Simulation In Anesthesia

163 Pages·2006·15.45 MB·English

by  Christopher J. Gallagher MD

Four Penn Center, Suite 1800
1600 John F. Kennedy Boulevard
Philadelphia, Pennsylvania 19103
SIMULATION IN ANESTHESIA ISBN 13: 978-1-4160-3135-2
ISBN 10: 1-4160-3135-9
Copyright © 2007, Elsevier Inc. All rights reserved.
No part of this publication may be reproduced or transmitted in any form or by any means, electronic
or mechanical, including photocopying, recording, or any information storage and retrieval system,
without permission in writing from the publisher. Permissions may be sought directly from Elsevier’s
Health Sciences Rights Department in Philadelphia, PA, USA: Phone: [phone], fax: (+1) 215
239 3805, e-mail: [e-mail]. You may also complete your request online via the
Elsevier homepage (http://www.elsevier.com).
NOTICE
Knowledge and best practice in this field are constantly changing. As new research and experience
broaden our knowledge, changes in practice, treatment and drug therapy may become necessary or
appropriate. Readers are advised to check the most current information provided (i) on procedures
featured or (ii) by the manufacturer of each product to be administered, to verify the recommended
dose or formula, the method and duration of administration, and contraindications. It is the respon-
sibility of the practitioner, relying on their own experience and knowledge of the patient, to make
diagnoses, to determine dosages and the best treatment for each individual patient, and to take all
appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor the Editors
assumes any liability for any injury and/or damage to persons or property arising out or related to
any use of the material contained in this book.
ThePublisher
Working together to grow
libraries in developing countries
Printed in China www.elsevier.com | www.bookaid.org | www.sabre.org
Last digit is the print number: 9 8 7 6 5 4 3 2 1
This book is dedicated to anyone who’s ever faked it.
Preface
Pick up three random drugs we might use in anesthesia, oh, let’s say, pavulon, pen-
tathol and potassium. Now, pick up the newspaper and read what three drugs they
administer during a lethal injection: pavulon, pentathol, and potassium.
Whoa! Dangerous stuff, this anesthesia. Better not try this at home.
And you’d better not try this out the first time on ME either. You practice a little
before you start waving those lethal syringes around me.
No better place to practice than the anesthesia simulator.
Why this book? What’s the need?
Simulation in anesthesia is catching on all over the world. Medical students, nurse
anesthesia students, anesthesia assistants, anesthesia residents, practitioners needing
some remediation—all these people can benefit from simulation instruction. And
all over the world there are simulator instructors looking for how best to run their
simulators.
This book should help everyone in the simulator, the instructors running the
simulator, and students running the gauntlet in the simulator.
So whether you’re starting a simulation center, revamping your curriculum, or just
plain wondering what simulation is all about, read on.
vii
Acknowledgments
A million people made this book and DVD happen, so thanks to all and sundry and
apologies to those we miss:
Natasha Andjelkovic, our Publisher at Elsevier, and her assistant Katie
Davenport, who participated in conception, maturation, and parturition of this
baby. It’s a book!
Dr. Lubarsky and the whole anesthesia department at the University of Miami,
who kept the ORs and their precious cargo of patients going while “Simulation was
in session.”
Our anesthesia residents, who participated in the simulations, the pictures, and the
DVD.
Ilya Shekhter and the staff at the Jackson/University of Miami Patient Safety
Center, who made the simulations hum.
Tom Church, videographer, who created the contents for the DVD.
Robert Simon, Daniel Raemer, Jeffrey Cooper, and the staff at the Harvard
Institute for Medical Simulation, who know and teach the craft of medical simula-
tion, and who took pity on a befuddled instructor and showed him the ropes back
in October of 2004.
Carolyn and Rachel, who cheer me on, cheer me up, and make it all worthwhile.
Tara, Zachary, Eric, Brianna, Ethan, who now know why our home was flooded
with thousands of simulation articles last summer and put up with my “madness” as
I sifted through each and every one of them.
ix
Introduction
“Abracadabra!”
