This week, Annals of Internal Medicine published a well written editorial about how Australia has managed to significantly reduce gun violence with a nod to the measures it took back in 1996. It’s unfortunate the physician base within the US hasn’t been more vocal to advocate on behalf of patient safety or even prevention. The attempt to combat gun violence with more guns (and arming more people) doesn’t seem to be working. It would be awesome to see stronger advocacy from a well organized group of physicians who have the ability to exert considerable influence. Until US physicians advocate more vocally, it appears to be an opportunity lost.

I came across this video via a feed on Facebook. It’s got nothing to do with sim, with helicopters, medicine or even education (well except maybe it contributes to general education of life).

http://www.upworthy.com/the-earth-shatteringly-amazing-speech-that-ll-change-the-way-you-think-about-adulthood-4?g=2

I thought it deserved to be shared. It struck a chord because I’ve been that guy stuck in line at the grocery store and just about ready to lose it…then having to get back in my car and drive home in Toronto’s ridiculous traffic. This video reminds us about others, that the people around us may not be in nearly the fortunate situations that we’re in or maybe they’ve just had an even worse day at work than me. Regardless, I hope I can remember this video next time I’m pissed off at how long the line in the grocery store is or when I’m stuck 3 hours of traffic, just trying to get home.

For those interested, the speech is an excerpt from a commencement speech delivered by David Foster Wallace in 2005 before his death in 2008.

This week, Annals of Internal Medicine published a critical review for strategies designed to enhance patient safety. The best part, the authors summarized their findings into a 1/2 page table outlining 10 “strongly encouraged” and 12 “encouraged” strategies…this makes  for a quick read! Extremely important for those of us who’s attention spans are so short that we can’t even wait in a line at the grocery store without checking our email twice, posting a tweet and reading the daily news.

Source: Shekelle et al. Ann Intern Med 2013 Ann Intern Med. 158:365-368. doi:10.7326/0003-4819-158-5-201303051-00001

I really liked this list and I think it’s great to publish  for people to review. You can look at what you’re doing at your own institution and if there are things missing, it provides a basis for advocacy.

It’s interesting that many strategies relate to intensive care medicine. I’m not sure if that’s a function of the interest by intensivists/anesthesists in patient safety, a result of funding bias towards ICU-level patient safety studies or maybe that’s where much of the difference can be made (at least from a mortality perspective). What this list also demonstrates is that there are many areas within primary care, trauma care and emergency care that require attention. 

The authors mention that “pre-operative checklists and anesthesia checklists” are strongly encouraged. I agree! But what about checklists during acute resuscitations? We simply don’t know because the evidence hasn’t been developed yet. Certainly I think this can act as a call to those funding and researching patient safety in acute care medicine . Cliff Reid wrote about the “Resus Room Life Guard” several months ago…we don’t know if this is a good idea or improves patient oriented outcomes because it hasn’t been studied. Though intuitively, it seems like a great idea!

There was also no mention about the importance of adequate discharge follow-up from the ED…some hypothesis generating studies that patients who don’t have great follow-up are at risk. But clearly more studies are needed.

Finally, for those of us interested in simulation, it offers additional support that team training and simulation exercises with a focus on patient safety are worthwhile undertakings. A recent study from demonstrated improved communication and teamwork in a trauma centre following in-situ trauma simulation training. In addition, there appeared to be some patient oriented improvements including improved speed without compromise in critical task completion.

The list of strategies is worth a read…see how you compare and see how your institution compares. If you’re not doing the “strong encouraged” items…its probably worth considering why not? Do you really need to put the femoral line in during the resuscitation or will the 2 large bore IVs suffice until the patient can be properly draped and line insertion done under fully sterile conditions? Do you wash your hands before and after every patient encounter? I know at our hospital we have people in the ED (maybe posing  with acute Percocet insufficiency) or hiding in the shadows…yet…they’re really monitoring our handwashing complicance.   While I have been known to get in arguments with them…they’re actually just trying to implement important patient safety measures.

#patientsafety.

That’s it for now. Feel free to post any thoughts/comments.

I’ve gotten a bit behind in my posts mostly as I’ve just moved back from New Zealand but I’m hoping to get a few more regular posts. For those who’ve read this blog, you’ll know that I like to highlight innovative approaches to simulation. This post is mostly for those interested in medical simulation…hopefully providing some new ideas.

One of my interests is procedural skill acquisition and how simulation can be used to enhance learning. So when I came across this paper I thought it deserved mention. The authors, from the University of Toronto describe using “hybrid” simulation for teaching knee arthrocentesis among internal medicine residents. Residents went through a procedural skills curriculum where they received teaching and practice performing arthrocentesis. They had to interact with a standardized patient and explain risks/benefits of the procedure. Then they were evaluated on both technical & non-technical skills in a separate scenario. They demonstrated the feasibility of this approach and they showed high ratings of realism among trainees & standardized patients and it functions as a hypothesis generating study for if these acquired skills are translated to the clinical setting.

Great use of hybrid simulation for obstetrical scenario – live patient actor “giving birth”. source: http://www.samuelmerritt.edu/hssc/task-trainers

Hybrid simulation is actually a pretty cool concept. For those are new to this, hybrid simulation combines patient interaction (using a standardized patient) with a bench model (or task trainer) that allows for procedural skill practice. The benefit of this technique is the learner gets to interact with a patient as if they’ll be the recipient of the procedure while also getting to master the technical skills of the procedure.

Using procedural competency as a goal in procedural training, hybrid simulation is an excellent method for integration into a training curriculum. In one definition of competency:

“it refers to a resident’s ability to safely prepare for, perform and navigate the complications of a procedure” (Mourad et al. J Gen Med 2010).

Hybrid simulation will allow the learner to manage each of these aspects. They practice how to prepare for the procedure (both technically and preparing the patient). This will include consenting the standardized patient to the risk and benefits. I think we often forget this key aspect and instead focus on the technical skill. Furthermore, hybrid simulation scenarios can also integrate complications and evaluate the learner as they manage both the technical and interpersonal issues that must be addressed.

Another group at the University of Ottawa has started using OSCEs as a method for evaluating procedural skills which also is quite innovative! I came across an abstract they recently presented and a quick google search revealed a manuscript that further outlines the integration of an OSCE for procedural skills. Definitely worth checking out.

In simulation, we spend thousands of dollars on advanced equipment that is designed to replicate real patient interaction. However, hybrid simulation shows us that we can enhance fidelity even more by using some imagination and combining a task trainer with a live actor.

Another example while I was in Auckland, I ran full trauma simulations with a live patient. At the helicopter base, we had an actor who had suffered a considerable trauma from a motor vehicle accident. Its very impressive to watch a team interact with a “real” patient compared to a manikin. There’s much greater concern with pain and emphasis towards communication of each management step – these are definitely lost during interaction with a manikin.

I think medical educators and those involved in curriculum design need to take the next step as we seek to improve procedural skill teaching in medicine – let’s start integrating live patient actors into our simulations. We’re starting to see that it’s feasible and that some considerable benefit can be ascertained. As we seek procedural competence, we cannot forgot the trainee should be evaluated for their ability to explain and work with a live patient throughout the procedure. Its not infrequent that trainees learn to perform a procedure but they have no idea the complication rate or even what can go wrong! Then when something does actually go wrong they haven’t thought about it. Integration of these  hybrid simulations will only enhance trainee skills and lead to improvements in patient safety – something we’re all working so hard to improve.

