Simulation Scenarios and Clinical Lessons Learned

CHAPTER 8 Simulation Scenarios and Clinical Lessons Learned




“Try it, you’ll like it.”


Exhortation by his siblings to make Mikey eat a suspicious-looking cereal


—TV commercial from the 1990s


This is the meat of the matter. No muss, no fuss, just one monster collection of simulation scenarios, 50 in all. They unfold as if you were there, in the examining room, the OR, or the ICU setting. Watch and listen along as the scenario develops, the residents try to puzzle it out, and the instructor dissects the whole shebang afterward during the debriefing. A summary at the end of the chapter touches on the main clinical lessons learned.





SCENARIO 1. A preop surprise: dealing with a provocative patient


The examining room has a standardized patient (an actor playing the part of a patient).


The resident picks up the chart and looks it over before going in to talk to the patient.


Case. A 47-year-old woman is scheduled for total abdominal hysterectomy. Large fibroids in her uterus have led to heavy bleeding and anemia. There is a history of chronic hepatitis for which she is on steroids, prednisone 20 mg/day. Every time her GI specialist has tried to wean her from the steroids, her hepatitis flares up again. Her SGOT is 90 (she always runs high per her GI clinic chart). Her hematocrit is 27.


Resident goes into the examining room


“Hey, Doc, you’re pretty good looking. You know, they’ll be taking out the baby carriage but leaving the playpen. What do you say?” She winks.


“Uh,” the resident stumbles, “OK, um.”


“Aw come on Doc,” the patient says, “don’t be shy.”


The resident soldiers on, “I’m Dr. Thompson, I’ll be your anesthesiologist, I just want to ask you a few questions and do a brief exam.”


“Sweet pea, you can examine me in my briefs any day and twice on Sunday!” the patient says.


“Have you ever had any trouble with anesthesia, or has anyone in your family ever had any trouble with anesthesia?” the resident asks.


“Well,” the patient says, “I got in trouble back when I was a teenager, but I don’t think it was no anesthesia doctor did it. Might have been Dr. Love though. You mind if I smoke?” She pulls a pack of Marlboros out of her purse.


“Um.” The resident looks up at the ceiling to see if there are any smoke detectors.


“Good, I like a man who doesn’t mind a little second-hand smoke,” the patient says, “my Daddy smoked all the time, prob’ly blew smoke rings in my crib, never did me no harm.”



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FIGURE 8-1 Dig in. As an instructor, remember this—The worst simulator scenario is still pretty good. (Sort of like sex, even when it’s bad, it’s still pretty good.) So don’t worry about getting it perfect. As a student, remember the same thing—The worst simulator scenario is still pretty good. No matter how you flounder, you’re still going to learn.


The patient puts a cigarette to her lips, is just about to light up, when the door opens.


“Simulation over!” the Simulator instructor says.


Clinical lessons learned from scenario 1


Simulations do not have to all involve high-tech mannequins with preprogrammed vital sign aberrations. Actors playing the part of patients make for great simulation too, particularly when the resident isn’t looking for this turn of events.


This resident probably thought he would go into an OR setting and end up coding a patient with an intraoperative MI. Instead, he was detoured to an examination room where he had to do a preoperative evaluation. The chart had some stuff worth exploring—hepatitis, steroid use, anemia—so the resident was probably formulating a line of questioning related to these points.


Hepatitis—“Any sign of easy bruising or bleeding?” Concern here centers on the all-important coagulation factors produced by the liver.


Steroid use—“Are you still taking steroids all the time?” Such a patient would not be able to produce a “stress response” of steroids during the perioperative period, so she would need steroid coverage in the OR.


Anemia—“Are you dizzy or short of breath? Do you feel worse now than usual?” With all the bleeding from the fibroids, this low hematocrit of 27 may be new, and the patient won’t have any compensatory mechanisms in place. She may need transfusion preop. On the other hand, if this has been a slow, long-term bleed, the patient may be “used to” such a low hematocrit, and the need to transfuse is less urgent.




BOX 8-1 Provocative Patient



• Legal landmine

• Keep professional

• Get other person in room

Then what happens?


The patient acts inappropriately, taking the interview into forbidden territory. Sexual innuendo and suggestion? What is this? What the heck is the resident supposed to do? This is a bolt from the blue. The resident stumbles, mumbles, and is completely lost with this bizarre twist.


What was an exercise in pharmacology and physiology (hepatitis, steroids, anemia) has turned into an exercise in professionalism (how to interact with a provocative patient).


“But, but …” the resident thinks, “I thought the Simulator was for … was for … you know, V-fib and stuff like that!”


Here’s how the debriefing goes.


Debriefing. “Hey,” the resident demands, “what was up with that? You guys are supposed to teach me how to handle stuff in the OR.”


“Oh, is that all we teach you?” the instructor asks. “Aren’t we ‘perioperative physicians’? Does that not include the preoperative and postoperative arena as well?”


“Well,” the resident admits, “yeah, yes I guess so.”


