Last week we my department ran another in-situ sim. It was quite a challenging one from a technical point of view.

• 62 year old BIBA looking unwell
• Paramedics hand over he was found on a park bench, blood around his mouth, GCS 13, HR 110, couldn’t get a BP, patient very unwell/periarrest
• A-E assessment done
• Haemorrhagic shock, evidence of malaena
• Major haemorrhage protocol activated
• First unit of O neg given – patient had anaphylactic reaction to transfusion
• Transfusion ceased, 0.5mg IM adrenaline (1/1000) given
• Transient improvement and then further deterioration (refractory anaphylaxis), further dose IM adrenaline given after 5 minutes
• PEA cardiac arrest
• 3 rounds of ALS protocol, non-shockable side of algorithm
• ROSC
• ITU consultant arrived, patient handed over

Our in-house Project Wingman pilots (Captain Dave Fielding and Captain Alexander Jolly) observed the sim and helped facilitate the debrief when we discussed the non-technical/human factors stuff.

This is the second time we have had a pilot presence for an in-situ sim. They have kindly written (another) fantastic follow up email with key learning points.

Good afternoon Robbie,

Once again a fantastic experience in the A&E sim. I was delighted to have my partner in crime Captain Dave Fielding to observe this simulation – two pairs of eyes paid dividends with the additional level of complexity that today’s event entailed. Dave has been a Captain for over 20 years operating the largest aircraft in our fleet all over the world on his long haul travels (I’m not jealous), so to have his human factors experience in the room was a massive plus.

As we watch more of these simulations, we will try to adopt a salient, more targeted approach to writing our human factors observations. In aviation, we have recently adopted evidence based training (EBT) as a way of self improvement. Through group discussion and debriefing, we are able to highlight our strengths and areas for improvement with reference to the key pillars of our operation – Workload Management, Communication, Situational Awareness and Problem Solving/Decision Making. The plan is to round off our observations with a couple of take home points for next time. As always, your feedback on this method or any areas you want us to focus on specifically is essential for us to fine tune our effectiveness going forward.

Firstly, we would like to say a huge congratulations to the whole team, especially the clinical lead. There was clearly a high level of complexity to the scenario, added factors included Covid-19 procedures and a lack of space due to the normal resus area being occupied.

Workload management & Comms: On initial handover of the patient, a deliberately limited brief was given to the lead. What a brilliant start to announce “I am the lead” and to ask everyone to adhere to Covid-19 procedures, donning full PPE. These calm methodical commands reminded me our procedures when dealing with a loss of cabin pressure. Protecting yourself and colleagues (in our case by donning O2 masks) whilst simultaneously giving yourself a moment to ‘sit on your hands’ and digest the information is key in the early stages. As the sim progressed, it became clear the patient’s vitals were deteriorating, yet pace, tone, and volume of the lead’s communication didn’t alter. Tasks were superbly allocated on a first name basis and no team member appeared to be overloaded. Impressively, the lead significantly reduced ambiguity created by PPE visibility impairment by using an appropriate level of pointing to equipment.

Situational Awareness: Empowering questions to team mates throughout “have I missed anything?” and announcing a timely summary “from the top” kept everyone informed. Having a good review during an emergency is something we use in flight to raise colleagues SA, commonly in the form of PPP (plane, path, people). In aviation, we often use the term NUTA (notice, understand, think ahead) to indicate how far ahead of the aircraft we are mentally projecting. The clinical lead was always operating at the highest level (think ahead) as demonstrated by anticipating cardiac arrest and allocating roles to mitigate this threat.

Problem Solving/Decision Making: As debriefed by Robbie, the quality of problem solving and decision making from a medical perspective was of the highest order. It would be great to see some more pressure testing of the decision “Tell me why I may have the wrong diagnosis?”. As part of the sim debrief, the lead admitted to feeling ‘decision paralysis’ with the amount of information coming in. Knowing how to deal with an overload of information often depends on your environment but in this case, selecting a team member to run the ABCDE for you would be a great way to catch your breath.

Takeaway points

• Distraction management: When the senior consultant arrived, it felt like everything stopped except for the lead’s briefing. Perhaps it would be a good idea to clearly hand over control of monitoring the patient. In the cockpit, we use the term “you have control” before we take our eyes off the instruments.
• Always pressure test your final diagnosis.
• Closed loop communication: There were a few requests for specific volumes of fluids and bloods, no read-back given. The threat could be two-fold; 1) an error if the information was not heard correctly (especially in PPE), and 2) your last chance to error check what you are asking for. Air traffic controllers are highly skilled at listening to our read-back before we carry out their instructions – as the lead, a great way to instil good principles may be to politely ask your colleague to write down and read back your request.

Brilliant job guys

Looking forward to the next one,

Alex & Dave

Do check out the podcast I have recorded with Alex and Dave. We discuss loads of cool human factors stuff in the context of the last sim that Alex attended.

Robbie
@Ponder_Med (twitter)
@pondermed (instagram)