The Australian response to gun violence…less is more

This week, Annals of Internal Medicine published a well written editorial about how Australia has managed to significantly reduce gun violence with a nod to the measures it took back in 1996. It’s unfortunate the physician base within the US hasn’t been more vocal to advocate on behalf of patient safety or even prevention. The attempt to combat gun violence with more guns (and arming more people) doesn’t seem to be working. It would be awesome to see stronger advocacy from a well organized group of physicians who have the ability to exert considerable influence. Until US physicians advocate more vocally, it appears to be an opportunity lost.


An intriguing video…not about medicine…not about sim…but just about life

I came across this video via a feed on Facebook. It’s got nothing to do with sim, with helicopters, medicine or even education (well except maybe it contributes to general education of life).

I thought it deserved to be shared. It struck a chord because I’ve been that guy stuck in line at the grocery store and just about ready to lose it…then having to get back in my car and drive home in Toronto’s ridiculous traffic. This video reminds us about others, that the people around us may not be in nearly the fortunate situations that we’re in or maybe they’ve just had an even worse day at work than me. Regardless, I hope I can remember this video next time I’m pissed off at how long the line in the grocery store is or when I’m stuck 3 hours of traffic, just trying to get home.

For those interested, the speech is an excerpt from a commencement speech delivered by David Foster Wallace in 2005 before his death in 2008.



Patient safety strategies ready for primetime

This week, Annals of Internal Medicine published a critical review for strategies designed to enhance patient safety. The best part, the authors summarized their findings into a 1/2 page table outlining 10 “strongly encouraged” and 12 “encouraged” strategies…this makes  for a quick read! Extremely important for those of us who’s attention spans are so short that we can’t even wait in a line at the grocery store without checking our email twice, posting a tweet and reading the daily news.

Source: Shekelle et al. Ann Intern Med 2013 Ann Intern Med. 158:365-368. doi:10.7326/0003-4819-158-5-201303051-00001

Source: Shekelle et al. Ann Intern Med 2013 Ann Intern Med. 158:365-368. doi:10.7326/0003-4819-158-5-201303051-00001

I really liked this list and I think it’s great to publish  for people to review. You can look at what you’re doing at your own institution and if there are things missing, it provides a basis for advocacy.

It’s interesting that many strategies relate to intensive care medicine. I’m not sure if that’s a function of the interest by intensivists/anesthesists in patient safety, a result of funding bias towards ICU-level patient safety studies or maybe that’s where much of the difference can be made (at least from a mortality perspective). What this list also demonstrates is that there are many areas within primary care, trauma care and emergency care that require attention. 

The authors mention that “pre-operative checklists and anesthesia checklists” are strongly encouraged. I agree! But what about checklists during acute resuscitations? We simply don’t know because the evidence hasn’t been developed yet. Certainly I think this can act as a call to those funding and researching patient safety in acute care medicine . Cliff Reid wrote about the “Resus Room Life Guard” several months ago…we don’t know if this is a good idea or improves patient oriented outcomes because it hasn’t been studied. Though intuitively, it seems like a great idea!

There was also no mention about the importance of adequate discharge follow-up from the ED…some hypothesis generating studies that patients who don’t have great follow-up are at risk. But clearly more studies are needed.

Finally, for those of us interested in simulation, it offers additional support that team training and simulation exercises with a focus on patient safety are worthwhile undertakings. A recent study from demonstrated improved communication and teamwork in a trauma centre following in-situ trauma simulation training. In addition, there appeared to be some patient oriented improvements including improved speed without compromise in critical task completion.

The list of strategies is worth a read…see how you compare and see how your institution compares. If you’re not doing the “strong encouraged” items…its probably worth considering why not? Do you really need to put the femoral line in during the resuscitation or will the 2 large bore IVs suffice until the patient can be properly draped and line insertion done under fully sterile conditions? Do you wash your hands before and after every patient encounter? I know at our hospital we have people in the ED (maybe posing  with acute Percocet insufficiency) or hiding in the shadows…yet…they’re really monitoring our handwashing complicance.   While I have been known to get in arguments with them…they’re actually just trying to implement important patient safety measures.


That’s it for now. Feel free to post any thoughts/comments.

Hybrid Simulation…using patient actors to enhance simulation

I’ve gotten a bit behind in my posts mostly as I’ve just moved back from New Zealand but I’m hoping to get a few more regular posts. For those who’ve read this blog, you’ll know that I like to highlight innovative approaches to simulation. This post is mostly for those interested in medical simulation…hopefully providing some new ideas.

One of my interests is procedural skill acquisition and how simulation can be used to enhance learning. So when I came across this paper I thought it deserved mention. The authors, from the University of Toronto describe using “hybrid” simulation for teaching knee arthrocentesis among internal medicine residents. Residents went through a procedural skills curriculum where they received teaching and practice performing arthrocentesis. They had to interact with a standardized patient and explain risks/benefits of the procedure. Then they were evaluated on both technical & non-technical skills in a separate scenario. They demonstrated the feasibility of this approach and they showed high ratings of realism among trainees & standardized patients and it functions as a hypothesis generating study for if these acquired skills are translated to the clinical setting.

Great use of hybrid simulation for obstetrical scenario - live patient actor "giving birth". source:

Great use of hybrid simulation for obstetrical scenario – live patient actor “giving birth”. source:

Hybrid simulation is actually a pretty cool concept. For those are new to this, hybrid simulation combines patient interaction (using a standardized patient) with a bench model (or task trainer) that allows for procedural skill practice. The benefit of this technique is the learner gets to interact with a patient as if they’ll be the recipient of the procedure while also getting to master the technical skills of the procedure.

Using procedural competency as a goal in procedural training, hybrid simulation is an excellent method for integration into a training curriculum. In one definition of competency:

“it refers to a resident’s ability to safely prepare for, perform and navigate the complications of a procedure” (Mourad et al. J Gen Med 2010).

Hybrid simulation will allow the learner to manage each of these aspects. They practice how to prepare for the procedure (both technically and preparing the patient). This will include consenting the standardized patient to the risk and benefits. I think we often forget this key aspect and instead focus on the technical skill. Furthermore, hybrid simulation scenarios can also integrate complications and evaluate the learner as they manage both the technical and interpersonal issues that must be addressed.

Another group at the University of Ottawa has started using OSCEs as a method for evaluating procedural skills which also is quite innovative! I came across an abstract they recently presented and a quick google search revealed a manuscript that further outlines the integration of an OSCE for procedural skills. Definitely worth checking out.

In simulation, we spend thousands of dollars on advanced equipment that is designed to replicate real patient interaction. However, hybrid simulation shows us that we can enhance fidelity even more by using some imagination and combining a task trainer with a live actor.

Another example while I was in Auckland, I ran full trauma simulations with a live patient. At the helicopter base, we had an actor who had suffered a considerable trauma from a motor vehicle accident. Its very impressive to watch a team interact with a “real” patient compared to a manikin. There’s much greater concern with pain and emphasis towards communication of each management step – these are definitely lost during interaction with a manikin.

I think medical educators and those involved in curriculum design need to take the next step as we seek to improve procedural skill teaching in medicine – let’s start integrating live patient actors into our simulations. We’re starting to see that it’s feasible and that some considerable benefit can be ascertained. As we seek procedural competence, we cannot forgot the trainee should be evaluated for their ability to explain and work with a live patient throughout the procedure. Its not infrequent that trainees learn to perform a procedure but they have no idea the complication rate or even what can go wrong! Then when something does actually go wrong they haven’t thought about it. Integration of these  hybrid simulations will only enhance trainee skills and lead to improvements in patient safety – something we’re all working so hard to improve.