“And as an ACGME accredited program, don’t we have to teach you all the core clinical competencies?” the instructor asks.


The resident nods, lips tightened, and face has turned into a “Oh, that ACGME stuff again” mask.


“And is not one of those competencies ‘professionalism’?”


Defeated, the resident’s shoulders slump. “OK, OK, you made your point.”


“Good,” the instructor can’t muffle the triumph in his voice, “what, to your mind, is the definition of a professional? We’re teaching ‘professionalism,’ so, after all, I guess we should know what a professional is, shouldn’t we?”


“Well,” the resident says, “a professional is someone who … someone who went to school and … oh hell, I don’t know.”



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FIGURE 8-2 A. Losing your professional aplomb. B. Get another person in the room—that should re-establish equilibrium. C. And if that extra person senses a lack of professionalism, then by all means a stern lecture is in order.


The instructor says, “Pros adapt. That’s the simplest definition of a professional and the best way to teach professionalism. Pros adapt, period.”


“In anesthesia that means we adapt when the airway’s difficult, we secure that airway by hook or crook, or, more appropriately, by fiberoptic or scalpel, when it comes down to it. We adapt when the lines are difficult—we go central line if we have to, we ask for help, we get a Site-Rite machine. We are pros, we adapt, we find a way.”


“And sometimes we have to adapt outside the operating room or ICU. We have to adapt to a sudden, disturbing fork in the road. But we are pros, we find a way.”




BOX 8-2 Why a Standardized Patient?



• Person-to-person interaction

• Explore behavioral issues

• Test flexibility

“Now here, you have something you never expected. A woman who had you thinking of liver disease and blood counts, and all of a sudden she comes at you from an entirely different direction. What do you do in such a case? What does a pro do?”


“Pros adapt,” the resident says.


Down comes the instructor’s fist on the table with a bang, “Damn straight you adapt! You’re a pro now and that’s what pros do!”


Now the resident is all smiles, but a cloud crosses that smiling face.


“Uh,” the resident says, “how, precisely, do I adapt? Um. Sir.”


The instructor is shaking his hand out now, he overdid it on the table, “Thought you’d never ask.”


“What is the crux of the problem you are facing?” the instructor asks.


“She’s being inappropriate,” the resident says, “she’s saying things of a sexual nature, which simply do not belong in the discussion. And nowadays you think, ‘Oh God, she’s going to sue me and said I touched her and who knows what else!’”


“Right,” the instructor says, “so how do you cool down the discussion, what would change the dynamic in the room? What would undo this enforced intimacy, this awkward and unprofessional jam you’re in?”


“I don’t know.”


“What resources do you have in a preoperative setting?” the instructor asks.


“Well,” the resident is looking around the room, trying to visualize the holding area, “there are holding area nurses.”


“And …” The instructor is letting the resident “find his own way.”


“I guess if I asked one of the holding area nurses in the room,” the resident is putting it together, “then with the extra person there listening the woman would probably chill out a little.”


“Anything else?”


“I’d be, sort of, ‘protected,’ because there would be someone else there, in case later the woman said I did something wrong,” the resident says.


“Bingo!”, the instructor says. “Getting an extra person in the room is the best protection for you. That should straighten the woman out, get her back to the questions you need to ask her—bleeding questions, all the stuff you need to know—and that extra person also provides you great back up in case of false accusations.”


Summary. Anesthesia does not just mean administering anesthetics and fixing vital signs. Anesthesia encompasses the entire perioperative experience, pre-, intra-, and postop. So a simulator experience that trains anesthesia personnel should include the whole shooting match, and that includes dealing with patients.


All kinds of patients.


Most patients are appropriate, but some aren’t. We deal with the whole population; and we, as professionals, must adapt no matter what problems we run into.


Provocative, like this patient

Litigious

Anxious

Mentally challenged from congenital or acquired cerebral problems

Threatening, as anyone who’s worked with the prison population knows

So a simulator session would include such a patient. Dealing with them is difficult, but deal with them we must!


Note how the Simulator session and the debriefing session mesh quite well with teaching the ACGME core clinical competencies—especially the “tough to teach” competencies such as professionalism and communication skills.


Note also how the debriefing session is not a straight didactic: “You did this right/you did this wrong. Got it? Good bye.” At a good debriefing session the resident thinks things over, looks at the gray areas, and then is given the time and freedom to eventually find the answer themselves, with guidance from the instructor.



SCENARIO 2. Headache with attitude, an intracranial bleed


“Get to room 3 right away!” The resident goes into the OR.


Case. An intubated patient is on the operating table, an arterial line is in, plus a 16 gauge IV. An anesthesiologist is at the foot of the table trying to straighten out the lines. An infusion pump running nitroprusside is on the IV pole, but it came disconnected and is dripping onto the floor. Two surgery people are placing pins on the head, and there is an obvious sense of agitation in the room.



