Anaesthesia Crisis Anaesthesia Crisis SimulationSimulation

BackgroundBackground

• Anaesthesia early adoption SBMEAnaesthesia early adoption SBME

• Driven by Gaba, Emily Bromily Driven by Gaba, Emily Bromily

• Similarities commercial airlinesSimilarities commercial airlines

• Increased monitor/environmental Increased monitor/environmental fidelityfidelity

• EMAC coursesEMAC courses

New Zealand New Zealand

• Both EMAC course providers in N IslandBoth EMAC course providers in N Island

• New anaesthetic registrar crisis courseNew anaesthetic registrar crisis course

• More SBME for trainees near these centresMore SBME for trainees near these centres

But But

• Limited access for S island based Dr’sLimited access for S island based Dr’s

• Different equipment/environment Different equipment/environment

• Lack of team based approach using local Lack of team based approach using local teamsteams

Christchurch AnaestheticsChristchurch Anaesthetics

• Limited SBME despite demandLimited SBME despite demand

PROMPTPROMPT

EMAC Course x1 in trainingEMAC Course x1 in training

CORE 7CORE 7

EMST/APLSEMST/APLS

PATCHPATCH

Ad hoc morning sessionsAd hoc morning sessions

The ProblemThe Problem

• SBME effectiveSBME effective

• Significant simulation debriefing Significant simulation debriefing resourcesresources

• Dose response relationship Dose response relationship

• Fidelity important to a point – buy in Fidelity important to a point – buy in

• Full simulation suite facilities Full simulation suite facilities expensive and not realistic for expensive and not realistic for peripheral centresperipheral centres

Solutions Solutions

• 2 avenues2 avenues

1) Collaborative approach with 1) Collaborative approach with UoOSCUoOSC

2) Development novel approach 2) Development novel approach using using equipment already available equipment already available in the in the hospital at no cost. hospital at no cost.

The “In situ” simulator The “In situ” simulator

• Clinical engineering calibration Clinical engineering calibration machines can be used to drive any machines can be used to drive any monitor monitor

• This allows scenarios to be run “in This allows scenarios to be run “in situ” situ”

in the clinical environmentin the clinical environment

Sp02Sp02

Sp02Sp02

• ““False finger” to attach Sp02 probeFalse finger” to attach Sp02 probe

• Dial up Sp02 and HRDial up Sp02 and HR

• Realistically changes over a number Realistically changes over a number of secondsof seconds

• Sometimes a little temperamentalSometimes a little temperamental

• Short period of flat line when Short period of flat line when changes made changes made

NIBPNIBP

NIBPNIBP

• Useful graduationsUseful graduations

60/40, 80/50, 100/60, 120/80 60/40, 80/50, 100/60, 120/80 etcetc

• Y connector!Y connector!

MP450 ECG, IBPMP450 ECG, IBP

MP450 ECG, IBPMP450 ECG, IBP

• Allows adjustment HR and common Allows adjustment HR and common rhythms.rhythms.

• Also invasive BP trace but fixed at Also invasive BP trace but fixed at 120/80 so limited utility. 120/80 so limited utility.

• Must attach to 5 lead ECG for all Must attach to 5 lead ECG for all rhythms to be availablerhythms to be available

The In situ OT set up The In situ OT set up

VideoVideo

Junior Trainee Crisis Junior Trainee Crisis SessionsSessions

• 0700 coffee, muffins, Non threatening0700 coffee, muffins, Non threatening

• 4 scenarios 4 scenarios

(anaphylaxis, MI VF arrest in PACU, Aspiration (anaphylaxis, MI VF arrest in PACU, Aspiration on LMA, Blocked ETT) on LMA, Blocked ETT)

• 4-6 trainees, 50% attended all. 4-6 trainees, 50% attended all.

