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

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?

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).

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.

Give induction drugs to induce anesthesia.

Ensure adequate mask ventilation.

Give paralytic drug.

Continue mask ventilation until paralytic agent has worked.

Perform laryngoscopy.

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. As your “helper” pulls out the stylet from your endotracheal tube, the stylet has the pilot balloon wrapped around it, and the pilot balloon snaps off, making the endotracheal tube cuff deflate, creating a big leak.

5. Start mechanical ventilation. Something in the back of the machine makes an irritating squeaking sound with each inspiration. The surgeon says, “Shut that damn thing up!”

In the big chapter on simulation scenarios, you can see this marriage of both functions. Some scenarios are mostly theater—dealing with an inappropriate patient in the preop assessment room. Some scenarios are mostly checklist—taking the appropriate steps once you diagnose malignant hyperthermia. But most are a delicious mélange of checklist and theater—getting a lung to deflate in a double-lumen case (checklist) while dealing with a ticked-off and demanding surgeon (theater).

So we’ve looked at this “checklist versus theater” issue from the angle of the instructor. How does it look from some other people’s point of view?

Program chairman

Resident education director

Risk management

Clinical Checklist

From a lot of angles, the Simulator as “clinical checklist teacher” has appeal.

• Consumer. “I don’t want any anesthesiologist taking care of me until they have proven they can handle all the “baddies” that can happen during a case. What the heck, they don’t let a pilot fly until he has proven that he can handle an engine flame-out, a landing gear hang-up, and a hydraulic loss. Is it so outrageous to ask that the anesthesiologist prove he or she can handle anaphylaxis, myocardial ischemia, and a tension pneumothorax?”

• Program chairman. “I don’t want to “release my residents into the wild” until they have proven their mettle. During their residence, they might not have seen malignant hyperthermia. But “out there” they may very well see this rare but potentially fatal disease. I, as chairman, am responsible for these residents, and I want them to know, to prove they know, before I sign off on them.”

• Resident education director. “How can I know that the residents know? Yes, we do in-training exams, we get evaluations from their attendings, we try to cover everything in the lectures and grand rounds, but, still, how can I know?”

• Risk management. “Keeping the rabid dogs of the legal profession off our tails is a full-time job. Setting up some kind of “we proved we can handle emergencies” or “we do everything to make sure our residents know what to do when the chips are down” may be of some help.”

• Resident. Residents who “know the score” realize that they lead a somewhat sheltered life. There’s always that attending back there who can jump in and save the day (or at least, take the heat). But as the end of residence nears, residents realize that it’s a cold, cruel world out there. When the sky caves in and a patient goes sour, you are all alone. Marooned.

“Damn, I wish I’d done more training in that Simulator!”

BOX 1-2 Who’s Interested?

• Patient (consumer)

Simulators find their biggest champions in the world of Anesthesia. No surprise, then, that anesthesia people have done the initial research on “Simulator as Clinical Checklist Teacher.”

Anesthesiologists at Washington University in St. Louis (great arch there, along with the largest Japanese garden outside Japan, plus a hip restaurant and music scene at Laclede’s Landing down by the Mississippi River) have looked at this with medical students and residents. (The article is in Anesthesiology 2004;101:1084–1095. The 41 references at the end of the article cover Simulation from A to Z. If you are going deep on Simulation information, this is the article to get. Take a look at those 41 references. They will make you an insta-Simulato-Savant.) During a single 75- to 90-minute session, residents pounded through six crises—anaphylaxis, myocardial ischemia, atelactasis, ventricular tachycardia, cerebral hemorrhage, and aspiration. They had about 5 minutes to figure out what was the matter and to fix it. For example, in the atelectasis scenario, the residents had to go through the standard maneuvers to diagnose and treat hypoxemia.

Go to 100% oxygen.

Listen to breath sounds.

Hand ventilate.

Their performance was videotaped and graded. More senior residents outperformed their junior counterparts. And glory, hallelujah to that! At least we must be teaching somebody something.

So great. But here come the tough questions, the real acid test for the “Simulator as Clinical Checklist Teacher.”

1. Do we make this a requirement? (They do in Israel.)

2. What if you’re good in every other measurable way (evaluations, clinical observation, in-service tests) but you blow it in the Simulator? Don’t graduate from the program? (Can you spell L-A-W-S-U-I-T?)

3. Take it a step further. If passing the Simulator becomes mandatory, then does a teaching tool (“Oh great, we get to go to the Simulator to learn!”) become a torture tool (“Oh no, we have to go to the Simulator to get screwed!”).

4. Take it two steps further. If passing the Simulator becomes mandatory, then does insider trading enter the equation? (“Psst, there’s a new website, Passthesimulator.com. It tells you just what you need to do to pass the ‘basic six’ scenarios that they always ask. Don’t tell anyone I told you.”)

FIGURE 1-3 The acid test regarding simulation: “Is it worth it?”

5. OK, so now it’s mandatory. Does every program have to buy a Simulator? Big bucks, especially if you have a small program. And if you don’t or you can’t afford a Simulator, then do you, what, fly your residents to a far off place for certification? Who pays? Who replaces them? Is this part of their 80 hours? Are they at a disadvantage (they never get to go in the Simulator) relative to the residents who have regular access to a Simulator?

6. Now we jump in our time machines and go forward. Are residents exposed to a Simulator actually safer? Did all that time and expense save a life? Stop a catastrophe? Ask these same questions after a “You must pass the simulator to graduate from any program” rule passes. Are these “We jumped through the flaming hoop of the simulator” residents better than “We never jumped through the flaming hoop of the simulator” residents?

