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October 2001
Volume 65 |
Number 10
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| Simulation
Saves Lives |
Michael A. Olympio,
M.D.
As I reflected upon my attendance at the International Meeting
on Medical Simulation held January 12-14, 2001, in Scottsdale,
Arizona, I realized that I heard of not one life saved because
of medical simulation. And then I thought, “How did we miss
this opportunity?” In all our excitement of presenting the
latest technology, applications, learning theory, performance
evaluations, patient safety and simulation center operations,
we neglected to include a panel on “Lives Saved Through Simulation
Experience.”
I recall reading a brief message, “Simulator Success Stories
Sought,” in the Spring 1999 issue of the Anesthesia Patient
Safety Foundation Newsletter and should have responded to that
request earlier. At least for me, simulation is a reality that
does not need to be proven. When my colleagues heard of the following
stories, they encouraged me to write this letter. The following
week, our chief resident, R. Paul Rieker, Jr., M.D., informed
me that he had just successfully rescued a failed airway —
for no other reason than his simulated training just days before.
That event prompted me even more to relate the following cases.
Case Number One: In July 1999, our CA-1 residents
came to our new simulation lab following a lecture on trauma anesthesia.
Although they were bright enough to place a chest tube for tension
pneumothorax, I, as a new operator, was not fast enough to decompress
the pneumothorax, and the “patient” did poorly. Someone
realized that suction to the chest tube had been interrupted,
the lung had not re-expanded, or the tension could have remained.
The new residents were visibly upset. I feared that I had broken
their confidence. Soon thereafter, I answered a stat call for
help in the real operating room. One of those same residents was
there with a visiting obstetrical anesthesiologist and an intensive
care unit patient who was rapidly developing ventilatory failure.
Peak pressures were off the scale, there were no breath sounds,
and manual ventilation was completely ineffective. Arterial oxygen
desaturation ensued as we attempted suctioning and bronchodilator
therapy.
The resident and I looked at each other and then at the four
chest tubes and simultaneously thought, “Could this be another
chest tube failure?” We immediately asked the surgeon to
check them as we ordered a stat chest X-ray. Upon witnessing the
patient’s condition, the surgeon canceled the X-ray and sequentially
placed two new bilateral chest tubes. The patient improved just
as quickly as the surgeon commented, “Those damn tubes keep
loculating. I was debating whether to change them today.”
Subsequent chest X-ray confirmed his diagnosis.
Case Number Two: Transtracheal jet ventilation
is conveniently taught in the simulation lab as it is difficult
to find suitable cases for its application. I was fortunate in
my career to have used this technique as a life-saving measure
in two previous cases. In the simulation lab, however, I never
fail to toss in a pneumothorax, a well-recognized complication
of jet ventilation. This allows the students to practice a needle
decompression, something rarely, if ever, done in practice, and
it reminds me to teach the students to follow the needle decompression
with a chest tube, especially if the first intervention is unsuccessful.
Following this simulation, another stat call came from Room 6.
This time, a suspended-airway case was going very poorly. The
team had elected to provide transtracheal jet ventilation as the
tumor was resected from the glottis.
Upon my arrival, there was much pandemonium in the room; the
patient was ashen gray, there was no obtainable blood pressure,
no ventilation and chest compressions had just begun. The surgeons
were struggling to visualize the glottic opening for intubation
and apparently thought they had placed an endotracheal tube successfully.
However, the anesthesia team simply could not ventilate the lungs,
and the ENT surgeons frantically began a surgical airway. Even
then, the lungs could not be ventilated; the bag felt remarkably
similar to that in simulation. As I looked upon the patient’s
lifeless chest, it seemed hyperinflated: no breath sounds, no
carbon dioxide, no gastric distention. This was a tension pneumothorax!
I verbalized my suspicion as I grabbed for a 14G catheter and
stuck it in her chest. As nothing happened, I instinctively called
for a chest tube, which the surgeons asked me to place. As I stabbed
the chest tube into her left chest, I thought I was puncturing
a car tire as a large hissing sound erupted from her chest. Instantaneously,
the arterial waveform leaped from nothing to everything, and the
capnogram jumped back to life. Another chest tube on the right
duplicated the same sound as ventilation suddenly normalized.
The patient awakened in just a few hours and was later discharged
home without a neurological problem.
