Simulated Obstetrical Trauma

CASE INFORMATION Demographics Case Title: Multiple Obstetrical Trauma Patient Names: Betty and Veronica Simulation Developers: Glenn Posner, Sean Moore, Michelle Chiu, Simone Crooks, Jacinthe Lampron, Devin Sydor Date of Development: January 2011 Appropriate for the following learning groups: Staff Obstetricians, Emergency Physicians, Anesthesiologists, and Trauma Surgeons Residents in Obstetrics, Emergency Medicine, Anesthesiology, and General Surgery Nurses in Emergency Department Respiratory Therapists Paramedics CURRICULAR INFORMATION Educational Rationale There are numerous instances in health care where the effective functioning of a team is essential to providing appropriate care to a critically ill patient. Good teamwork is a function of good leadership, good collaboration, and exceptional communication skills among team members, and these assumptions are borne out in the literature.1 The goal of this scenario was to teach and formatively assess these skills at the postgraduate level, using a simulated obstetrical trauma as the clinical backdrop. Simulation has been shown to be an effective modality for team training exercises of this nature.2 In addition to medical expertise, the curriculum is designed to address the Accreditation Council for Graduate Medical Education (ACGME) competencies3 (United States) of “systems-based practice” and “interpersonal and communication skills,” which equate to the CanMEDS competencies4 (Canada) of “collaborator” and “communicator” as they pertain to the management of a pregnant trauma patient. Specifically, the objective of the project was to promote interdisciplinary collaboration among trainees in emergency medicine, general surgery, anesthesiology, and obstetrics. The obstetrical trauma is the ideal clinical scenario because of the confluence of specialties required for effective patient care. Emergency physicians and trauma surgeons are adept at the assessment and management of trauma patients, yet there is a tendency for all physicians to become uncomfortable when the patient is pregnant. At our institution, residents from each of the aforementioned specialties participate in teaching sessions at the simulation center, yet interdisciplinary collaboration among specialties has been restricted to dyads of anesthesiology and obstetrics or anesthesiology and surgery. The clinical scenario we have developed is the first to involve the collaboration of 4 specialty residents simultaneously. The scenario taxes their abilities to establish effective leadership, multitask, share information, perform appropriate triage, and collaborate as a team. Learning Objectives Demonstrate appropriate resource allocation with limited resources (ACGME core competency “systems-based practice,” CanMEDS competencies “manager” and “collaborator”). Demonstrate efficient and effective communication during a crisis (ACGME core competency “interpersonal and communication skills,” CanMEDS competency “communicator”). Demonstrate expedient leadership and ability to handover leadership (ACGME core competency “interpersonal and communication skills,” CanMEDS competencies “collaborator” and “communicator”). Demonstrate establishment of roles within a multidisciplinary team (ACGME core competency “interpersonal and communication skills,” CanMEDS competencies “collaborator” and “communicator”). Guided Study Questions/Precourse Reading Materials For the emergency department, surgery and anesthesiology trainees, the authors recommend that the participants have a basic understanding of trauma care or have participated in an Advanced Trauma Life Support (ACLS) course previously. For the obstetrical trainees, experience working in the obstetrical assessment unit (triage) is sufficient. Assessment Instrument The authors have not used an assessment instrument for this simulation scenario. The debriefing notes cover the essential expected performance items in this formative experience. PREPARATION Part of the challenge of preparing for this scenario is ensuring the participation of 4 different medical specialties. Here are some tips for success: Identify like-minded simulation aficionados from each of the 4 target specialties. Start planning early. We book the simulation center more than a year in advance and contact the stakeholders (program director, simulation instructors) from each department with firm dates before the beginning of the academic year. Each specialty sends a reminder to the participants 2 days before the session, explaining the importance of punctuality and the mandatory nature of the session. To promote a nonthreatening learning environment in the debrief room, ensure that the number of debriefing instructors is equal to or less than the number of learners. At each session, one of the instructors who will not be a debriefer is responsible for taking notes and sending a summary to everyone in the team, including what went well and what could be improved. Collect feedback from participants to improve future sessions and ensure ongoing buy-in from stakeholders. Personnel Required