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The Death of Mrs. Smith

Eason, Martin P. MD, JD

Teaching and Learning Moment
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Dr. Eason is assistant professor, Department of Academic Affairs, and director, Center for Experiential Learning, James H. Quillen College of Medicine, East Tennessee State University, Johnson City, Tennessee.

“Please help me, I can’t breathe!” Mrs. Smith had just delivered a healthy baby boy when she told the nurse she couldn’t catch her breath. The residents were called to see her. While they were evaluating her, she became hypotensive, dyspneic, and unresponsive. The residents ordered fluids and oxygen. Despite their frantic efforts at resuscitation, Mrs. Smith’s condition continued to deteriorate and she expired. The residents, noticeably distraught, realized that their failure to recognize and treat her amniotic fluid embolism was partially responsible for her death. Fortunately for them, there would be no proud father to tell that he was now a widower and single parent. Nor would there be discussions with the risk managers or Morbidity and Mortality conferences to attend. No, the only repercussions from their experience would be some ribbing from their fellow residents.

Mrs. Smith was a patient I created in our simulation laboratory to train obstetrical residents to manage complications they may not often see. Following the simulation, we held a debriefing session with the residents to discuss how the management of Mrs. Smith’s condition could have been improved. After the session, we all congratulated ourselves and talked about how much the residents learned. But as I walked back to my office, I couldn’t help but think about the questions continually posed by the critics of simulation who want data and outcomes measures showing that simulators are effective teaching tools. In that moment, I began to wonder whether my time creating the scenario with Mrs. Smith was worth it; or did Mrs. Smith just die in vain?

The next morning I received an urgent call from one of the attending physicians who had participated in the Mrs. Smith simulation. She relayed to me that two hours after the conclusion of our session, an extremely unstable postpartum patient was transferred to our facility. A presumptive diagnosis of amniotic fluid embolism was made, and the obstetrical team treated the patient aggressively with fluids, blood, fresh frozen plasma, inotropes, and ventilatory support. She told me the patient was currently stable, and that she was expected to survive. The attending thanked me for running the scenario the day before and attributed the successful management of the patient to the lessons and discussions learned from the simulation. The patient survived the initial insult and over the next few days had an uneventful recovery from a condition that typically carries a greater than 50% mortality.

After I hung up the phone, I smiled, collected my thoughts, and shared our success with my department. Our work had made a difference. So how do I feel about the validity of medical simulation now? I still know that simulation in medical education remains to be validated with research and studies. But in my heart I know that my efforts are truly worthwhile and that Mrs. Smith did not die in vain. I no longer care what the critics think. I will continue to create more Mrs. Smiths.

This essay is dedicated to Dr. Elizabeth Pryor. Through her commitment to medical education and dedication to her patients, she exemplifies the kind of physician every medical student aspires to be.

Martin P. Eason, MD, JD

Dr. Eason is assistant professor, Department of Academic Affairs, and director, Center for Experiential Learning, James H. Quillen College of Medicine, East Tennessee State University, Johnson City, Tennessee.

© 2005 Association of American Medical Colleges