As physicians, some of us love to read the latest journal publication while some of us don’t give a s@#!. Those in the latter category are more than happy to get the information at conferences or journal clubs in due time. There’s nothing wrong with these people…in fact, it could be argued this is a healthier approach than being addicted to your wireless device or computer waiting for the newest publication!

But for those of us who do get turned on by reading then talking about the newest publication the day it comes out “Epub ahead of print”, it can be a daunting task to stay up to date.

In our world where we’re exposed to up to the minute Twitter feeds, blog posts or push notifications, we can easily become overloaded and inundated with how to manage this information. The challenge is particularly difficult with journal publications. I admit, that I really enjoy reading the latest research data and while that doesn’t make me a bad person…it arguably makes me a less attentive husband (one woman’s opinion).

Are there any strategies for improving information intake and staying up to date with recent research? I don’t think this area is well taught in medical school or residency, partly due to the fact it’s a brand new method of information acquistion. Also, it’s rapidly changing with new sites and apps coming all the time.

I follow a few different journal topics including emergency medicine related, critical care, general medicine and medical education. Overall, this probably results in about 15-20 journals per month. I don’t read every article, nor do I read every abstract but I routinely read through table of contents or titles to make sure I’m staying up to date.

I’ve been thinking about this recently and while this post isn’t intended to be comprehensive, it does offer a few strategies that I’ve used to ensure I’m reading the newest evidence (any mention of a product/app below is only because I’ve found them helpful…I take no money from anyone). The following are in no particular order of preference. And if there’s an app or strategy I’m missing, please comment and I’ll add it to the post!

Here we go.

QxMD “Read”: I just started using this app and I really like it and I highly recommend it for any physician trying to keep up with the medical literature. And it’s FREE!  Anyways, it’s a Canadian company that “provides a single place to discover new research, read outstanding topic reviews and search PubMed“. It allows you to sign up through your library Proxy account and access PDFs for any medical journal that your library has available. If your university isn’t supported, email them, I believe they are really working hard to add new institutions. The key component for this app is the user can select which journals they want to receive regular updates from and easily access. Here’s a great review of the product.  For those using Android/non-Mac products I don’t think its available for any other platform than Apple (I only use Mac so I can’t confirm this).

Settings page for “Read”

Main interface used when reading articles

Feedly: I also highly recommend this! and it syncs with GoogleReader which inexplicably is getting shut down. This program provides regular updates to any journal you wish to add to your list. The benefit to this approach is that it syncs well across platforms (both mobile and desktop) and it also houses all of your non-medical blogs and news sites. The difference between Feedly and QxMD is the latter offers a much easier route to read the PDF. Feedly simply provides you with the abstract then its up to you to figure out your own access method.

Subscribe to a journal’s table of contents (TOC): Most journals allow you to provide your email so that every time a new volume is published, the TOC arrives in your inbox. This is how I started following journals though depending on the number of emails you receive (and the number of journals you follow), this process can easily overwhelm.

Example of “The Lancet” Table of Contents email

Subscribe to programs such as Journal Watch or InfoPOEMs (from Cdn Med Assoc): Essentially these organizations review the literature (typically 1-2 months behind) and send brief summaries of selected articles. This isn’t comprehensive and they’re not always free (e.g. Journal Watch) but it does help you find out about papers that maybe you wouldn’t have read. I use these methods then I download the article myself using my University library account. But it is a bit more labor intensive than Feedly or QxMD.

Follow an up to date medical blog. For those in emergency medicine/critical care, lifeinthefastlane.com is a must. The authors of this blog provide high quality, regular, up to date information about new publications that will interest EM physicians. Sign up to their LITFL review and they outline some of the newest journal articles out there. In addition, they link you up with all the most recent blog posts from around the EM world.

For those interested in medical education – I highly recommend a new blog “Medical Educator 2.0” that compiles medical education (and general education) related topics from sources around the world. Ali Jalali is a medical educator at the University of Ottawa (and happened to be a professor of mine in med school) and he puts together a very high quality site. If you subscribe then you’ll get regular emails when a new version/updates are posted.

Download each journal’s app: Great if you only read 1-2 journals but not sure how useful this is if you’re looking for regular updates from a broad range of journals. Here’s a list of journal apps for download.

Twitter: Either sign up and follow a journal’s twitter account (e.g. @EmergencyMedBMJ) or follow individuals that often retweet or post comments about new articles. This approach really maximizes the power of crowds and can make reviewing new articles much easier. On Twitter, you can also follow hasthtags like #meded and #FOAMed.

So those are a few strategies that I use. I welcome feedback and suggestions that I’ve missed. I’m happy to update this post with any ideas that you feel should be included.

This post is being written while on a plane back to Toronto…I’m just settling into some serious jetlag so I figured no better time than put down a few thoughts on my experience in Auckland. For the past 6 months I’ve worked in NZ with the Auckland Rescue Helicopter Trust as the HEMS education fellow and flight physician. Coming from Canada where putting physicians on-board helicopters to work in a pre-hospital environment is about as foreign as …. I came to Auckland with little knowledge about what to expect.

Posing for the photo op. Realized a modeling career isn’t in my future.

To say the least, the entire experience was amazing and unforgettable! And much of this must be attributed to amazing group who work at ARHT. My supervisor and HEMS medical director, Chris Denny, got me organized and met with me weekly. We set out a plan, established learning outcomes and gradually implemented an advanced simulation plan at ARHT. Amazingly the ARHT facilitated this with the purchase of several brand new simulation manikins which only enhanced the learning possibilities. I worked alongside several talented physicians (Sam Bendall and Scott Orman) who mentored me in advanced simulation techniques, e-learning, integration of social media and blogging into education.

My time at ARHT was divided between educational endeavours and work as the HEMS duty doctor. Both allowed me to work and learn with the entire ARHT team who taught me more than they can imagine! While I can’t possibly thank everyone in this format, I developed great relationships with Barry Watkin (chief paramedic) and Herby Barnes (head crewman) who both worked to help me implement some of our educational objectives!

A view of Auckland at sunset

As the HEMS education fellow, I ran weekly simulations (often based on jobs we had recently done or questions that had come up), case-based learning sessions and finally task training sessions. We described our learning online both through the aucklandhems.com blog and via Twitter. We flew across the Tasman to practice our pre-hospital ultrasound skills at SMACC2013 (an impressive 2^nd place…despite our less than optimal subject matter we had to teach)! (link). We implemented new standard operating procedures based on (and tested in) simulation. There was collaboration with teaching and simulation with the Auckland City ED as I worked there part-time as well.

On the west coast outside Auckland

Finally, I had the opportunity to practice pre-hospital & retrieval medicine. This opportunity to learn from some amazing doctors, paramedics, crewmen and pilots in a setting that previously was entirely unfamiliar, was awesome! I gained an entirely new appreciation for ergonomics as practicing medicine in the back of a helicopter is entirely different than even the craziest of emergency departments! I had opportunities to do winch rescues (both practice and operational), jumping from helicopters, rock swims with surf rescue, run resuscitations in remote areas and the list goes on.