• Trainee tech Trainee tech

• Guest “Volunteer” debrieferGuest “Volunteer” debriefer

• Sign up sheet, evaluation survey and Post Sign up sheet, evaluation survey and Post scenario resources provided on drop box scenario resources provided on drop box

Anaesthetic Crisis Experienced During Clinical Work (alone or

supervised)

0 2 4 6

Failedintubation

SevereLaryngospasm

Severe Trauma

Bronchospasm

MassiveHaemorrhage

Cardiac arrest

SOB in PACU

Endobronchialintubation

Can't intubate,can't ventilate

Burns

Anaphylaxis

LA Toxicity

MI

MH Crisis

Failure to w akein PACU

Seizure inPACU

other

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Failed intubation

Severe Laryngospasm

Severe Trauma

Bronchospasm

Massive Haemorrhage

Cardiac arrest

SOB in PACU

Endobronchial intubation

Can't intubate, can't ventilate

Burns

Anaphylaxis

LA Toxicity

MI

MH Crisis

Failure to wake in PACU

Seizure in PACU

1 Very Unconfident 2 3 4 5 Very confident

These scenarios have been These scenarios have been a valuable learning a valuable learning

experience experience

strongly disagree

disagree

neither agree nor disagree

agree

strongly agree

FidelityFidelity

0

1

2

3

4

5

6

7

1 2 3 4 5

Fidelity (1: very unrealistic, 5 very realistic

Fidelity of in OT set up

Fidelity Breakdown

0% 10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Scenario fidelity (clinical accuracy and realismof scenario)

Environmental fidelity (similarity of environmenteg. in theatre/drug trolley etc to normal

workplace)

Technical fidelity (similarity of machine, alarms,traces etc to normal workplace)

Patient fidelity (realism of mannekin, clinicalfindings compared to a real patient)

1

2

3

4

5

What were the strengths of the OT set What were the strengths of the OT set upup

• More realistic, better prepared for real-life situationMore realistic, better prepared for real-life situation

• Acting in real environmentActing in real environment

• same environment we spend the majority of our time same environment we spend the majority of our time in which makes how we might respond to the situation in which makes how we might respond to the situation in real life more realistic and how we make use of the in real life more realistic and how we make use of the resources in that environment.resources in that environment.

• Familiar environment, with equipment that we use Familiar environment, with equipment that we use everyday.everyday.

• It's where we work and where we would actually It's where we work and where we would actually experience these eventsexperience these events

• Same environment as place of work. Realistic Same environment as place of work. Realistic scenarios with added realism from use of usual scenarios with added realism from use of usual monitors and anaesthetic machines.monitors and anaesthetic machines.

Weaknesses of in OT set up Weaknesses of in OT set up • Already identified, but would be useful having people playing Already identified, but would be useful having people playing

their usual roles, ie real nursestheir usual roles, ie real nurses

• Difficult to hear lung sounds, other people in scenario should Difficult to hear lung sounds, other people in scenario should have a card of what they can / cannot offer to dohave a card of what they can / cannot offer to do

• having a scenario where when you do call for help and you gets having a scenario where when you do call for help and you gets heaps of willing assistants who may not be the most heaps of willing assistants who may not be the most skilled/appropriate to assist in that particular situation and the skilled/appropriate to assist in that particular situation and the subsequent distraction/stress this can provide and/or strains on subsequent distraction/stress this can provide and/or strains on communication when having to deal with that and the emergency communication when having to deal with that and the emergency at hand.at hand.

• Acting outside usual roles is unrealistic but necessary.Acting outside usual roles is unrealistic but necessary.

• Within limitations of mannikin (aka can't actually have real Within limitations of mannikin (aka can't actually have real patients having cardiac arrest...) no real weaknessespatients having cardiac arrest...) no real weaknesses

• Not using volatile is the only unrealistic aspect, but Not using volatile is the only unrealistic aspect, but understandable.understandable.

IssuesIssues• Clinical areaClinical area

limited availabilitylimited availability

scrupulous control of equipment scrupulous control of equipment

• Set up time/ chasing collecting bitsSet up time/ chasing collecting bits

• Potential for unskilled debrief Potential for unskilled debrief vulnerable participantsvulnerable participants

• DropboxDropbox

QuestionsQuestions