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FIGURE 8-3 Why oh why could the blood pressure be so high? Ooops! The nipride is disconnected. Sound unlikely? You’d be amazed how often this simple glitch occurs (kinked or disconnected lines, malfunctioning pumps).


On the monitors, there is an arterial line, but you can only see the “bottom part” of the arterial line trace. The number on the art line reads a nearly incredible 300/160. The patient is tachycardic to 120.


“Big bleed in the head,” the neurosurgeon says, pointing over his shoulder at a CT that is up on the view box. A huge bleed is apparent. The OR table is turned around 180 degrees, so the feet are by the anesthesia machine and the head is up by the surgeons. The head is cranked down with the chin touching the clavicle.


The anesthesiologist in the room doesn’t notice the disconnected nitroprusside or the sky-high blood pressure.


Now the surgeon looks up and sees the blood pressure, “Holy shit, is that right? What the hell are you guys doing up there?”


Just as the surgeon says that, the heart rate drops to 100, then 80, then 60, then 40.


“Hey, he’s bucking!”


The resident in the room reaches over to the drug cart, grabbing a syringe of rocuronium and another of Pentothal. Running around to the IV, the resident pushes the Pentothal and rocuronium, wham bam, one after the other.


Opening the patient’s eyes, the neurosurgeon says, “Hey, look at this.”


After opening the IV wide open to carry in the Pentothol and rocuronium, the anesthesia resident goes up to the head of the bed and looks. The left pupil is blown.



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FIGURE 8-4 Careful with positioning. If you hyperflex the neck and have the chin touching the clavicle, you can stretch vessels supplying the spinal cord and end up with a quadriplegic patient. Rule of thumb? Two fingerbreadths separation between the chin and clavicle for each 70 kg of body weight. Another trick? Put your own head in the position you put the patient’s head in. If you are uncomfortable, the patient is too. For that matter, this lesson applies for all positioning. If you don’t like it, the patient won’t.


The heart rate drops to 30.


The blood pressure drops down from the stratosphere, now down to 200/120.


Up go the drapes, and the surgeons go at it.


“Hey, this brain is tight as a drum skin, what are you doing up there?”


The anesthesia resident looks at the end-tidal CO2. In all the excitement, the ventilator wasn’t checked: 55, the end-tidal monitor says.


The resident increases the ventilation, asks for some mannitol. After a few minutes, the surgeon’s report: “That’s better.”


At the same time, the heart rate increases to 60.


“Simulation over!” the instructor says.


Clinical lessons learned from scenario 2


Haste makes waste, never more so than in a medical emergency.


Getting called into a room with a 4+ disaster is a hair-raising experience, enough to discombobulate the best practitioner. Everything is happening all at once. Everything is going wrong, and everything needs fixing now, sooner than now, more like 10 seconds ago. You try to organize your thoughts along the ABC line; but with surgeons yelling at you, a blood pressure that could launch a Titan V rocket, and a Medusa’s head of lines, it’s hard to do the right things in the right order.


If only you could press a freeze button, you could make order out of chaos. But fate has not handed us such a magical button. And a critically ill patient doesn’t hand you that most luxurious of gifts—time.


And things happen in a rush. Stuff gets disconnected, but, hey, you were in a rush to get the patient over to the table. If you took all the time in the world and made sure absolutely everything was neat and tidy, the patient might die a neat and tidy death.


Let’s look in the mind of this anesthesia resident during the debriefing from this scenario.


Debriefing. The instructor opens the discussion, “What were your priorities in this case?”




BOX 8-3 Controlling Increased ICP



• ABC—fix all three

• Stop bucking

• Pharmacologic measures

“Like any case,” the resident says, “a quick survey, focusing on the ABC. It was evident the patient was in extremis and needed cerebral decompression as soon as possible.”


“Did you listen to the chest to make sure the endotracheal tube was in?” the instructor asks.


“No, I could see that there was end-tidal CO2, so I knew the tube was in the right place,” the resident says, “and I saw the saturation was 100%, so I went right to the most pressing issue, the ‘C’ part, a deadly high blood pressure.”


“What were you thinking?”


“With the big bleed the surgeon mentioned,” the resident says, “I envisioned the compensatory mechanisms the body uses to maintain cerebral perfusion pressure. Because the intracranial pressure was high secondary to compression from the hematoma, the body raised the systemic blood pressure in an attempt to keep the rest of the brain supplied with blood.”


“So why try to get that pressure down?”


“At 300 systolic, the strain on the heart would be unbearable and would lead to a cardiac arrest within minutes. Also, if this cerebral bleed were from a ruptured aneurysm, that pressure of 300 would turn that torn aneurysm into a fire hose, pouring more blood into the brain.”


“What was your goal?”


“Get the pressure down to something the heart might be able to tolerate,” the resident says, “say a systolic of 200 or so. Still high, so you could still get cerebral perfusion, but not so high that it places the heart at risk.”


“But you didn’t have time to look everything over, did you?”