“Zendra! My hat, please!”
Little Jimmy, six years old and all scraped knees and goggle-eyes, sat transfixed in
the front row of the magic show.
Roger the Magnificent was out of this world! First that thing with the ace—how
did he pick that out of the middle of the deck like that? And then, those little red balls
between his fingers. Where did that extra red ball keep coming from? And, and the
scarf out of his nose! Try putting ten scarves up your nose at home. Mom would kill
me! What would this Roger guy do next with that hat?
“Dad,” Jimmy asked, “what’s that little stick?”
“That’s a magic wand, Jimmy,” Dad said.
Over and over the hat the magic wand goes. Roger the Magnificent, with the lovely
and talented Zendra at his side, is drawing on the powers of the universe, the mysti-
cal essence of the stars and planets.
“Watch the wand, don’t reach up and grab it,
For out of this chapeau comes a fuzzy rabbit!”
Jimmy didn’t have much use for Zendra, and he wouldn’t know a chapeau if it bit
him, but that wand was zooming round and round, and it must be doing something
to that hat because there sure as heck was not a rabbit in there a minute ago when
Roger showed it to us. Jimmy even stood up and craned his neck to make extra sure
that the hat was empty. Kids on the playground said magicians used tricks, and Jimmy
was no fool. He had looked good and hard in that hat; and, no sir, no rabbit was in
there—no way.
“Abracadabra,” Roger the Magnificent said, and buried his arm in that empty hat,
going all the way in to the elbow.
“Dad,” Jimmy said, “there can’t be a rabbit in there, that hat was empty. You saw,
didn’t you?” Dad nodded.
Roger the Magnificent pulled a snow-white bunny, big floppy ears, twitching
whiskers, right out of that hat. Then he reached under the rabbit with his other arm,
cradled it, and held it right out to Jimmy to pet. It was the genuine article. Jimmy’s
mouth, ringed with cotton candy pink, almost said the bad word, almost said “God”
(which Mom would get mad at but Dad would just say, “Try not to say that word,
Jimmy.”). But all that came out was the sound “Caa-aaah.”
xiii
xiv Introduction
FIGURE I–1 Rediscover your inner child when you enter
the Simulator. You’ll need to “suspend disbelief” and pretend
that the mannequin is a real person. In effect, you’ll be, well,
“playing doctor.” OK, so be it. Go for it and have some fun.
On the way out of the tent and back to the car, Jimmy’s circuits, previously
frazzled by the sheer impossibility of what he had seen, regained some measure
of normalcy.
“Dad, how did the wand do that?”
Dad picked Jimmy up, hiked him up on his shoulders with a grunt, and said,
“Believe it or not, partner, it wasn’t the wand that made the rabbit come out of
the hat.”
* * * * * *
This book is going to look at Simulators in anesthesia. How do anesthesia Simulators
pull educational rabbits out of the hat? To understand this, we must look at all the
components that went into Jimmy’s magical experience.
Jimmy, now regretting all that cotton candy and the two corn dogs, believes that
the wand made the rabbit appear. Dad, more savvy in the ways of the world, knows
the magician pulled the rabbit out of the hat. Ah, but the magician, Roger the Mag-
nificent, knows even more. He, lest we forget, drew on the powers of the universe,
the mystical essence of the stars and the planets. Roger the Magnificent knows that
three components play a part in the rabbit’s phantasmagoric arrival on the stage.
● The wand
● The magician
● Jimmy himself
And Roger the Magnificent got magnificent by knowing how to work all three of
these components into his magic show.
An anesthesia Simulator has three main components, each corresponding to an
element of Roger the Magnificent’s show.
● Simulator (Wand)
● Instructor (Magician)
● Student (Jimmy)
Introduction xv
FIGURE I–2 The first time you see a magician, you may think that the wand is responsible for the rabbit’s appearance. Wrongo!
