‘I’d usually get the nurse to do this, but everyone’s gone home for the weekend…’
‘Is this what you were looking for, doctor? (brings the wrong thing)’
‘I called 000 but they were asking me heaps of questions so I hung up, can you call them instead?’
‘I’m new here, I haven’t had my orientation yet…’
‘I’ve only ever given adrenaline in an autoinjecter’
‘Should we leave him here or move him to the treatment room?’
‘I’ve never actually used a defibrillator of this model before’
‘This bung doesn’t seem to fit on this sort of cannula’
‘Do we have a bag of fluids we could give?’
‘Wasn’t the algorithm on the wall somewhere?’
‘I can’t find any amiodarone in the doctor’s bag…’
‘I think I mistook this vial for that one – they look so similar and were in the same box!’
‘Did anyone call the ambulance?’
‘This looks like it’s out of date, should I still use it?’
‘Should I write these vitals down anywhere?’
‘I don’t think we have anything small enough for a baby’
‘I think the oxygen tank might be empty’
‘I don’t know how to make the bed go flat’
‘He’s collapsed in the toilet and we can’t lift him…’
‘The bed won’t fit through that door’
‘Should I take the whole emergency trolley it through that door’
GP simulation is a valuable way of maintaining emergency skills and improving practice systems.
Whether you are an urban GP or working in rural / remote environments, emergencies can and do occur in general practice. It is challenging to try and stay prepared for anything and everything, especially when extremely serious illnesses may occur rarely but can deteriorate rapidly. Simulation is one way that you can maintain these skills and make sure your practice systems are well designed to cope with a broad range of emergencies. In essence, sometimes ‘doing’ is much more effective than ‘talking’.
Simulation is a useful tool for a range of people in your practice. Registrars and trainees often like simulation as it gives them immediate feedback from their supervisors about critical skills and helps with OSCE preparation. Supervisors and practice principals value the lessons learned about the practice systems, and can modify equipment, storage and/or training as a result of the ‘latent safety threats’ that might be found during the scenario. At my practice, we’ve found that the practice staff also appreciate being involved, because they can better understand their roles and responsibilities as well as ‘knowing they are in good hands’ with better awareness of the skills of their nurses and doctors.
There are many ways to do simulation, from ultra-low fidelity to ultra-high tech. Often GP simulation doesn’t need to be high tech to be effective. Unlike in ED, GPs often don’t have sophisticated monitoring systems and advanced equipment anyway, so we need to focus more on clinical reasoning, teamwork and system design. In contrast to the ED environment, there aren’t a lot of apps or tools that are relevant for simulation in General Practice yet. So, here are a few simple ideas that might help you to get started with simulation and build the emergency capabilities of your general practice.
1. Mind Games
Emergencies (real or simulated) can be daunting because they focus on skills that we may rarely use. One way to make it less intimidating is to consider using cognitive warm-ups (mind games) before building up to full-on scenarios. This aims to avoid the ‘throw them in the deep end and see if they sink or swim’ approach that can be a feature of badly-done simulations. It takes practice and experience to be ready for anything!
Warm up exercises might refresh some basic clinical skills, talk through some ‘hypothetical’ situations or revise the relevant roles and responsibilities of practice staff in an emergency. The more often these skills are refreshed the better, but it also means that you can then move on to focus more on the bigger problems such as communication, teamwork and practice systems. After all, the simulation exercises listed below are not really a test of individual knowledge but a trial of the whole practice system.
To get started, here some examples of mini revision topics that might be useful as a cognitive warm up. Perhaps you might choose to discuss a hypothetical emergency situation at the end of your teaching session every so often…
Where should you insert an intraosseous needle?
Proximal tibia: Anteromedial surface, 2-3 cm below the tibial tuberosity
Distal tibia: Proximal to the medial malleolus
Distal femur: Midline, 2-3 cm above the external condyle
In an emergency, if there is no Broselow tape, what is the formula for estimating a child's weight from their age?
Weight = (age + 4) x 2
In an arrest, what are the two shockable arrhythmias?
VT and VF
GCS is too hard to remember, especially if you use it infrequently. AVPU is easier. What does AVPU stand for?
Alert - a patient scores A if they are alert. (GCS 15)
Voice - responding to voice (GCS 9-14)
Pain - only responding to pain (GCS 4-8)
Unresponsive (GCS 3).
If they score a P or a U, you are 'In the PU (poo)' and need to think about protecting the airway!