“No, the patient bucked, indicating he wasn’t paralyzed. That bucking is bad for increased intracranial pressure. The patient was at risk for cerebral herniation with that huge bleed. When I first got in the room, I feared that might happen, as indeed it did.”


“How did you know?”


“At first,” the resident says, “the patient had hypertension, increased intracranial pressure, and tachycardia, so he didn’t have the classic Cushing’s triad. But that changed after the patient bucked. Then the patient did develop the classic triad of blood pressure elevation (to keep cerebral perfusion pressure up), increased intracranial pressure (from the bleed), and reflex bradycardia (the heart’s response to the high blood pressure).”


“So what did you do?”


“The nitroprusside was disconnected, so I couldn’t use that to drop the blood pressure, so I reached for Pentothal to drop the blood pressure and rocuronium to paralyze the patient and prevent further bucking.”


“Would nitroprusside have been your first line to drop the blood pressure?” the instructor asks.


“No,” the resident says, “nitroprusside is a dilator and can increase cerebral blood flow and hurt our intracranial pressure picture. Pentothal is good for decreasing the cerebral metabolic rate of oxygen—a good drug in this setting. Plus, Pentothal helps drop the blood pressure.”


“What did you think about the head positioning?” the instructor asks.


“I didn’t like it,” the resident says. “Extreme flexion of the head with the chin touching the clavicle is too extreme. That can cause stretch of the vessels supplying the spinal cord and can lead to spinal cord ischemia. I would have preferred to reposition the head, making sure there were at least two fingerbreadths of space between the clavicle and the chin for each 70 kg of patient body weight.”


“But you didn’t do that.”


“No,” the resident says, “the patient herniated, as evident by the pupil dilating unilaterally. The brain was getting squished down into the foramen magnum, and death would result in minutes, so it was more important to get that head open and drain the blood as soon as possible. Truth to tell, it would have been all too easy to forget about that later on.”


“When troubles come, they come not as single spies,” the instructor says, “but in battalions.”


“Amen to that,” the resident says.


“And once the head was opened, what was the next problem that appeared?”


“The surgeon complained of a ‘tight head,’ indicating that I needed to do what I could to reduce brain volume. That means adequate drainage, no kinking of the head or neck vessels, hyperventilation, and osmotic diuresis.”


“But the CO2 got away from you,” the instructor observes.


“Yes,” the resident admits, “guilty as charged. With all the excitement of the herniation, I forgot to check all the details, and I had inadequate ventilator settings. Once I saw the high CO2, I increased ventilation to drive the CO2 down and help shrink the brain.”


“But not too much, right?” the instructor asks.


“Correct,” the resident says, “I would aim for an end-tidal CO2 of about 25 to 30. More severe hyperventilation could result in cerebral ischemia, plus the resulting respiratory alkalosis could impair oxygen delivery.”


“These neuro cases are real physiologic showcases, aren’t they?”


“Don’t you know it.”


Summary. Hours of boredom, moments of panic. So goes one description of anesthesia. An impending cerebral herniation certainly qualifies as one of the “moments of panic.”


In this case, a patient had been rushed up to the OR, probably from the CT scanner, with a life-threatening intracranial bleed. In the zippety doo-da transfer to the OR table, a nitroprusside drip had gotten disconnected, unmasking a horrific hypertension that could kill the patient, well, a second time if the herniating brain didn’t kill him first. Talk about double jeopardy!


Into this high stress simulator scenario an anesthesia resident arrives, just when everything starts to fall apart. A quick assessment and quick thinking brought all the important points into focus (tube’s in, pressure’s high, patient needs paralysis), although a couple of other points did escape this initial scan (making sure to undo the severe neck flexion, hyperventilating).


The resident demonstrated a good understanding of intracranial pressure, cerebral perfusion pressure, and the signs of herniation. Actions were quick and appropriate, a nimble response to a tough case.



SCENARIO 3. Local in the wrong locale, intravascular injection during an epidural


The overhead speaker says, “Anesthesia to labor room 2, anesthesia to labor room 2 to top up an epidural.” Into labor room 2 goes the anesthesia resident.


Case. On a labor table, a pregnant patient with attached epidural is groaning (through the speakers in the mannequin). The patient’s feet are up in stirrups, and the OB is sitting in front of her, holding forceps.


“Hey,” the OB says, “glad you showed up. I could use a little help here. Your epidural is no great shakes.”


“OK,” the resident says, “how are you doing, ma’am?” As the resident speaks, she looks around for the anesthetic paperwork—preop evaluation, anesthetic record detailing the epidural placement, dose and rate of local anesthetic given and running.


“Bozhe moi,” the patient groans, “bozhe moi, boleet, boleet! Rebyonik vilyezaet!”


“Oh yeah,” the OB says, “she just moved here from Minsk. She only speaks Russian or Ukrainian or something.”


The patient is connected to a blood pressure cuff, a fetal heart rate monitor, and a pulse oximeter.



