Category Archives: Medical Technology

The SWEETest Sim – Real People, High Fidelity at #SWEETs15

 

The sweetest

In March 2015 I invited myself to the Swedish Emergency Medicine conference SWEETs in Stockholm. It was a huge privilege to learn about EM in Sweden and to work alongside some of my favourite people. I had an absolutely amazing and exhausting time – as well as presenting on presentation skills for the Teaching Course, reprising my SMACC Gold talk on Paediatric EM and giving a new talk about imaging decisions in PEM, I joined the faculty of the Critical Care Course to give a Paeds Critical Care workshop and to take part in some of the simulations.

We have been using in-situ simulation in our ED for a while and we’ve learned absolutely loads; about our department, our team, our processes, the art of post-sim debrief and the nuances of sim itself. What was great about simulation at the SWEETs Critical Care Course was the mixture of mannequin-based and real-patient based scenarios.

Obviously (being a drama enthusiast) the chance to role-play as a patient was not something I wanted to pass up and I joined two other faculty members (one playing the nurse, one overseeing and facilitating the simulation) in a scenario. I played a 35-year-old woman called Natalie (sounds familiar – Ed), an intravenous drug user who had developed necrotising fasciitis after injecting but she had attended the ED because of severe pain. The patient I was playing simply wanted pain relief and had no real idea how sick she was. It was a really, really interesting experience.

The first thing to say about this approach is that it gives a different feel to the simulation. Clare Richmond heads up simulation at Sydney HEMS where they use the iSimulate simulation software, controlled via iPad, to create deranged physiology on the monitor even though your actor is healthy and haemodynamically stable. Clare and I talked about her simulation experience and wisdom afterwards – the use of real people, she says, offers an incomparable level of immersion for the participants. Having a real person in front of you gives an added degree of reality.

Using Clinicians as Simulated Patients

The advantage, Clare says, of having a clinician in the role is that they can improvise when necessary too. Antibiotics were given in all six simulations we ran and in most of them no-one had asked about my allergies. Being the “helpful” kind of person I am, I would wait until they were administering the drugs then ask whether it was pain medicine (I asked for that a lot) and when I was told it was antibiotics I’d respond with “it’s not penicillin, is it?” The scenario was tricky enough without anaphylaxis complicating things so I had decided that my fictional persona would report only a mild vomiting reaction to penicillin in childhood, something patients often refer to as allergy, but there’s nothing like the stomach-dropping terror of potential iatrogenic harm to remind you to check allergy status in future.

Of course there are risks in using clinicians. Clare is wary of the tendency of some actors to go over-the-top or detract from the original learning objectives of the session. If the performance is too exaggerated then the advantage of using a real human is lost, she says, and we risk losing the trust of our participants – something which is particularly important with those nervous learners who are only starting to trust basic simulation.

Bringing Communication Skills Back to Sim

Real-patient sim also means that some of the things which get forgotten in our mannequin simulations – the patient’s concerns, emotions and need for explanation – are suddenly thrust into the foreground. As a sim facilitator I’ve tended in the past to focus on the physical and clinical situation but this experience will definitely change that for me in future. We ran our scenario six times; on one occasion the simulating team decided I was sick enough to warrant an RSI. There was no explanation, no consent, no emotional support for me – it was actually 4pm so as soon as I managed to get the participants to explain to me that they were going to “give some medications to get me off to sleep” I became very distressed – I needed to pick up my imaginary five-year-old daughter from school. I’ve seen this distress frequently in real-life emergency medicine; no-one expects to find themselves critically unwell in the ED so they rarely make plans for their dependents, pets and other life responsibilities. We need to understand our patients’ priorities; good healthcare is holistic, it extends beyond physical health alone. This type of immersive sim offers that additional level of realism making it cognitively tougher than mannequin-based sim. We can use it in paediatric sim too – supporting and dealing with anxious parents is a real challenge we need to include when managing sick children.

