With What Other Disciplines Should We Work?

Published on 27/02/2015 by admin

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CHAPTER 6 With What Other Disciplines Should We Work?

“Why can’t we all just get along?”

Rodney King

Cooperation among specialties, especially between anesthesiology and surgery, is the stuff of legend. Of note, a legend is defined as “a story coming down from the past; one popularly regarded as historical although not verifiable.”

Try verifying this legend.

A 68-year-old man with benign prostatic hypertrophy was on the OR table, spinal anesthetic in place and functioning well. He was a calm man requiring little sedation, so he was quite awake and aware of his surroundings though, of course, unable to move his lower body with the spinal anesthetic on board. The drapes were up and the circulator was prepping the patient.

His urologic surgeon and his anesthesiologist were discussing the schedule in a manner most heated. Both doctors were standing to the left of the OR table, on the patient’s side of the drapes, so the patient, merely by turning his head to the left, could see them.

And, of course, he could hear them too.

“They was sayin’ somethin’ about some other guy, I guess it was someone gonna have the same thing as me, you know, the ream out job of the prostate,” the patient said. “And they’s gettin’ louder, you know, which first I think is kinda funny ’cause I thought doctors just talk that quiet kind of ‘I’m real smart and you’re not, so I’ll take this real slow’ kind of talk.

“But now they’s yellin’ and start to pushin’ and I’m thinkin’, ‘Hell’s bells who’s gonna do the ream job if one of em cold cocks the other one?’ and sure enough they start throwin’ punches. I’m not kiddin’.

“Well I had to laugh cause I thrown a few punches in my day and these docs here they look more like girls fightin’ and pretty soon it’s a huggy up and down to the ground they go and they’re rollin’ around. And now the one nurse comes around and spill some brown stuff out a little plastic dish and she’s yellin’ and people comin’ in hollerin’ and oh my God such a sight to see and here right in the hospital and me so numb and jes’ layin’ there with all my privacy danglin’ in the breeze for all the world to see.”

Suffice it to say, there is room in this world for more cooperation between the specialties. What better place to accomplish this than the simulator!

The simulator is just the place to mix and match the various medical elements, getting them to work together in a crisis, iron out who does what, and most importantly to start to talk to each other.

• Anesthesiology and Surgery—to foster better understanding in the OR, and possibly reduce the number of fist fights!

• Anesthesiology and Internal Medicine—we most often encounter each other in the supercharged atmosphere of a code. No time for much dialogue in a real code, but there sure is in a Simulator mock code.

FIGURE 6-1 Interdisciplinary interaction can get heated in the hospital.

• Anesthesiology and ICU nursing staff—another group of highly trained specialists we work with every day. Training together in the Simulator makes perfect sense, plus can help build esprit de corps among ICU teams.

• Medical students and nursing staff—as the twig bends, so grows the tree. At an early point in their training, future doctors can practice doctor–nurse interactions in a crisis.

• Anesthesiology and OR nursing staff—we work hand in glove with the OR nursing staff through all kinds of emergencies. Because we work together, we should practice together too.

• Anesthesiology and anesthesia techs—we need their help in a big way in the big cases, so practicing together in the Simulator with them makes sense too.

• Anesthesiology and Pharmacy/Information Technology/Billing—automatic pharmacy dispensing systems, automated billing and record keeping, all these elements are entering the ORs. And new systems have quirks, glitches, and potential disasters. Work them out in the harmless setting of the Simulator.

• ER docs and EMTs—hand-off of the critically ill patient has its own set of dangers. Do a few “critical handoffs” in the Simulator to make sure the transition from emergency response team to hospital team is seamless.

• Anesthesiology and OB—you want a critical situation where two specialties may be at odds, try the stat C-section. Every variant (lost airway, twins with the second one breech, shoulder dystocia that just won’t go) you can rehearse together in the Simulator.

• Anesthesiology and Pediatrics—neonatal resuscitation after a stat C-section? The Simulator’s the place to work it out.

• Intensivists (from any discipline) and nursing staff.

• Intensivists and nursing students.

• Office-based practitioners (plastic surgeons/oral surgeons) and their nursing staff.

• Military teams of doctors/nurses/technicians.

The list goes on. In the Simulator, any combination, any threesome of different specialties and training can work together. You can put together entire teams, for example look at all the people involved in a code.

ICU nurse—calls the code

Unit clerk—sends out the word, makes sure the code cart is stocked, ready to go, and refilled at the end of the code

Anesthesiologist

Surgeon (say it were a surgical intensive care unit)

Respiratory therapist

Pharm D (often in intensive care units these days)

Medical students

Nursing students

A whole army of people descends on a code, each with a certain role to play. And rather than working together the first time in a real code, it is better to practice together the first time in a mock code.

