Draft Scenario 1

Template for Simulation Patient Design, Developed by Jeffrey M. Taekman, Duke University http://simcenter.duke.edu/support.html

Assessment system based upon Non-Technical Skills for Surgeons(NOTSS), University of Aberdeen. http://www.abdn.ac.uk/iprc/notss

Scenario written and developed by Tim Jones and Mike Lewis.  Copyright Royal College of Surgeons of England



This document is written to help smooth the development of a patient / scenario for our human patient simulator. “Story-boarding” is a common practice in movie making and computer multimedia design. Story boarding involves scripting out on paper what you would like the final product to look like. We will use the story-boarding process in simulation module design and development.


We have found this process to be quite important in the simulation development. The following form was designed to help in the storyboarding process.



The first component of the template is the “Case Information”. This includes the educational rationale behind the simulation module, the reason for the simulation module, the objectives, the target audience, the developer’s names, the equipment and support components needed, etc.


The next part of the template, “Equipment and Supporting Objects” requires you to think through the equipment and multimedia elements needed in support of the simulation.


The next component of the template is the “Simulation Scenario Set-Up”. This is the information given to the learner in the debrief room (or at bedside) before they begin the simulation. On the latter part of this page, one should include information destined specifically for the facilitator, but not to be viewed by the learner. 


There are actually two components to any simulation: the patient and the scenario. For instance we may run a Malignant Hyperthermia scenario on a “healthy” patient or a patient with severe co-morbidity.


The scenario represents how the simulation plays out over time. Each scenario should be broken down into mini-scenarios (called “states”). Each state represents a progression of the simulation. Stepping  from state to state is caused by a “trigger.”. Triggers may be time, drugs, or specific learner actions. For instance, our malignant hyperthermia scenario might be broken down into baseline, mild, moderate, severe, and resolution states. Use of volatile agent in the simulation would “trigger” the mild MH state. Time might cause the trigger between mild, moderate, and severe MH. Finally, the use of Dantrolene in the simulation would trigger resolution state. Failure to give Dantrolene would strand the simulation in the “severe” MH state which would eventually lead to “death”.


The next component is the “Patient Background Information and Baseline Simulation State”. This should follow a traditional H and P format. The baseline state is the state the learner will find the simulation in at the beginning of the exercise. The baseline state for your simulation is developed by manipulating the simulator’s “perfect” 70kg, healthy physiology to resemble the patient you envision. You will need to also write down the “trigger” to move to the next state.


The next component is “Scenario Development States 2-?”. For each state you should write down what you would like the learner to do, what happens to the patient (including vital sign changes, lab values, etc) and what the trigger would be to move to the next state.  The table on the “Clinical Course for Scenario” page may be used in lieu of these pages if you prefer.


The final component of the template is the “Parameter Adjustment Form”. This should not be filled in unless you have scripted many cases. These tables will be used in the simulator programming process to keep track of the adjustments made to the simulator to achieve the “look” of the desired patient.




Case Information


Section 1: Demographics


Case Title: Wean from bypass (grafts)


Patient Name: Tim Graham


Scenario Name: Just another routine day…?


Simulation Developer(s): ML/TJ


Date(s) of Development: 29/06/11


Appropriate for following learning groups (circle all that apply)

Faculty:                                                CME√

Residents:(PGY)                       1          2          3          4          5          6√        7√

Specialties:                               Anesthesiology√            Nurse Anesthesia          Surgery √

Perfusion√                    Team Training   √          Critical Care     

Medical Students (yr):                1          2          3          4

Nurse Anesthesia Faculty:         CEU

Nursing Students (yr):                1          2         

Other:                                       _____________________          


Section 2: Curricular Information


Educational Rationale: 



Learning Objectives: (ACGME Core Competencies: Medical knowledge (mk), Patient care (pc),  Practice-based learning and improvement (pli),  Interpersonal and communication skills (cs),  Professionalism (pr),  Systems-based practice (sbp))


  • Understand the learning environment- “ground rules” will be established
  • Demonstrate  the importance of situational awareness by listing 3 key elements
  • Sequence and prioritise key information
  • Identify appropriate management options
  • Establish a shared understanding with team and communicate plan
  • Identify factors affecting performance and decision making ability



Guided Study Questions:

  • How does teamwork and leadership influence outcome?
  • What is “good communication”?



