Physician anesthesiologists have been the drivers of patient safety in medicine. A focus on vigilance has led to significant advancements in the prevention of perioperative complications. As residents, we seek out opportunities to manage rare and unusual clinical scenarios, but we are finding that such opportunities are increasingly less common in the setting of improved patient safety. We spend our years in residency becoming proficient at making clinical judgments that allow us to manage patients safely, while making our job look “easy.” In other words, we gain the knowledge and understanding of our patients to anticipate and prevent complications, thus, making our jobs look effortless. Anesthesiology, like everything in medicine, has its risks and complications. Some of the most severe complications in anesthesiology are, fortunately, the rarest. They require early recognition, precision in management, effective communication, coordinated teamwork and the confidence of a seasoned veteran. Yet how exactly are we expected to become veterans in the management of local anesthetic toxicity or malignant hyperthermia or intraoperative anaphylactic shock, if we spend our entire residency diligently preventing such situations?
The answer is really quite simple: simulation training. Simulation training has become an integral component of the practice of anesthesiology. In 2011, the ACGME Resident Review Committee mandated that each resident should participate in simulation training at least once per year.1 The ABA took this a step further and now requires that board diplomates after 2008 participate in simulation education as a part of Maintenance of Certification in Anesthesiology (MOCA®).2 Learners may become exposed to simulation edu-cation starting in medical school, and many programs showcase their simulation centers as part of their residency interview tour.
Mayo Clinic’s Paula Craigo, M.D., Medical Co-Director of the Mayo Multidisciplinary Simulation Center, and Laurence Torsher, M.D., Associate Professor of Curriculum Development for the simulation center, are intimately involved in the integration of simulation training into residency program education. Dr. Torsher states “the simulation center gives learners an opportunity to try out what they have learned, or to rehearse how they might manage uncommon situations that we all need to be equipped to handle.” He goes on to say “simulation is really about recognizing problems and going through the steps of managing it with time pressure and the blips that come along in real life.” Simulation as a learning tool is well suited for practice and exposure to high-risk clinical situations with little room for error in management. It is also useful in reflecting on one’s management of more common critical situations (e.g., laryngospasm). Simulation is frequently used in airway management courses as well as for training in ultrasound-guided techniques.
Simulation training is an excellent tool; however, it should be viewed as supplementation to, not substitution for, didactics, reading and clinical practice. Dr. Craigo states, “simulation is not well suited to learning detailed bits of information. However, simulation offers the opportunity to apply information in a realistic setting, and practice skills (communication, situation awareness, team skills and leadership) that require more than cognitive info.” She offers “hybrid training” as the ideal situation, where readings or lectures are followed by simulation cases. It is also important to remember that despite the realistic settings and scenarios simulation centers portray, they will never be able to prepare us 100 percent. While participating in a scenario it is hard not to overanalyze everything and expect a potential disaster. Our ability to maintain vigilance and properly respond to a situation cannot be defined by a 20-minute scenario. Solid real-world clinical experience is, of course, irreplaceable.
Nevertheless, the benefits of simulation center training have been evident to many of our colleagues. Past residents had a simulation case that became a reality when the early recognition of bupivacaine-induced cardiac arrest led to successful intralipid resuscitation.3 More recently, Justin Klanke, M.D., CA-3, recalls a circumstance when he was asked to assist in the management of an acute operating room situation. He entered the room as the consultant anesthesiologist was assessing an unstable patient for the common complications that follow central line placement. After looking at the patient’s vitals, he queried the possibility of anaphylaxis. The care team felt this was plausible, as the catheter inserted had been an antibiotic impregnated central venous catheter. The patient was empirically treated for anaphylaxis and the results of blood testing revealed a markedly elevated tryptase level. When asked about his clinical intuition, Dr. Klanke stated that it was “because of having simulation training the prior day, I was able to effectively diagnose the patient and assist a staff anesthesiologist during an emergent situation.”
Simulation centers are becoming a key aspect in the realm of Anesthesiology. Residency education is using them as a means to recreate countless scenarios, and the ABA now utilizes simulation as a component of MOCA®. It should be embraced as another tool in our ongoing quest for safe and effective patient care.
Jennifer Bartlotti Telesz, M.D. is a CA-2 Resident at Mayo Clinic, Rochester, Minnesota
Brian Telesz, M.D. is a CA-2 Resident at Mayo Clinic, Rochester, Minnesota.
1. Simulation: new revision to program requirements. RRC News Anesthesiol. March 2011:1-2. https://www.acgme.org/acgmeweb/Portals/0/PFAssets/PublicationsNewsletters/Anesthesiology_Newsletter_Mar11.pdf. Accessed Jauly 10, 2013.
2. Maintenance of certification in anesthesiology (MOCA). American Board of Anesthesiology website. Accessed July 10, 2013. http://theaba.org/Home/anesthesiology_maintenance
3. Smith HM, Jacob AK, Segura LG, Dilger JA, Torsher LC. Simulation education in anesthesia training: a case report of successful resuscitation of bupivacaine-induced cardiac arrest linked to recent simulation training. Anesth Analg. 2008;106(5):1581-1584.