Now that we’ve beaten the “Clinical Skills Teacher” issue to death, let’s turn to the second item on the hit parade—the “Simulator as Theater of the Medical World.” Let’s look at those same people who might like this “Theater” idea.

• Consumer. Behavioral therapy for the doctors? I’m all for it. While you’re at it, do a little electroconvulsive therapy for the bastards. They keep me waiting in their office for 3 hours, then they see me for 2 minutes, write a scrip for some high-priced pill (that later gets recalled because it killed a few dozen people), and blow out the door, reminding me to stop at the cashier on the way out to fork out for the co-pay. If your Simulator can breath a little humanity into those white coat-besmocked cretins, so much the better.

• Program chairman. “Oh great, another e-mail, just what I needed.”

Dear Mr. Chairman,

A word about your resident—during a code last night, your resident was entirely inappropriate. Our floor nurses have noted, on more than one occasion, that this doctor acts rudely and….

I hate to bring this up again, but Dr. Smith simply does not understand the team concept in the ICU. During his entire rotation last month, Dr. Smith….

… the operating room is not the place to engage in such theatrics …

… like a deer caught in the headlights. One would think a senior resident….

… is no way to ask for a rapid transfuser. A professional demeanor is not too much to expect from a….

Oh yes, program chairmen would embrace some behavioral improvement in their residents. If for no other reason than to debulk their e-mail inboxes.

• Resident education director. The 600-pound gorilla in resident education is the ACGME (American College of Graduate Medical Education). Residency programs from Jacksonville to Juneau are scrambling to fulfill the six ACGME-mandated core clinical competencies. These “Six Horsemen of the Educational Apocalypse” are:

Medical knowledge

System-based practice

Practice-based learning and improvement

Professionalism

Interpersonal and communication skills

At the American Society of Anesthesiology meeting, for example, entire workshops are devoted to “making sure you are covering your butt on the ACGME core competencies.”

Most programs and most specialties are good at teaching medical knowledge, patient care, and practice-based learning and improvement. But system-based practice? A little tougher. A little fuzzier. How about professionalism and interpersonal and communication skills? Tougher still, fuzzier still. Well, as these last two are kind of hard to teach, can you kind of forget about them?

Yes! That’s the good news. You can, indeed, blow them off entirely. There is, unfortunately, a small catch to this approach: The ACGME will shut down your program.

Here’s where the Simulator comes charging over the hill to rescue your program. The Simulator, especially when employed in the “behavior” mode, fits hand-in-glove with those last two core competencies—professionalism and interpersonal and communication skills. And this “salvation from the ACGME monster” can spread to other specialties as well. For example, if, say, the surgery department is found to be lacking in the “warm and fuzzies” of the core clinical competencies (professionalism and interpersonal and communication skills), send the surgery residents over to the anesthesia department’s Simulator. Cooperation between departments? Surgery and anesthesia holding hands instead of beating the living daylights out of each other? What a concept!

• Risk management. When a risk manager “looks for clues at the scene of the crime,” he or she usually comes across a host of “behavioral faux pas.”

“At this point, no one was sure whom to call.”

“Internal Medicine thought they were running the code but forgot to check with the ICU staff.”

“Upon review, no one was sure who ordered the fatal dose of….”

“By failing to check the chart, no one realized that….”

“Protocol required that … but what ended up happening was….”

“Respiratory therapy was unaware….”

What can the Simulator offer the beleaguered risk manager? A safe forum for team practice. A place to examine protocols and, if nothing else, make sure everyone knows what to do. In the panic and chaos of an emergency, roles blur, orders fly, and people die. In the HD-TV stop-action of the legal aftermath, every oversight sticks out in stark relief.

Practice, practice, practice in the Simulator. Get whole clinical teams together and clarify everyone’s role before the disaster. Hone those emergency team behavioral skills in the Simulator. If not, you can gape at your emergency team behavioral faults in court. (Does a Simulator pay for itself? If it prevents one disaster it does. Run the numbers with your hospital’s legal counsel.)

• Resident. Team learning is fun. Most of the time residents are in their own little zone, learning their own craft, brushing up against others occasionally. In a multispecialty Simulation, residents can gain some cross-connectivity. Plus they can pick up tips, tricks, and insights from their comrades in the field. When an anesthesia resident, an ICU nurse, a respiratory therapist, and an internal medicine ICU fellow get together, everyone learns something.

FIGURE 1-4 A. ACGME is the 600 pound gorilla in medical education. You ignore it at your own risk. Fortunately, education in the simulator can fill in a lot of core competencies. Fuzzy, Montessori-esque competencies such as Professionalism and Interpersonal Skills lend themselves to simulator-based education. Note (B and C)—This gorilla can assume many shapes and can appear anywhere.

Behavioral learning is a real eye-opener. Medicine can be pretty cut-and-dried.

Algorithm for myocardial infarct

ACLS protocol for pulseless V-tach

Fluid guidelines in resuscitation

So when you take a “walk on the wild side” of behavioral education, you step out of “memorization” mode and get into “independent thinking” mode—something most medical people haven’t done since college.

How do you deal with “Do Not Resuscitate” orders when the family wants one thing and the patient another?

If you encounter a cultural hitch in your clinical routine (a Somali immigrant insists on a female anesthesiologist but you’re a man and the only anesthesiologist on call), how do you react? Now the fetal heart rate monitor registers a big decel and she still doesn’t want you to touch her. What next?

Ants got into your ICU and bit up a newborn on a ventilator. How do you professionally break this horrible news to a yuppie couple who just appeared on the cover of Parenting magazine?

A lone electron can sort of do “two things at once”—miraculously passing through two holes at the same time. Can simulators perform similar “quantum mechanics”? Can simulators constitute both a clinical checklist and an educational theater? Of course.

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