Good explanations are priceless – I got a really good taste of what it’s like to have a group of doctors and nurses surrounding you, speaking across you and forgetting to explain things. Introductions were pretty good with most of the participants introducing themselves at the beginning of each sim session. The treating doctors decided I needed various procedures (an ABG, an ultrasound assessment of volume status). Most of these procedures were never explained to me – and when I asked “what are you doing?” the answer given was a factual one (“an ultrasound” or “an ABG”). As a non-medical person these answers mean nothing but it doesn’t take too much reflection to realise that when patients ask us what we are doing to them, they really want to know why it is necessary and what it means. I asked repeatedly for pain medicine throughout each scenario – I begged at some points – and while I know as a doctor the sim participants had recognised my critical illness and were trying desperately to save my life, as a patient I felt ignored. I didn’t know why they were doing all these crazy things to me as I only wanted analgesia. It suddenly became crystal clear to me why some of our most vulnerable patients suddenly decide to escalate their behaviour or leave – they are frightened and they don’t feel listened to. I know I’ve been guilty of this in the past, more than once, and it’s been a wake-up call. There’s always time to explain to patients and their relatives/carers and it’s a change I’m definitely going to make as a result of this experience.

Look After Your Sim Actors!

We also need to look after our sim patients – one of the first interventions the teams took (completely appropriately) was to request high flow oxygen via facemask. The non-rebreathe mask itself was customised by the sim faculty (the bottom section cut out) so that I wouldn’t spend all afternoon rebreathing my own expired carbon dioxide – but at some points the course participants held the mask onto my face, generating a seal that we had been trying to avoid. For fidelity I tried to remain in character but I relied upon the keen eye of Clare who frequently noticed and asked the participant to stop. There were other potential issues too – at one point my t-shirt was pulled down so that a doctor could examine my right shoulder as he asked for permission simultaneously (“Can I just look under here?”) – not quite informed consent!

I’m not a shy person so I really don’t have hangups about it at all – but if we are facilitating the simulation we need to protect our sim patients first and foremost. It might be helpful in advance to warn them that this might happen and to check what they are comfortable with. I was really well looked after by the faculty team but it’s paramount if you are using real people that your faculty is vigilant to their welfare, particularly as some participants can get completely immersed in the scenario.

An Extra Layer of Feedback

The final advantage of a real-patient sim is the ability to involve the patient in the feedback and reflection phases. We frequently paused the scenario to recap and explore our progress and I thought it was great during some of the conversations to be able to offer my perspective as the patient. The participants often took a long time to give analgesia, conflicted between their natural urge to treat my severe sepsis and my continual requests for pain relief. As the patient what I really needed was one of the doctors to tell me that the severe pain was likely to be the result of a very serious infection and that while they understood and would treat my symptoms as soon as possible, they really needed to undertake some important interventions to prevent the situation becoming even more serious. I think we worry about scaring our patients but I’m sure that for most of them the fear experienced from not knowing is far greater than an understanding that the situation is serious but that the team knows what needs to be done about it.

It’s Looking Good for ED Critical Care in Sweden

Image courtesy of Bjorn Nicholas Aujalay
Image courtesy of Bjorn Nicholas Aujalay

On the whole I was really impressed by the sim participants – EM is a new and developing specialty in Sweden so much of the critical care we are used to delivering in the ED is outside their remit. The cognitive load was enormous and it’s easy to see how under that sort of pressure and with such a steep learning curve, patient factors can get left behind. There was a great moment when one of the doctors, unprompted, held my hand, looked into my eyes and told me everything was going to be ok. It was also great to be able to feed back on what a difference that had made. These patient factors really do matter and in the UK where we are more used to providing upstairs care, downstairs I would be really interested to see how using real people could add to the educational value of our sim sessions. So, watch this space as Simon and I start to plan…! Meanwhile I’m looking forward to my Oscar nomination in 2016 :-)

Clare Richmond, yet another awesome Sydney HEMS doc!
Me with Clare Richmond, yet another awesome Sydney HEMS doc!

With huge thanks to Clare Richmond, the Critical Care Course faculty and participants, and Katrin Hruska for tolerating my self-invitation to the conference.

PODCAST update with Mark Wilson on the GoodSAM app at the London Trauma Conference

Mark Wilson GoodSAM stemlyns

 

 

Earlier this year we published a blog on the GoodSAM app, a device developed by Mark Wilson and colleagues in London that has a real potential to save lives. Since then we have heard him speak at a number of conferences including an inspiring talk at the London Trauma Conference. Iain was lucky enough to catch up with him there to record the following podcast. Listen, learn, and then download the app. You might just save a life.

Don’t forget that Mark will be at SMACC this year (you should be too).