What stood out however, was the theme of safety. In medicine, safety is sadly a relatively new topic…but for many of our pilots and crewmen, safety has been a part of their work since they started. In fact, those in aviation who don’t embrace safety…tend not to have very long work careers (for obvious & unfortunate reasons). Working in a helicopter is among the highest risk occupations around so it’s not surprising the ARHT team take safety so seriously. I spoke with the crewmen and pilots as much as a could to better appreciate their perspective…so that perhaps in medicine I can borrow and learn from their obsession. I suspect (as others have as well) that medicine lags in safety management because bad outcomes don’t harm clinicians directly…in a helicopter however, lack of concern for safety does affect everyone onboard. Thus the entire team has a vested interest in promoting and ensuring safe procedures. We run safety briefings, we have an online safety management system in place and just like the rest of aviation we incorporated checklists for both routine & high-risk procedures. As HEMS doctors, we tried to emulate the pilots/crewmen so we also use a checklist for our high-risk procedures like rapid sequence intubation…this is just starting to catch on in the ED but in my opinion there’s much room for improvement! I once asked one of our pilots about checklists and why they use them… I told him that in medicine, people fear checklists because they think it will take away their ability to think…he laughed and replied:

“we have checklists not so that we stop thinking…but so we can start thinking during a crisis and not worry about forgetting small details”.

And that brings me to the end of my last blog post at ARHT. A huge thanks to the entire team at HEMS & ARHT for inviting me to Auckland, helping me learn and trying new things! I will continue blogging but likely with a shift towards simulation and education. I’ll still be collaborating with the HEMS team at ARHT and hopefully posting some stuff on aucklandhems.com. So that’s it for now…back to my inflight movie, Argo.

It’s great to see articles now about the impact and effects of social media in medicine especially in other specialities. This article titled “Social Media and Clinical Care” was just published in Circulation and deserves at least a brief review by any clinician who uses social media either to augment clinical care. It’s also encouraging to see this appear in the journal Circulation which has as a relatively high impact factor (around 14). Clearly the academic medical community and more importantly the general medical community is taking note of the importance of social media.

Whether you like it or hate it, I would argue we shouldn’t fight social media. It’s unlikely to disappear especially now with more than 1 billion smartphones on the planet.  Instead as clinicians we should use it in a way that helps us communicate with each other, with patients and ultimately improves care. That being said, social media does NOT equal good or better! (it can be ). We always strive to “do no harm” and social media in medicine should be no exception.

To borrow the Spiderman quote “with great power comes great responsibility“. The same applies to social media…in fact maybe I should try and coin my own modification “with great social media power comes great social media responsibility”! But as we increasginly engage in social media we must recognize it’s power…which is why we should continue to use it but also understand how it can be quite dangerous.

What this article does it outline the various ways that it can be used within clinical medicine. It also highlights the ethical challenges we face and provide some perspective using an ethical framework.  The great thing is that in the spirit of FOAM (free open access medicine) this article is free! Congratulations for Circulation for making this accessible to all.

Who should read this article?

• Any clinician who has patients participating in social media as a source for medical advice
• Any clinician who uses social media as a form of communication/education with other clinicians
• Any clinician who engages with their patients through social media as a form of education
• Any clinician looking for some good references of studies that evaluate the impact of social media within medicine/patients

Does this sound like all clinicians should read it? I would say unless you still think rotating tourniquets is the optimal method to treat heart failure, yes…you probably should at least give it a glance.

What I found interesting was the discussion about whether it’s appropriate to use specific patient cases on a blog. I haven’t taken up this practice, but I really do value reading other medical blogs when authors recount specific instances. It’s helpful to read these accounts – almost as if you’re speaking with a colleague about an interesting/challenging case…but now your colleague can be anyone in the world. Powerful stuff! But at the same time, I respect the issues of confidentiality that surround such discussions. What was interesting was the article quoted data that found

“medical educators…felt that writing a deidentified patient narrative using a respectful tone was never or rarely acceptable (61%)”

That is really quite high…61%! And impressively it was a “deidentified” patient described  using a “respectful tone”. I’m curious to know what others think but I personally don’t have a problem with it. I think it’s obviously better to have patient consent but what if the case was 2 years prior? Does that change anything? Pragmatically it would be hard to find that patient…and perhaps considerable learning can be achieved from the case. This is definitely a challenge for educators/clinicians in balancing the risks & benefits. More importantly, it doesn’t seem like our colleagues may support such actions!

The authors of this article outline some recommendations for physicians who have blogs/websites as well as those who engage in online social networks. None of these are revolutionary but they provide us with good reminders of how we can continue to uphold our commitment to improving patient care in an ethical manner.

Source: Chretien & Kind Circulation 2013

Source: Chretien & Kind Circulation 2013

For those of us involved in acute care medicine, you’ve likely faced the question

“should we invite the family to be present during the resuscitation?”

More than likely you also have an opinion on the matter. In fact, as I’ve started to look at the literature, people have very strong opinions about this subject! For those with short attention spans…check out a recent New England Journal of Medicine article for further evdience! 

I’ll be candid – I support the practice of having families present for the resuscitation, or at least inviting them to be present. I understand some families will decline which is entirely their choice but importantly other families will find this important to be present.

The last time I invited a family to observe was in an ICU setting where we were in the process of resuscitating a young person who had suffered cardiac arrest. The patient was extremely unstable with episodes of CPR and increasing pressor requirements.  I knew the family was waiting in the family room so I handed over the role of team leader to another colleague and visited with the family. Before leaving, however, the entire team was made aware of the plan to have the family present. Everyone was in agreement with the plan. I invited all family members to be present though only 3 of 5 requested to observe. Before entering, I outlined that they would see their loved one with a “breathing tube” and that “CPR” may be in process. We had our most senior ICU nurse with the family throughout the resuscitation to explain exactly what was happening. Never once were they left alone, however, we did encourage if they wished to hold their loved ones hand. We had planned our equipment prior to allow for this. Unfortunately the patient died but the family expressed their gratitude to the entire team for their efforts. Furthermore, they thanked us for allowing them to be with the patient during the final moments of her life. I can’t speak to why the family chose to be present, but they expressed nothing but gratitude for the invitation.

Detractors will say that family presence may have hindered the teams performance and perhaps led to psychological harm to the patient’s family. I also can’t speculate on the long term consequences for observing this potentially traumatic event. However, our team unanimously decided it would be appropriate and we proceeded accordingly.

Importantly, our team had a short de-brief afterwards where any concerns, comments and opinions were heard. There was no disagreement among team members that what was done was appropriate.

I recalled this story after reading this week’s NEJM which published a pre-hospital trial which randomized family members to observation of CPR compared to standard practice. The primary outcome was the proportion of relatives with PTSD related symptoms. Impressively, those family members who observed the resuscitation had significantly lower frequency of PTSD related symptoms than those who did not witness the resuscitation. There was no affect on resuscitation characteristics, patient survival and none resulted in medicolegal claims.

In conclusion, the authors stated that:

“family presence during CPR was associated with positive results on psychological variables and did not interfere with medical efforts, increase stress in the health care team or medicolegal conflicts”

Some will argue that this study applies only to the pre-hospital setting since in-hospital situations are very different. In this study setting, many may have witnessed the actual collapse which differs from the hospital. So in the pre-hospital setting, maybe this is sufficient evidence to proceed with offering family presence? I can’t imagine there’s going to be another randomized trial any time soon. This is likely the best evidence we’ll get…at least out of hospital.

There is a vast array of highly opinionated individuals who have posted replies to this topic and I believe these warrant reading. Its amazing how strong the opinions are despite the lack of evidence. There have been several studies that have evaluated ED personnel opinion – these show equipoise…in one study it was 50.9% who supported family presence.