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FIGURE 8-5 Language barrier—what do you do? Do you just pretend that there isn’t a problem? Not an effective plan. There are a lot of creative ways around this—get acquainted with the hospital’s translation service. Find a relative who can function as interpreter. Best answer—learn the language yourself! A little involved, to be sure, but a great way to impress people at cocktail parties.


Lost in the paperwork, the anesthesia resident says, “Uh huh.”


The anesthesia preop outlines the case.


More of the case. A 22-year-old G1P0A0, previously healthy woman appeared for delivery. Good prenatal care, no complications. Takes vits. Translator—husband (patient is Russian speaker only). Airway, Mallimpotti 2; labs pending. Patient currently at 3 cm dilation and in discomfort. “Plan—combined spinal epidural. Case fully discussed per translator, detailed risks/benefits/options. Patient agrees to proceed.”


Vital signs were normal, and the patient was not morbidly obese. If ever there were a routine case, this was it.


The anesthetic record detailed an unremarkable course.


“Patient given fluid bolus, FHR checked and monitored throughout. Patient sat up, prep/drape, local placed at L3–4. Loss of resistance technique used to identify epidural space. A 25 g pencil point needle used through Touhy needle, clear CSF, no paresthesias. Fentanyl 15 μg was injected after a positive aspiration. Spinal needle withdrawn, epidural catheter placed, Touhy withdrawn, catheter secured. Aspiration negative for blood or CSF, test dose without adverse reaction. Infusion of 0.125% levobupivicaine (10 cc/hr) with 5 fentanyl (5 μg/cc) begun.”


“Good pain relief, patient stable, FHR OK throughout.”


So far, so good.


But now the OB was complaining, in English, and the patient was complaining, in Russian.


“OK, is the husband around?” the resident asks, “my Russian is not too good.”


“He was here all night,” the OB says, “he’s conked out in the lounge. Listen, honey, this here epidural is not winning any Nobel prizes for pain relief, can you do something to help me here? Baby needs a little help with these forceps, and mom isn’t going for it.”


“Um, OK,” the anesthesia resident says, “my name is Dr. Nelson, not ‘honey’.”


“Bozhe moi, pomogeetye mnyeh, rebyonik vilyezaet, rebyonik vilyezaet!” the patient shouts.


“Fine,” the OB snaps, “I’m so happy the political correctness, thought and mind control Gestapo have shown up to make sure I don’t step on any feminine sensibilities, Doctor Nelson. Now make this god damned epidural work!”


“Boleet, boleet! Akh da, gdye moi moozh?” the patient shouts.


Dr. Nelson goes to the head of the bed, looks at the epidural catheter and notices that the infusion tubing has come disconnected from the cap. In sterile fashion, she reconnects them.


“So,” the OB still has attitude in his voice, “can you help me or not, or do you want me to do like they did in Gone with the Wind, and just put a knife under the bed so it cuts the pain in half?”


“No need,” Dr. Nelson says, “the epidural became disconnected, I’ll have to rebolus.”


“Oh great,” the OB says, “well make it snappy, I’ve got to get these salad spoons on.”


Dr. Nelson draws up a syringe of 0.25% levobupivicaine, connects to the tubing, aspirates, then injects 5 cc. She waits a minute, then injects the other 5 cc.


“Chto eto!” the Russian woman says, “Chto sluchilas? Mnye ochen … chto eto zvonok?” Then she falls silent.


The fetal heart rate monitor drops to 40, the patient’s pulse oximeter stops beeping.


“Hey!” the OB shouts, what’s going on here? What did you give?”


Dr. Nelson gives a sternal rub and shouts at the patient, then reaches down for a pulse, there is none.


“Oh Christ!” the OB shouts, then drops the forceps, goes up to the chest, and starts CPR. “Call a code!”



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FIGURE 8-6 Know your fetal heart rate strips! Baby dumpling is heart rate-dependent. So when that heart rate drops, baby dumpling is in big trouble!


Dr. Nelson looks around for a laryngoscope, an Ambu-bag, anything.


“Simulation over!” the instructor chirps.


Clinical lessons learned from scenario 3


Dr. Nelson faced a prickly path in labor room 2.


She was “inheriting” an epidural, so she had to come up to speed on that.

Her co-worker and fellow doctor treated her dismissively.

Things were coming to a clinical head, or, more precisely, an occiput, as the woman was in need of a forceps delivery.

A regional anesthetic was in use, and there was a language barrier.

And that was just the start of Dr. Nelson’s troubles.


The debriefing picks up the thread.


Debriefing. “So,” the instructor says, “how do you think that went?”


Dr. Nelson’s head is hanging down, “Not too good, I think I killed them both. 200% mortality. Not a stellar performance.”


“Relax,” the instructor reassures, “be glad she didn’t have twins. Then it would be 300%.”


“Thanks,” Dr. Nelson groans, “I feel a lot better.”




BOX 8-4 Language Barrier



• Symptoms?

• Instructions?

• Communication?

“Before we get to the thrilling conclusion, let’s go over things from the start. What was the situation, and what were your concerns when you came through the door?”


