BY DR. BRIAN GOLDMAN
Excerpt from his new book, The Power of Teamwork
“Ann, this will make you a bit sleepy.”
The young gynecologist pushes the plunger into a 5 ml syringe filled with midazolam, a sedative that works in two minutes. “I’m feeling drowsy,” says Ann, her voice muffled by a high-flow oxygen device, a breathing mask and a beeping heart monitor. Dr. Glenn Posner looks on impatiently.
The experienced gynecologist is about to perform a hysteroscopy, a minor procedure for diagnosing and treating abnormal vaginal bleeding. Ann is sedated so Posner can dilate the cervix and insert a thin telescope that enables him to look inside the uterus for abnormalities. He’s showing his young colleague how to do it. From the procedure tray, Posner takes a 10 ml syringe filled with a local anesthetic to numb Ann’s cervix. “Sorry, this will sting a bit,” says Posner. “I’m not feeling well,” Ann says unexpectedly.
The rhythmic beeping of the heart monitor slows to a stop, and the smooth, regular tracing turns into a jagged sawtooth. “Call a code blue,” Posner says as he starts chest compressions. His young colleague makes the call and then starts fumbling with an oral airway and oxygen tubing.
At this small community hospital, there is no dedicated cardiac arrest team. When the code blue call sounds across the hospital communication system, people pour into the procedure room from everywhere. Posner never knows in advance who is available to attend. He spots a respiratory therapist (RT). “Al, can you help with the airway?” Posner asks the RT, who tries to connect a plastic tube to a suction unit on the wall. But he can’t get it working. “I’ve got the crash cart,” says a nurse, wheeling in a cart with drawers that contain resuscitation drugs and other supplies. The nurse opens a sealed pack of cardiac leads and connects them to the defibrillator on the crash cart. But when the nurse turns on the defibrillator, no electrical tracing appears on the monitor. The patient is in distress, and the monitor is dead. Two gynecologists try in vain to help the nurse.
“One amp of epinephrine,” orders Posner. “I can’t find any,” says a second nurse, sounding alarmed. “Someone call the emergency department and tell them to bring three amps.” The wall suction and the defibrillator don’t work, and one of the most essential medications used during a code blue isn’t on the crash cart. Ten minutes have elapsed since Ann went into cardiac arrest. Posner’s gaze pans the room, making eye contact with everyone. “Everybody take a deep breath,” he says. “Nobody died.”
If it isn’t obvious to you yet, Ann is a mannequin. But that doesn’t matter to the health professionals assembled here. When the code blue sounded on the hospital communication system, only Posner and his young colleague knew it was a simulation. The whole point is to help teams work better together and to figure out latent safety threats. Now, everyone in that room wonders what would have happened had this been a real patient.
“My job is to sneak mannequins into the hospital,” says Dr. Posner, medical director of the Simulation Patient Safety Program at the University of Ottawa’s Skills and Simulation Centre. He’s also a gynecologist. “When I’m not wearing scrubs but nice clothes and I walk onto the ward, the nurses think, ‘Oh shit, Glenn’s here. Where’s the mannequin?’”
Smuggling a mannequin onto an actual ward is known as an in-situ simulation. When you run simulations at a fancy centre away from the wards, team members say things go wrong because of the unfamiliarity with the environment and equipment. Running a scenario on their own ward eliminates that factor. The other advantage of in-situ simulations is that they catch people who would normally skip these exercises.
“Instead of people taking the afternoon off, I can sneak into the hospital with my mannequin and scream, ‘My uncle’s having a heart attack. Somebody do something!’”
How do colleagues feel when they’re called to an emergency only to find that the patient is a mannequin? “I’ve made their heart race,” he says. “They’re pissed off because they’ve just been punked, but that quickly changes to appreciation because they have ideas about how this crisis could be managed better.”
Posner has been pro-simulation since he was a resident in obstetrics and gynecology in 2005. He took postgraduate training in medical education and simulations from the University of Cincinnati. He thinks they’re critical to the education of young physicians.
“When a fourth or a fifth-year resident has to make the decisions themselves, it’s a safe learning environment to make mistakes.”
Posner adds the second most important thing about simulations is the scheduled debrief that follows. “It’s the forty-five minutes afterwards when you beat this case to death with what went well and what could have gone better,” he says.
There’s a whole branch of research on debriefing. Experts from Canada and the United States have developed a technique that replaces the traditional Socratic method of questioning with more gentle suggestions for better management of the case. “It’s a much nicer and safer way of exploring a knowledge gap or a performance gap,” he says. During the debrief they also break down how the team communicated; for instance, did the leader identify themselves clearly, or was that assumed but not stated clearly?
“Hopefully the next time they lead an [actual] emergency, they’ll remember my teaching and they’ll say, ‘Okay, Joanne, you’re the most senior person here. You be the leader, and we’ll be the followers,’” says Posner. “Followership is also hard in medicine. The hierarchy in medicine is so rigid sometimes.”
One of his most formative experiences with simulations came early on when a mentor ran a scenario that brought residents in ob-gyn and anesthesiology together for a simulated code blue set inside an OR. “What was most interesting in the simulated environment was to work on teamwork skills and communication skills,” says Posner.
He was one of the first to bring health professionals from different specialties and their residents together in one simulation. One reason is to address latent and actual biases that hospital personnel have about one another. To an emergency physician like me, general surgeons sometimes appear sullen and obstetricians tired.
“If you don’t have the real specialist playing themselves, then all you get is a caricature of that specialty,” says Posner. He says they also bring nurses and other allied health professionals into each scenario so that they function in their usual roles during the simulation. In an actual resuscitation, nurses make helpful suggestions based on their experience. It’s unrealistic to expect doctors to go through code blue simulations without nurses to prompt them. Ultimately, Posner says, multidisciplinary simulations serve two main goals.
“Number one is to get everybody together in the same room, learning the same thing with the same objectives,” he says. “That is really rare in medicine.” The second goal is to identify and address hidden dangers.
Remember Ann, the mannequin who had the code blue during a hysteroscopy? Posner says that scenario happened to an actual patient.
Dr. Brian Goldman is an emergency room physician and the host of CBC Radio’s White Coat, Black Art and The Dose. He is the bestselling author of four other books – The Power of Kindness; The Night Shift; Real Life in the ER; and The Secret Language of Doctors.
To read more about mannequins that breathe, blink and bleed in the service of medical education and patient safety/quality care, go to Pamela Fayerman’s articles here or below: