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Case Report/Simulation Scenario

From Beginning to End in Anesthesia: A 3-Part Series on Obtaining Informed Consent, Handling a Difficult Airway, and Delivering Bad News

Spofford, Christina M. MD, PhD; Szeluga, Debra J. MD, PhD

Author Information
Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare: August 2013 - Volume 8 - Issue 4 - p 262-271
doi: 10.1097/SIH.0b013e3182888d1d
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CASE INFORMATION

Demographics

Case Title: From Beginning to End in Anesthesia: A 3-Part Series on Obtaining Informed Consent, Handling a Difficult Airway, and Delivering Bad News

Simulation developer(s): Christina M. Spofford, MD, PhD, and Debra J. Szeluga, MD, PhD.

Date of Development: 2009–2012

Target Audience: Anesthesia trainees and student nurse anesthetists in their first months of clinical anesthesia.

CURRICULAR INFORMATION

Educational Rationale

Anesthesiologists and nurse anesthetists routinely meet patients within minutes of starting an anesthetic. In most hospital systems, there is limited time to develop a professional rapport, ask questions, address concerns, and obtain informed consent before going into the operating room. Likewise, if complications arise perioperatively, it can be emotionally difficult to address these with the family owing to the limited interactions and lack of relationship with family members. There is both an art and science to developing the skills necessary for delivering information to family members, as well as delivering bad news. With practice, this becomes easier for the professional. Airway management is the hallmark of anesthesia practice, and understanding the factors that predict difficult airway, the signs and symptoms of inadequate airway patency, and tools that can be used to correct the problem are of unparalleled importance.1 This scenario teaches novice trainees how to use jaw repositioning and airway devices to manage an unanticipated difficult mask airway after the induction of anesthesia. This 3-part scenario is designed to teach the key elements of preoperative workup, including obtaining informed consent, handling a difficult mask airway using a mannequin, and a structured approach to the disclosure of bad news.

The Goals of This Scenario Are the Following:

  1. Practice communication skills with live actors,
  2. Perform a preoperative evaluation,
  3. Develop an anesthetic plan and obtain informed consent for anesthesia,
  4. Recognize and treat upper airway obstruction,
  5. Refine leadership skills and obtain expert consultation,
  6. Reflect on strengths and weaknesses in performance, and
  7. Formulate specific professional self-improvement goals.

Learning Objectives

Through this 3-part scenario and debriefing, learners will satisfy all the Accreditation Council for Graduate Medical Education general competencies. At the conclusion of the scenario, learners will meet the general competencies in the following ways:

  1. Medical knowledge. Describe key elements of a preoperative evaluation. Formulate an anesthesia plan, discuss risks and benefits of general endotracheal anesthesia, and obtain informed consent from a standardized patient. Read a chest x-ray.
  2. Patient care. Demonstrate how to manipulate the head and neck to open upper airway obstruction, place oral and/or nasal airways, and intubate using direct laryngoscopy. Learners will consult and integrate care teams for a patient who has experienced dental damage.
  3. Interpersonal and communications skills. Communicate concerns and action plans with other members of the health care team. Learners will speak with patients, and with patient families. They will recognize how nuances in body mannerisms, tone, and word choice impact the experience of the patient and/or their family.
  4. Practice-based learning and improvement. Self-reflect about their performance during each phase of the simulation. Through discussion with faculty, learners will set goals for future improvement in performance.
  5. Systems-based practice. Obtain assistance from consultants during a medical crisis as well as document and report adverse events.
  6. Professionalism. Show compassion, empathy, and integrity when responding to a patient and/or family. Demonstrate ethical principles in the disclosure of adverse event information. Learners will also demonstrate respect and collegiality toward other health care providers and consultants.

Faculty Guide to Debriefing

Debriefing questions should be tailored to the performance of the trainee. Not all questions will be relevant, and there may not be time to explore each topic. Ideally, using assessment instruments and observations, conversations between faculty, standardized patients, and trainees should be bidirectional, allowing the trainee to recall and explore the various key points of their performance. We have grouped debriefing questions into 3 main areas as follows: factual knowledge, communication styles, and trainee feelings during the process.

PART A: INFORMED CONSENT

In this part of the scenario, trainees will have the opportunity to interact with a live standardized patient. This part of the scenario is used to assess how well the trainee (1) reviews and confirms the pertinent history and physical findings available, (2) develops a plan for anesthesia, and (3) obtains informed consent. Depending on the experience and educational level of the trainee, certain elements will be more or less difficult. Effective patient-anesthetist communication has been shown to reduce the length of stay and cost of care as well as to reduce postoperative pain and anxiety levels.2,3

Factual Knowledge

  • 1. For this relatively healthy patient, which elements of the provided history and physical examination were important for you to review? Why?

Trainees early in their training can have difficulty separating out important parts of the history and physical examination from those of little consequence to perioperative anesthesia care. This question is helpful to explore how the trainee approaches the information they are given, which elements are confirmed, and which are not necessary to review.

  • 2. What are the crucial elements of physical examination before anesthetizing a patient? Why are these important?

The 3 key elements of physical examination before anesthetizing a patient include airway, pulmonary, and cardiac examinations. These 3 key examinations provide relevant information that impacts further testing (electrocardiogram, chest x-ray, etc) and are necessary when formulating anesthesia plans. Airway examinations should include an assessment of the Mallampati score, degree of flexion of the neck, determination of thyromental distance, ability to subluxate the mandible, mouth opening, as well as examination of the oral cavity and dentition. Pulmonary examination should include respiratory rate, SpO2, chest wall excursion, use of accessory muscles, and auscultation of the chest. Cardiac examination should include blood pressure, heart rate, auscultation of the chest and carotid arteries, as well as examination of peripheral pulses. Further examination elements can be considered based on history or primary examination findings.4

  • 3. What are the key elements of informed consent?

Conceptually, informed consent is based on the fundamental principles of autonomy, self-determination, and disclosure. The Centers for Medicare and Medicaid Services (CMS) guides our practice to ensure that competent patients or their representatives are given the information and disclosures needed to make an informed decision about whether to consent to a procedure or intervention. To obtain informed consent, communication between patient and anesthesia provider must take place. The underlying goal is to provide information so that the patient understands the problem, the major and minor risks, the benefits and alternatives to the proposed plan, and the consequence of refusing care. The discussion should allow for questions to be raised and answered. Documentation of the discussion should be placed into the medical record.5

  • 4. What are the major and minor risks of general anesthesia in a healthy patient?

Although there are long lists of complications that can occur under general endotracheal anesthesia, the most common ones are listed here.

Major risks of general anesthesia include possible awareness, aspiration, organ failure, inability to maintain oxygenation, drug reactions, myocardial infarction, stroke, coma, and death.

Minor risks of general anesthesia include damage to the mouth or teeth, sore throat, nausea and vomiting, hoarseness, headache, and drowsiness.

Communication Styles

  • 5. What kinds of strategies did you use to create a relaxed and open atmosphere for your preoperative discussion with this patient?

Some commonly used strategies include sitting down, maintaining eye contact, avoiding writing or reading computer documents while talking to the patient, using a quiet and pleasant tone of voice, closing the door for privacy, smiling, and having a warm and friendly demeanor.6

  • 6. Reflecting on your body posture or mannerisms, how do you think this impacted the patient?

Increasing trainee awareness on how their nonverbal communication impacts patients is of unparalleled importance and rarely taught in training programs. The key elements of nonverbal communication consist of visual communication (facial expression, eye contact, posture, gestures) tactile communication (handshakes), intonation, and use of personal distance (1.5–4 ft, which conveys a sense of closeness without encroaching on intimate distance).6

Trainee Feelings

  • 7. How comfortable were you with the interaction?