2. Mini Games
If you have 5-10 spare minutes in your teaching sessions, consider getting your supervisor to try out a brief simulation scenario. Rather than managing a full emergency, this mini-scenario might focus on a particular skill or piece of equipment. It can be a good learning exercise for registrars, but also might highlight ways you could improve the practice organisation to make it easier for all the GPs to manage a similar real situation in future.
There are some skills that registrars and other trainees frequently stumble on, either because it is intrinsically difficult or because we often tend to rely on other staff members (especially practice nurses) to perform them. These skills can make particularly good mini-scenarios for registrars. Here are some ideas to get you and your supervisor started:
Christopher Green, age 18 months, is suddenly wheezy and covered in a widespread urticarial rash after just having had an immunisation. He is 10 kg. Find the appropriate medication, bring it here and show me how you would draw it up (using water substitute instead of real medication).
Adrenaline 1:1000 vial, 0.01 mg/kg, 0.1 mL. It is useful to have a wallchart available for ready reference. If you need to make the scenario easier, make it an adult.
Joe Wright, age 74, is breathless, febrile and coughing. He has no history of lung disease. His SpO2 is 81% on room air. You need to find the oxygen and an appropriate mask, bring it here and turn it on.
This might be difficult if they usually depend on the nurse to set this up, or are only used to wall oxygen from hospital. Find a non-rebreather mask (if available). How long do you think the cylinder oxygen will last for on ‘high flow’? Also ensure the oxygen cylinder is turned off properly at the end, else it may be empty the next time you want to use it!
Joe Biggs, age 12 months, has just choked on a small piece of toy in the waiting room. He is trying to cough but it doesn’t seem to be working. He is going blue. Pretend this pillow is the child. Show me what you would do…
A choking child is one example of a scenario where you don’t really have time to look it up. There is an algorithm.
Bob Bright, age 54, is a type 2 diabetic who has just started on insulin. He is found slumped in the waiting room and his BSL is 1.2. Find the appropriate medication(s), bring them here and show me how you would use them.
Management of hypoglycemia will clearly depend on what you have available. Glucagon is available in the PBS doctor’s bag medications.
Mick West, age 55, came in smoking a cigarette. When asked to put it out, he swore and dropped it in the paper bin. The bin is now alight. What would you do? (if equipment is required, please bring it here and talk through what you would do to use it).
Fire safety should be a part of normal workplace induction, but unless it is revisited this knowledge can fade. Even if you walk past the fire extinguisher every day, it is surprising how easily its location can be forgotten!
Do you have ideas for more scenarios? Use the feedback form…
3. Whole of Practice Games
If you can find 30 min or more, why not ask your supervisor about running a full emergency scenario at your practice? It might involve multiple members of staff and it could be in the practice (i.e. treatment room, consulting room or bathroom…) or out in the carpark. The more complex the scenario is, the closer it can get to reality. But that doesn’t mean that you need fancy mannequins or equipment.
As you involve more people and more ‘moving parts’, it is important that the person running the scenario has developed skills in pre-briefing, psychological safety and debriefing. Here are some guides and scenarios that might help you and your supervisor to get started:
Choose a tab above for info
Choose a scenario and Print scenarios for all participants if needed. Try to minimise the amount of ‘role play’ so that most participants are performing their usual duties, e.g. a nurse is the nurse in the scenario and a registrar is a registrar.
Check equipment is available.
If using expired stock / dummy medications, be very sure to clearly label them as SIMULATION ONLY.
Plan a time: this could be during or out of hours, but you will have to consider the impact on practice workflow.
If your team is new to simulation, consider beginning with a scheduled exercise that the whole practice is aware of. If they are more experienced and up for a challenge, instead of scheduling a specific time you might announce that it will occur ‘sometime that day’ or ‘sometime that week’. Completely unannounced simulation may be overwhelming for an inexperienced practice but highly realistic for teams who are able to cope with this.
Set the location: If you are testing out a scenario that is likely to occur in the treatment room, then try to run the scenario in that room. Otherwise the available equipment and physical space may not resemble reality.
Consider evaluation: You don’t have to use questionnaires, but it may be useful to have a way of collecting feedback from participants so that you know how they felt and what worked well or what could be improved about the process of running the simulation.
On the day, before you start the scenario you can gather the participants for a quick pre-briefing.
Aims: e.g. we’re doing this simulation to build and maintain the practice’s capacity to manage a range of emergency situations.