As many who are against the practice have pointed out, lack of support and communication during the resuscitation are detrimental and counterproductive. There must  be a designated individual who can provide perspective and explanation to the family. Furthermore that individual must recurrently reassess the emotional state of the family. While some feel this is a pandora box that should NEVER be opened, I would disagree. One of the editorialists for the NEJM article summaries the situation quite well:

“Part of our job as physicians is to help patients and families establish goals of care, process life-threatening events, and, at times, orchestrate the best death possible.”

 

What is most important as acute care clinicians is that we continue the discourse and encourage future study. There is clearly no definitive answer and to argue in one direction or the other without acknowledging the lack of evidence is ignorant. We have multiple surveys that report equipoise among clinicians followed by anecdotal reports of success with family observation.  Interestingly, several large guidelines have endorsed family presence including those from the AHA.

Based on this emerging evidence, it certainly doesn’t discourage me from further pursuing family presence. I will continue to invite families into the resuscitation room, however, before this occurs I will ensure the following:

1. Discuss with the team so that everyone is aware that the family will be entering 
2. Offer to the family the opportunity to be present
3. Prepare the family for what they may see and that the resuscitation may be stopped during their present
4. Ensure there is a well experience clinician (either RN or MD) with the family throughout the resuscitation
5. Debrief the resuscitation team afterwards

What should be encouraged is similar situations be incorporated within simulation training. Before we fully integrate family presence, just like any other high-risk procedure, we should practice it and be competent. The entire team should be aware and understand the implications.

For those wishing to read more, I highly recommend a critical review of the literature published in 2005. While it’s a bit older, it is quite helpful! At that time there was little evidence to support many of the concerns expressed by those do not support family presence…

Check out this video – the new Google Glass promo video.

I just watched this video at a conference combining social media & critical care (SMACC 2013 and I thought it deserved a mention). I have no affiliation with Google, but gotta love how they push the limits of awesome!

Imagine how this could work within medicine – what if, as the Resuscitation Team Leader, you were wearing Google Glass…all the drug doses, adverse reactions, algorithms would be available immediately. Or more interestingly, an educator could review the perspective of a trainee who is running a resuscitation. Or perhaps the trainee is provided with this technology to help enhance their learning experience. Or what about improving tele-medicine, where experts in a different city can provide expertise by viewing what’s happening in the trauma room. While this happens now, imagine if it came right from the team leader’s perspective. The possibilities…pretty well endless!

The past 3 days has been a whirlwind experience in Sydney, Australia where I attended the Social Media and Critical Care Conference (@smacc2013).

I joined a group of several of my colleagues at Auckland HEMS to participate in the inaugural conference. It combined two seemingly unrelated things – social media & critical care. Making it probably the among the first (if not the first) medical conference to have social media as a key theme. Over the past few years, physicians in critical care, emergency medicine and prehospital medicine have become leaders in social media and using the internet as a learning tool. The creators of the conference started the innovative website Lifeinthefastlane which is a blog read by thousands of acute care physicians around the world. They decided to extend their scope and create a conference which in my opinion was a huge success! This conference was a natural extension of the relatively new concept that highlights “medical education for anyone anytime, anywhere” – this concept is known as FOAM or “free access open meducation” (#FOAMed on twitter). I won’t describe it fully here as others have already done so. But it’s the way in which we use social media and the internet to share, disseminate and collaborate within medical education.

As a reflection on the conference I’d like to share a couple highlights and concepts that emerged. What was unique about the conference was the use of Twitter. There was heavy emphasis on live tweeting during each session with a designated twitter coordinator who would pose questions to the speakers directly from those asked on Twitter. There was constant discussion on Twitter with both conference attendees and even those clinicians half-way around the world. Let me provide a brilliant demonstration of this in action. In one session about coagulation in trauma, the session facilitator (Dr. Minh Le Cong from the blog PHARM) tweeted asking for comments from those in the twittersphere. Within minutes there were comments coming in from Dr. Karim Brohi, a trauma surgeon in London, England who is a world expert in coagulation in trauma. A discussion among the speaker and the audience resulted based on his comments. Never before had I seen such interaction at a global level occur during a conference. The power in capturing ideas and facilitiating live discussion among both those attending the conference and leading experts sitting in a room across the world is amazing!

When I would look around the room in each session, there was a barrage of tweeting with many sending out comments made by conference speakers as they happened. This is incredibly powerful. It allowed for an immediate online commentary for those not attending the conference. But it also allowed those of us in other sessions to hear some highlights and really get an idea of what was happening especially if there were controversial topics being discussed.

Every talk was videorecorded and posted online for free viewing by anyone in the world. This represents a huge step in promoting free open access medial education (FOAM). Why we restrict education to those who can afford or arrange travel to these conferences is mindboggling. Our business is to improve patient care and if we can collaborate and share ideas that emerge from great meetings like this then our patients will definitely benefit.

Imagine a speaker says something quite controversial. Previously it might never really be discussed again. Or perhaps it might be misrepresented several weeks or months later in a report. At this conference, speaker comments could be disseminated rapidly with the opportunity for rapid responses and discussion.

Unlike many academic conferences, speakers were introduced based on their blog (and not their publication count or number of academic achievements). While the merits of publications should not be diminished, it highlighted that an online presence where your ideas are shared, exposed and subject to review from people around the world is a new way to gain status within the medical world.

Finally, the conference started to address how FOAM, social media and asynchronous learning can be incorporated within medicine. There were enthusiastic talks that demonstrated the power of online education but also some excellent perspectives that online learning is not a learning panacea. These sessions were humbling since we must remember that despite all this technology, we still treat people. Our job requires human interaction and without reflection we can begin to forget this. Those on blogs and twitter drive the curriculum because topics are interesting, but sometimes the less sexy topics deserve discussion. There’s no curriculum to guide us online and this may not always benefit learners.

As long as we can appreciate these limitations we can maximize the potential of a asynchronous learning using an online platform. Never before can we collaborate, share, discuss and even criticize. It’s an exciting time for medical education and SMACC did a great job making it a reality!

This post discusses a great article about death in simulation and the impact on learning. I’ve learned about the importance of this topic from @jameslhuffman, an ED physician with an interest in simulation. For those interested/involved in simulation, its importance is understated but probably moving forward we’ll hear more about.  I highly recommend that anyone who is regularly running simulations or involved in medical simulation check out this paper. I’ll review some of the highlights below.  This article follows the same topic that I wrote about a few weeks ago regarding the ethics (or impact of being unethical) of medical simulation.

Important to decide how much of a grim reaper you should be as a simulation facilitator

The authors reviewed the literature for evidence about the impact of death during simulation and how it affects learners. I won’t discuss their methods as I really don’t think that’s the important message of the paper – it should be noted it’s simply a literature review rather than anything more detailed or comprehensive (e.g. systematic review or meta-analysis).

Who cares whether the simulated patient dies? Why does this even matter? These are two very reasonable questions and hopefully this review will help to shed some light on why some consideration should be made about the impact of the simulated patient’s life expectancy during the scenario!

The authors outline a few concerns that have been described regarding simulated death:

• Stressful situations including death may negatively affect learning and memory, as a result the scenario may not achieve its predefined learning objectives
• Death during simulation may instill negative feelings among learners about simulation (e.g. “every time I do a simulation, the patient dies…I don’t ever want to participate in that again!”)
• Death of a simulated patient may overtake the other objectives of the scenario and may occupy most of the debriefing 
• Inability to maintain an environment of psychological safety – learners lose trust in the instructors if too many unexpected and difficult situations occur thus detracting from learning

I think all of these are very reasonable concerns and should be considered when designing a simulation scenario however, I don’t believe (nor do the authors of this review) that death in simulation should be abandoned. It clearly has a role as death in real life is inevitable and we should train and practice how to manage it. In addition, trainees must be exposed to scenarios where regardless of the therapies implemented the patient will inevitably die. This happens almost every day for clinicians involved in acute care medicine.

