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!
— Cliff Reid (@cliffreid) March 18, 2015
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
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 🙂
With huge thanks to Clare Richmond, the Critical Care Course faculty and participants, and Katrin Hruska for tolerating my self-invitation to the conference.