We have more to come from the LTC so keep an eye out for those and other St.Emlyn’s podcasts in 2015. Related to this post is the concept around Impact Brain Apnoea with Gareth Davies. If you’ve not already listened to that then do so now as these two posts link really well.
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Before you go please don’t forget to…

Free Open Access RESUSCITATION – the GoodSamApp with Mark Wilson

 

 

Screen Shot 2014-08-27 at 08.53.07Mark Wilson.

One of the things I love about medicine is the cross-fertilisation of ideas and techniques from one discipline to another. I worry that as more subspecialisation occurs, cross-fertilisation will be lost. Emergency medicine and critical care, spanning so many areas, are unique in that they may be the last places of true open-minded generalists. It’s in these environments that innovation can flourish.

Being involved in pre-hospital care allows you privileged access to the few moments immediately after an injury has occurred. Physiology is very different at this time. One thing that occurs in animals who sustain head injuries, and we believe also occurs in humans is a phenomenon called Impact Brain Apnoea. There are many historical articles reporting it but it seems to have been largely forgotten in modern literature. A bang on the head, even with minimal or no parenchymal brain injury, can result in a period of apnoea – with obvious consequences if sustained and untreated. We wanted to find a way to minimise this phenomenon. Suggestions included training paramedics better airway skills, but they already have great skills – its just they are not there…

It dawned on us that, like you are never more than 10 feet away from a spider, you are probably never more than a couple of hundred metres away from a doctor, nurse, paramedic or first aider… Harnessing this community would not just be beneficial in traumatic brain injury, but more importantly in cardiac arrest.

And hence the GoodSAM App (www.goodsamapp.org) was born. Consider the scenario. Someone collapses in a bookshop. If a bystander opens the App, it automatically dials 999 (or the appropriate number for whichever country you are in). It simultaneously alerts a trained and registered responder, who may just be in the coffee shop next door. It is the equivalent of shouting for help, but being able to shout through walls. The ambulance will still arrive (in London about 70% arrive within 8 minutes for category A calls); but with a trained responder arriving earlier, they should be less hypoxic have had high quality CPR and may even have been defibrillated if appropriate.


Now if reading this you may be thinking, but I don’t want to be called when out shopping! And that’s fine! If you are a registered responder you can switch the App off and if you can’t go when alerted, that’s fine, the next nearest responder is alerted. When responder densities are high (nearly 1000 in London) the chances of you being alerted are actually very small.

How many Neurosurgeons also work in prehospital care?
Mark in prehospital guise with London HEMS

We also built a defibrilocator into the App – it now has nearly 2000 defibrillators across the UK in it. If a responder sees an Automatic External Defibrilatior (AED) attached to something fixed (e.g. in a tube station), they simply use the App to take a picture of it and state the opening times of the location. Using the Geotags of the photo it is then put on the GoodSAM map.

You may have some concerns about this App – that’s ok – we had too. Questions such as “how will you stop abuse”, “how do you check people who register”, “what about indemnity” are common and we have addressed them as best we can here.

This is something of a social experiment! But the Good Samaritan community seems to be building rapidly both in the UK and internationally. If it works, it might really make a difference, not just in maintaining airways in trauma, but by providing high quality CPR and early defibrillation in out of hospital cardiac arrest.

Get in touch at info@goodsamapp.org to tell me more and to share the word, but before you do that please consider downloading the app and joining the team. You might just save a life…..

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Mark Wilson

 

 

Guest Blogs at St.Emlyn’s

Mark Wilson
Mark Wilson

This week’s guest blog comes from Mark Wilson. Here he talks about the GoodSam app which we think is marvellous. Mark is a super chap who is an inspiration to all of us in #FOAMed, Meducation, PHEM and Neurosurgery. I met him at SMACCGold where he did an amazing sessions on Neurosurgery for everyone (you have to watch this) and ICP monitoring. You should also check out the links below to see examples of his contributions in the past.

However, he is not guest blogging on the past, but on the present. He has developed the GoodSamApp with help from the #FOAMed community and it’s just an amazing idea and one that really deserves widespread dissemination and adoption.

Please read Mark’s thoughts above and please, please, please consider joining in on this amazing idea.

Mark asked us not to be so gushing. He’s much more devoted to the project and to making the world a better place than to any self promotion. He is rather modest, but to be honest we couldn’t resist. He’ll be at SMACC in Chicago next year so why not book your flights now and come meet him in person.

What we really need is some momentum….. anyone know of some organisations that might promote and support @goodsamapp… I think I do.

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