In this segment, dialogue is centered on exploring how the interaction felt for the trainee, during which segments they felt at ease and competent, and segments that were harder for them.

PART B: DIFFICULT AIRWAY

In this part of the scenario, the trainee will induce general anesthesia for a patient who is healthy without a difficult airway (Table 1). The purpose of part B is to teach trainees how to manipulate the upper airway to allow for ventilation and to develop critical problem-solving strategies after chipping a tooth while intubating. This part of the simulation also teaches systems-based practice approaches to consultation, adverse event reporting, and payment for dental restoration.

TABLE 1
TABLE 1:
Flow Sheet of Simulation Instructions
FIGURE 1
FIGURE 1:
Normal chest x-ray result.
FIGURE 1
FIGURE 1:
Abnormal chest x-ray result with tooth visible in the right lung.

Factual Knowledge

  • 8. What are the clinical signs you observe in a patient who is difficult to mask ventilate after induction of anesthesia?

Common signs of inadequate patency of the airway during mask ventilation include leaking of air around the mask, peak pressures greater than 25 cm of water to inflate the lungs, desaturation, loss of end-tidal CO2, cyanosis, lack of fog in the mask, lack of chest rise, and inaudible breath sounds.7

  • 9. What are some of the tools and maneuvers you can use to help open an upper airway obstruction after the induction of anesthesia?

Common maneuvers to open airway obstruction include repositioning the head, flexing the neck, jaw thrust, pulling the tongue forward, two-handed mask, placement of an oral airway, and placement of a nasal airway.7

  • 10. What are the clinical signs you observe in a patient who is difficult to intubate after induction of anesthesia?

Patients who are difficult to intubate after induction can display the following signs: increased tongue size, poor attainment of the sniffing position, Cormach-Lehane grade 3 or 4 view, and excessive secretions, blood, or vomitus in the mouth.

  • 11. After you have caused dental damage, what is the appropriate course of care in the operating room? In the recovery room? On the ward?

In the operating room, one needs to look for the tooth. It might be in the mouth, on the laryngoscope blade, or near the patient’s head. Exercise caution if placing fingers inside the mouth in patients without adequate neuromuscular block. Direct laryngoscopy should be avoided because further damage may ensue. A better choice is a video-assisted or fiberoptic approach. If the tooth is not found, the surgical team should be notified, and a portable chest x-ray study should be ordered. If the tooth is visualized in the airway, a consultation to a colleague with tools and expertise at retrieval should commence. Oftentimes, trainees will state that they would call for a fiberoptic scope to retrieve the fragment themselves. On further discussion at the bedside, it is revealed that most anesthesia scopes are not capable of extracting foreign bodies.

In the post-anesthesia care unit, when the patient is awake, they should be told about the incident. A dental consult (if appropriate at your institution) should be made, and reassurance should be given to the patient. The extent of damage needs documentation.

On the ward, patients should be seen daily until discharged from the hospital, and continual communication about the resolution of the dental care and postoperative sequelae should be discussed.

  • 12. What are some possible sequelae of having a tooth lodge in the lower respiratory tract?

A broken tooth is a sharp, dirty, foreign body and poses several risks to the patient including infection and abscess, laceration, obstruction, and difficulty with oxygenation and ventilation.

Communication Styles

  • 13. What are some ways you can instruct others (operating room nurses, surgeons) to help you care for this patient after you recognized there was a problem?

In this segment, there is an opportunity to explore how the trainee communicated with the surgical team, with consulting physicians and dentists, and PACU nurses. One goal is for the trainee to learn strategies for providing clear, succinct information to colleagues and consultants. In our experience, trainees can call for help, but then when help comes or returns the call, the trainee does not know what they want help with.

Trainee Feelings

  • 14. When you realized that you had caused the patient some harm, how did it affect you?

