SimLIFE-EM Challenge: Add to the conversation

SimLIFE-EM Challenge: Add to the conversation

2016-11-07T12:40:10+00:00

simLIFE-EM

Debriefings in medical simulation are meant to be the bow on top of the gift that is medical simulation. It is the ultimate delicious dessert, served after a grueling dinner course. All analogies aside, debriefings are meant to drive home the teaching points, to gain a deeper understanding of medical resuscitation as a group, and create mental frameworks of the approach to various patients. But this is often easier described than actually done. We here at ALiEM paired with Dr. Henry Curtis to come up with a creative way of developing debriefing skills and gain deeper understanding of mental frameworks.

SimLIFE-EM Case

We partnered with Dr. Henry Curtis and students from the Academy of Art University in San Francisco to film a resuscitation of a critically ill patient. We purposefully did not include any discussion or insight into the thought process of the doctor in the case. You are an observer of this simulated case.

Your challenge:

  1. Educators and Clinicians: Using the comment section below, YOU be the debriefer/ facilitator. Write a debriefing session that you would have with the learner. You pick the learner level. You pick the learning points.
  2. Learner: Using the comment section below, write out any question that may have come up while viewing the video or any area that you would want to learn more about.

We will explore the themes and common questions that come up from you.

End Credits

Thank you to our volunteer actors and crew! It indeed took a village.

  • Nikita Joshi, MD – lead physician
  • Dina Wallin, MD – patient
  • Amber Quelvog, RN – nurse
  • Max Ritzenberg, MD – paramedic
  • David Duong, MD – respiratory  therapist
  • Henry Curtis, MD – director, writer
  • Jordi Funtanet – director of photography
  • David Tw Yu – assistant director
  • Jingru Sun – editor
  • Albee Zhang – sound recordist
  • Yi Yu – production assistant
  • Eating Liang – gaffer
  • Jassy Jiang – book operator

simLIFE-EM Cast and Crew


Nikita Joshi, MD

Nikita Joshi, MD

ALiEM Chief People Officer and Associate Editor
Clinical Instructor
Department of Emergency Medicine
Stanford University
  • Charlotte Alexander

    Learner (med student): it looked like we were not going to get a lot of history from the patient and therefore would heavily rely on examination and investigations. I would want to go through why they chose those investigations and how the results would change management.

    • Hi Charlotte: Great observation. Many times, undifferentiated patients arrive in the ED with very little history available. You are presented with a young woman with vomiting, altered mental status, and tachycardia (HR 120-130). The differential diagnosis is quite broad. What’s top on your list, ordered by likelihood? What’s top on your list, ordered by life threatening conditions? This then drives the diagnostic testing.

    • Great point Charlotte. Often times this is why it is so important to talk through your differentials and your thought process in order to be able to debate the pros/cons of each investigation and how those results would change management. Especially during simulations, it is important for the learner to verbalize everything. Thanks for your great comment!

  • Victoria Brazil

    Great stuff
    My main questions s are – how did you get such great performances from Dr Joshi and your SP……!

    seriously tho..

    The main issue here for a debriefer is that there is potentially so much material for discussion
    – handover, initial assessment, expression of empathy (or lack thereof), approach to the undifferentiated pt, resources required for ETT/ calling for help, use of checklist for ETT, readback communication with nurses, referral skills ( ICU), breaking bad news (family), dealing with unfamiliar presentations – salicylate OD –
    – and yet we can realistically only pick about 3 of these.
    Choice will depend on what you set up this scenario to be about ( edu geek alert – start with the LOs in mind – don’t expect or hope they will just ‘pop up ‘ in the scenario)

    but in the absence of that guidance i might take the approach of……..

    NB (assuming dr is main target of debriefing.. I would take different approach if it was the team)

    1. How was that?

    2. Lets just run through facts of the case – distressed unwell pt, salicylate OD diagnosed, required I&V and referral ICU. Was that clear?

    3. This was an undifferentiated unwell pt. I saw you started with primary and secondary survey, and i liked the systematic nature of that approach. Tell us how you decided on that approach.
    (and follow up with discussion regarding clinicial reasoning and DDx)

    4. I think it would be good to talk about the patient experience. That same systematic approach did feel very ‘clinical’ to me and i would be concerned that it might not be reassuring to a very distressed patient. What do you think?

    5. The patient dropped her GCS and i think you decided correctly that intubation was indicated. There was only you , a nurse and RT present. I’d be worried that was inadequate assistance for sick pt. What do you think?
    ( and follow up with discussion re resources, call for help, checklist etc)

    6. Are there other issues the case raised for you?

    7. Summarise

    • Hi Victoria!

      Thanks for your step by step thought process of how you would go about designing a debriefing for this complicated case. You are right, the first thing is that this case provides a gold mine’s worth of discussion points, but what to discuss??? You only have so much time, and so it has to go back to the objectives.

      I like that you select the doctor to be the one to get the debriefing, because your debriefing would be focused a little differently if you were to focus upon the nurse – always know who your learners are before designing a debriefing.

      All of your points are open ended questions that can jump start discussions, not pointed questions / guess what I am thinking questions / or gotcha questions – all of which can kill a good discussion and turn off a learner during a debriefing.

      But at the same time, you do add areas where you as the evaluator might be concerned and what to address in the learner to change for future management – such as being worried there was not enough assistance during intubation.

      Thank you so much for your valuable insight!!!

