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Paradigm Shift

Real-time simulation raises the bar for teaching

Aspects Volume 29 No. 2

Written by Rebecca Buddie • Photography by Jason Johnson

Real-time simulation raises the bar for teaching

Sixty-five-year-old John Petter collapsed in the faux living room at Memorial’s Center for Learning and Innovation (MCLI) on December 18. His 911 call set a series of events in motion that have the potential to better health care delivery and improve patient safety.

The largest simulation in size and scope of its kind, this groundbreaking event showcased the collaboration between multiple organizations and disciplines. "This was an opportunity to show people at Memorial, the School of Medicine and the community what this building can do," says Christopher McDowell, MD, MEd, assistant professor and emergency medicine residency program director at SIU and medical director of the MCLI. "This space allows us to take the skills we use to provide care for patients, practice them, streamline the process and make care more efficient and at a higher level for when it really matters – when we’re taking care of an actual patient."

More than 50 people planned and executed the simulation, but the vast majority of the participants had no knowledge of how the event would unfold.

It was a combination of an improvisational performance blended with a well-rehearsed production. "We have the chance to bridge the gap between the classroom and real life in simulations like these," says Audra Chestnut, MCLI system director for organization learning and simulation. "We got pretty darn close with this one." Dr. McDowell, Chestnut and approximately a dozen others watched the event on monitors behind the scenes.

While Petter played the rehearsed part of the patient, health care teams cared for him as they would have in real life.

At 8:55 a.m., paramedics from the Chatham Fire Protection District responded to the 911 call, assessed Petter’s vitals, took a history and evaluated the situation while "transporting" him to the emergency department. They responded quickly and appropriately when his blood pressure plummeted en route to the hospital. "This team did a fantastic job; they didn’t miss a beat," said Sapan Desai, MD, PhD, MBA, who also complimented their assessment of Petter’s condition and attention to detail. Dr. Desai is assistant professor of vascular surgery and vice chair of research for the department of surgery. Dr. Desai is also director of the J. Roland Folse Surgical Skills Lab at the MCLI and director of the quality alliance and predictive analysis for Memorial Medical Center.

Petter was admitted to the emergency department approximately 40 minutes after his initial 911 call, where Jeff Austen, MD, third-year emergency medicine resident, and attending physician Dr. McDowell continued medical treatment, evaluated and quickly diagnosed him with a ruptured abdominal aortic aneurysm (AAA).

The planning team chose to simulate a ruptured AAA because of the difficulty in diagnoses and fatality of the condition. Upwards of 90 percent of patients with a ruptured AAA will not survive the event with a 40-50% mortality even for those who make it to the hospital alive, a statistic that hasn’t changed significantly since the 1960s, according to Kim Hodgson, MD, professor and chair of the Division of Vascular Surgery.

Dr. Hodgson has developed a protocol to change that statistic. "The key to improving survival of this critical condition lies in its early diagnosis and prompt initiation of treatment," Dr. Hodgson says. He has developed diagnosis and treatment protocols for physicians who suspect a ruptured AAA so that patients receive expedited and coordinated care, regardless of the hospital they initially present to. "A systematic approach for a patient who presents with the symptoms of a ruptured triple-A will save many lives," Dr. Hodgson says, speaking of the Ruptured Aortic Centers of Excellence (RACE) protocols he developed.

This simulation is one way to test protocols currently in place. "Dr. Austen and Danielle (an emergency department nurse) talked about implementing the RACE protocol for AAA," Dr. McDowell says. "This isn’t something they see every day – it’s not like a stroke or heart attack – the fact that they remembered the protocol was very heartening and impressive."

Petter was swiftly moved to the operating room (OR) around 10:15 a.m. where Janet Ketchum, surgical skills director and skills coach, brought in his stunt double – a medically anatomical mannequin known as Sim Man. Before the surgeons were present, Sim Man’s heart stopped, and operating room staff began chest compressions. The team watching from behind the scenes held their breath in anticipation as his vitals returned to normal. "They performed flawlessly," said Dr. Hodgson of the OR staff.

Dr. Hodgson and third-year vascular surgery resident Kevin Caldwell, MD, performed an open AAA repair after his vitals returned to normal. Sim Man made it through surgery, and Petter reprised his role in the Intensive Care Unit.

The uniqueness of this simulation is that it addressed the entire spectrum of care for the best learning experience for all the teams. According to the paramedics involved, they often don’t see the patient again after the handoff in the emergency department. "Miscommunication between different teams is one of the main reasons for breakdowns in health care delivery," Dr. Desai says. "The lingo is totally different for a paramedic than it is for a physician, a nurse or even the patient. The goal is to get everyone to speak the same language and follow the same protocols."

Dr. McDowell recalls seeing some of the cardiovascular operating room staff since the simulation and has more of an understanding and appreciation for their role in patient care. "These are the hidden values of doing things like an interprofessional simulation," he says. "When we do these trainings, it affects care tomorrow."

Systemic complications were added to the simulation to test responses and add to the reality. "We wanted to see how the team would fix the problems," Dr. Desai says. "They all handled them beautifully." Some of the system failures included a delay in obtaining a CT scan, wrong phone numbers, patient hypotensive episodes and a code blue in the operating room.

"These barriers can be common in the emergency department," Dr. Austen says. "I’m reliant on techs, nurses and other ancillary staff — they are the cogs that make it all function smoothly. No one person can manage the flow alone."

"This is a paradigm shift in how we make health care safer and better: We can now evaluate skills and fix errors prospectively, before they affect a real patient," Dr. Desai says. Simulations of this nature will become standard events in the training curricula.