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Reflections on Simulation

My Simulation Journey

Making the Impossible, Possible

del Moral, Ignacio PhD, MD

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Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare: February 2020 - Volume 15 - Issue 1 - p 3-4
doi: 10.1097/SIH.0000000000000438
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My simulation journey started 22 years ago on August 23,1997, at 1:30 p.m. when working as an anesthesia faculty member at my university hospital. My patient underwent a successful hip replacement. When surgery finished, I brought the patient out of general anesthesia and removed the endotracheal tube, so he could breathe normally. At that moment, the patient moved both hands to his neck with his eyes wide open in fear as he could not breathe. I tried to calm him saying, “Surgery is over, everything went well. Try to breathe normally.” His hands clenched his neck and he could not get air into his lungs! I decided to anesthetize the patient again. I looked around the room and realized I was alone. I shouted, “I need help!” and began administering the anesthetic drugs. I tried to bag valve mask ventilate him, but I could not. I tried to intubate him, but I could not. At that moment, I realized I was facing a life-threatening cannot-ventilate cannot-intubate situation. Suddenly, the room filled with nurses and physicians trying to save my patient's life. With the patient's oxygen saturation dropping, I became desperate and inserted a needle into the patient's trachea. The needle system broke. I failed. I became paralyzed, curled up in a corner, and started to cry. At the very last second, my colleague, José Manuel, courageously cut the patient's neck and inserted a tube into his trachea. Finally, my patient received life's breath. José Manuel saved my patient's life.

This deeply emotional and frightening experience changed my life's course. I cried because I was not able to provide my patient with the care he needed and deserved. That horrifying experience galvanized my resolution to change the world of clinical education and to place patient safety highest among my clinical values.

Life is amazing and full of surprises. While I was dealing with those intense emotions, a colleague showed me an advertisement about simulators in an anesthesiology journal. We did not know what it was about. We explored and got excited about the educational possibilities. Getting started required money, so we knocked on the door of Santander Bank, headquartered nearby, to ask for funds to purchase a simulator. They said, “No.” Around the same time, I was committed to improving my clinical skills in cardiovascular anesthesia and enrolled in a fellowship at Stanford University. Serendipitously, I met David Gaba and he invited me to his course on anesthesia crisis resource management. While attending, a revelation came over me, “Wow, I can feel the power of simulation!” My next thought was, “That's what I want for my country.” I returned home, and we knocked at Santander Bank again, and again, they said, “No.” We did not give up but crafted a detailed plea to inspire them about the value of simulation in healthcare. Finally, after 2 years, they said, “YES!” We were excited and proud to receive the first patient simulator in Spain, and one of the very first in Europe.

Having the simulator was like having a ball, but not knowing how to play the game. On top of that, we did not even have a knowledgeable team. We assembled a group of clinicians interested in education. In 1999, we offered the first simulation-based course in Spain. A few years later, in 2004, I received an e-mail from SESAM, the Society for Simulation in Europe, announcing a simulation instructor course taught by faculty from the Center for Medical Simulation. A colleague and I flew to Boston to take the course. That program was another surprise that transformed my approach to the teaching-learning process. I realized that there is a science behind simulation as a teaching tool; there is research-based methodology to change and guide the way we train clinicians. The impact of that program continually inspired us to explore the science with the hopes of making contributions to simulation-based education and to expand its use in clinical education.

My journey continued when in 2009 the government of my state, Cantabria, decided to establish a center of excellence in simulation, from the ground up. It was one of those moments when I thought, “We are making the impossible, possible.” I was asked and honored to lead that governmental organization. To prepare myself, I had the good fortune to spend a fellowship year at the Center for Medical Simulation where I gained a much deeper understanding of what simulation means. I learned from my mentors, Jeffrey Cooper and Robert Simon, something that is still etched in my heart, “It's all about people.”

Upon returning to Spain, in 2011, the Hospital Virtual Valdecilla was officially established. I designed a faculty development program with the goal of investing in people, just as others had invested in me. To this end, I collaborated with a colleague, José María Maestre, who became the Education Director. The two of us have grown to be close, complementary partners. We realized that if we wanted to change the culture of healthcare, we needed to start changing people's lives first.

At the Hospital Virtual Valdecilla, we listen closely to clinicians to understand their challenges and then figure out how simulation can help solve those problems. Solving real-world problems is satisfying and has engendered a lot of support for our work. In the path of service to others, we have had the good fortune to establish national and international collaborations across Spain, Colombia, Mexico, Chile, Peru, and Argentina. We have also been able to inspire and mentor other simulation leaders to create their own teams of experts, to design their own programs, and to continue changing the clinical education paradigm.

My simulation journey began with a frightening, humbling experience of nearly losing a patient, and I reflect on the guiding principles that have helped me the most in trying to make the impossible, possible. Two thoughts strongly come to mind. First, it is truly all about the people. Second, the value of my organization is not determined by what we have, but by what we can give.


Reflections; Personal story; Personal experience; Journey; Inspiring; Values; Education; Patient safety

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