      • Shannon McNamara

        Victoria makes some fantastic points about debriefing this case – there are so many areas one could cover, and realistically we have to focus in. Ultimately, this will depend on how the learner reacts to the case. She may have particular areas of perceived weakness that it would be helpful to focus on, or the debriefer may need to prioritize the discussion.

        To start: Summarize the case for us. How did you think it went? What do you think you did well? What would you like to improve on? (This may help focus the direction on areas of perceived deficits.)

        In this case, the main areas of medical management that drew me for debrief were:

        1. Differential and stabilization of the sick undifferentiated patient.
        What was on your initial differential? (write it down)
        What interventions did you immediately start based on the patients differential and complaints? (Can match the interventions to the differential, note if any items on differential require early actions that weren’t done).

        I would point out to the learner that this clinical picture would also be typical for DKA, and encourage adding a POC glucose in AMS for early diagnosis.

        2. Intubation: What is on your checklist as you prepare for intubation? Take me through it step by step and write down your checklist. Self-reflect: what did you do well in this intubation? What could you improve on?

        In this case, I would focus on confirmation of ETT placement. I did not notice any clinical evaluation of tube placement prior to CXR (no capnography, listening for breath sounds, or confirming O2 Saturation post-intubation). It will be important to try to expose the learner’s frames here to find out why she didn’t confirm the tube until CXR.

        Overall, the learner did a nice job with the management of salicylate toxicity. She was very clear and detail oriented in communication with the nurse and RT. Even though she appeared very confident about the treatment and diagnosis, I would review the pathophysiology of the toxidrome by having her explain her thought process about it. Sometimes learners will get all the “right answers” without knowing all the background.

        Thanks to Nikita and the ALiEM team for your great work on the video – generates some great discussion points!

  • Amazing video and what a great concept to use as a knowledge share stimulus. I really like the opportunity for considering a scenario that I haven’t written myself. This is very good practice for when a scenario de-rails. Having expected learning outcomes is no doubt very important, but sometimes we just need to let them go. I completely agree with all of Dr Brazil’s points and as such won’t reiterate.

    My fictional context for this simulation:
    Education Program – Medical Registrar Training program
    Participants – Multi-dis team
    Curriculum context – Managing the critically ill pt with Altered Mental Status scaffolded from basic rapid assessment sims in week one – increasing complexity throughout term, this scenario culminates with physical assessment, time critical management and RSI
    Flipped classroom approach – Pre reading/podcasts #FOAMed and Core content on common toxidromes
    My primary learning points:
    – Barriers to effective assessment in this context (COMMUNICATION)
    – Time critical diagnosis
    – RSI in the deteriorating patient with suspected toxidrome.

    Although I prefer the advocacy/inquiry style Victoria has scripted, I think it’s pertinent to consider another approach for a scenario that has so many possible outcomes and essentially only two participants (maybe three but I would almost see the RT as a confederate here). So here is another approach I may use:

    Good pre-brief including seeking the permission of the trainees to have an open and honest discussion post scenario (this really works well).
    1. Gather participants allow venting – “wow that was hard” etc and just listen.
    2. Like Victoria, recount the known aspects of the case – I would get the Medical Officer to lead this as it will give me insight into their perceived priorities and clinical reasoning.
    3. Dissect Video into three parts/headings – Initial assessment, formation of DDx, Decision to intubate/ RSI process. Playback marked portions of the video as stimuli and use plus/delta approach (what went well/what could we change). Short sharp process (almost gut reactions to the video). List these points under the headings.
    4. Get the participants to agree on one critical element from each heading to discuss a little further – this will allow for different professions to explore the common ground areas. Also hold a potential wildcard, which is a point that I may want to explore that the participants didn’t raise.
    5. Wrap up with summary of the essential points raised, assess body language of the group and ask if anyone has any further questions.

    I have to admit that my go to approach is much more like that outlined by Victoria. I just thought it opportune to offer a different approach that I have enjoyed using with more advanced trainees to good effect (depends if they are hanging off your every word or just want to drill down and get on with the next sim.

    Thanks so much for an awesome sharing circle Nikita. Look forward to hopefully meeting in person next year in Chicago!

  • Eve Purdy

    Learner (final year med student)- questions from the case

    1. Is that your sim lab or is that an in situ lab? If sim lab it’s legit!!

    2. How do you think the speed at which we get labs back in sim affects the “reality” of the situation. To me in sim, everything seems like fast forward and I wonder how that affects cognitive processes.

    3. Why did you have the sister step out?

    4.Why an abg after 10 minutes on the ventilator? Why not an vbg?

    5. It seems like your sim team in this video were made up of people in their actual roles. Our sim sessions are often run with all residents (i.e. not inter professional). How often/ how do you do organize inter professional sim at your school?

    6.What are your pro tips for students starting out in sim?

    Thanks for an awesome and interesting case.

  • I find it amazing that you can take this discussion in a zillion different ways, based on your interests and the knowledge level of your learners. Interestingly, when Nikita et al piloted this video in a flipped classroom approach with preclinical medical students, preclinical pharmacy students, and a broad range of nursing students, they wanted to discuss the following:

    1. What things can cause ASA toxicity? Other meds? Classic presentation? Pathophysiology?

    2. Why the rapid sequence induction medications and the need for sedation with paralytics?

    3. What ARE the roles of the different providers in this patient’s care?

    Love that we have an international group of simulation experts to share their personal styles and approaches with this video.

    Some behind-the-scenes photos from our shoot, which was done in the resuscitation bay, courtesy of my hospital ED (San Francisco General Hospital).