What I liked about this review is that the authors included some recommendations for educators to consider when designing a scenario.

First, they defined 3 types of simulated death:

1. Death expected by both the facilitator & the learner – include discussion about end-of-life
2. Death expected by the facilitator & unexpected learner – may include a planned respiratory arrest that the learner must attempt to manage
3. Death unexpected by facilitator & the learner – this involves the learner administering a fatal drug or failing to recognize a fatal condition

Depending on what type of death occurs may dictate the implications for debriefing. The following are recommendations that the authors make based on a combination of evidence and experience but in general, they’re quite reasonable. In planning for a death during simulation here are some considerations:

• Ensure the instructor is prepared for the discussion
• Ensure the participants have a pre-briefing session that includes mention of the possibility that the simulated patient may die 
• Simulated death should probably not be used with novice learners
• Scenarios for advanced learners should include simulated death if clinically appropriate
• Simulated death shouldn’t be used for punishment (e.g. death shouldn’t occur if a participant administers a noncritical drug) – death should only occur when the learner’s actions lead to a life-threatening consequence in real-life
• A de-briefing after a simulated death is essential – it must safely address the factors  that led to the patient death with discussion about team dynamics & medical management
• Acknowledge participant emotions associated with death 

In my opinion, most important however is simply to acknowledge that death during simulation isn’t without consequences. The impact on learners is relatively unknown given the lack of evidence. But we should consider how much stress we place on the learners as it may positively or negatively impact their learning.

Hopefully these considerations will be helpful in evaluating the sim patient’s life expectancy! I found it extremely useful and I acknowledge that the paper is better than any summary I can provide. Here’s the reference below for the article

Simul Healthc. 2013 Feb;8(1):8-12. doi: 10.1097/SIH.0b013e3182689aff. To die or not to die? A review of simulated death. Corvetto MA, Taekman JM. 

In-situ simulation has become increasingly popular and just recently there’s some evidence that it’s achieving the holy grail of simulation…simulation resulting in improved patient-centered outcomes. Intuitively it makes sense that more practice will make us better and probably practice within the exact place that we work, will be good too! Look at an Olympic downhill skier…they train several days in advance of their race on the exact same course as the race. Why? So that they can gain a better understanding about where every difficult turn is located or how they should navigate through a particularly challenging section. I mean, for such a high risk setting, why wouldn’t you practice where you work? Well I think the same can extend to resuscitation medicine. We should practice where we work! And at the very least, it won’t hurt us…and it will probably help. And maybe, just maybe it will benefit our patients too. 

This study was just published in Resuscitation. It’s a prospective study that implemented in-situ simulation in a pediatric setting with their emergency response team and they studied several clinical outcomes in a pre-post study design.

Their results included that after in-situ simulation, deteriorating patients were recognised more promptly and more rapidly escalated to intensive care (median time 10.5/5 h, p = 0.024). Furthermore there were additional trends (though not significant) towards decreased morbidity & mortality – which warrants further investigation.

The authors also note some key features of their team training & human factors considerations that may have contributed to the success of this intervention. Each of these 5 factors are EXTREMELY important for successful in-situ simulation:

(1) Regular training for all team members (4–10 times/year depending on rotation).

(2) Training in real clinical roles in real clinical environment.

(3) Key decision makers (paediatric registrars and charge/deputy charge nurses) from all wards participate in team and team training, building capacity to deal with evolving critical illness on the wards, even if the team as such is not called.

(4) Senior medical and nursing staff from many departments are team trainers – enabling trainers to address issues identified in clinical practice during team training and to facilitate acceptance of team and team training across traditional departmental boundaries

(5) Senior clinical and managerial staff support team and team training (willingness to respond early to calls from team; protected training time).

Finally, I’ve included the study abstract if you’re interested.

Regular in situ simulation training of paediatric medical emergency team improves hospital response to deteriorating patients. U. Theilen et al.  vol 84 (2):218-222

Aim of the study

The introduction of a paediatric Medical Emergency Team (pMET) was accompanied by integration of weekly in situ simulation team training into routine clinical practice. On a rotational basis, all key ward staff participated in team training, which focused on recognition of the deteriorating child, teamwork and early consultant review of patients with evolving critical illness. This study aimed to evaluate the impact of regular team training on the hospital response to deteriorating in-patients and subsequent patient outcome.

Methods

Prospective cohort study of all deteriorating in-patients of a tertiary paediatric hospital requiring admission to paediatric intensive care (PICU) the year before, and after, the introduction of pMET and concurrent team training.

Results

Deteriorating patients were: recognised more promptly (before/after pMET: median time 4/1.5 h, p < 0.001), more often reviewed by consultants (45%/76%, p = 0.004), more often transferred to high dependency care (18%/37%, p = 0.021) and more rapidly escalated to intensive care (median time 10.5/5 h, p = 0.024). These improved responses by ward staff extended beyond direct involvement of pMET.

There was a trend towards fewer PICU admissions, reduced level of sickness at the time of PICU admission, reduced length of PICU stay and reduced PICU mortality. Introduction of pMET coincided with significantly reduced hospital mortality (p < 0.001).

Conclusions

These results indicate that lessons learnt by ward staff during regular in situ team training led to significantly improved recognition and management of deteriorating in-patients with evolving critical illness. Integration of in situ simulation team training in clinical care has potential applications beyond paediatrics.

Earlier this week I posted about the integration of a cric task-trainer at ARHT. I’ve decided to follow this up with some general evidence about cricothyroidotomy training.

The data regarding technique selection for cricothyroidotomy exists primarily in the context of simulation. It would be impossible to run a trial to compare techniques in real patients given the rarity of the scenario. In general, there are two types of techniques: 1) open or surgical cricothyroidotomy 2) percutaneous or needle cricothyroidotomy. I tend to favor an open technique (and maybe with a bougie)  given the simplicity but there is some evidence to support the needle method. There is a nice  Below is a brief outline of some evidence-based considerations for anyone involved in training clinicians for cric performance.

Needle vs. Open

• Randomized trial of emergency physicians performing surgical and percutaneous cricothyroidotomy on cadavers. Time to first ventilation was significantly longer using the surgical technique (108 seconds vs. 136 seconds) while there were significantly more injuries to surrounding structures using the open technique (6 thyroid vessel injuries vs. none)
• Authors concluded results tend to favor percutaneous technique
• I’m quite surprised that time was shorter with the percutaneous technique – interesting result!