“Pregnant patient, so you think about all the concerns there—full stomach, possible difficult airway, any sedation you give to mom you give to the baby, decreased FRC so the patient can desaturate quickly. Plus we have an epidural in, so you are always thinking—is this in the right place, is it working, could it be intrathecal, could it be intravascular?”


“Right,” the instructor says, “so you have the physiology of pregnancy on your mind, the pharmacology of epidurally infused local anesthetics and narcotics on your mind. But then, it’s not like we do things in a library, is it, a physiology textbook on one side, a pharmacology textbook on the other?”



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FIGURE 8-7 Believe it or not, the fruit and vegetable world provides us with some partial-task simulators. The epidural needle gets a loss of resistance as it goes through the skin into the, the (what do you call it?), the banana meat? The banana essence?


“No,” Dr. Nelson says, “there is the human factor.”


“Aah yes,” the instructor agrees, “and what are the human factors at work here?”


Both the OB and the patient (the Russian speaking technician who was providing the voice for the simulator mannequin) enter the debriefing room.


“Well,” Dr. Nelson starts out, “the OB was a demanding asshole of a chauvinistic pig.”


“I try,” the OB says.


“So I had to deal with his ‘woman-doctor-as-honey’ comments and still try to keep a professional head on my shoulders and assess the patient.”


“Let’s give the devil his due, Dr. Nelson,” the instructor says, “let’s look at things from the OB’s point of view and add a touch of real world to this scenario.”


The OB chimes in, “I mentioned the husband had been up all night; guess what, I had been up all night too. So now I’m wiped out, I don’t have my ‘Mr. Perfect’ hat on because I’m frustrated with a poorly functioning epidural. And yes, I said a stupid thing. You could kick my ass on this, and I guess you’d be within your rights, but keep in mind, I am your referral base. And if you go ape every time someone says something stupid in the hospital, then you’d better transfer to Perfection Memorial Surgery Center, where everyone is always considerate and kind and wonderful 24/7. And let me know when you find that place.”


Dr. Nelson bristles, “I thought I handled it OK, though. I made my point without going to the Supreme Court, and I passed over his ‘thought Gestapo’ swipe.”



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FIGURE 8-8 Some parturients are somewhat, um, short for their weight. So to practice this sometimes difficult epidural placement, use a fruit that is also somewhat, um, short for its weight.


The instructor says, “Touché, you did that. What was the other human factor going on here?”


“Russian. The woman spoke Russian, and that really hurts my ability to ask for symptoms,” Dr. Nelson says.


“What do the textbooks say about that?” the instructor asks.


“Some say that a language barrier is an absolute contraindication to using a regional anesthetic!” Dr. Nelson says. “In theory, that is right. How can you ask about ‘ringing in the ears, a funny taste in the mouth’ and other subjective signs of an intravascular injection of local anesthetic?


“But on the OB floor, that is just plain not practical,” Dr. Nelson continues. “What are you going to do—a general anesthetic on every patient with a language barrier? The prime dictum of obstetric anesthesia is doing everything in your power to avoid general anesthesia, with the risk of airway loss and hypoxemic catastrophe. So we do the best we can, using whatever translation services we can—family members, nurses, orderlies—you can even get some translation services over the phone nowadays.”


“But there is still that risk,” the instructor says. “There is still that concern that the patient is saying something that you need to know, but you can’t understand it.”


“Yep,” Dr. Nelson admits, then turns to the Russian technician, “What were you saying, anyway?”



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FIGURE 8-9 Our obstetric friends can also tap the fruit basket to practice their skills. Here a banana demonstrates how a C-section is done. Prep, cut open the peel, take out the banana, close up the peel. Then weigh the little darling and give him a cute blue cap. Maybe clean him up a little too.


“Turns out I was saying something important,” the technician says, in perfectly unaccented English, “I was saying, ‘It hurts, the baby is coming.’ The whole controversy here swirled around dosing me up for a forceps delivery. But while you and the OB were sniping at each other, the baby was coming down on his own, obviating the need for forceps and for the dose-up.”


“Oh,” both OB and Dr. Nelson say; neither had been privy to what the Russian speaker would say. Damned clever twist he came up with. No one had been thrown by the fact the voice was that of a man. Oh well, pros adapt, as they say.


“All right,” the instructor says (wow, even he didn’t know about that sneaky little tweak—better remember that at Christmas bonus time). “We talked about the pharmacology and physiology and the human factors. What else heaves into view as we get toward the end of our little morality play?”


“Equipment,” Dr. Nelson says.


“Why do you say that?” the Russian speaker asks.


“When I dosed the epidural, despite giving the local anesthetic in divided doses, the local anesthetic either went intrathecally—causing a total spinal and plummeting blood pressure—or intravascularly—causing cardiovascular collapse,” Dr. Nelson says. “Either way, I needed to resuscitate the patient, and that means having resuscitative equipment nearby—intubating stuff like endotracheal tubes and laryngoscopes, Pentothal to stop seizures.”