The exploration of feelings after knowingly causing harm to a patient is extremely important. The emotional impact felt by anesthesia providers has been shown to impact decision making8 and can lead to severe depression and destructive behaviors.9 In some cases, severe emotional distress after an adverse event can cause career changes.10 Despite the safety of a simulated environment, the psychological impact in this scenario may manifest as real stress for the trainee. During this segment, we engage the trainee in discovery of support systems that are meaningful to them. These can include identifying people that the trainee could talk to after an event, hospital-based resources designed to assist with work-related stress, and methods of obtaining confidential consultation with a specialist in physician psychology.

PART C: DELIVERING BAD NEWS

Most trainees are poorly prepared to deliver bad news to patients. Historically, there is a culture of silence after adverse events, with the fear that discussing events will make everything worse. In this segment, trainees disclose an adverse event to a standardized patient. The goal during debriefing is to help the trainee develop strategies and knowledge for the disclosure of bad news and also to understand the importance of doing so.11 They will also explore their feelings about having to do this.

Factual Knowledge

  • 15. What is the incidence of dental trauma in anesthesia?

The incidence of dental trauma after general endotracheal anesthesia has been measured at 1:2000 to 1:4500. The injuries most commonly occur in the upper incisors and involve only one tooth.12,13

  • 16. What steps must you take after a dental trauma to ensure continuity of care for this problem?

If the tooth is completely displaced from its socket, then immediate reimplantation insures the best prognosis if done within 15 to 30 minutes. A prompt dental consult is necessary.14,15 For less traumatic injuries, in which the enamel is cracked or the tooth is chipped, the situation is not emergent and can be managed after the operation.

  • 17. What kind of documentation do you need for the (a) doctors of dentistry and (b) patient?

The doctors of dentistry will need to know which tooth was damaged, the extent of the damage, and whether the tooth is primary or permanent. The patient will need to be informed if the cause of the damage was due to a difficult airway, and a form will need to be given to them and filed in their medical record stating the details of the intubation attempt.

  • 18. What are the legal and financial ramifications of causing dental damage in a patient under anesthesia (institution specific)?

Anesthesia claims for dental trauma continue to rise.16 Causes of dental damage are related to poor dentition, emergency surgery, lack of trainee oversight, failure to predict difficult intubation, aggressive laryngoscopy, and patient factors (restricted visual field due to macroglossia, retrognathia, etc). In cases where documentation of vulnerable dentition existed in the preoperative assessment, patients were less likely to proceed to litigation or be awarded claims.17 In our hospital, consultation and treatment for dental damage related to endotracheal intubation is paid in full by our department. To provide another perspective, the other hospital in town will not pay any claim related to dental damage, with the belief that it is a known risk of anesthesia and discussed fully in the consent process. It is important for trainees to discover what the local policy is at their institution.

