This book attempts to lay out the principles of learning and teaching anesthesia crisis resource management (ACRM) in anesthesia practice. Although the principles can be summarized in a book, and even represented on a single reminder graphic, mastering and honing these skills requires various sorts of hands-on practice. Some practice can occur during real patient care. Principles of teamwork and decision making are exercised in almost every case during the delivery of patient care even when everything runs smoothly. In fact, for everyday clinical work, perhaps the issue is not lack of practice but rather that routine work can make people complacent. Perhaps with the exception of those administering anesthesia near the battlefield, in busy trauma centers, or with high volumes of unusually ill patients, the challenges of everyday cases are small compared with those seen when things go wrong. Thus many aspects of crisis management are likely to become rusty unless special mechanisms are put in place to counter this natural trend.
How, then, should people organize to teach ACRM skills? First, there are a variety of ways to become highly conversant with the principles of ACRM, and these are described in detail in Chapters 1 and 2 . Being conversant with the principles means more than just knowing about them or being able to answer multiple choice questions about them. It means being able to explain them and then to recognize them when discussing cases or videos of cases (real or simulated). Finally, it means to be able to enact the principles when called upon to do so. Simulation—using various modalities—is an important technique for teaching, learning, and practicing ACRM, although it is neither the only way to do so nor the only way to get started.
Methods to Learn the Principles of ACRM
Articulating Key Points
One technique that we have used successfully to help people become more conversant in the principles of ACRM involves using a list of ACRM key points without describing the meaning or subelements for each point. With a group, we may hand each member an 8.5 × 11-inch laminated sheet, each with a different key point printed on it. We then ask each individual to describe for the group the meaning of that key point—as if explaining it to a novice. The instructor and the group then probe the individual for more clarification, and the group as a whole discusses the point and its relationship to other key points and to the issues raised in the discussion. This continues for all members of the group and/or for as many key points as time allows.
Identifying and Discussing Key Points of ACRM in “Trigger Videos”
The term “trigger video” refers to a video that is used to trigger discussion about specific issues, often those with significant affective components. Trigger videos can be created locally for specific purposes. In our experience, effective trigger videos can be made by an experienced simulation team using existing audiovisual resources and without extensive script development or acting talent. Some completed trigger videos may be available for download from online health care education resources such as the MedEd Portal operated by the Association of American Medical Colleges (AAMC— https://www.mededportal.org/ ). Use of this portal is free to the public, requiring only registration. One of our group’s trigger videos depicting a simulation of an intraoperative cardiac arrest is available at the MedEd Portal ( https://www.mededportal.org/publication/7826 ).
It is also possible to use commercial films or videos created for entertainment as trigger videos. For example, for more than 24 years we have used a segment from an episode of the Public Broadcasting System’s NOVA television program (“Why Planes Crash”) depicting a reenactment of what transpired in the cockpit during a classic airliner crash (Eastern 401).
Our European simulation colleagues, Peter Dieckmann, PhD, and Marcus Rall, MD, have highlighted the use of portions of Hollywood movies as trigger videos. Based on their advice, we frequently use the opening decision-making sequence of the film Master and Commander: The Far Side of the World (2003, Twentieth Century Fox, Miramax Films, Universal Studios) to trigger discussion of crisis resource management (CRM) issues, or as the basis for an exemplar role-play of a debriefing.
Using such generic videos as a vehicle for learners to recognize elements of CRM and to apply them to health care has some advantages. In general, no one in the learner group—possibly composed of individuals from various fields of health care—is an expert in the domain of the nonmedical film, thus putting everyone on an even footing. This methodology also reinforces that the key points of ACRM are really about fundamental issues of human performance and thus apply to everybody.
Regardless of the source or type of trigger videos, exactly how they are used is important. As the name trigger video suggests, merely showing the video is typically not sufficient; the instructor must use the film as a trigger for recognition and discussion of the key aspects of performance related to the learning objectives of the exercise. The same techniques and processes used in facilitating a simulation debriefing apply to facilitating the discussion of a trigger video.