Procedures: as others in the building are working, we’ll be using the treatment room only. If you need something outside of this room, let me know and I will arrange it or give you a substitute. If you think you need to activate the duress alarm or make a phone call, state loudly that this is what you would do but do not sound the actual alarm or make the call.
Equipment: If you want to use a drug, you need to find it and show me so I can swap it for this water / dummy / expired stock. Please don’t open any ampoules or defibrillator pads as they are expensive, but we want you to practise finding the equipment in case we need to look at better storage / availability for the practice.
Fictional contract: Some parts of this simulation won’t resemble reality (i.e. plastic, imaginary things). We ask that you treat these fictional things as if they were real.
Time out: If at any time you feel overwhelmed or want to stop the scenario for any reason, please say “Time Out”.
Confidentiality: What happens in sim, stays in sim. Any perceived errors or mistakes that happen here will not affect your role outside of this exercise. As a practice we value your participation because it allows us to improve our systems and plan better for the future. Sometimes mistakes are the best learning opportunities of all.
A good simulation scenario can be constructed from most emergency presentations. Sometimes the best topics come from recent experiences you might have had at the practice. This could be an emergency, a near-miss, or a ‘what if’ extension of a real patient.
Here are a few ideas:
Drug overdose / loss of consciousness in the carpark
MVA out the front of the practice
Central crushing chest pain / MI / VF arrest
Syncope in the toilet with massive haematemesis
Mirena insertion complicated by cervical shock
Anaphylaxis in a child after an immunisation
An angry drug seeker at reception
Hypoglycemia in a diabetic
Acute severe asthma
Infective exacerbation of COPD
Seizure in a known epileptic
Psychological safety is absolutely critical for simulations to work. If participants don’t feel safe to make mistakes, they won’t engage or perform at their usual level and the scenario will not resemble reality. Creating a safe space depends on having respect and a positive regard for the participants and their abilities, approaching them on a level playing field (i.e. we all make mistakes), building a team approach, and having clear expectations for how the exercise will run (see pre-briefing).
“This is an opportunity to practice and get better at really difficult skills. It is not about testing, assessing or embarrassing someone. It is about the practice as a whole making it easier to manage emergency situations. Everybody makes mistakes and these are great opportunities to learn from.”
Sometimes the unreal aspects of simulation can be made into an advantage. Here are some examples of ways that your supervisor might change the simulation if needed:
Pause: If you pause the scenario, you might have time to discuss something that was missed / done incorrectly / ambiguous and brainstorm possible solutions. This can bring a scenario back on track.
Rewind: Following timely feedback, you might be able to embed skills better if participants can then go back to that point in the scenario immediately and re-do their actions.
Substitutes: if there is someone on the team who is stuck, or someone who is dominating, consider swapping their roles around.
Lifelines: if the team is floundering, throw in something that might bring the scenario back on track.
Whisper in the ear – ‘could he be a diabetic?’
‘Look what I found in my pocket! A glucometer!’
The ambulance is here, I’m the paramedic – can someone tell me what’s happening?
I’m his wife, I think he might be having a hypo!
Confederates: Some people in the scenario might be deliberately instructed to be helpful, incompetent or disruptive. At a more sophisticated level, these confederates might take cues from the facilitator about if / when to play these roles. For example, a disruptive or incompetent person might make the scenario more difficult if the participants are coping well – but this might be overwhelming and unnecessary if there are already too many challenges in the basic scenario.
Most of these modifications are designed to enable participants to build a positive outlook towards practice emergencies and deteriorating patients. Mistakes are a valuable part of simulation as learning points, but achieving a successful resolution to the scenario is also important. Overwhelming or impossibly difficult scenarios are unnecessary and potentially damaging. We would like registrars and practice staff to have the confidence that there is a lot that can be done to reverse emergency situations, rather than the false expectations that ‘all patients like this crash eventually’ or ‘no matter what I do, I know you’ll make them arrest anyway’.
Make sure your supervisor allows enough time after the scenario to debrief the participants. It is often said that this is where the learning actually happens. Good debriefing is a challenging skill and you do need to be confident in being able to facilitate this before placing participants in stressful situations without the ability to manage the resulting emotions / conflicts / challenges and potential for distress.
Debriefing questions might include:
Objective descriptions: What did you do / see / hear?
Clarifying: I couldn’t see if you did X… It looked like it was getting confusing then, was it?
Exploring: ‘When do you tend to call for help?’ What were you thinking when you did X? What else could you have done instead?
Plus/Delta: Identify what worked well / what you would do again? What would you do differently?