Lessons from the Simulator
Dr Andrew Robinson
Senior Instructor, Southern Health Simulation Centre, Melbourne
Visiting Medical Officer, Monash Medical Centre, Clayton
Visiting Medical Officer, Mercy Hospital for Women, Heidelberg
Honorary Lecturer, Monash University, Clayton
Obstetric anaesthesia is a challenging sub-specialty that is generally regarded as high risk. The obstetric anaesthetist may be faced with a difficult airway, seizures, life threatening haemorrhage and many other crises, occurring at any time of day or night, sometimes in small centres with inadequate resources.
In addition to the medical problems, there is often associated emotional overlay, with the potential death of a neonate - or even a young mother - that adds additional stress to an already dire situation.
In this context, merely knowing what needs to be done is not enough. The successful management of these kinds of crises also requires effective behaviours in order to get it done.
It is also important to acknowledge that the stress and time pressure in a crisis degrades performance. Normally useful diagnostic techniques such as 'frequency gambling' ("common things occur commonly") may predispose to fixation error. Working things out from first principles is often too slow to make a difference in outcome
These problems were well recognised in the aviation industry in the 1970s and led to changes in the way pilots worked and were taught.
The work of David Gaba in the late 1980s and early 1990s to translate the concept of 'crew resource management' (CRM) from aviation into "Crisis Management in Anesthesiology" (1) marks a turning point in our understanding of how the so called 'human factors' can influence the outcome of any crisis.
Derived from that work are the Key Points of Crisis Management
- Know, modify and optimise your environment
- Anticipate and Plan
- Ensure a leadership role and role clarity
- Communicate effectively
- Call for help early enough
- Allocate attention wisely and use all available information
- Distribute the workload and utilise all available resources
The relevance of these key points in obstetric anaesthesia has been highlighted many times by the triennial publication "Why Mothers Die" (2). Repeatedly we see failures in communication, failures to call for help, failures to adequately plan as contributing factors in the deaths of obstetric patients.
Simulation training offers a unique opportunity to practice these key points and improve the way in which we manage crises.
(1) Gaba, D Fish, K Howard, S. Crisis Management in anaesthesiology. New York: Churchill Livingstone, 1994.
(2) Confidential Enquiry into Maternal and Child Health. Why Mothers Die 2000–2002: The Sixth Report of the Confidential Enquiries into Maternal Death in the United Kingdom. London: RCOG Press, 2004
Time of Presentation
1330