One important way trigger videos can be used is to dramatically illustrate issues of hindsight bias. This ubiquitous human bias means that one’s perceptions or analysis of a situation are strongly affected by already knowing its outcome; this is sometimes referred to as the “I knew it all along” phenomenon. Hindsight bias can be very difficult to prevent or ignore, even when people try to avoid it; thus it is ideal to present situations without the eventual outcome being known. By pausing a video before viewers learn the outcome, the viewers can discuss decisions and actions made by the protagonists in terms of what was known at the time. Similarly, if the same video is viewed without pause, the potential for hindsight bias can be made clear. Issues of hindsight bias in debriefing of simulation scenarios are discussed more fully in Chapter 4 .
Analyzing Real or Simulated Cases Using the Three-Column Technique
Another technique we often use with groups is the analysis of interesting cases divided into three categories: (a) the medical/technical issues of care; (b) the examples of the use or nonuse of the key points of ACRM ; and (c) the various systems issues underlying why things transpired the way they did, or system-oriented mechanisms to prevent errors or failures. Typically, we list each of these categories as a heading of a column on a whiteboard. At various pauses in the case narrative, we facilitate a discussion of the relevant elements for each column that were observed or triggered by the preceding case segment. The key thrust of this approach is to help learners see the interrelationships between medical/technical decisions and the actions that resulted from those decisions, and between the CRM issues and the organizations and systems they affect. These interrelationships often explain why people behave the way they do or reveal the interventions that might be most effective in preventing such adverse events from recurring.
This technique is equally applicable to analyzing simulation scenarios or to real cases, as in morbidity and mortality conferences or when swapping clinical “war stories.” The three-column technique can be used whether or not there is a video of the case.
The Role of Simulation in Teaching ACRM
The previous sections of this chapter illustrate that simulation is not absolutely necessary to teach people about ACRM. When simulation is not feasible, facilitated discussions are a useful way to engage individuals in learning about these principles. Nonetheless, more than 24 years ago, we adapted the aviation paradigm of CRM for health care specifically in the context of developing a simulation-oriented approach to teaching. As a core technique used to optimize learning and practice of ACRM, we believe that simulation has enormous advantages, including that it:
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Forces learners to walk the walk, not just talk the talk
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Allows practice in a controlled, psychologically safe environment
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Allows situations that challenge behavioral aspects such as communication or leadership and followership as well as the medical/technical aspects
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Allows self-reflection with feedback from peers and experts
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Allows team members to discuss care outside of caring for real patients
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Allows discussion of hierarchy
In discussing simulation more fully, it is important to remember that it is a “technique, not a technology.” Simulation applicable to ACRM can be conducted in many different and complementary ways, some of which require no technology at all. Thus there are various “modalities” of simulation to consider, each with its own pros and cons. Simulations that challenge the anesthesia professional’s decision making can be conducted with little or no physical realism or technology. Verbal simulation—asking “What would you do if…”—is one technique. Such verbal simulation and questioning has formed an important component of examination for specialty board certification for decades. An enhancement to verbal simulation is to use apps available for smartphones or tablets that can display and modify waveforms and numerics as if on a physiologic monitor. One downside of verbal simulation is that there are many people can “say it, “but they can’t” do it.” Other people can recognize a situation when the information is fed to them but when they have many different things to attend to, they do not do as well picking up cues and responding to them sensibly.
Another low-technology technique that concentrates on the behavioral skills of ACRM is role-playing. Participants interact with each other while playing the role of themselves or another team member or instructor. The goal of the interaction is to probe and challenge participants to actually say the things they would say in a particular situation rather than to simply describe what they think should be said. For example, it is one thing to suggest how best to word a conversation with a surgeon; it is another thing to actually “play it out” with someone acting in the role of surgeon. As described earlier in this book, choice of words, manner of speaking, and tone of voice are all critical to optimal interaction with other team members. Role-playing can be useful for practicing the interactions between professionals, including team members, outside consultants, patients, or family members.