“Did you have any of that stuff?” the instructor asks.


“Oh, I didn’t check,” Dr. Nelson admits. “That, I should have done. What was that you were saying, anyway?” Dr. Nelson asks the Russian speaker.


“I said, ‘What’s that, what happened, what is that bell?’ Then I stopped. I was responding the way a patient might respond to an intravascular injection of local anesthetic, when they first feel funny, then they might hear ringing in their ears, then they lose consciousness. I would seize too, but the simulator mannequin can’t do that yet.”




BOX 8-5 Intravascular Injection of Local Anesthetic



• Stop injection (duh!)

• Cardiovascular and respiratory support

• CPB if necessary

“Anything else you might have done differently?” the OB asks. “Like when the code started and I went up to the chest to start compressions?”


“I don’t follow you,” Dr. Nelson admits.


“How effective are chest compressions in the still-pregnant patient?”


“Oh yeah,” Dr. Nelson tumbles to it, “chest compressions in the pregnant patient are ineffective until the baby is out. Better to deliver the baby right away—your forceps might have been able to snag it—then the chest compressions are much more effective.”


“Righty-oh,” the instructor wraps it up.


Summary. A simple epidural and anticipated forceps delivery encounters some turbulence. Dr. Nelson has to brush off a snippy and demeaning comment, focus on the patient’s needs, work through a language barrier, and handle an intravascular injection of local anesthetic.


Just thinking “To hell with it, the husband is asleep” left both OB and the anesthesia resident blind to extremely important information. That baby was coming, and there was no need for them to do anything! Also, the subjective symptoms of the intravascular injection escaped Dr. Nelson.


Routine practice means making sure you have all your “rescue stuff” nearby. Dr. Nelson was caught short when disaster struck. Plus, in the “who-wouldn’t panic” mode of a code, Dr. Nelson forgot a fundamental principle of CPR in the pregnant patient—get the baby out before you do chest compression.


The final lesson: When injecting local anesthetic, stick to this rule—every dose is a test dose. Never slam in a gallon of that stuff because if it goes intravascular you could be in deep Kimchee.


Maybe next time they should do that “knife cuts the pain in half” trick from Gone with the Wind.



SCENARIO 4. Help from across the drapes, hypoxemia in the OR


“Any anesthesiologist to OR 18, any anesthesiologist to OR 18 stat!”


A CA-3, a senior anesthesia resident, answers the call and goes into OR 18.




BOX 8-6 Obstetric Pain Relief



• Regional

• Parenteral

• Knife under the bed?


image

FIGURE 8-10 Stat call? When an anesthesiologist calls for help stat, it is the real McCoy. Lost airway, cardiac arrest, whatever it is, they need that extra hand and they need that extra hand right now.



image

FIGURE 8-11 Fly to the room if you can. That extra pair of hands and that extra brain might be just the thing to save your anesthesiology partner, and, lest we forget, save a patient as well.



image

FIGURE 8-12 The best part about being the “second person in the room” is that you always look good. If you save the day—great. If you don’t, well, then at least you showed up and tried.


In OR 18, a CA-1, a junior resident, is at the head of the table, hand ventilating the patient. The patient is intubated, the drapes are up, and everyone is in mid-operation, two surgeons operating and the usual surgical team doing their thing.


“Hey,” the first surgeon yells, “lend a hand here. Bozo here just graduated clown school and made a wrong turn into my OR.”


That cracks up the other surgeon, and he chimes in, “Blood-brain barrier, right. How about the blood-brainless barrier!”


They get back to work.


“What’s up?” the senior resident asks.


Hand ventilating and cranking his head around to the screen, the junior resident says, “Look at the STs.”


On the EKG, a tombstone pattern of ST elevation is present. Ischemia that a blind man could see.


The CA-3 looks over the vital signs, oxygen saturation 100%, BP by cuff 85/50, pulse 130.


“Why are you hand-ventilating?” the senior asks.


“Well, he’s ischemic, so I figure he’s going to arrest. I know you hand ventilate in an arrest, anyway, it seemed like a good thing to do,” the junior says, flustered and shook.


Flipping the ventilator switch from manual to automatic, the senior resident says, “Relax, let the ventilator do the work. You have to figure out what’s going on, free up your hands.”


“Now why’s this guy ischemic?” the senior asks.


An audio alarm goes off, both reach up to silence the alarm.


“OK, this is a liver resection, that’s what it says; and they’re losing a lot of blood. I’m trying to keep up, but I think I’m behind,” the junior says, then hands the senior the preop. “This guy’s had a couple stents, he’s 70, so he’s got ischemia. I mean he’s a setup for ischemia, and now this.”


Another audio alarm goes off. Again, both reach to silence the bothersome alarm.


“You guys OK up there?”, the first surgeon asks, now a shred of concern in his voice. “The blood looks a little dark here.”


