Episode 5 - Simulation in Medicine with Dr. Jesse Guscott
How to make simulation effective
Although equipment is expensive and may seem like a barrier to establishing a simulation program, the emphasis of a simulation focused on CRM principles should be communication and having skilled debriefers who can facilitate skills development
Using simulation to have someone experience a crisis and reflecting on why things didn’t go well, with the help of a skilled debriefer/facilitator is key in identifying systems we can put in place to mitigate these issues when the occur in reality
“Simulation without goals is just playing”
When designing a good simulation experience, it is important to keep the learning goals at the forefront; this may mean that the simulation is not the highest fidelity, but sometimes they don’t need to be
When designing a simulation for learning, you have to make a safe environment and make it clear to the participants there is no evaluation component; learning is the single priority
It is hard to have the dual role of coach and assessor and may make the environment challenging for learning
Why simulation is important
As we have seen with the episodes focused on the airline industry, rarely are the catastrophic events due to a technical proficiency, catastrophic mechanical failure or knowledge issue; they are more often caused by failures in communication or decision making
When we analyze issues in medicine we can see similar trends
The evidence shows that simulation improves confidence of participants. It is very hard to measure competence; there is anecdotal support from bystanders, simulation facilitators, allied health that it makes people better, but there are no RCTs to demonstrate this as it is inherently a difficult thing to measure
For physicians who are at risk of leaving high acuity fields (IE: rural physicians working emergency medicine or hospitalist medicine), increasing their confidence may help with retention, which is pivotal in some of these communities. This may also encourage junior physicians to practice at full scope, especially in underserved communities where it is traditionally hard to hire physicians
Simulation directly works on team dynamics; improving team dynamics may improve the work environment and improve retention
Different kinds of simulation
There is a specific kind of simulation focused on logistics and ergonomics
Although some Simulation focused on CRM principles may bring this out, there is a dedicated form of simulation meant to test this
This can be implemented locally without a lot of equipment or cost by a hospital “code committee” to solely look at implementation in a site or system
Rapid cycle deliberate practice is a tool you can use to work on specific technical skills in a short time frame without needing a full theatre simulation experience
Can we use simulation as an evaluation tool for competency?
In medicine, we are rarely given the opportunities to practice what we learn in simulation, or real life scenarios reflective of what we see in simulation, so there are not many opportunities to practice these events prior to being evaluated on them
If we build a training system that the skillsets of CRM are taught well, and people have the opportunity to practice those skills, in training and in independent practice, with a very low barrier to entry, we may have the foundations for using simulation as a competency assessment tool, like they have in aviation
There are some residency programs that make simulation a mandatory part of their program and use it as a formal assessment tool during their licensing
Some key CRM themes
Fixation vs focus:
Fixation is when you devote your attention and mental resources to the wrong thing in a crisis situation
Focus when you devote your attention and mental resources to the correct thing in a crisis
If you are maintaining your situational awareness (an accurate mental model of what is occurring and what the priorities are) then you are not fixated.
The issue is that our attention narrows when performing complex tasks and we lose our situational awareness (e.g. when intubating, we momentarily lose sight of the bigger picture).
Either delegate such tasks (IV access, intubation, chest tube insertion, etc) or have someone else run the rest of the resuscitation and then inform you of what occurred while you were performing that task.
If our system is built around the infallibility of a single person, or a few key people, our system will inevitably fail because no one can be perfect 100% of the time
Crisis resource management is fundamentally moving from a theoretical solution to a problem in crisis, to a practical solution to this problem
Ways to improve your performance in crisis
Think about the resources you have available that can help you; sometimes this is a colleague, or a more experienced member of the team. You may also lean on support outside of your immediate institution
Use a whiteboard or other visible task board to help maintain situational awareness in crisis and manage priorities
Develop and practice communication, situational awareness, leadership and communication, even if it is in a low fidelity sessions like table rounds, similar to journal clubs you may already have
Safety intervention worth mentioning
Cognitive aids, such as the Stanford Emergency Manual (there is also a phone app)
Buy a whiteboard and put it in the resuscitation area
Resources mentioned in the episode
Jesse Guscott’s SCORE course
Random recommendations
The Shadow of the Sun by Ryszard Kapuściński
Take more photos of the people you love
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