Communication Styles

  • 19. What strategy did you use to deliver the information about the chipped tooth?
    • Regardless of the strategy chosen, the disclosure of unanticipated outcome, which includes medical error, is a professional obligation of anesthesiologists. In our institution, we teach the SPIKES model to our anesthesia trainees along with the principles of the Sorry Works program.18,19 SPIKES is an acronym that stands for Setting, Perceptions, Information, Knowledge, Empathy, and Summary. Each segment will be briefly explained with some examples.
    • Setting. Assure a quiet and private area where everyone can sit, turn off pagers and cell phones, and ask the patient “Is this a good time to talk?” Starting a conversation on the patient’s terms is better than assuming the patient will listen because you are ready to talk. Gather other members of the family that the patient would like to be present; this saves you from repeating information when the loved one arrives. “Are there other people you would like to be present while we discuss what has happened?” is one way of doing this.
    • Perception. Discover what the patient’s perception about the event is. Has the surgical team already disclosed the event? Did the PACU nurse already smooth things out for you? Understanding what the patient has been told is helpful for tailoring your approach. One way of doing this is to ask the patient, “Has anyone had a chance to talk to you yet about what happened today in the operating room?”
    • Information. Determine how much detail the patient wants while reassuring that you will provide as much information as you know. Some patients do not want details, especially if details are gory; others want minutiae relayed. Asking up front tailors the conversation to the needs of the patient. One way of doing this is, “I want to assure you that I will tell you everything I know about what happened today. Can you let me know how much detail you want? I do not want to overwhelm you with details, and I do not want to give you too little either.”
    • Knowledge. Share the knowledge about what has happened. Avoid assigning blame and remain neutral. If confronted with a question you do not know, do not guess, but state that you will look into it and get back to them. Assure them you will continue to look for answers to ambiguous situations. One approach is “That is a good question. At this time, I do not have enough information to answer that. My team will be looking into this, and when I have more information, I will share it with you. I ask for your patience while we sort out some of these issues.”
    • Empathy. A genuine feeling of empathy needs to be conveyed. Trainees can be afraid to say “sorry,” but data support the benefit to the patient, care provider, and family when this word is spoken. It is important that trainees do not assign or accept blame during disclosure conversations, but relating “I am so sorry this has happened to you” is very helpful.
    • Summary. As the conversation moves to a close, answer questions the family has. Provide them with the next steps in their care. Give them a way to contact you, using a business card, a direct line to your assistant, or if you feel comfortable, your e-mail or cell phone number. Patients become angry when they feel abandoned and having a written way of contacting you provides immense comfort.

Trainee Feelings

  • 20. When you disclosed the adverse event to the patient, how did you feel? What parts did you do well? What would you do differently?

Exploring how the trainee feels about the disclosure is very important and is a step that should not be skipped. Often, the trainee will be overly critical of their performance, and the standardized patient can provide critical feedback during this phase, with many observations of things the trainee did well.

Assessment Instruments

These tools are helpful for organizing a debriefing session for the trainee.

  1. Video tape feedback for self-appraisal of skills
  2. Actor feedback checklist
  3. Faculty instructor feedback
  4. Self-reflection questionnaire

PREPARATION

Supplies and Equipment

  • High-fidelity simulator mannequin
  • Noninvasive blood pressure cuff
  • Pulse oximetry
  • Electrocardiogram
  • Gloves
  • Anesthesia machine
  • Anesthesia cart with drugs
  • Suction—canister, tubing, Yankauer
  • Intravenous catheter (IV)
  • IV fluid
  • Oral airways—adult sizes
  • Nasal pharyngeal airways
  • Endotracheal tubes
  • Laryngoscope with Mac/Miller blades
  • Laryngeal mask airway
  • Video cameras
  • Patient actor
  • Gown/robe for patient actor
  • Small room or curtained preoperative holding area
  • Small room or curtained postoperative room
  • Consent document

Supporting Files

  • Preanesthesia evaluation note
  • Chest x-ray (anterior-posterior, lateral) normal (no tooth in airway or chest)
  • Chest x-ray (anterior-posterior, lateral) abnormal—tooth in airway

Time Duration

Setup: 5 minutes

Consent: 15 minutes

Intraoperative simulation: 15 minutes

Delivery of bad news: 15 to 30 minutes

Debriefing: 30 to 60 minutes

CASE STEM (FOR TRAINEE TO SEE)

You are an anesthesia trainee who is caring for a 38-year-old woman who is scheduled to undergo a laparoscopic cholecystectomy.

She is 91 kg (body mass index, 34) and has well-controlled depression. She has no known drug allergies. She denies alcohol, tobacco, or illicit drug use. She has had nothing by mouth for 12 hours. She walks a mile or two regularly and can climb two flights of stairs with ease. She takes bupropion for depression. She works full time as a professional opera singer and is on break before the next season starts. She has no known problems with anesthetics and had an uneventful surgery 4 years ago when she had a tubal ligation under spinal anesthesia. The nurses have placed a 20-gauge IV in her hand.

