The aviation industry and the military have awakened the healthcare field to the virtues of incorporating simulation into education as a means of developing clinical skills and managing medical events with a high degree of reliability. Simulation is becoming a mainstream learning methodology that is rapidly moving into the domain of healthcare practitioners.
David Gaba, MD, associate dean for Immersive Simulation-Based Learning and director of the Consortium for Immersive Based Learning at the Stanford School of Medicine, describes it as “a technique—not a technology—to replace and amplify real experiences that evoke or replicate substantial aspects of the real world in a fully interactive manner.”1 Applying this definition to medicine, simulation provides the opportunity for individuals and clinical teams to practice technical, cognitive, and teamwork skills without subjecting actual patients to the possibility of being harmed.
While simulation takes many forms, it is proving to be most efficacious for training and practicing events that are regarded as emergent or high acuity. Because these types of events are encountered infrequently, it is difficult to perform the appropriate interventions with a high degree of reliability. Obstetrical emergencies, such as shoulder dystocia and post partum hemorrhage (PPH), are classic examples of the types of events that benefit from simulation.
The following PPH case outlines how simulation might have been useful in avoiding, or at least mitigating, an adverse outcome:
A 32-year-old gravida 3 para 2 presented to the hospital at 39 weeks’ gestation in active labor with complaints of contractions two to three minutes apart and some vaginal bleeding. Due to continued vaginal bleeding, an ultrasound was performed six hours after admission. It revealed a right posterior, low-lying placenta with no sign of previa. Pitocin augmentation of labor was begun. Twelve hours after admission, the patient’s vitals remained stable, and a spontaneous rupture of membranes occurred. About 30 minutes later, the patient had the urge to push. The Pitocin infusion was increased, and the patient was soon completely dilated and pushing. A vacuum extractor was applied, and delivery occurred shortly afterward. Apgars were 9 and 9.
The placenta delivered spontaneously at 1755. At 1800, the patient’s blood pressure fell to 90/60, and she was bleeding profusely. Despite uterine massage, 20 units of Pitocin IM, and Methergine IM, the bleeding continued. At 1900, Cytotec was administered rectally and repeated 20 minutes later. Both times Cytotec was administered, bleeding stopped temporarily then resumed. Hemabate was not available. At 1940, the patient, pale and lethargic, was transported to the operating room. She coded on the table. She received CPR and multiple blood products, but platelets were not available at the hospital. She was transferred to another hospital where she eventually recovered but with severe anoxic brain injury.
An in-depth review of the case revealed many opportunities to improve the management of catastrophic PPH. Here are some examples of the improvement opportunities that simulation may have addressed in this case:
Simulating PPH in-situ helps clinical and support staff examine their rapid response systems, identify where they may be vulnerable to error, and facilitate practice of technical and teamwork skills needed for optimally managing such events.
Realizing that simulation has become a significant driver in the patient safety movement, The Doctors Company embraced it as a key initiative nearly five years ago. After introducing simulation to our members in the field of obstetrics, we are now expanding our activities to include anesthesia, emergency medicine, and hospitalist programs. Other specialties will follow.
Because we also recognize that simulation is fast becoming a valuable experience and a requirement for board certification/recertification for some of our members, we have adopted a plan to support those who choose to participate in simulation activities. The plan entails the following actions:
The Doctors Company is fiercely committed to advancing the practice of good medicine. Our simulation program is just one example of the steps we are taking to meet that goal. If you would like to learn more about our program, contact the Patient Safety Department at (800) 421-2368, extension 1243.
“My involvement with the simulation of OB emergencies and urgencies ‘in-situ’ (in our Labor and Delivery Department) has been one of the most rewarding experiences in my career. It has done more to change the hierarchal barriers to communication and team building on our unit than any other single thing. It is very satisfying to see our staff express how happy they are to be part of our ‘Family Birthplace Team.’”
“This program demonstrated how simulation can improve our communication and confidence in managing emergency OB events. I very much enjoyed it and learned a ton! Thank you!”
“Thanks—this was a great experience! The knowledge and skills presented will help to make me more comfortable in dealing with potential OB emergencies.”
“This experience gave us a safe, non-threatening environment in which to learn—greatly appreciated.”
“Wow…what an effective way to make sure we’ve got it all together! Fabulous!”
By Dieter Zimmer, MHA, FAAMA, Regional Vice President, The Doctors Company; Marion Y. Constable, MSN, CNM, Director of Simulation and the Obstetrical Collaborative, The Doctors Company; and Roxane Gardner, MD, MPH, DSc, Assistant Professor, Obstetrics and Gynecology, Brigham and Women’s Hospital, and Simulation Specialist, Center for Medical Simulation.
This article originally appeared in The Doctor’s Advocate, second quarter 2011 (www.thedoctors.com/advocate).
The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider in light of all circumstances prevailing in the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.