Our 2nd birthday passed unannounced: predominantly due to too much rather than not enough activity on our part. Now seems a good time for an update. Our last summary can be found here.
Shirin had a beautiful baby girl and a year’s maternity leave. Ian Lee moved from the ED to work for the Clinical Educator Programme but remains a member of the Sim Team and joins us during simulation events when able. 3 of our senior nurses (Julia, Gillian and Chris) have attended the Scottish Simulation Centre’s Faculty Development course and we’re looking forward to supporting them adopting more leading roles in our future simulation events.
Attendance at Resus Fridays, our weekly skills, drills and simulation-based sessions, continues to be fantastic and the formal feedback attained at each session is both welcome and encouraging.
The rest of the EM Consultant group joined us and now also lead sessions. We’ve continued to expand our session bank with the help of our learned colleagues. Here’s the current list of scripted sessions (which doesn’t include some of our funkier ones such as “The Mystery Challenge”…):
Arterial Lines | Basic Airways | Belmont Rapid Infuser & Major Haemorrhage Protocol | Bradycardias & Pacing | Chest Drains (Surgical technique | Combat Application Tourniquets | DCD Category 2 Organ Donation | Escharotomies | Failed Intubation | Intralipid | Intraosseous Access | Major Incident Triage | Non-invasive Ventilation | Pelvic Binders & Scoops | Personal Protective Equipment | Precipitous Deliveries | Preparation / The First 5 Minutes | Resus Races (find that kit!) | Rapid Sequence Intubation (Non-Trauma) | Rapid Sequence Intubation (Trauma) | Stroke Thrombolysis | Traction Splints
Send us your ideas for future sessions and let us know which ones you’d like us to cover more frequently!
Craig’s Chop Shop
When we started out, we were light on simulation kit. We begged and borrowed as much as we could from others (borrowing especially the Clinical Skills Suite and our Resus Officers – thanks again!). A particular success was when I found an old “Resusci Annie” CPR manikin in the ED basement. Further searches located a separate intubatable head & lung set of the kind frequently used in ATLS courses. With a drill, some spanners, bolts, washers, lots of manoeuvring and a few swear words, “Resusci Annie” became “Resusci Frankie” and the ED had a new intubatable and CPR-enabled manikin. Despite looking a bit achondroplastic, he served us unfalteringly through many Resus Fridays and prehospital simulation sessions (although the foam arms did start to fall off a bit after a few too many extrication exercises...).
New Sim Manikin & Monitoring System
As useful as “Resusci Frankie” was, we’d previously discussed putting forward a business case for funding for a higher-fidelity simulation manikin for our ED. After reviewing the many possibilities, I put forward the case for Laerdal’s MegaCode Kelly (http://www.laerdal.com/gb/MegaCodeKelly) and iSimulate’s ALSi Patient Monitoring system (http://www.isimulate.com/product/alsi-advanced-patient-condition-simulation).
Why this combo? We wanted a manikin that was robust, had advanced airway management capabilities, was suitable for manual chest compressions and had resilient but flexible limbs for use in extrication exercises. Combining the manikin with the ALSi system meant we also had a patient monitoring system that was lightweight, intuitive, easily portable and emulated our own.
We were successful and lucky enough to receive funding from the Medic One Charity. We’ve since put our kit to use during many of our prehospital and in-hospital simulation sessions. The closed Wi-Fi (and Mi-Fi) systems mean that we can use it pretty much anywhere!
Dr Richard Lyon (now Professor) joined the team and, drawing on his extensive experience with Kent, Surrey & Sussex HEMS, has since facilitated many joint prehospital-focussed sessions between our Medic One medical, nursing and paramedic colleagues. More to come.
Lights; Cameras; Sims; Action!
Thanks to the combined works of Dr Gareth Clegg and many others, our rebuilt Resus Rooms came complete with live-recording SMOTS video cameras. For the simulation perspective, once we got them linked to the SMART board in our handover room, we could finally bring high fidelity, live video-simulations and debriefing sessions back to our ED. The tech isn’t everything (far from it: some of our most useful sessions have been on low-fidelity manikins – or no manikins at all). The main gain for us has been allowing far more observers to join in without crowding round the participants and reducing fidelity; they can then participate in the debriefs with the added perspective obtained from viewing the events from afar. Replaying short video clips during debriefs can also help unpick events and highlight practice which may have been otherwise difficult to discern.
The added fidelity of running simulations using your own kit and in your own work environment should never be underestimated: we identify points for improving our work environment during almost every session. For example, Sevofluorance canisters attach to our Anaesthetic machines in the rare event that we have to mechanically ventilate patients with life-threatening asthma exacerbations (which is always challenging…). We discovered during last week’s session that the connections to two of the machines were faulty, resulting in no Sevofluorane being delivered. The evidence base for the use of volatile inhalational agents in intubated asthmatics might be light but we’d rather find out the fault during simulations than try to troubleshoot failing kit with patients in front of us. Medical Physics are on the case…
Half- & Full-Day Sim Sessions
In addition to our other team training sessions, we introduced “Boss Sims” to the mix. These sessions were focussed at our EM Consultants and Charge Nurses.