And even those who may not participate to a large degree (the Pharm D, for example, or some extra medical or nursing students) may benefit from seeing how a code’s done. Plus, the Law of Unintended Consequence plays a role. The Pharm D may be an expert on resuscitative drugs during a code, long-term problems with amiodarone, and current thoughts on the ever on-again, off-again role of bicarb or calcium. So at the end of the code team’s exercise, the well informed Pharm D may bring everyone up to speed with an impromptu talk.

Good things happen when you throw people together.

Scheduling hassles with this multidisciplinary love-fest? Yes.

As detailed in the previous chapter, moving the meat around is the biggest headache of “Simulato-land.” So getting people there and, trickiest of all, getting different disciplines there at the same time is tough.

FIGURE 6-2 Lost in these “ego battles” is the question, “What is best for the patient?” We may get all huffy and defend our ego, our specialty, and our point of view to the exclusion of the patient’s welfare. Wrong maneuver! Remember the mantra, “Patient first.”

• ICU nurses? The nursing shortage landed with a loud thump in our intensive care units. Pull a few ICU nurses from a busy ICU when they’re getting unexpected admissions? Fat chance.

• Surgery residents? Surgery programs are strug-gling with the 80-hour rule, just like all the other specialties. So on any given day, they may have to send someone home in the middle of the work day as he is fast approaching “Hour 80.” Now the clinic is busy, they’re short already, oh, and now you want us to send someone to your Simulator session? Fat chance.

• Information technology person? The entire pharmacy system just crashed, and no one’s sure if it’s a virus, a Trojan horse, a phish attack, or any of the other myriad cyber-assaults upon every computer system in the world. Or maybe it’s just that this system is too old to handle all this information. Oh, is that simulation thing today? And you expect me to go with this going on? Fat chance.

• Medical students? They just matched last week, so they’re all blowing off everything in this, their “Swan song of goofing off” before internship starts and life ends for them. Will they arrive on time or, for that matter, at all? Right.

So, once again, something looks good on paper—“We’ll all work together, learn together, grow, and self-actualize. The moon will be in the seventh house, Jupiter will align with Mars, and this simulator session will usher in the dawning of the age of Aquarius.” But scheduling this educational free love-fest becomes a logistical nightmare.

Oh, what about the money? Oh, that.

• ICU nurses. Would they expect to get paid for their time? You bet they would, and at last glance ICU nurses do not come cheap. Who would pay for them? The hospital? Sure, all the hospitals are flush with cash, they’re drowning in black ink, they’d love to cough up the dough. Can the Simulator pay for them to come over? Um, Simulator centers usually want to charge people for coming over there. Hmm. Who would foot the bill for the ICU nurses?

• Surgery residents. Though less of an “hourly wage” question, you still have to consider that, for residents, time is money too.

• Pharm D, information specialist, anyone else who wants to join in—you still have to answer the tough question, “Who is paying them while they spend time in the Simulator?

So time and money rear their ugly head. While we’re tossing wrenches in the works, try adding this one—coordinating the schedules of all these people.

Friday is a slow day in the ORs, a good day for anesthesia.

But Friday is the clinic day for surgery, bad day for them. How about Thursday?

Thursday is in-service day for the ICU, when they give their CME credits and get everyone ACLS certified. But Wednesday is all right, how about in the mornings?

Wednesday morning is inventory for pharmacy; and with a spate of inconsistencies in narcotic returns, the DEA is up in arms so … Tuesday?

But on Tuesdays, the medical people have Grand Rounds and that’s their busiest day, so … Monday?

How about next week? Oh, that’s right, everyone’s out of town for the conference?

How about Wednesday, May 5, 2097 from 1 a.m. to 2 a.m., that’s the one time that everyone can. …

So it’s impossible, right?

BOX 6-1 Making Simulators Happen

• Talk to kahunas

• Get $ backing

• Rent to train others

Never. This is where you have to go to the big guns, invoke the hammer of Thor, and smash all resistance with one mighty swing.

Go to the Chairman of the Hospital, the Dean of the Medical School, the President of the University. You must make the pitch to the Mightiest of the Mighty, the All-Powerful, the Holder of the Purse Strings.

(Running a Simulator center, you have to be part pitchman.)

In a frank discussion, you lay out all the problems detailed above, but you end with, “But this is something we just plain need to do, no matter how, we just need to do it.”

If they don’t back you, indeed the problem is unsolvable, and any one of the above-listed problems will torpedo your multidisciplinary effort.

But if they do back you, the problems part like the Red Sea before Moses’ staff. The head of surgery sends you his resident, the ICU finds a way to cover for that nurse, IT lives without their tech for one morning, and someone covers that OR and springs an anesthesia resident.

Then, once you have called on “help from above,” you run a great simulation, get everyone excited about this new learning method, and you’ve planted the seeds for future “help from below.”