BACKGROUND AND BRIEFING INFORMATION FOR INSTRUCTOR (FOR FACULTY ONLY)

The simulation has 3 main objectives as follows: (1) preoperative evaluation and obtain informed consent, (2) handle difficult mask airway, and (3) provide explanation of bad news after chipping a tooth during intubation. The best execution of this scenario will require use of a standardized patient to participate in both the consent process and the bad news and a high-fidelity simulator mannequin for the intraoperative portion.

The patient being anesthetized is a healthy woman coming for a routine laparoscopic cholecystectomy. The consent process is for general endotracheal anesthesia. The examination is normal except for moderate obesity.

In part A, the trainee will visit with the standardized patient and perform a routine preoperative examination, develop an anesthetic plan, and convey information about the plan to the standardized patient. The encounter should occur in a quiet room that is set up like a preoperative holding area. We use a live video feed for the instructor, and assessments are made in real time. We also record the encounter to be used during debriefing. When the trainee is finished and leaves the patient’s room, you can answer any questions the trainee has. In this mini-debrief, you can discuss the anesthesia plan together, modifying as needed. You instruct the trainee to enter the simulation center laboratory operating room and set up the room as they would for the day. While the trainee is in the operating room, the standardized patient can fill out their assessment.

Part B will take place in the simulation center laboratory operating room using a high-fidelity patient simulator mannequin. You will remain with the trainee and assist in the induction, much in the same way you would in the real operating room. After induction of anesthesia, the mannequin will be a difficult mask airway. Trainees should be encouraged to try to reposition the mask, extend the neck, and lift the chin if they do not do so automatically. The airway will continue to be difficult, but the obstruction can be relieved by oral or nasal airway. The goal is to have the trainee diagnose the absence of patent airway and remedy the situation. After establishment of a good mask airway, neuromuscular blocking agents will be given, and the trainee will attempt to intubate the patient. In that process, they will likely successfully intubate the patient but will also “chip” the front teeth. As the faculty anesthesiologist, you will point out that the front teeth are chipped and begin a dialogue with the trainee about what they should do next. You will remain with the trainee throughout the simulation and help guide them to appropriate care.

At the conclusion of the intraoperative portion, you will emerge and extubate the mannequin. You will tell the trainee that the patient will go to the PACU and that we will tell the PACU nurse to call when the patient is fully awake so that we can disclose the chipped tooth to them. You will then need to “fast forward” time and tell the trainee that you have been paged to the PACU to talk with the patient but that you are in a meeting/giving lunch relief/starting another case, and therefore, the trainee will need to go alone. The trainee will need to return to the patient actor and tell them about the airway complication and dental trauma. This will be stressful for this patient because she is worried it will affect the quality of her voice and, hence, her career. Scripts are provided to help the actors create conversations with the trainees.

SCRIPTS/QUESTIONS FOR ACTORS (FOR FACULTY AND ACTORS ONLY)

Part 1: Preoperative Visit

Patient is nervous and/or anxious before the surgery.

Do I have to have a breathing tube?

What are my anesthetic options?

Is there a risk of vocal cord damage?

Will my singing be affected?

Part 3: Postoperative Visit and Delivering Bad News

Patient is visibly upset after delivery of bad news.

How did this happen?

Did something go wrong?

Who did it?

Will my voice be affected? What about my career?

What about my tooth? How do I get it fixed? Who will pay for it?

PATIENT DATA BACKGROUND AND BASELINE STATE (FOR TRAINEE TO SEE)

Medical History

  • Depression
  • Obesity
  • Normal spontaneous vaginal delivery × 2

Surgical History

  • Tonsillectomy as a child—no complications
  • Tubal ligation under spinal anesthesia

Social History

Married, 2 young children, no tobacco, no alcohol, no illicit drugs. Works as an opera singer. Walks her dogs for exercise regularly.