Two confederate nurses are to be in the room at the start of the case: Emergency nurse 1 (confederate) Emergency nurse 2 (confederate) Two simulation technician operators are required to run the simulators. Debriefing personnel. Typically the authors have used one person from each specialty to observe and help debrief. These will be called in Emergency physician (E) Anesthesiologist (A) General surgeon (S) Obstetrician (O) Respiratory therapist (confederate, upon request) Equipment Required Room. The simulation room has to be sufficiently large to have 2 simulators and 6 personnel in it, and the control room needs to have adequate viewing space for up to 4 debriefing observers and 2 simulation technicians to operate.TABLECASE STEM Prebriefing. We prebrief each of the 4 participants separately, as they are not aware until the scenario begins, which this is a multidisciplinary session. Each specialty briefs its own participant in a separate area of the simulation center, and each participant waits by a separate telephone for their call. Welcome to the center Objective/expectations for the day—manage a crisis in the emergency department Establish the fiction contract Establish the safe learning environment Reminder about confidentiality Discuss the purpose of debriefing Discuss the use of video Outline the plan—one scenario, 10 to 20 minutes, followed by a 45-minute debriefing session Orient to place today—tertiary hospital, you are the attending physician covering your specialty, when the telephone rings, it will be for you—answer it! Solicit questions Background and Briefing Information for Facilitator/Coordinator’s Eyes Only The emergency physician (E) will receive a call in the waiting room: “There is a multiple trauma coming in. ETA 2 minutes.” The E will proceed to the simulation room where they will encounter 2 pregnant trauma patients. Upon activation of “code trauma,” the surgeon (S) and anesthesiologist (A) will be called. Ideally, obstetrician (O) will be called as well. If other participants are not called, their presence will be suggested by the confederates. Patient A (Betty) has abdominal pain and an atypical fetal heart rate (FHR). This should be recognized as a placental abruption, necessitating immediate cesarean delivery. Patient B (Veronica) is hypoxic and has abdominal pain. Initially, the FHR is normal but deteriorates as the patient becomes more hypoxic. Patient B has a tension pneumothorax and will improve with decompression. The FHR recovers with decompression of the tension pneumothorax and recovery from the hypoxia. PATIENT DATA BACKGROUND AND BASELINE STATE Information for Learner Upon entry into the emergency department, the emergency physician is informed by one of the emergency department nurses: “Two friends were in a car on their way to their prenatal yoga class. High-velocity MVA, their car was T-boned in the intersection by truck. One is 36 weeks’ pregnant, and the other is 28 weeks’ pregnant” (nurse points to each one). Patient A (Betty): 26-year-old woman, 36 weeks’ gestational age, primiparous. Healthy otherwise. No medications. No known allergies. Patient is talking and complaining of abdominal pain and will consistently ask, “How’s my baby?” Patient B (Veronica): 26-year -old woman, 28 weeks’ gestational age, primiparous. Healthy otherwise. No medications. No known allergies. Patient is talking, but less so. She appears breathless at times, complains of right-sided chest pain and abdominal pain, and will ask about her baby. PATIENT HISTORY: PATIENT A (BETTY, PLACENTAL ABRUPTION) Review of Systems CNS: alert and oriented Cardiovascular: no chest pain Pulmonary: normal breathing Gastrointestinal: pain in lower abdomen Renal/hepatic: normal Endocrine: normal Hematologic/coagulation: normal Skin: normal Genitourinary: bleeding per vaginaTABLECurrent Medications and Allergies Prenatal vitamins, no allergies Physical Examination General: anxious looking, grimaces with pain. On backboard with c-collar Weight, Height: 90 kg, 170 cm Vital signs: HR, 123 sinus; BP, 88/60; O2 saturation, 95%; RR, 24; GCS score, 15 Eyes open: pupils normal 4 mm reactive Airway: patent, no abnormalities, in c-collar Lungs: clear bilaterally Heart: normal heart sounds Abdominal examination: covered by gown, pregnancy with blood per vagina, blood on towel between legs Laboratory, Radiology, and Other Relevant Studies HCT: not Available yet Fetal heart rate (FHR), 100 if checked CXR: not available yet EKG: not available yet Baseline Simulator State What underlying alterations in physiology would this patient have when compared with a “perfect” 70-kg man or woman? Include target numbers. This will comprise your baseline state: Vitals: HR, 123 sinus; BP, 88/60; O2 saturation, 95%; RR, 24; GCS score, 15 Neuro: normal Respiratory: RR, 24/min; nonlabored, normal breath sounds Cardiovascular: hypotensive, IV in place, heart sounds normal Gastrointestinal: simulate pregnancy with abdominal padding (or use Gaumard NOELLE mannequin) Genitourinary: simulated blood per vagina, towel between legs Metabolic: normal Environmental: patient is on backboard, c-collar in resuscitation area. Monitors in place. Patient does not have wedged left uterine displacement (LUD) position at baseline. PATIENT HISTORY: PATIENT B (VERONICA, TENSION PNEUMOTHORAX) Review of Systems CNS: alert and oriented Cardiovascular: chest pain right side, feels like she may “pass out” Pulmonary: patient states “can’t breathe,” worse with deep breathing Gastrointestinal: pain in the upper abdomen Renal/hepatic: normal Endocrine: normal Hematologic/coagulation: normal Skin: normal Genitourinary: no bleeding or cramping Current Medications and Allergies Prenatal vitamins, allergic to penicillin Physical Examination General: anxious looking, grimaces with pain. On backboard with c-collar Weight, Height: 85 kg, 167 cm Vital signs: HR, 132 sinus; BP, 90/60; O2 saturation, 93% initially; RR, 30; GCS score, 15 Eyes open: pupils normal 3 mm reactive Airway: patent, c-collar, trachea deviated to the left Lungs: decreased breath sounds on the right side Heart: normal heart sounds, JVP elevated 5 cm Abdominal examination: covered by gown, pregnancy obvious Laboratory, Radiology, and Other Relevant Studies HCT: not Available yet CXR: not available yet EKG: not available yet FH Doppler, 130 if participant checks Baseline Simulator State What underlying alterations in physiology would this patient have when compared with a “perfect” 70-kg man or woman? Include target numbers. This will comprise your baseline state: Vitals: HR, 132 sinus; BP, 90/60; O2 saturation, 93% initially; RR, 30; GCS score, 15 Neuro: normal Respiratory: RR 30/min, labored, decreased breath sounds right side, simulated pneumothorax (commercially available or may be fashioned using readily available materials in simulation laboratory) may be applied to exterior of mannequin if not possible to insert chest tube into simulator used. Some simulators are designed so that chest tube may be placed. Cardiovascular: BP, 90/60; IV in place Gastrointestinal: simulate pregnancy with abdominal padding (or use Gaumard NOELLE mannequin) Genitourinary: normal; FHR, 130 initially; no bleeding Metabolic: normal Environmental: patient on backboard, c-collar in resuscitation area. Monitors in place. Patient does not have wedged LUD position initially. CHECKLIST This is a guide to the essential tasks of each specialist, with the understanding that each foursome will delegate these tasks somewhat differently. Emergency Medicine Declare the emergency, declare a trauma code; Handover to trauma team and obstetrics as they arrive; Ensure that primary survey and secondary survey are performed on both patients, personally or delegated; Negotiate “trauma team leadership” with the surgeon; Ensure that both patients are “wedged” for left uterine displacement; Recognize airway/breathing issue with Veronica and task anesthetist appropriately; Task obstetrician appropriately with assessing FHRs and assessing obstetrical issues with both patients; Recognize Veronica’s tension pneumothorax and initiate needle decompression, assist with or perform chest tube placement; Summarize state of both patients for team, as needed; Communicate effectively with patients, nurses, and colleagues. Surgery Ensure primary that survey and secondary surveys are performed on both patients, personally or delegated; Negotiate “trauma team leadership” with the emergentologist; Ensure that both patients are “wedged” for left uterine displacement; Recognize Veronica’s tension pneumothorax and initiate needle decompression, assist with or perform chest tube placement; Communicate with obstetrician about Betty’s possible intra-abdominal bleed and suggest midline incision for cesarean delivery; Communicate effectively with patients, nurses, and colleagues. Anesthesiology Quickly assess which patient requires airway/breathing support and go the head of that patient; Recognize tension pneumothorax and give feedback to team leader regarding effectiveness of needle decompression/chest tube; Decide on need for intubation, intubate as needed; Remain aware of Betty’s condition and need for urgent surgery, perform preoperative assessment; Communicate effectively with patients, nurses, and colleagues. Obstetrics Assess each patient with respect to the establishment of gestational age, FHR, uterine activity, uterine tenderness, and vaginal bleeding; Ensure that both patients are “wedged” for left uterine displacement; Communicate with patients with respect to their fetal status; Recognize that Betty is likely experiencing placental abruption and communicate the need for emergency cesarean delivery with those concerned; Decide that cesarean delivery should take place in the main operating rather than the labor and delivery operating room and should be performed through a midline incision; Inform the neonatology team or pediatrician on-call of the impending urgent delivery; Recognize that once Veronica’s respiratory status is stabilized, her fetus will not require intervention; Communicate effectively with nurses and colleagues. DEBRIEFING GUIDE We conduct our debriefings with primary and secondary