I kid thee not, this takes a lot of energy. It’s hard enough to pull your “own” residents. But keeping the energy level high enough to pull “other” residents, ICU staff, and the like is draining.

Nothing worthwhile is easy.

Same goes for running a multidisciplinary simulation center.

Let’s take a peak at the kind of stuff that can come from these “adventures into the multidisciplinary unknown.”

NEW DRUG-DISPENSING SYSTEM

Pharmacy and the information technology people have put together a new system for dispensing drugs. This system uses a log-in and fingerprint recognition system. The pharmacy and IT people gather round as a senior resident starts a simulated case. This resident uses the old system of getting drugs—a cart with all the drugs just sitting in drawers.

FIGURE 6-3 Automated drug dispensing systems can baffle anyone. Why not get used to them in the simulator? That way, if you flounder around, no one gets hurt.

A second senior resident goes through the same scenario later with the new system of getting drugs—log-in and fingerprint recognition system.

“The patient is a 55-year-old man with end-stage ischemic heart disease and one episode of sudden death. Fortunately, he collapsed at an automatic external defibrillator Mardi Gras party and was saved, going on to win third prize in the “Best Costume” contest.

“Now he is for implantation of an AICD. He has external pads on and is ready for induction.”

The first resident does a careful induction, mindful of the patient’s tenuous cardiac status, but at intubation the sympathetic simulation proves too much and the patient fibrillates.

“Shock! Defib!” the anesthesia resident shouts.

An OR nurse (part of the multidisciplinary team too) works the defibrillator as the code protocol rolls.

Shocking is the most crucial thing, but after three shocks it’s time to go to the next step. The anesthesia resident intubates, CPR starts (a medical student does chest compressions), and then it’s time to get the drugs.

The pharmacy/IT people note the time and ease of getting the drugs out, but also note that at the end of the case there is no record-keeping, no charges filled out for the drugs. The important stuff was the code, of course, and billing/paperwork play second fiddle.

But still. If we never charge, if we never fill out the paperwork, the hospital goes broke. So you can’t just blow this stuff off. And this is part of systems-based medicine, a core clinical competence we must teach as mandated by ACGME.

So at the end of the simulation, everyone’s learned something.

• The anesthesia resident ran a code and also learned about systems-based medicine.

• The OR nurse participated in the code, with a hands-on review of the defibrillator.

• The medical student got to observe and do chest compressions.

• Pharmacy and IT picked up a weakness in the “paperwork chain of command.”

And all these lessons at no risk to a patient.

Now the second anesthesia resident enters the room, does the same induction, with the same results. When she goes to get drugs out of the automated system, there’s a hang-up: she enters the code wrong, waits while the fingerprint reader does nothing (it hadn’t gotten the correct input yet), and the resident couldn’t get the emergency drugs. Valuable time passed (CPR is in progress, after all) before the resident enters the correct information and springs the drugs free from the new machine.

At the end of this simulation, people have still learned good lessons.

The anesthesia resident ran a code.

The OR nurse worked the defibrillator again.

The medical student did chest compressions.

But aha! The big lesson went to our pharmacy and IT people.

That roadblock of a code entry and fingerprint read prevented easy access to the emergency drugs. Precious time slipped away in an easy-to-imagine sequence.

You’re in the middle of a code.

You type in stuff too fast.

You don’t notice the computer gives you an error message.

You stand there with your finger on the scanner, mad with impatience because the room is going bananas with this code in progress and you can’t get the damned drugs!

IT and pharmacy go back to the drawing board, and add a “code button” to the dispenser cart, allowing instant access to code drugs in an emergency.

Thank goodness this problem was worked out in the simulator, and not at the expense of a patient’s life. This is the kind of magic that can happen with a multidisciplinary approach to simulation sessions. In the GREAT BIG chapter on simulation scenarios, you will see more of these multidisciplinary efforts in action.

And there’s a final twist to this “bring in other people” idea. If you are in a university setting with hot and cold running grad students, you can bring in nonmedical people to participate in and study the entire simulation experience. They will learn something, and they may very well enhance the Simulator experience for your students as well.

• Theater majors. Face it, the more entertaining and fantasmagorical this is, the more the suspension of disbelief. Theater people could help us with acting, makeup, sound effects, and the whole “feel” of the theater.

• Education majors. Simulation is the Wild West of learning. Is this the way to teach and learn? Is there a better way? Is competence testing valid? If not, how can we make it valid? How do the various people learn? A lot of educational ground to cover here.

• Behavioral psychologists. The lion’s share of the learning in the Simulator is the behavior aspect—crisis management, working in teams. Behavioral psychologists could help us here.

• MBA/business. Red ink, black ink. New technology. Lots of expense, lots of potential. An MBA could spend his entire “project” time on the Simulator.

There’s a whole world of people out there who could learn from, or add to, the Simulator experience. Maybe the Simulator is where we will finally learn to “get along.”

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