To the Editor:
Juan finished his general surgery residency 1 year ago and is now specializing in minimally invasive robotic-assisted colorectal surgery. He has already completed an online training module, several in situ training sessions to learn docking, instrument planning, and so on and successfully accomplished the basic and advanced skills training. He has now started a state-of-the-art training program to optimize outcomes and accelerate his learning curve in low anterior rectal resection. He is doing his third complete case following the principles of experiential learning theory, based on active experimentation in an animal laboratory and guided reflection with feedback. After anesthesia was induced, the team placed the robot in the correct position, the trocars were setup, and right and left hemicolectomies were performed with moderate bleeding while sectioning the colon vessels. During anterior resection, the inferior mesenteric vessel ligation was ineffective, causing profuse bleeding. Despite early help from the attending surgeon and excellent collaboration by the team, the animal experienced a cardiac arrest and died.
During debriefing immediately after the training session, Juan was both upset and frustrated. “I have devoted so much time to being proficient in this technique that I was not expecting this outcome. Other times I could figure these things out. I am not sure I am going to be able to do this procedure,” he stated. The instructor acknowledged his feelings and, being at the early stages of his learning curve, normalized the situation. On the other hand, the veterinarian, who was taking care of the animal, confirmed the presence of preoperative anemia and a poor response to fluid replacement. Although Juan tried to move on, he finally decided to postpone reflecting on the decisions and technical steps that lead to the situation.
In the article, “To die or not to die? A review of simulated death” published in your Journal by Corvetto and Taekman,1 they suggest that it is essential to carefully consider whether to allow death during a training session, as there is still a lack of evidence on whether such a fatal event may affect the student’s learning process and emotions. This is only controllable when using mannequins. When training in simulation laboratories with anesthetized animals, outcomes cannot be fully controlled and unexpected adverse events may happen from a learner’s action or inaction.
In the case presented, death was unexpected, and the learner was psychologically impacted and reluctant to reflect on the case. Although there is a lack of evidence in this area, Corvetto and Taekman cite reports that suggest it may make learners feel guilty, lose self-confidence, lose overall long-term interest in simulation as an educational modality, or even decrease their motivation in clinical care. In this case, its occurrence obliterated the discussion of the desired learning outcomes. Nevertheless, the following day, Juan was prepared to talk about what happened and was able to build on and learn from it. We do not know if the stress affected his memory retention and long-term learning. We are not aware of any report of posttraumatic stress disorder from simulation; posttraumatic stress disorder is commonly related to overwhelming life experiences that threaten a person’s life. On the other hand, several findings minimize the possibility of significant psychological effects and distraction from the learning objectives.1
In our center, during 2012, 237 professionals (123 surgeons, 74 surgical residents, and 40 operating room nurses) were trained on 210 swine. Death occurred in 12% of the cases, especially in long and complex procedures.2 Participants typically feel frustrated and sad. They process emotions normally and are able to analyze the situation and generalize to everyday practice. Intense responses are not frequent, and the reaction Juan experienced was the only one found during that year.
We are not aware of reports on how to confront the possibility of death when training in the animal laboratory. Therefore, to cope with this possibility in our center, we plan on three levels: preventive strategies, actions when complications arise, and reactive strategies to cope with the emotional reaction of the learner if death happens.
We believe “an ounce of prevention is worth a pound of intervention.” During the introduction to the course, we assure psychological safety, orient to the simulation environment, and set ground rules on respectfulness and confidentiality about performance and debriefing conversations. Psychological safety is a person’s sense that the environment is safe for interpersonal risk taking; that when trying out a new set of skills, new ways of doing or acting will not be ridiculed; that mistakes will be worked on together as a source of learning instead of being treated as a crime to be punished or covered up.3 In our opinion, it is essential to explicitly orient participants about the chance of undesired outcomes, including death. When talking about respectfulness, we not only refer to participants and instructors relating to each other but also agree to treat animals in the laboratory with respect. We encourage the learners to operate and assist in every case as they would do with a patient. For example, we emphasize that if the position of the robot or the insertion of the trocar is not adequate, if manipulation of the tissues is not delicate, if tissue lacerations are not repaired early, and if participants do not work as a team, then complications are more likely to happen.
When complications arise during the surgical procedure, the instructor can pause the procedure and give the team more time to discuss and decide what to do next or can intervene to modify the course of the procedure as in “scenario lifesavers” during simulations.4 Participants respond better if the possibility of intervention is announced before the training starts. On the contrary, others may not advocate intervention, as death in the real world may occur unexpectedly and may give learners the opportunity to experience the consequences of their actions without putting a real patient at risk and the opportunity to reflect on their personal feelings about mortality.
If death occurs, instructors must be prepared to provide emotional support to the learner as needed. Our approach follows a series of steps based on the debriefing processes described by the Center for Medical Simulation.5 We start by recognizing and naming what has happened, tell the trainee that we believe it is important to talk about it, and invite her or him to do so whenever they feel ready. When the conversation begins, we ask for reactions, to clear the air, and set the stage for reflection, acknowledging the feelings and emotions that may arise. Normalizing the situation generally facilitates acceptance and synthesizes their emotional state. We follow by giving them options (such as taking a break or diverting the conversation to another topic from the simulation) before engaging in rigorous reflection and feedback.
Jose M. Maestre, MD, PhD
Jose C. Manuel-Palazuelos, MD, PhD
Ignacio Del-Moral, MD, PhD
Hospital Virtual Valdecilla
1. Corvetto MA, Taekman JM. To die or not to die? A review of simulated death. Simul Healthc
2013; 8 (1): 8–12.
2. Copca N, Hanna A, Pivniceru C, et al. Experimental liver transplantation on pigs—technical considerations. Chirurgia
2013; 108 (4): 542–546.
3. Rudolph JW, Simon R, Dufresne RL, Raemer DB. There’s no such thing as “nonjudgmental” debriefing: a theory and method for debriefing with good judgment. Simul Healthc
2006; 1 (1): 49–55.
4. Dieckmann P, Lippert A, Glavin R, Rall M. When things do not go as expected: scenario life savers. Simul Healthc
2010; 5 (4): 219–225.
5. Rudolph JW, Simon R, Rivard P, Dufresne RL, Raemer DB. Debriefing with good judgment: combining rigorous feedback with genuine inquiry. Anesthesiol Clin
2007; 25 (2): 361–376.