But why separate the grades of doctors and nurses? Isn’t that a backwards step? Shouldn’t we all train together?!?!
Of course we should train together; we already do and will continue to do so. “Boss Sims” are additional and were borne out of a desire to increase buy-in from senior staff who might otherwise have missed out on our sessions. I’m of an age where I’ve been exposed to simulation-based training in some form throughout much of my career. I know not that’s the same across all of my other colleagues and we wanted to help demystify simulation sessions. We provide a safe environment where staff who might otherwise have had little exposure to simulations (possibly none as active participants) could do so as a group. There have been many other benefits to the sessions, including:
- Targeting our learning objectives towards the clinically trickier decisions and interactions (which may otherwise have made the debriefs less relevant to those at earlier stages in their training)
- Allowing more opportunities for discussing and performing some crucial practical skills. In combined sessions with other grades of staff, the Consultant would often (appropriately) adopt a hands-off Team Lead role; these sessions help maintain currency for when the Consultant is the only one present with the skill set to perform certain practical procedures (e.g. Senior specialty doctors unavailable).
The feedback from the multiple sessions was that they were gratefully received and that they achieved all the above objectives (and more).
Craig’s (Pork-) Chop Shop
Sometimes, you want to enable people to perform a procedure, rather than just discussing how they would do it (with the aim of improving skill acquisition and retention). Sure, we could talk through how to do a Resuscitative Hysterotomy or how to deal effectively with catastrophic limb haemorrhage, but letting people actually perform the steps required (in simulated scenarios) can be even better.
So, with the help of the other members of our Sim team (special mentions to Ian Lee, Nathan Oliver, Alistair Dewar and David Wright), we set about creating more “Resusci Frankie”-style monsters. They had to be inexpensive and hands-on. Future blog posts will detail the steps required. A common theme was using a fair amount of free pig skin and fat from friendly butchers…
Here are a few pics in the meantime.
These are impromptu simulations that take place in our Resus Rooms (also known as “Guerilla Sims”). The calls for staff go out in an identical manner to real “Crash Calls” and are treated as such. When staff arrive and see that it’s a simulation-based exercise, we ask them to suspend their disbelief and run it as we would do any other Resus – but with the added benefit that there’s always a “Hot Debrief” at the end. These wouldn’t be possible without the support and goodwill of our ED staff, with particular mention to the support received from the EM Clinical Lead (Dr Sara Robinson) and Clinical Nurse Manager (Chris Connolly).
We’ve had a hand in creating and/or facilitating some courses held in the Scottish Centre for Simulation and Clinical Human Factors (SCSCHF): The Obstetric Patient in Emergency Medicine (TOPEM) and the Simulation Course in Paediatric Emergencies (SCiPE). They are thoroughly recommended courses and help cover areas that senior EM doctors felt they would benefit from further training in. They’ve received excellent ratings since their inception and have now run several times.
Nominations & Acknowledgements
The Medic One Sim Team were lucky enough to be nominated for the Clinical Educator of the Year Award by the Faculty of Clinical Educators. We didn’t win it (there were far more deserving nominees) but it was genuinely heartening to be nominated.
The Clinical Educator Programme has set up a new “Introduction to Simulation” workshop, showcasing our Medic One Simulation Team as a “shining example” of what can be done. That’s what I’ve been told, anyway. I haven’t made it to their workshop yet so perhaps we serve as a warning to others…
In other news, EM Manchester appears to have appropriated our “Resus Fridays” idea, which is great!
Brand New “Trauma Team” Course
Our bespoke “Trauma Team” course (co-written by Shirin Brady, Dean Kerslake, Richard Lyon, Nicola McCullough and myself) had its inaugural run on Tuesday 4th April and was a mixture of simulation-based scenarios with additional expert demonstrations and skills stations. Learning objectives targeted the whole team, not just the team lead. We had fantastic participation and feedback on the day and will share learning points with the rest of the EM staff.
Some of our half-day simulation events have included our Anaesthesia and Acute Medicine colleagues. We aim to increase the frequency of such joint sessions, increasing our inter-disciplinary shared learning.
In amongst all that, our “Resus Fridays”, “Crash-Sims”, “Trauma Team Course” and other Simulation Half- and Full-day sessions and will all continue.
We look forward to working and training with you.
Dr Shirin Brady
Consultant in EM
Co-Lead, Medic One Sim Team
Dr Craig Walker
Consultant in EM & ICM
Co-Lead, Medic One Sim Team