Alternative techniques

• Randomized trial comparing standard surgical technique with a modified technique for percutaneous insertion using “incision-first” technique – described as 2cm vertical incision then palpate cricoid membrane through incision, once identified continue with needle technique
• Scalpel-finger-tube technique
• Ultrasound guided, bougie assisted cricothyroidotomy with a median time to completion of 26 seconds
• We should probably NOT be teaching a percutaneous indicator guided approach

Time to Completion 

• Highly dependent on when the timer starts but regardless everyone agrees time is important! And less is more!
• 40 seconds was achievable in one study – time to skin palpation to first ventilation when all equipment was laid out
• 95 seconds (mean) was recorded in another study as time from first grasping cric equipment to first ventilation

Number of times to achieve competence

• Debatable whether experience = competence
• Performance times plateau after 4 attempts (using a manikin)
• Very little evidence to support number of times needed especially since all evidence is manikins or cadavers

Room for improvement as an inter-disciplinary approach

• Several studies show that often it’s the surgeon performing cricothyroidotomies in emergent settings (article 1, article 2) 
• This has important training implications – we should be training as a trauma team and incorporating the trauma team during in-situ simulation
• EM teachers & educators must also be aware of this issue and work with surgeons so that they understand cricothyroidotomy is completely within the scope of practice for EM physicians (or anyone who performs RSI)

Some High Quality Learning (FOAMed)

• Needle vs. Knife for cricothyroidotomy from EMCrit
• Great compiled list of cric resources and literature from Andy Neill at emergencymedicineireland.com
• Amazing description of 24 surgical cricothryoidotomies!

Newest addition to the ARHT simulation centre. Cricothyroidotomy task trainers built from old manikins. Rolled them out successfully last week with our paramedics using them for the first training session.

One of my medical education interests is looking at how we train and practice rarely performed procedures. For these situations, simulation offers an excellent method of training. The challenge, however, is recreating the fidelity of such situations since many rarely performed procedures are quite invasive.  Often we’ll start the training with a task-trainer like model and then progress to a full size manikin. Task-trainers are simulation models specifically designed for one type of procedure. 

In emergency and pre-hospital medicine, the cricothyroidotomy is among the most invasive, time critical yet rarely performed procedures. In addition to the potential technical challenges of this procedure, the decision to perform a cric might be even more difficult.  Identifying a “can’t intubate, can’t ventilate” scenario and then to “pull the trigger” may be one of the hardest cognitive leaps we face in resuscitation.  For example, last week, in the  Auckland emergency department we ran an in-situ simulation scenario for the registrars that required the performance of a cricothyroidotomy. The goal of the simulation was only to perform a cric…in fact, we even gave the registrar team a heads up that the patient would required a cric. Amazingly while we only used a task trainer that didn’t even allow for intubation, the trainees still tried to proceed with intubation. There was considerable reluctance to finally acknowledge that it was a “can’t intubate, can’t ventilate” situation.  I don’t think we train enough to practice taking that cognitive leap to the final step in the failed airway algorithm. Even this short little scenario provided evidence that such scenarios require practice and should be simulated.

This past week at the base we rolled out our cricothyroidotomy task trainers. We constructed our trainers based on a model created by Agnes Ryzynski & Dr. Jordan Tarshis at Sunnybrook Health Sciences Centre. They described the creation of such task trainers using old/broken manikin heads and some innovation using easily found products within the hospital. The value of such a trainer extends beyond its simplicity as it also  maintains good fidelity, it costs less than $30 to make and it recycles old manikin heads! 
Such a trainer might supplement an even lower fidelity construction depending on the setting. At the ARHT, our go-to method for cricothyroidotomy is a bougie-assisted technique which is described in this article and video. We’ve selected this technique based on simplicity in the field and relatively minimal equipment required. But there’s good debate out there whether these should be performed using the needle or surgical approach. Scott Orman (ED physician and blog author for aucklandhems.com) wrote about the topic last week with some great links.

You can see from the pictures, that the paramedics have set up on the left side of the patient. We were trying out different approaches and set ups to find out what works best. Personally, I prefer the right side of the patient. In our setting within the helicopter  we only have access to the patient’s right side. As a result, there may be some benefit to be on the right side. The ergonomics of such a high stakes procedure are probably understated so training in the same way that you’ll perform the procedure is essential. I acknowledge that you might need to be a bit flexible regarding setup but in general, the airway team should be well prepared and anticipate where equipment and personnel will be placed.

Here’s a few more pictures of our training day.

Next post will have a bit more about the evidence base around cric performance.

This week’s post was prompted from a recent set of articles in the journal Simulation in Healthcare. Until recently, I’ve given little thought to purposeful deception during  simulation scenarios. Often scenarios are designed to be somewhat “tricky” with a key learning point. This often takes place by incorporating a random medical fact/concept that the learner may not pick up. For example, the seizing patient in refractory status epilepticus…if the participants took a proper history from the family they would have found out that patient has recently started treatment for tuberculosis. The diagnosis of INH induced seizures would be clinched  But what about when you purposefully try to mess with the participants and actually challenge their personality, their ability to behave as a physician and arguably break the psychological safety that should exist within a simulation? Is this beneficial or does such a scenario inhibit learning? 

I’d like to review and comment on the articles and editorials published in the most recent edition Simulation in Healthcare. The article is a description about how simulation was used to test/study medical hierarchy during a medical resuscitation.

The authors (pediatric intensivists) implemented a scenario where a young child was critically ill with hyperkalemia resulting in a dysrhythmia and incidental hypophosphatemia. The team leader (who was a confederate) was scripted to order potassium phosphate to replace the low phosphate, however, this would also result in death of the simulated patient. The learners (ICU residents/fellows) had some idea that a team leader (staff intensivist) would appear part way through the case but were unaware that such hierarchy conflict would emerge. The team leader confederate was instructed to comply by not administering the drug only if the team demonstrated repeated or sustained challenges in giving this potentially deadly medication. The authors describe running the scenario 3 times and reported the following responses:

1. Appropriate, successful challenge of drug administration and team leader complied
2. Appropriate challenge but delayed resulting in delayed appropriate management
3. The order was not challenged and the simulated patient died

What are you thoughts after reading this? Do you have a visceral reaction that this was a good or bad idea?

My opinion is that in the right circumstances with trained educators I think this is extremely powerful, useful and should be part of the educational toolbox. There’s an accompanying editorial where the authors have raise multiple concerns about this approach which I won’t reiterate – all of which are valid. Though interestingly they also provide well written counter arguments in anticipation of how others may respond.

Simulation scenarios that address non-medical aspects that can lead to patient harm should be simulated. While I agree that this type of case probably is best administered by an experienced simulation educator with highly skilled participants, I disagree with the editorial which suggests that such scenarios should be avoided. They were concerned that this may cause the participant to think:

“Am I the kind of person who is unwilling or unable to challenge a respected colleague who I think is making bad medical judgments, even when this may result in serious injury to the patient, or even death”

I would argue (like the study’s authors) that with proper briefing regarding the educational purpose of the simulation and adequate de-briefing to explore the cognitive decision points that resulted in the patient’s outcome, then learning can be achieved. The degree of deception should be related to experience level of the participants since junior learners would unlikely benefit from such a difficult scenario. However, increasingly, we recognize that teamwork and crew resource management (CRM) play an important role in how we care for patients. Our non-technical skills and awareness to our own cognitive biases during critical situations has considerable impact on patient outcomes.  It’s inevitable that during critical situations we may face challenging interpersonal interactions or difficult decisions.  We should train by pushing the limits of the team and the system. I acknowledge there are some who are concerned regarding the disregard for psychological safety during such simulations. I argue that with proper approaches that psychological safety can be managed. Furthermore we can do a much better job controlling the psychological safety of a simulation than we can simply leaving learners to fend for themselves during a real-life situation where not only their psychological safety is at stake, but the medical safety of the patient is at risk.