Review of Systems

Central nervous system: Negative for stroke, migraine, paresthesia, weakness

Psychiatric: Positive for depression

Cardiovascular: Negative for angina or shortness of breath.

Pulmonary: Negative for asthma, recent upper respiratory infection

Renal/hepatic: Negative for renal failure, cirrhosis, jaundice

Endocrine: Negative for diabetes, thyroid disease

Hematology/coagulation: Negative for anemia, bleeding, bruising, anticoagulant medication

Current Medications and Allergies

  • No known drug allergies
  • Bupropion 300 mg daily

Physical Examination

General: Well appearing, pleasant, no distress

Weight, height: 91 kg, 5 ft 4 in. (1.63 m)

Vital signs: Heart rate (HR) 60, blood pressure (BP) 118/64, respiratory rate (RR) 16, temperature 37.2°C, sat 98% on room air, pain 4/10 in right upper quadrant

Airway: Mallampati I, thyromental distance is 4 finger breadths, neck has full range of motion, mouth opening is normal, positive subluxation, native teeth with good dentition

Lungs: Clear bilaterally

Heart: Regular rate and rhythm

Laboratory, Radiology, and Other Relevant Studies

Hemoglobin/hematocrit: 13.2 g/dL and 38%

DISCUSSION

Variations

It can be ideal to have several variations of a simulation so that educational objectives are tailored to the needs of the learner or to function within the constraints of the system. We have included several variations for each part of this simulation for interested readers.

During Part A: Obtaining Informed Consent

  1. Preoperative information can be withheld from the trainee. This can provide an opportunity to assess how well the trainee performs a preoperative evaluation (including history and physical examination skills) in addition to reviewing a plan for anesthesia and obtaining informed consent.
  2. A confederate surgeon can interrupt the trainee and standardized patient and place pressure to hurry up and get the patient into the operating room to start. This can lead to exploration of attitudes and reactions to unprofessional behavior, how interruptions affect the cadence and flow of communication, and whether steps are skipped because of the intrusion.
  3. It is possible to stop the scenario after the informed consent is finished and move immediately to debrief without continuing to parts B or C. This might be ideal if time is limited, if the trainee displays excessive stress from the interaction, or if the performance reveals that the trainee would benefit from extensive remediation.

During Part B: Managing Airway After Induction of Anesthesia

  1. Once the intubation has been completed and the declaration that a tooth has been chipped, the trainee will either find the tooth in the lung (more complicated explores systems and interprofessional communications) or not.
  2. It is possible to stop the scenario after the airway/intraoperative portion is finished and move immediately to debrief without continuing to part C. This might be ideal if time is limited, if the trainee displays excessive stress, or if the performance reveals that the trainee would benefit from extensive remediation in elements contained within parts A or B.

During Part C: Disclosure of Bad News

  1. The responses of the actors can be tailored to fit an education goal, the level of the trainee or the experience of the actor. We have explored the following responses with our actors: silent anger with poor eye contact, boisterous anger with yelling and demands for information, and extreme sadness with crying and despair. All of these work well and are relatively easy to do.
  2. The complexity and intensity of the scenario can be increased by having a partner at the bedside during the disclosure. We have used same-sex partners to explore trainee feelings and emotions about nonconventional family units. This also increases the difficulty because there are 2 people to answer instead of 1.

Evaluation and Assessment Tools

The evaluation and assessment templates used in this 3-part simulation are based on institutional requirements for obtaining informed consent, practice parameters, and culture at our institution. The SPIKES model of delivery of bad news and the Sorry Works program for disclosure of adverse events are the didactic elements we use to teach disclosure.18,19

Actors used in the scenario fill out standard evaluation templates and provide written feedback to the trainee. Actor comments are based on trainee mannerisms, word choices, and tone and have less to do with content or information delivered. The most frequently encountered comments by the actors include excessive jargon, speaking too quickly (cadence of speech), speaking too much (not pausing), and standing with arms folded (appearing closed off or angry).

