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Curriculum and Cases for Pain Medicine Crisis Resource Management Education

Brenner, Gary J. MD, PhD*†‡; Nemark, Jordan L. MD*; Raemer, Daniel PhD*†‡


In the article that appeared on page 107 in the January 2013 issue of volume 116 of Anesthesia & Analgesia , the second author’s last name was incorrect in the authors’ byline. The correct byline should be:

Gary J. Brenner, Jordan L. Newmark, and Daniel Raemer

Anesthesia & Analgesia. 116(2):442, February 2013.

doi: 10.1213/ANE.0b013e31826f0ae0
Technology, Computing, and Simulation: Special Article

Medical crises that may occur in the setting of a pain medicine service are rare events that require skillful action and teamwork to ensure safe patient outcome. A simulated environment is an ideal venue for both acquisition and reinforcement of this knowledge and skill set. Here, we present an educational curriculum in pain medicine crisis resource management for both pain medicine fellows and attending physicians as well as the results of a successful pilot program.

Published ahead of print December 7, 2012 Supplemental Digital Content is available in the text.

From the *Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston; Center for Medical Simulation, and Harvard Medical School, Cambridge, Massachusetts.

Accepted for publication August 3, 2012.

Published ahead of print December 7, 2012

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (

The authors declare no conflicts of interest.

Reprints will not be available from the authors.

Address correspondence to Gary J. Brenner, MD, PhD, Massachusetts General Hospital Center for Pain Medicine, WAC 330, 15 Parkman St., Boston, MA 02114. Address e-mail to

Pain medicine services, both hospital- and freestanding clinic–based, provide diagnosis and treatment for patients with a wide range of pain complaints. These include those associated with perioperative pain control, cancer-related pain, and chronic pain due to a variety of underlying causes. Providers of these services come from multiple primary specialties, including anesthesiology, neurology, physiatry, internal and oncologic medicine, rheumatology, surgery, and nursing. The treatment of pain, chronic and cancer related, often requires a multidisciplinary approach, involving pharmacologic management, invasive procedures, psychological or psychiatric evaluation, and physical therapy. Although serious adverse treatment-related events rarely occur, the potential for acute life-threatening complications is inherent to the medications and procedures that are routinely used in pain medicine. In addition, the practice of pain medicine regularly generates ethical and interpersonal challenges for health care providers.

There is a movement toward the use of medical simulation in education and certification throughout health care because of growing evidence for its effectiveness.1 The Accreditation Council for Graduate Medical Education now requires anesthesiology residents to participate in at least 1 simulated clinical experience in each year of their training.2 The American Board of Anesthesiologists now requires a simulation component for its Maintenance of Certification in Anesthesiology3 and is considering a similar requirement for Maintenance of Certification in Anesthesiology in Pain Medicine. A simulation curriculum and an associated pilot course are necessary initial steps toward implementing any such educational and certification requirements in pain medicine.

The management of critical events requires practiced skillful action and teamwork. The wide range of training backgrounds and experience of pain practitioners at any acute medical complication adds to this general need for practiced teamwork. Courses for learning to manage critical events have been successfully designed and implemented in various health care settings, and we wanted to apply this experience to pain medicine practice.4–10 Therefore, we initially designed and implemented curriculum and simulation cases that would offer pain medicine trainees and experienced providers with an educational program to learn and practice dealing with acute situations in various pain medicine settings. We selected a hybrid simulation model (using computer-controlled mannequins and standardized health care providers and standardized patients) because of our extensive experience with this technique.11 More recently, we have added ethical and interpersonal communication issues to our resource management education program.

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While recognizing that there are many important subjects for this simulation curriculum, we decided to focus on 3 main topics considered from departmental quality data, institutional malpractice data, and experience of the course developers to be of particularly high impact and relevance: (1) managing an acute crisis, (2) ethical decision making during an acute event, and (3) dealing with medical errors. We derived a set of 3 learning objectives for the program.

By the end of the simulation-based educational experience, the participant should be able to do the following:

  1. use principles of crisis resource management and institute appropriate life support measures to deal with an acute medical complication of pain medicine treatment;
  2. implement a team process for ethical decision making in an acute pain medicine–related situation;
  3. understand the principles of pain medicine–related medical error evolution, prevention, and treatment and be able to appropriately disclose and apologize to patients and their families for medical errors when they occur.

