Simulation team training proves worthwhile during real life crisis
By Jutta Novalija, M.D., Ph.D., CHSE, Anesthesiologist, Director of Milwaukee VA Simulation Program and Tina T. Smith, MS, CHSE, RN-B
Clement J. Zablocki VA Medical Center
MILWAUKEE – Undergoing surgery and anesthesia is much safer now, and many practicing physicians and nurses can go through their entire career without encountering a life-threatening crisis. In preparing for critical events, simulation is a powerful teaching tool to maintain or further develop skills and prepare the team to function well when seconds count.
Malignant Hyperthermia (MH) is one of these serious events that can happen in the operating room (OR). This is a life-threatening complication if not treated immediately and managed correctly. While extremely rare, some people have a violent reaction to medications routinely administered during general anesthesia and develop extremely high body temperature, dangerously rapid heart rate and breakdown of muscle cells. To prepare for a crisis like this, the interprofessional operating room team at the Clement J. Zablocki VA Medical Center here practices regularly with how to respond to a patient presenting MH using high-fidelity simulation. The curriculum was published, and simulation as a teaching tool is valued. But, how do you know that the team really learned from these drills?
Recently, a patient developed complications at the end of a seemingly routine procedure. The entire OR team responded swiftly and calmly to one of the most feared complications from general anesthesia. The skilled anesthesia team, consisting of a certified registered nurse anesthetist and an anesthesiologist, recognized the possibility for MH when they noticed unexpected muscle stiffness along with other suspicious changes in the patient’s vital signs and called for the necessary equipment, medication, bloodwork and help.
The patient was observed in the intensive care unite (ICU) overnight and recovered quickly after the event. He was discharged without further consequences shortly after. He will undergo further testing in the future to evaluate the future risk for himself and his family members as Malignant Hyperthermia is a genetically inherited disease.
Seeing the signs and symptoms of MH is only the first step. It takes the whole team to be successful in managing the critical situation. Many things can go wrong and delay the effective treatment, but in this case, the team of nurses, physicians and technicians were prepared. They practiced this situation over the past four years by simulating the crisis in the actual OR environment.
Twice a year, scenarios are run in which one of the simulators experiences the typical signs and symptoms of MH during surgery. Team members bring the necessary resources to the room, initiate cooling measures, prepare medication and practice the communication within the team and to the MH hotline to streamline the care. Barriers to success are discussed in a team debrief after the simulated scenario and improvements implemented before the next practice drill. During these simulation sessions, the team practiced different ways to draw up the life-saving medication Dantrolene faster, or found better ways to get crushed ice from the ice machine to the OR to help cool the patient. Improvements to the MH cart were made and while they were seemingly small changes, all of them added up. The most important effect of the regular training is the ability to anticipate what will happen in this event.
When the real crisis occurred, the team members knew all the pieces of the puzzle which led to success for the patient. They were able to stay calm and coordinated.
“Everybody knew what they were doing and the communication was clear,” said Matt Burkart, CRNA, who was leading the team throughout the crisis with Zafar Iqbal, MD. “It was just like in the simulation sessions we practice every year. The team just knew what needed to be done, and the resources were organized without any yelling and stress.”
Simulation training in the actual environment of rare but critical events is the best way to practice crisis resource management concepts and improve available resources and communication. The OR team at the Milwaukee VA continues to practice MH simulation drills every year, as well as other rare, life-threatening complications like massive transfusion, anaphylaxis and patient/airway fires to improve the safety of our Veterans.