A total score is calculated from all the different evaluations and compiled into one debrief document. This debrief document will contain the self-reflection comments from the trainee, the comments from faculty, the comments from the actors, and a score for how well the trainee accomplished the metrics in the evaluations. Trainees are debriefed one-on-one with faculty and the actor(s). Trainees are given the opportunity to watch their performance on taped video, comments and metric measures are discussed, and behaviors are explored. For some trainees, additional examples of how to phrase questions and responses to patients were provided by the faculty in an effort to help them assimilate the information.

Debriefing Methods

Debriefing for this simulation can occur in 2 ways as follows: the standard method of immediate debrief at the end of all 3 parts or a short immediate debrief after each part, coupled with a longer, more detailed and data-driven debrief later. In our institution, we have had success with the latter method and find that 30 to 45 minutes are needed to run the 3 phases of the simulation and another 45 to 60 minutes for the longer debrief.

The immediate debriefing involves explanation of the goals of the scenario and solicitation of feedback from the trainee about things that were unclear to them. Oftentimes, trainees will ask a question about a specific medical fact that they were asked or how to phrase things that seemed awkward to them. We do not deeply explore any concepts; rather, we use the time as a break before moving onward in the scenario. At the end of part C, we ask trainees to fill out a short self-reflection form, which is used during the larger debrief as a starting point.

The goal for our longer debrief is to use the methods of Rudolph et al20 in which debriefing involves trainees explaining and analyzing their own behavior while receiving information about how others (faculty and actor[s]) saw the same event. This allows the trainee to set goals for future behavior and learning through analysis of previous events.

Our Experience With This Simulation

We have performed this scenario on 4 entire classes of trainees at our institution. They participated after 1 to 3 months of clinical experience. We found that the best use of this scenario is earlier in their training, when their patterns and habits for obtaining consent are not solidified and during a time when they are less familiar with difficult mask ventilation and airway devices. None of our trainees had experience in delivering information about adverse events in anesthesia at the time of the simulation. Few had limited exposure with disclosing terminal diagnoses.

Our initial experience revealed that more than 90% of our trainees were not competent at obtaining informed consent, as measured by missing 30% or more of the key elements on the informed consent assessment. This finding led to restructuring our educational programming and retesting the trainees on their ability to obtain informed consent. In this regard, the assessment instruments were helpful for improvement of our educational efforts.

CONCLUSIONS

In this 3 part simulation workshop, novice anesthesia trainees are challenged to consider the continuum of anesthesia care. In part A, trainees encounter a standardized patient and perform a preoperative assessment. They must assimilate information available to them from the history, confirm findings, develop an anesthetic plan, convey that plan to the patient, and engage in a discussion of informed consent. In part B, they move into the simulated operating room where they induce general anesthesia and encounter some difficulty, resulting in a chipped tooth. They will explore the local systems approach to handling this problem and develop solid medical principles for managing the patient. In part C, they will return to the standardized patient who is fully awake after the anesthetic and disclose the adverse event to the patient. This segment is designed to develop a structured strategy for disclosure conversations as well as to remind residents of the importance of disclosure. Within this framework, trainees receive feedback from the standardized patient and faculty who can provide key insight into communication strengths and weaknesses (both verbal and nonverbal).

ACKNOWLEDGMENT

The authors acknowledge the excellent faculty members of the Department of Anesthesia who ensure every trainee can participate in simulation during a busy work day. Numerous trainees reviewed this scenario and provided insight and feedback: Drs Jared Lake, Trevor Ponte, Somchin Puangsuvan, and Lee Kimball. We are greatly appreciative of our excellent actors, Gregory Geffrard, Michael Petkewek, and Janan Winn. None of the simulations in the Department of Anesthesia at the University of Iowa would be possible without the skill and dedication of Johann Cutkomp, who runs the daily operation of our simulation center.

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