The argument that we should study this more before widespread use is reasonable but I’m not sure that results from one centre will be applicable to others. The validity of such studies remains challenging to say the least. Certainly larger studies will help, but meanwhile simulations including misdirections or deceptions that challenge not only technical knowledge but interpersonal and team dynamics should be supported.

Abstract from cited article above 

Case & Commentary: Using Simulation to Address Hierarchy Issues During Medical Crises. Calhoun AW et al. Simul Healthc. 2013; 8(1):13-19

Medicine is hierarchical, and both positive and negative effects of this can be exposed and magnified during a crisis. Ideally, hierarchies function in an orderly manner, but when an inappropriate directive is given, the results can be disastrous unless team members are empowered to challenge the order. This article describes a case that uses misdirection and the possibility of simulated ‘‘death’’ to facilitate learning among experienced clinicians about the potentially deadly effects of an unchallenged, inappropriate order. The design of this case, however, raises additional questions regarding both ethics and psychological safety. The ethical concerns that surround the use of misdirection in simulation and the psychological ramifications of incorporating patient death in this context are explored in the commentary. We conclude with a discussion of debriefing strategies that can be used to promote psychological safety during potentially emotionally charged simulations and possible directions for future research. (Sim Healthcare 8:13Y19, 2013)

Last week there was a very interesting perspective/editorial published in the NEJM. But one that I thought deserves some comment because I strongly disagreed with the authors. In fact, I thought it was unfortunate to see this commentary in such a widely read journal.

The title was “Service: An Essential Component of Graduate Medical Education“. It was authored by two Boston physicians (both appear to be oncologists). The authors outline their concern that service should be seen as an educational objective that shouldn’t be minimized, instead “resident duties that confer a high degree of service may still provide high educational value, in the form of genuine experience with patient care”. In essence they argue that seeing any/all patients is a learning opportunity! We will often joke about this on a shift when there’s a patient that likely won’t be a valuable learning experience for the trainee. I would agree that learning probably can gained from most patient interactions however, the quality and the yield may very often be low. Plus rather than subscribe to these authors’ belief  any patient presents learning opportunities and service should be viewed as learning, we should recognize that different learners have different needs. I would argue that in the emergency department, a surgery intern may gain very little from seeing a patient with chronic back pain that is seeking opiates and has considerable behavior issues. Patients like this can be challenging and often provide little learning especially when there are other patients to see. For instance, it’s very possible there’s a patient that needs to be seen that will better fulfill the pre-defined objectives of the surgery intern. However, this patient may be useful for the senior emergency medicine resident to manage as such patients will be their responsibility once they’re staff.

The authors then provide several examples of “service” which I found quite interesting.  One which particularly caught my attention…”A family practice resident misses a teaching conference in order to see her last clinic patient, who arrives late because of transportation problems“. They argue that a “didactic” teaching session is not nearly as valuable as seeing that final patient in clinic! I think this sets a dangerous precedent. Residents/trainees should not be made to miss preestablished learning opportunities for service. Whatever this “teaching session” is, it’s been integrated into the curriculum such that the resident can work towards achieving competence in their field. There may be exceptions but as a rule I would advocate against this mindset.

We have begun to move towards a competency-based approach to medical education with a set of competencies laid out for residents to achieve by the end of their training. As they work towards these competencies, there’s no doubt that they’ll be doing “service” and “less valuable” tasks but to think that simply seeing patients and doing scut work is valuable because you never know when that little piece of learning may occur is wrong.

The final words of the authors addressed the aspect of competency-based education head on: “many medical educators have worked to optimize the educational value of residency and protect trainees from engaging in menial activities from which they do not learn. As such reform continues, however, it risks going too far and sacrificing certain essential educational experiences that can emerge from service activities, as well as the opportunity to teach trainees about service’s importance to the profession”

Overall  the author’s argument came across as annoyed staff physicians who were having to do their own work and no longer being able to pawn it off on their residents.

In general, I strongly disagreed with the authors’ argument. In an era in medical education when time has become a commodity and duty hour restrictions have become reality, we must continue on the path towards ensuring trainees are competent based on pre-defined learning objectives. We should seek efficient and high yield methods for trainees to learn. To continue forcing a resident to do dictations for the same thing over and over simply because they need to learn the value of service seems to go against this approach. It will not help trainees become better doctors and as a result our patients will suffer. And as most of us agree, we became physicians to become experts in patient care and help those who can’t help themselves.

I actually saw this video a little while ago, then came across it just this week on a great new EM education blog iTeachEM and I felt it warranted a post.

It’s a lecture by Sir Ken Robinson who is an educator and who provides big picture ideas on the future of education. It definitely deserves to be watched by anyone interested in education. Ideas like these are important to consider as without them change for the purpose of improvement will be impossible. It’s amazing to think that our current method of education (our whole educational system) is not much different than it was 100 or 200 years ago. Despite our access to technology and information we continue to teach and educate in the same way. It might be time for an educational revolution to follow the technological revolution.

One of my favorite ideas (paraphrased quote) from the video

working together in schools is cheating, while in the workplace its called collaboration

It really is an interesting concept…do we teach enough of collaboration now? I think we still really quite isolate students to answer questions on their own. Yet now we live in a world where with a single keystroke we can connect to anyone with an internet connection, anywhere in the world.

Our current approach to education highlights individualism in problem solving and perhaps this can be counterproductive especially as we’re faced with increasingly complex problems. The concept of Wicked problems is quite interesting…and yet I can’t imagine that the solution will be solved by an individual. Check out the video below.

This past week, I had the opportunity to present to the Auckland Trauma Forum about the in-situ simulation and its value within trauma training. I believe however that it’s value extends far beyond trauma training. We’ve been using it at the helicopter base and in the ED. The pediatricians and obstetricians have recognized its utility as well especially given

the rare but high risk scenarios they may encounter.  As a result, I thought it would be appropriate to put up a post on the topic.  I’ve titled this “the 10 commandments” however, please feel free to disagree, challenge or critique my list…I just though the title sounded better that “a list of 10 things to consider while doing/planning in-situ simulation”.

Increasingly, educators are recognizing that in addition to traditional simulation (which occurs in a simulation centre), in-situ simulation provides benefits that are unattainable elsewhere. For those new to the concept, one definition of in-situ is

“simulation that is physically integrated into the clinical environment“

This quote is from a must-read for anyone interested in in-situ simulation. (Patterson et al. chapter on In-Situ simulation in the book “Advances in Patient Safety: New Directions and Alternative Approaches)

And now for the 10 Commandments of In-Situ Simulation (in no particular order…except maybe the first one or two).

1. Always run an in-situ simulation with well defined goals and objectives (and ensure participants have been briefed). I don’t think this needs elaboration

2. Always ensure there’s a debriefing period that’s adequate. This goes for all simulation but in-situ can easily be derailed especially if you’re using the on-call team and a sick patient arrives. Have a contingency plan for a debrief later on.

3. Use in-situ simulation to improve teamwork and coordination especially in acute care settings and high-risk situations. This will lead to improved patient outcomes (my opinion…data is promising). New data suggests the value of in-situ simulation includes improving teamwork and communication but may also lead to patient-oriented benefits.

Debriefing after a successful simulation. We have 3 different personnel here – doctor, paramedic and crewman. Truly multi-disciplinary.

4. Use in-situ simulation as a method of testing the ergonomics of your current clinical setting (current state analysis). We NEVER do this in medicine. I bet the next time you go into your resus room that you’ll find 10 things that are placed or designed in non-user friendly manner. Maybe the monitor isn’t easily visible. Maybe the chest-tube tray is just a big S***show everytime you open it…leading to delayed placement. Running simulations in your own work environment then evaluating it can be helpful! A study in one ED found that their response to life-threatening arrhythmias was horrible after running unannounced in-situ simulations…but it lead to improvement!