Because of the rare and essentially unpredictable nature of critical events in pain medicine practice, we decided that the educational program should ideally include all potentially involved members of the responding care team. To be able to cover the topics indicated in the learning objectives, a 1-day intensive experience model was chosen. On the basis of our prior experience with simulation courses for anesthesiologists, operating room teams, and labor and delivery teams, a course-day agenda was developed to include the elements shown in Figure 1. The introduction and familiarization included personal introductions and trust building, establishing psychological safety, familiarization with the simulation environment, establishment of a fiction contract,12 and presentation of the learning objectives. All of the scenarios focused on the principles of Crisis Resource Management,13 while scenario 2 added a focus on ethical decision making and scenario 3 added a focus on managing medical errors. All scenarios were debriefed using a “good judgement technique.”14

Figure 1

Figure 1

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Case 1: Responding to Catastrophic Decompensation During Stellate Ganglion Block

A middle-aged patient receives a local anesthetic block of the stellate ganglia performed by a junior trainee (actor) under the supervision of the course participant. The trainee impulsively injects the medication before instruction from the course participant. There are 4 possible complications that can be simulated: a vasovagal reaction (bradycardia and cardiovascular collapse), an intravascular injection of local anesthetic (seizure or cardiac dysrhythmias), a pneumothorax (hypotension and respiratory difficulty) caused by misplacement of the needle into the nearby pleural space, and an intrathecal injection in the nearby spinal canal resulting in high spinal anesthesia (respiratory arrest).15 The participant will need to manage the acute physiologic derangements depending on the complication depicted.

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Case 2: Resuscitating Anaphylaxis in the Pain Clinic

A middle-aged paraplegic inpatient presents to the pain clinic requiring an epidural steroid injection for severe back pain. During the procedure, the patient, while in the prone position, develops an anaphylactic reaction to an antibiotic that was previously started. The simulation can proceed to mild or severe consequences of anaphylaxis.16

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Case 3: Respiratory Support for Inadvertent Pneumothorax

A young patient receives an interscalene nerve block for an operative shoulder procedure in a monitored regional block setting while complaining of severe pain from an infiltrated IV. The surgery had been canceled because of acute illness of the surgeon. The patient develops symptoms of occult pneumothorax caused by pleural interruption during the interscalene nerve block.17 The simulation can proceed to mild or severe respiratory distress and respiratory collapse.

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Case 4: Ethical Decisions During a Resuscitation Secondary to an Iatrogenic Overdose of Pain Medication

A geriatric patient with a terminal disease in the care of the pain service has recently undergone magnetic resonance imaging (MRI). The patient has an active “do not resuscitate/do not intubate” order. Because of an infusion pump mixup during reconnection after the MRI, the patient experiences an acute overdose of pain medication. The course participants are called to assess and resuscitate this patient in the recovery area of the MRI unit. Actors in the simulation assist the pain service when the team realizes that the patient has an active do not resuscitate order; however, the patient’s complication is likely iatrogenic. The participants must have an ethical discussion during this acute crisis to decide whether to continue, stop, or gather more information.18,19

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Case 5: Medication Error During a Pain Procedure

A cognitively impaired child accompanied by an anxious parent is in the pain clinic for a diagnostic local anesthetic ilioinguinal block. The participant is asked to do the procedure with the assistance of a nurse (actor). After a skin wheal of local anesthetic, the nurse provides an open medication ampule for the participant to draw up in a sterile manner. The injection evokes a strong pain response, well beyond what would be expected. The nurse then discloses to the physician participant that the empty ampule appears to be absolute alcohol rather than the appropriate local anesthetic.20,21 The participant must manage this error medically and disclose and apologize to the family in an ethical manner.

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We ran 15 pilot courses between January 2004 and December 2010 using the curriculum described earlier for fellows and attending physician staff of the Massachusetts General Hospital Pain Service. Pain medicine faculty (anesthesiologists, neurologists, emergency medicine, and physiatrists) participated in 5 of the courses. The pain medicine faculty attended as part of their hospital credentialing requirements. As part of an agreement with the institutional malpractice insurance organization, the faculty’s department received an insurance premium reduction (10%–25% depending on the year). Pain medicine fellows and anesthesia residents participated in 8 of the courses as part of their clinical training requirements. On 2 occasions, a deliberate mixture of attending faculty and trainees as well as pain medicine nurses and technicians participated. A total of 68 physicians and 4 nonphysicians participated in ≥1 of these courses between 2004 and 2010.

Satisfaction with the course was measured with a simple course evaluation survey distributed to the physician participants at the end of each training session. The 2 items on the questionnaire were an overall course rating and the course repetition interval that participants thought should be offered. Differences between attending physician and trainee physician responses were measured using the Fisher exact test for proportions, with P < 0.05 deemed significant.

Five scenarios (see Supplementary Digital Content 1, were developed for use in this pain medicine curriculum. The criteria for the scenario content included the following: a high likelihood of addressing one or more of the course learning objectives, a representation of patients likely to be seen on a pain service, settings plausibly encountered by the pain clinician, and content that would be challenging but not beyond the scope of any course participant. Three of the 5 cases were selected for each of these pilot courses based on covering the learning objectives without redundancy and whether any course participants had seen the cases in prior simulation experiences. Common objectives of crisis resource management and ethical decision making were inherent in all of the cases.

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Most of the 15 pilot courses ran smoothly and according to the agenda. In 2 cases, the debriefings went on longer than anticipated, and only 2 case scenarios were conducted. Pain medicine physician course evaluation data are shown in Figure 2. Ratings for the attending physicians and pain medicine fellows were not different.

Figure 2

Figure 2

A recommended repetition interval for the pain medicine physicians is shown in Figure 3. The frequency of intervals is different for attending physicians and trainees, with the trainees suggesting that they repeat a similar course in a shorter interval (6 months) than do the attending physicians (between 1 and 2 years).

Figure 3

Figure 3

Noticeably richer discussions during the case debriefings occurred during the 2 interprofessional courses that included attending and trainee physicians as well as the nursing staff. Feedback during and after the courses by the participants and the impression of the instructors suggest that the interprofessional course model is preferable.

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We have presented a curriculum and cases suitable for pain medicine crisis management education of attending physicians, trainee physicians, and mixed groups composed of attending physicians, pain medicine fellows, nurses, and patient care technicians. The cases presented were both challenging and engaging for most of the pain practitioners in our cohort. Other procedures such as regional blocks of many varieties, patient and consultant communication issues, complications from coexisting medical conditions, and diagnostic dilemmas would be suitable for future cases. The primary criterion for inclusion of the curriculum is relevance to the particular pain practitioners, direct connection to the learning objectives, and challenge.

As course developers, we were concerned that anxiety about performing in front of peers with different backgrounds and experience would cause some participants to not fully engage in the educational process. Although some participants articulated anxiety initially, this did not seem to prevent anyone from benefiting from the experience. Participants typically helped each other and used their different backgrounds synergistically. By the end of the exercise, all participants reported being relaxed and appreciative of the training.

This study is limited to the development and implementation of a hybrid (mannequin and standardized health care provider) simulation course for pain medicine clinicians. No attempt was made to assess the learning of the participants beyond their willing participation in the course, satisfaction scores, and verbal summary of their perceived learning at the end of each session. Further study is needed to assess the learning, transfer of training to the real environment, comparison of learning with different educational techniques, and retention intervals.

The positive response of attendees to our pilot courses over a substantial period, regardless of the mix of participants, suggests that the curriculum and cases are appropriately matched for this particular target group. The trainees’ recommendation for a more frequent repetition interval (i.e., <1 year) compared with the attending physicians may relate to a greater openness to the value of this type of educational experience on the part of the trainees. The participants’ feedback suggests a more frequent repetition interval and the use of mixed groups, whenever possible. Lastly, allowing for team building via an interdisciplinary approach appears to result in the most positive experience for participants.

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Name: Gary J. Brenner, MD, PhD.

Contribution: This author helped develop and implement the curriculum with Dr. Raemer and helped prepare the manuscript.

Attestation: Gary J. Brenner approved the final manuscript.

Name: Jordan L. Nemark, MD.

Contribution: This author helped develop the curriculum.

Attestation: Jordan L. Nemark approved the final manuscript.

Name: Daniel Raemer, PhD.

Contribution: This author helped develop and implement the curriculum with Dr. Brenner and helped prepare the manuscript.

Attestation: Daniel Raemer approved the final manuscript.

This manuscript was handled by: Dwayne R. Westenskow, PhD.

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