It is the magician who makes it happen. In a similar vein, the first time you go into the Simulator, you may think that the high-tech
mannequin makes all the magic happen. Wrong again! The mannequin is an integral part of the process, yes, but it is the instruc-
tor who plays the key role. The instructor makes that rabbit jump out of the Simulator.
xvi Introduction
FIGURE I–3 Not every simulation scenario goes all the way to catastrophe. You can make all kinds of teaching points in the
Simulator and keep “the car on the road.” But every now and then, KABOOM!
This book examines all three elements: the Simulator itself, the Simulator instruc-
tor, and the student. We look at the technology available in current Simulators—from
partial-task trainers to high-technology anesthesia mannequins. Cost, upkeep, prob-
lems, limitations—everything you wanted to know about anesthesia Simulators but
were afraid to ask. We also look at the Simulator instructors—What are you looking
for in instructors? How should they teach? What educational principles should they
use? And always we’ll be looking at the students. Do they learn much from a Simu-
lator? Will students someday face accreditation in a Simulator? How do students react
and learn in a Simulator?
An annotated and detailed bibliography at the end of the book will steer you
through the original work that examined these questions.
But the main focus here is the magic show itself, the simulation scenario. Yes, it’s
worthwhile to dissect the component parts of simulation, but it’s when you put it all
together that the stars come out—and the rabbits too.
The center of this book’s solar system is a collection of 50 anesthesia scenarios,
complete with a play-by-play of the scenario, a detailed debriefing, and a summary of
Introduction xvii
the main lessons learned. You become a fly on the wall as simulation students wrestle
with codes, malfunctioning paddles, line crossovers, difficult patients, impossible
coworkers, rare diseases, and all-too-common vexations. You look over the shoulder
of superb students as they peg the diagnosis and strike at the heart of the matter. And
you also get to see some not-so-superb students in action as they swerve off the road,
break through the guardrail, and sail over the cliff and onto the rocks below.
From the safety of this book’s covers, you get to watch it all happen. So grab some
cotton candy, slather a couple corn dogs with mustard, and pull up a seat.
“Zendra, my wand, please!”
11
CHAPTER
What Is a Simulator—a Clinical
Checklist or a Theater?
“Schrodinger’s cat is both alive and dead.”
One of many unfathomable ideas from quantum theory
JJ
immy grows up, insists you call him “James” now, The clicks fade out and the lecture hall gets
although most of the students in his quantum quiet. Outside, in the distance, the carillon’s bells
physics class call him “Professor.” start playing “Amazing Grace.” Every student’s
In this most advanced of disciplines, the professor head lifts up from their laptops as they look at the
still delivers his lectures the old-fashioned way—white blackboard.
chalk on a blackboard. The students shuffle in, take off The single electron passes through both holes.
their bulky jackets, and set up their laptops to take Now just how the heck can it do that?
notes. James had initially resisted this maneuver, and A single simulator passes through a couple holes of
he found the clicking keys irksome; but alas, after a its own. For a simulator can be viewed as two separate
while there was so much clicking it became a kind of creatures:
white noise, and you tuned it out.
A clinical checklist
“What does a single electron do when it comes to
A theater
this sheet of metal with two holes in it?” the professor
asks. But like the elusive and tricky electron, the clinical
No one’s hand goes up. There weren’t any hands checklist and the theater inhabit the same simulator
free; they were all glued to their keyboards! experience. Is this as incomprehensible as quantum
James turns around, draws a square representing physics?
the sheet of metal, and draws a little dot, the electron, No. As the core of this book—the 50 simulator
with a little arrow pointing toward the square. scenarios—show, each scenario has an element of
Click, click, click, click, click, click.
(“How are they drawing this picture on their
computers?” James thinks. “Notebooks and pens were
better for drawing pictures.”) BOX 1–1 What is a Simulator?
“Simple,” James explains, “the single, indivisible
electron passes through both holes.” ● Checklist
Click, click, click...click. Click, click. Click.
● Theater
Click.
1