Most anesthesiologists excel at routine procedures. But how do they fare when faced with an emergency, such as a sudden cardiorespiratory arrest, a severe allergic reaction or a massive hemorrhage?
"Like airline pilots, it's the ability to handle the unexpected that patients, or passengers, are really paying for," said David Gaba, MD, a professor of anesthesiology, perioperative and pain medicine at Stanford.
Gaba helped pioneer mannequin-based simulation tools used to hone the skills of both novice and highly-experienced physicians. During a simulation, a computerized mannequin fills in for the patient. "The mannequin has pulses and eyes that blink. It breathes, talks and provides all the waveforms and numbers to the clinical monitor displays that physicians and nurses are used to seeing," he explained. "The instructor can tell the system to do all sorts of things, and can recreate many situations."
These mannequins are particularly useful to practice how to handle unexpected life-threatening situations, he said. "We can allow medical students and residents in training to be the final decision-maker in simulation, whereas fully-experienced physicians will take over to protect a real patient," Gaba said.
Since practicing teamwork is critical, the simulations are sometimes done with a full team of anesthesiologists, surgeons, nurses and technicians. Sometimes, team members such as nurses are following the instructor's directions; in other situations, all participants are new to the scenario, Gaba said.
In a recent study, 263 board-certified anesthesiologists participated in simulated crisis scenarios with team members who were working with the instructor. In one scenario scripted by Stanford, the simulated patient undergoing an urgent belly surgery had a severe heart attack, causing an abnormal heart rhythm and dangerous drop in blood pressure.
The study identified different types of performance deficiencies: lack of knowledge, reluctance to use more aggressive treatments or failure to fully engage the surgeon. However, the most important lesson may be the need to call for help sooner. "When help was called, it almost always improved the overall performance of the team," Gaba said.
In the scenario described above, for example, the unstable patient's dangerously low blood pressure necessitated the aggressive treatment of shocking the heart with a defibrillator, he told me. "Although most anesthesiologists know this, they are more familiar with using a variety of medications and some participants were reluctant to do the appropriate, but more invasive action," Gaba said.
Gaba identified various ways to overcome these performance gaps, such as using role-playing, verbal simulations with a colleague, full simulations and emergency manuals.
During the 30 years he has been researching mannequin-based simulations, Gaba said he's witnessed many changes:
When we started, people thought that simulation was a 'nice toy,' but they couldn't see all of its applications. They thought that it was good just for simple technical things like CPR. But, we saw the cognitive parallels between our world in anesthesiology and worlds like aviation. Similarly, 30 years ago the notion of emergency manuals would have been called 'a cheat sheet' or 'a crutch.' It is now recognized that smart people use such cognitive aids because no one can remember everything, especially in the heat of a crisis. That's why pilots and others use them - it's just common sense.
Despite this progress, Gaba said that simulations are still not fully embedded in health care training. He estimates that only about five percent of practicing physicians have been through a meaningful simulation, beyond the basic life support or advanced CPR courses.
But he is still hopeful. "We're pretty sure that there are hearts, brains and lives that have been saved due to our work, and I'm not retiring any time soon," he said.
Previously: On rare conditions & anesthesia: A case study, What health-care providers can learn from the nuclear industry and A closer look at Stanford's simulation technology
Photo courtesy of David Gaba