debriefers who are from 2 of the 4 target specialties. Representatives from the other 2 specialties sit in the debriefing room as content experts but are not engaged in the debriefing unless spoken to. This arrangement ensures that the number of debriefing instructors is equal to or less than the number of learners in the room. At each session, different debriefers take turns as primary, secondary, and content experts. The following is our standardized debriefing script: Debriefing will follow agreed upon “debriefing with good judgment” style, endeavoring to use advocacy-inquiry.5 It is understood that as important concepts emerge, the debriefers should be encouraged to seek information about skills and specific opportunities to evaluate knowledge on communication and collaboration. Although ACLS/resuscitation principles are not the primary learning objectives of this scenario, it is important to address specific issues for the scenario (wedging the patient, decisions to manage the airway, indication for going for stat caesarean delivery, choice of incision, etc). Encourage use of the video to point out examples of good/poor crisis resource management principles. On bringing the group back to the room, general introductions should be done by the primary debriefer—ask each learner and those in the room to introduce themselves, their specialty, and year. Include both debriefers. Start by introducing the emergency physician and giving them an opportunity to discuss what happened before the arrival of the other participants. Video review may be helpful to show the other participants what was happening before their arrival. “What are the indications for a trauma code or calling for additional resources?” The debriefer may review the indications for TRAUMA code at local hospital as well as the concept of Code 222 (neonatal emergency) and code 333 (obstetrical emergency). “How do you optimize handover during an evolving crisis?” “Are there specific tools or ways to make this more effective or more systematic?” Bring up concept of SBAR [Situation, Background, Assessment, Recommendation] style communication. “What are essential elements of effective and efficient communication during a crisis?” (Discuss closing communication loops, using names, introductions, recaps, huddles, speaking clearly and unambiguously.) a. Problem solving b. Situation awareness: ABC’s, concurrent Rx, reassess and reevaluate c. Leadership: calm, decisive, big picture d. Communicate: clear, directed, close loop, listen for input e. Resource use: call early, delegate, direct “How do you establish priorities when caring for multiple critically ill patients? In the scenario, how did you establish priorities when priorities may be conflicting?” “How did you divide tasks and establish roles when multiple physicians were present?” “How do you establish leadership roles when multiple providers are involved? When did you try to pass the torch of leadership through the evolving scenario?” What problems occur when providers work outside of their usual environments? Please tell me one thing you did well and one thing you might change in a crisis situation after participating in this session. SUMMARY AND COMMENTS FROM PREVIOUS SIMULATIONS The authors have run the simulation 8 times each year for the past 4 years. The program directors from each specialty involved were approached and agreed that this would be a mandatory educational experience for each third-year resident from emergency medicine, surgery, obstetrics, and anesthesia (5-year programs in Canada). We chose the third-year residents because they would have sufficient knowledge to deal with the medical expertise required, allowing us to focus on communication, leadership, and collaboration skills. The simulation runs between 20 and 25 minutes and the debriefing lasts approximately 40 minutes. We have collected feedback for the past 4 years, and this is commonly viewed by residents as one of the best educational experiences of their programs and is perhaps one of the few times when they are formally being taught and provided concrete feedback on the ACGME core competencies “systems-based practice” and “interpersonal and communication skills,” which are equivalent to the CanMEDS competencies of “manager,” and To the scenario the simulation or program leadership needs to from each specialty and ensure that there are no in the of learners or debriefing as participation from each specialty is This and for learners not involved in a The debriefing from each specialty is helpful so that the performance of each learner is the simulation that during the 25 minutes. we to a run with all nurses, and simulation technicians 1 before the learners start the sessions to ensure that we have all the and the scenario is clear to everyone In this simulated a opportunity for a of the in the emergency department among 4 medical specialties who are with leadership and clinical The debriefing a opportunity for these 4 specialties to about communication and collaboration skills.

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