Taking charge, the CA-3 decides he’s had enough from the knife-wielders, “Yeah, we’re fine, see if you can slow down that bleeding. They did teach you to tie in school didn’t they? Or do you need Velcro on your shoes?”


Two alarms now go off, and both get silenced in a split second.


“OK, let’s look all this stuff over, that’s the way you do it when things go south in a case, go it?” the CA-3 soothes the CA-1. “ABC, always start with ABC.”


He looks around, “Tube’s in, so we got A and B, now the C part needs a little work,” the senior says, pausing only to push another “silence alarm” button.


“I’m not kidding you guys,” the second surgeon says, “this blood really does look dark!”


“Yeah yeah,” the CA-3 says, “sure it does. We got it.”


On the EKG, the STs are even higher.


“Listen, this is all about myocardial supply and demand, and right now there’s too much demand—look at that heart rate—and not enough supply—look at that blood pressure,” the senior explains. “Hang blood, keep transfusing until that heart rate goes down. They’ve obviously lost a ton resecting that liver.”



image

FIGURE 8-13 ST troubles. When ST segments go down, it usually means subendocardial ischemia. That is not good. When ST segments go up, it usually means transmural ischemia. That is not good with capital letters. And those capital letters can go to these capital letters—RIP.


From the other side of the drapes, the surgeon suddenly appears and bursts between the residents. “What in blue blazes is going on up here, I tell you the blood’s dark, and no one pays attention to me, do you even have this ventilator on, I don’t see the chest rising!”


“Hey,” the CA-3 is bristling with territoriality, “what are you doing….”


“Wait,” the CA-1 says, “he’s right.” Reaching over, the junior resident turns on the ventilator. The senior resident had switched from manual to ventilator but had not turned the ventilator itself on.


A look of triumph on his face, the surgeon goes back to the other side of the curtain.


“We’re done!” the instructor says.



image

FIGURE 8-14 When it comes to ischemia, go for the myocardial oxygen supply/demand teeter-totter. Decrease the demand (beta blockers) and increase supply (improve oxygenation, transfuse). If you’ve fixed everything you can fix, you have to go to the big guns—revascularization by stent or even CABG.




BOX 8-7 Ischemia Treatment



• Increase O2 supply

• Decrease O2 demand (beta blockade!)

• Think of teeter-totter

Clinical lessons learned from scenario 4


“Any anesthesiologist to OR 18!” is enough to send chills down any anesthesiologist’s spine. No one puts out such a call unless the ship has hit an iceberg, the car is plummeting over the cliff, the airplane’s wing just fell off.


But call it you must, if in trouble. And respond you must, if you hear it.


The junior resident was overmatched by circumstances. (After all, you can’t know it all at the beginning—that’s why we do residencies!) So he put out a call to his more senior colleague.


Upon arrival, the senior resident pegged the problem—blood loss, low blood pressure, high heart rate—all the classic signs of hypovolemia. Couple this with a patient prone to ischemia, and you get, no surprise, ischemia. The heart is banging away, trying to compensate for the low blood volume, so that places a high demand on the heart. But supply is short—the patient has bled a lot, so there is low oxygen content. Also, the pressure head pushing blood down the coronaries is low, so the heart is going into oxygen debt.


Presto-chango, ischemia prone myocardium is now ischemic myocardium.


Never fear, senior resident to the rescue!


The debriefing reveals just how good a rescue he delivered.


Debriefing. “What were you thinking when you called for help?” the instructor asks the CA-1.


“I knew from the preop that this patient could develop problems related to his coronary disease. Then when the surgeons, well actually the circulator, reported a lot of blood loss, then I saw the low blood pressure and the STs, and it started to be too much too fast,” the CA-1 says, “so I sort of ‘went to ground,’ hand ventilating and getting someone to help me.”


“Did you think you would need an a-line for this case?” the instructor asks.


“Well, the surgeon said he had one of these kind of oscillating Harmonic Scalpel things, that cauterizes as it cuts, so you shouldn’t lose much blood,” the CA-1 explains.


“But he did.”


“Boy howdy, he did,” the junior says.


“How would you rank your interaction with the surgeon? Were you able to communicate effectively with him or the surgical team?” the instructor asks.


“Not too well, they were bugging me, mostly, and not much help,” the junior says.


“Does that matter?” the instructor asks.


“Yeah, I mean, the OR is not meant to be a fight about pecking order,” the junior says, “the patient sort of trumps all that.”


“Listen,” the surgeon, now sitting in on the debriefing, says, “you might not like getting a little static from your surgery buddies, but I got news for you. That’s exactly what you’re going to get when you graduate from here. Private practice medicine is not a cruise on The Love Boat.”

Related posts:

Attendance and Scheduling Issues With What Other Disciplines Should We Work? How Anesthesia Simulation Is Done What Is a Simulator–a Clinical Checklist or a Theater? The Great Debate Bibliography
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May 31, 2016 | Posted by in ANESTHESIA | Comments Off on Simulation Scenarios and Clinical Lessons Learned

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