A number of simulators that go by the rubric “on-screen simulator” or “microsimulator” are available. These are similar to computer games or programs—like the venerable Microsoft Flight Simulator—that present all aspects of a simulated world on the computer screen, with interaction via devices such as a mouse, joystick, or specialty inputs. These simulators are quite good at presenting some aspects of reality, including monitor waveforms, photos, animations, or videos of the patient, but are less useful, for example, at providing direct interaction between team members, although an on-screen simulation could potentially be used by a group, and could be combined with a role-playing exercise.
A nascent modality of simulation is the online, multiplayer, virtual world. Here, each individual can have an “avatar,” co-located in a single virtual environment presented on the computer screen. Avatars can act in the virtual world and they can interact with other avatars (sometimes only by text messages, but often by voice). Such virtual worlds can, in principle, marry the on-screen simulator with team interaction. Advantages include lower cost and no need for team members to be located in the same physical space (in fact, in principle they can each be in opposite “corners of the globe”). As of early 2014, there are a few virtual worlds in health care, but many are still rudimentary and it is uncertain whether they can provide the clinical challenge and interactivity needed for ACRM training. However, they may improve in the future and could become important adjuncts to other modalities of simulation.
The ultimate in simulation would be full-blown virtual reality, a technique that would create experiences that are indistinguishable from the real world. The current modalities of virtual reality encompass either systems with devices like head-mounted displays and data-gloves (which can provide powerful “immersion” but limited interactivity) or computer augmented virtual environments, that have multiple, large, high-resolution displays, typically occupying several walls of a room. The latter approach can provide virtual immersion while allowing for multiple players in both the virtual and physical space. Combining participants in the physical space (possibly with a mannequin and clinical equipment) with participants, “scenery,” or tools in the virtual space is known as mixed reality simulation. Perhaps in the future, such virtual experiences may allow certain kinds of ACRM simulation that are hard to accomplish with any other modality.
Physical Simulation Using Mannequin-Based Simulation and Clinical Equipment
Mannequin-based simulation is the modality of simulation that is most commonly used to teach, practice, and hone ACRM skills. A computerized mannequin that can provide a number of physical cues (e.g., breath sounds, heart sounds, palpable pulses, etc.) and that allows various physical interventions (e.g., endotracheal intubation; IV drug administration) is combined with real clinical equipment (e.g., anesthesia machine) and with all the relevant personnel to present scenarios. The scenarios for ACRM training are usually chosen to incorporate challenges about decision making and actions regarding the medical and technical situation (often serious but uncommon events, such as anaphylaxis, MH, and myocardial ischemia) along with challenges in terms of interpersonal interaction and team management. Such simulations attempt to marry the physical elements inherent in real clinical care with the challenges of dynamic decision making and behavioral skills that are at the core of ACRM. This all comes at a price in terms of logistics, cost, efficiency, and realism. Plastic mannequins are poor substitutes for human beings. Not all interventions can be carried out as they would be in real patients. Getting a real OR team together in one room can be logistically difficult. Even conducting simulations with role-players who are the confederate of the instructor is expensive and difficult in practice. Some mannequin-based simulations can be conducted in situ in real patient care areas (the OR suite, for example), but others may be best accomplished in a stand-alone simulation center, which itself is an expensive proposition. Nonetheless, a large number of sites have been conducting ACRM-like simulations for anesthesia professionals. Thus it is appropriate to describe this kind of training, at least as we conduct it, and to discuss various aspects of using simulation for this purpose.
Choices, Choices, Choices
The field of simulation is quite diverse. Even narrowing it down to the use of mannequin-based simulation as a mechanism to focus on the key points of ACRM (rather than only focusing on the medical/technical aspects of cases), the instructor has many choices to make.
Single Discipline or Combined Team?
One key choice is whether to target participants from a single discipline—such as anesthesia professionals—or to bring together teams from multiple disciplines and domains, teams of people who work together or might work together. There are pros and cons to each approach ( Table 3-1 ). Because these approaches complement each other, the ideal situation would be to conduct single-discipline training for all members of the team and supplement it with periodic combined-team sessions.
