytic, you are going to be in for the fight of your life as they bite down on that scope.”

Good lessons all, and good lessons linked to the “simulator as a clinical checklist.”

But the good thing about the simulator, and what really gives it a zing from the instructor’s and the student’s point of view is that the simulator also functions as “educational theater.” And theater is limited only by the imagination of the playwright and the actors. So you can end up with Juliet lamenting her romantic plight, Willie Lomax lamenting his wasted life, or Stella lamenting that she has “always depended on the kindness of strangers.”

Bring up the lights, lift the curtain, and “Break a leg.” The educational theater is going live. Anything—but anything—that the instructor wants to teach is now on the playbill.

Inducing General Anesthesia in a Routine Patient: Theater

1. Check the preop and consent. “Wait!” the preop nurse says, “this consent is outdated, and you gave her some sedative already, what should we do?”
2. Preoxygenate. “Oh, I can’t stand that!” the patient shouts. “I’m claustrophobic, that shut-in feeling with the mask just kills me, get it off, get it off!”
3. Perform laryngoscopy. The light doesn’t work, even though it did before, and you don’t have an extra scope around. You turn to tell the circulator to get you another one, but the circulator is in the middle of a count and won’t be bothered.
4. Intubate.

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