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.

14 Comments

  1. Nick Harvey Smith

    Thanks for this Nat,

    This mirrors the experience we have had in undergraduate simulation when we got one of our faculty member to play an asthmatic patient instead of using SimMan though we used the SimMan monitor. Both the fidelity and challenge increase considerably over previous scenarios using SimMan with the students having to deal with a severely breathless patient using lots of accessory muscles who was constantly trying to sit up on the edge of the bed and finding the mask claustrophobic.

    Reply
  2. peter

    Sounds great. Would have been a great session!

    Reply
  3. akutdoktorn

    Thanks Nat! Thanks for coming to SWEETs, for contributing to the course and to the conference, and for sharing your thoughts. It is amazing how much one always learns from being a teacher. I think that self reflection is what makes sims so valuable. In every case there is a new lesson to be learned and what it is depends on where you are in your development and how well the instructors manage to encourage and facilitate that process.

    It’s sad that you weren’t given analgesia when you asked for it. A lot of our patients are in pain and can’t even ask. There is so much we can do to make the patient feel like the main character in our resus rooms. I hope the Oscar nomination you get is for best supporting character. I’ll definitely vote for you!

    Reply
  4. foamedgp

    Helpful review – thanks for sharing your insights into what appears to be a great learning experience. Much appreciated.

    Reply
  5. Jesse Spurr

    Thanks for sharing such a great post Nat. SWEETs looked amazing from a distance via Twitter.
    I think what you are talking about is perfectly framed by a quote that is pretty well known in the simulation ‘world’ – ‘Simulation is a technique—not a technology—to replace or amplify real experiences with guided experiences that evoke or replicate substantial aspects of the real world in a fully interactive manner. The use of people as then simulator – or ‘simulated patients (SP)’ adds a great degree of psychological fidelity to scenarios in which patient clinician communication is an implicit requirement. First off, I really agree with having someone with clinical knowledge playing the patient, they can adapt there symptoms and expressions as they receive treatment. My experience has been that certainly not every clinican is capable of playing a realistic patient and it can quickly turn into a pantomime. So SP selection is really important. There is a really nice paper by Sanko and colleagues (2013) on looking at conventions for actors in health care simulation – well worth a read.
    Other than using virtual monitors like iSimulate, SimMon etc (nicely outlined by Tim http://kidocs.org/2014/06/apps-simulation-review/), I have stumbled on heaps of cool little tips for increased fidelity using simulated patient. I have run up a set of stairs or done push ups, star jumps, etc. to become sweaty, tachypnoeic and tachycardic and raise BP. A cut off glove finger place on SP’s digit can mimic low or unrecordable pulse ox. A confederate (simulated participant) with a phone and some recorded audio loops can add auditory realism – example from using SP for maternal emergency scenarios was foetal doppler sound loop played from “Dad’s” phone when midwives placed doppler probe on abdomen. A well timed complaint of nausea or vomit can mask or divert participants from noticing the confederate changing obs parameters or adding another adjunct. There are so many fun and easy techniques to use.
    Another useful addition is hybrid sim – use of SP with an added part-task trainer (one arm tucked in gown and replaced with IV cannulation training arm with connected drainage system, allowing “patient’ to be cannulated and have drugs administered. Wearable solutions like Laerdal Mama Natalie birthing trainer can also work well.
    Your point on setting the rules of interaction is really important for both SP safety and participant engagement. It is best to negotiate this with the SP prior and then give a pre-brief rules of engagement to participants – ‘you can actually prick the finger and draw a blood glucose test, you can actually apply ECG leads, etc.’
    Thanks again for another great post from team St. Emlyn’s. I’m loving the fact that sim is starting to rapidly move out of the sim lab and into the workplace and you guys are doing a great job of sharing your experiences and learnings as there is very little in the traditional literature about this stuff.

    Ref.
    Sanko et al. 2013 ‘Establishing a convention for acting in healthcare simulation: merging art and science.’ http://www.researchgate.net/publication/251878299_Establishing_a_Convention_for_Acting_in_Healthcare_Simulation_Merging_Art_and_Science

    Reply
    1. Natalie May (Post author)

      Thanks so much Jesse – what an amazing set of tips! Great addition to the post 🙂

      Reply
      1. Jesse Spurr

        No worries Nat. This stuff grills my corn 🙂

        Forgot to attribute the quote: ‘Simulation is a technique—not a technology—to replace or amplify real experiences with guided experiences that evoke or replicate substantial aspects of the real world in a fully interactive manner.’ – David Gaba 2004. From a very pertinent article too: ‘The future vision of simulation in health care’.
        http://qualitysafety.bmj.com/content/13/suppl_1/i2.full.pdf+html

  6. Sandra Viggers

    This is such a inspiring post! thank you for sharing your experience and as a medical student often “the sim person” at our simulation center – thank you for reminding us how important it is to take care of us. It is not fun to be bag masked when you are in fact feeling just fine and completely awake 😀
    And Thank you Jesse for the very good tips to use in simulation – I will for sure adapt some of them into our simulations.

    Reply
  7. Nicholas Aujalay

    Thanks Nat for sharing your experience! Question to all of you out there – which ED in the UK would be a good role model for Swedes to visit – a place where ED docs manage intubations, critical care stuff etc?

    Reply
  8. Kata

    Ahh such an inspiring post for a young med student in Sweden aiming for emergency medicine when I sometimes have to battle even my supervisors regarding the need for this specialty!

    When we had real life “sims” during one semester I learned two things: 1) “hmm, maybe I actually have some sort of natural affinity for this” despite my initial thoughts and fears that I’d just run around and scream, and 2) quoting my groupmates, “you really have a talent for acting extremely annoying”. It must be tons more educating (in a more… clinically useful way) for all of you who actually work with this!

    (Maybe I could’ve offered my acting services for this to at least get to walk in the same building as my seniors… it’s no fun being a student with no money for education :'( )

    Reply
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