Case Numbers Three and Four: A typical airway simulation
involves multiple devices individually selected and applied to
the developing situation. Debriefing allows the student to witness
and critique his or her own performance with a lasting visual
memory. Invasive procedures such as the retrograde wire also can
be practiced without traumatizing a patient.
Another stat request came for help in Room 8. Dr. Rieker had
just induced a critically ill patient with superior vena cava
syndrome. The rapid sequence intubation failed, and the patient
could not be ventilated or intubated. Although his blood pressure
was maintained, the patient’s neck was grotesquely swollen
from his plethoric torso to his mandible. A disposable #3 laryngeal
mask airway (LMA) beckoned from behind the gas machine, and it
was too easily inserted into such a large head. Miraculously,
the chest rose and the saturation rose along with it, but we had
a large leak and a tenuous airway in a patient who would not breath
spontaneously and would not awaken. The surgeon balked at the
notion of a surgical airway, constrained by the high venous pressure
and anatomical distortion. The small LMA would not accept another
fiberoptically loaded endotracheal tube. Options were quickly
disappearing.
Recalling our simulated airway emergencies, Dr. Rieker and I
prepared a #4 Fastrach® intubating LMA, fully lubricated and
ready for use, along with a thick fiberoptic scope loaded with
a 7.5 mm endotracheal tube. Our plan was to remove the #3 LMA
and attempt oral fiberoptic intubation while manually extruding
the tongue. The backup plan was to insert the intubating LMA to
re-establish ventilation and then to blindly secure the trachea
with the Fastrach endotracheal tube. The fiberoptic placement
went smoothly on the first attempt, but the entire team felt confident
that we had carefully considered all options. We had been through
this drill many times in simulation.
Dr. Rieker later commented, “Another case of mine similarly
involved airway management. A Class II airway exam was complicated
by potential ligamentous injury. Rapid-sequence induction with
in-line stabilization failed to visualize the glottis as the patient
became cyanotic. Mask ventilation succeeded, the patient was allowed
to awaken, and a carefully orchestrated induction with Fastrach
LMA insertion was successful in subsequently securing the trachea.
I believe that experience in the simulator lab has enhanced my
ability to assess such critical situations and to quickly formulate
management strategies. I can state that throughout my two and
one-half years of residency training at a tertiary hospital, I
have directly been involved in no more than six failed rapid-sequence
inductions. I have participated, however, in multiple difficult
airway and critical incident scenarios in the patient simulation
laboratory. That experience has increased my ability to communicate
difficulties and to engineer complex management strategies, which
have a direct impact on patient safety in critical incidents.
| “As I stabbed the chest tube into her left chest,
I thought I was puncturing a car tire as a large hissing sound
erupted from her chest. Instantaneously, the arterial waveform
leaped from nothing to everything, and the capnogram jumped
back to life.” |
Case Number Five: It seems to me, as an attending
anesthesiologist, that esophageal intubations during routine inductions
are followed by immediate removal of the tube, mask ventilation
with cricoid pressure and successful re-intubation of the trachea.
These are common events among new students in a teaching hospital.
Fortunately, I have yet to see an aspiration following these otherwise
“easy” airways, and I never want to see one. In simulation,
many centers are teaching students to leave the first tube in
the esophagus and to calmly introduce a second tube into the trachea
in normal anatomical situations. This procedure is not done instinctively
by supervising anesthesiologists. We practice this in simulation.
In just the past month, I managed two of these actual occurrences
according to this rehearsed procedure, and it was accomplished
more easily and more calmly in both patients than the initial
intubation. The esophageal tube then provided a conduit for gastric
suctioning, which produced, in both cases, gas and significant
quantities of acidic fluid. Although I read about this procedure
years ago, I will be honest in saying that I never did it until
I practiced it in simulation. Maybe in these two cases I did prevent
an aspiration!
In summary, I know that many simulation testimonials are out
there and that many lives have been saved through simulation.
The recent International Meeting on Medical Simulation presented
much scientific data, but no data on the number of lives saved.
The Anesthesia Patient Safety Foundation and a request by the
ASA NEWSLETTER encouraged me to write something I should
have done a long time ago. I hope to see more of these testimonials
published.
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Michael
A. Olympio, M.D., is Associate Professor of Anesthesiology,
and Director, Patient Simulation Laboratory, Wake Forest University
School of Medicine, Winston-Salem, North Carolina. |
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