5. Separate in-situ simulation equipment from real equipment: We use identical equipment at the helicopter base for our in-situ simulation as we do in our real work. This is the benefit of in-situ simulation (we practice with the same equipment we work with). However, mixing equipment inadvertently can be dangerous. Imagine a ventilator purposefully tampered for a simulation that somehow ends up being used for a real patient. BAD. We label everything with big red tags “Defective – training gear”. Whatever you decide, just make sure everyone is aware. Sometimes you may want to use real equipment in the sim, but have someone responsible to ensure its appropriate re-integration into the clinical environment.

6. Notify others that in-situ simulation is in process: nothing worse than starting an in-situ simulation in your resus room and someone, unaware to the exercise, activates a code blue with personnel running from all ends of the hospital only to find that its just a simulation. This can be remedied by notifying others in the clinical environment via email/posters and signs.

7. Maximize learning for on-duty personnel by running an in-situ simulation: There are huge benefits of incorporating teaching for your on-call team while they’re at work anyways. Why bring people in on their day off to train when you can use down time during the day to run a sim in their own work environment! It’s efficient from a cost and time perspective. Who knows…maybe that failed airway drill run earlier in the day will prepare them for something later on!

No better way to see what its like to intubate in a helicopter then to actually practice…in the helicopter. A sim centre just isn’t good enough for this objective. Notice our paramedic is in full gear too! Plus we can assess ergonomics of patient positioning. 

8. Multi-disciplinary is key for In-situ simulation: We work with large teams from all different specialties all the time. Engage your colleagues – not just fellow physicians but nurses, respiratory therapists, etc…

9. Seek departmental support to run in-situ simulation regularly: This doesn’t just mean one department…we rarely work in isolation during high risk/acute care situations. Often trauma or medical resuscitations require multiple teams so get support to gather teams from more than your own department.

10. Be creative! We don’t practice often enough the situations that can lead to bad outcomes. Wouldn’t it have been great if you had practiced running a resus in CT before you brought that trauma patient who crashed there? While initial decision making may have been an issue…maybe the fact the suction was missing could have been identified had an in-situ sim been run!

Bonus (#11): In-situ simulation is a fantastic way to test out new equipment/cognitive aids. We love new toys in medicine but rarely do we try them out other then when the rep comes in, gives us lunch and before we know it the new equipment is in use. This isn’t safe but despite our efforts we often escape bad outcomes. We should test run new equipment especially those used in high risk clinical settings. In addition, while I’m a huge fan of checklists or cognitive aids…I dont think these should just be implemented without some in-situ testing. Maybe the RSI checklist needs some tweaking…or maybe it doesn’t read well when it’s used in a time-sensitive manner. Get your team accustomed to using before you need it for that next failed airway.

Any feedback…I welcome hearing it!

Recently JAMA published a short viewpoint on the role of the attending physician on ward rounds. This was brought to my attention from a great blog/website that highlights what’s new in the world of medical education.

In medical education there’s been quite a bit about different teaching methods and how to incorporate new approaches like simulation and case-based learning. But this viewpoint brings up an interesting perspective that we rarely consider…the role of our teachers and how it should change. While I didn’t agree with everything that authors mentioned, the concept is important to address.

In the article, the change from “older” to “younger” attendings was discussed and how it will impact trainees. The authors argue the hierarchy has disappeared and younger attendings are more comfortable helping trainees out with the workload. This works well given the increased emphasis on duty hour restrictions. Furthermore, the authors describe older physicians as more likely to teach at the bedside and less comfortable with technology.

I was surprised, however, to read how little attention was paid to the impact of technology on trainee education. To discuss the changing role of the attending must also include the changing methods that trainees learn. Attending physicians are no longer the fountain of knowledge they once were. Wikipedia has quickly taken over this role!  Trainees can easily access the opinions of 100 attendings with a quick glance on their smartphone. The experience of attendings in stating “I had a similar case and this is how I dealt with it” is arguably less important now as evidence-based medicine has become pervasive in medicine. Technology has augmented the trainees ability to find 10 articles about how to manage a particular condition, often drawing on the results of several studies – this is significantly more than an “experienced clinician” can provide. I write this understanding this may be provocative and subject to disagreement but sometimes controversy is good! What’s more is that some have used this article to prove the utility of apprenticeship. It’s difficult to imagine that in an era where competency-based education has been repeatedly shown to be superior to the “see one, do one, teach one” method, we still have to continue talking about it. More studies than I care to cite have demonstrated that its no longer good enough to have “done a procedure” as a surrogate for competence. There should be a uniform approach where trainees meet a minimum standard. They’ll have knowledge of complications and ideally even demonstrate this in a simulation (without having harm come to a patient). Finally, they’ll be assessed as they perform the skill in the clinical setting – all stakeholders benefiting including the patient, trainee and teacher.

A reply to the article mentioned above was posted by another group of authors who have addressed teaching by staff attending physicians. These authors conducted a survey that identified  ”Sharing of attending’s thought processes” as among the most important attributes an attending physician could share during rounds. This highlights nicely how trainees are changing and as a result how staff physicians should re-focus their teaching.

Trainees can be effectively taught by flipping the classroom and learning on the web. 30 years ago this wasn’t possible but now with exponential growth of technology, learning can occur before actually seeing patients. However, what must be learned from experienced clinicians is their cognitive reasoning. Learning such a skill from the web or a textbook is much more difficult. Rounds or bedside teaching sessions should focus on how clinicians avoid biases in their decision making. Trainees should be taught early on how to think like an expert.

Attending clinicians must focus their efforts on training new doctors to think like they do – employing a sound approach to each clinical decision . And teaching faculty should be taught how to teach these skills.  In an era when trainee clinical time has become a scare commodity, efficiency becomes paramount. Teaching core content has become increasingly inefficient especially during precious clinical rounds when both the trainee & attending have access to patients!  Trainees have no shortage of information to diagnose and treat patients but they must be taught to use it. This is the new role of the attending physician in medical education.

We had a great day biking & hiking part of the Hauraki Trail which is only about 1 hour outside of Auckland. Here are a few pics.

While most of my blog focuses on the benefits of simulation within medical education, I’m always keen to read about the opinions of others. In a concise and well written article in the Atlantic by Dr. Richard Gunderman. While he acknowledges the pitfalls of lectures, he raises some excellent points regarding their value. Just like most things, absolutist statements (like all lectures are bad and provide no learning) are likely wrong. He argues that

The great lecture opens learners’ eyes to new questions, connections, and perspectives that they have not considered before, illuminating new possibilities for how to work and live.

I still recall some of my favorite learning moments in medical school and many occurred during lectures. Some of my most memorable professors were memorable because they lectured in a way that was captivating and inspiring. While I do strongly advocate against lectures (in general) because I believe we have superior methods for education, they should not be eliminated. We need to harness the skills of those lecturers to whom we could listen all day and impress that upon learners. Learners can then be encouraged to become great lecturers or they will become so inspired by a topic that they wish to become an expert that leads to great change. I’ll end with this quote from the article. It highlights the value of lectures often beyond our typical perceptions.

The real purpose of a lecture is to show the mind and heart of the lecturer at work, and to engage the minds and hearts of learners