References used (included PubMed ID when possible):

  • Flin R, Maran N. Identifying and training non-technical skills for teams in acute medicine. Quality and Safety in Health care, 2004: 13 (supplII), 180-184
  • Shiralkar U. Smart surgeons sharp decisions. The Surgical Psychology Series. tfm Publishing Ltd. 2011



  • powerpoint slide set-Orientation to facility briefing
  • Scenario cards –Trainee and Faculty




Assessment Instruments:

  • NOTTS framework
    1. Situation awareness

                                                               i.      Monitors ongoing physiology

                                                             ii.      Recognises Problem- reflects and discusses significance of information

                                                            iii.      Shows evidence of  having a contingency plan

    1. Decision making

                                                               i.      Recognises and articulates problem

                                                             ii.      Asks perfusion, anaesthetics, scrub team for help/opinion

    1. Communication and Teamwork

                                                               i.      Keeps team informed about situation

                                                             ii.      Seeks and listens to advice of team members

                                                            iii.      Clearly communicates plan

    1. Leadership

                                                               i.      Makes appropriate decisions

                                                             ii.      Emphasises the urgency of the situation

                                                            iii.      Delegates tasks and coordinates team appropriately






Section 3: Preparation



Monitors Required:



  Non-Invasive BP Cuff X Urinary catheter    
X Arterial Line        
X CVP        
  PA Catheter        
X 5 lead ECG        
X Temperature Probe        
X Pulse Oximeter        
X Capnograph        



Other equipment required:


X Anesthesia Machine X ETT    
X Anaesthetic Pumps   LMA    
  Brochoscope   Laryngoscope    
X Defibrillator        
  Nerve Stimulator X Porcine heart lung block    
  Echo Machine and Probe        
X CPB Machine + Circuit        
X Orpheus Simulator        
X SIM Man        



Supporting Files (cxr, ekg  echo, assessment, handouts, etc)

  1. CXR – normal, male
  2. ANGIOGRAM – 3 vessel disease, good LV



Time Duration


Set-up 4 hours



Case Stem


Case Stem (one to two paragraphs on pertinent patient and scenario information-this should be the stem for the learner and should include location, physician/help availability, family present, etc.):



Cardiac theatre.  65 year old male with hypertension, diabetes and chronic stable angina with 3 vessel coronary artery disease and good biventricular function is currently undergoing coronary artery bypass surgery on cardiopulmonary bypass (CPB).


Prior to entry to the OR you will conduct a team brief.



You are about to come off CPB following full revascularisation with LIMA to LAD and LSV to OM and RCA.  You have completed your proximal anastamoses and the heart is beating.  There is no significant bleeding.



Background and briefing information for Facilitator/coordinator’s eyes only:


Routine case for orientation to facility to demonstrate principles of good communication and teamworking.


Simulation will use CPB wean and trouble shooting to examine NoTTS.



Simulation begins with candidate in a position to wean patient but candidate needs to perform pre wean checks and assimilate data (which is all normal).


INTERVENTION: completion of pre wean checks and communication with anaesthetist and perfusionist (detail pre wean checks for faculty)



Patient successfully weaned from CPB, prior to protamine administration and following a brief period of stability


Trigger: 1 minutes



There is ST elevation, moderate hypotension and increasing CVP.


(Candidate should check grafts / consider inotropes)


Trigger: 3 minute



Profound hypotension and ST elevation



Recommence CPB / IABP


Trigger: 3 minutes (if not back on CPB / IABP)



Ventricular tachycardia









 Patient Data Background and Baseline State


Patient History (should follow standard H and P format):


Review of Systems:

                CNS:                                      NAD

                Cardiovascular:                   3 VD, good LV

                Pulmonary:                           NAD

                Renal / Hepatic:                   Creatinine 78

                Endocrine:                            Diabetes on oral hypoglycaemics

                Heme/Coag:                         Hb 12.7 g/dl; coag profile normal


Current Medications and Allergies:


                No allergies

                Aspirin, simvistatin, atenolol, glibenclamide



Physical Examination:

                General:                                                well

                Weight, Height:                    178cms, 72kgs

                Vital Signs:                            SR 64

Airway:                                   NAD

                Lungs:                                    NAD      

                Heart:                                     NAD


                Conduits                                                LSVs satisfactory



Laboratory, Radiology, and other relevant studies:

CXR:                                      Clear

ECG                                       SR 64 bpm, inferior Q waves           





Baseline Simulator State at commencement of scenario:


Vitals:                                       SR 88;  ECG isoelectric, NP temperature 36.5C


Neuro:                                      GA, paralysed,


Respiratory:                              Enotracheal intubated, NOT ventilated and disconnected

                                                Sats probe not recording


ABGs                                       pH 7.2; pO2 200KPa, pCO2 4.7KPA, lactate 3, glucose 12.2, HCO3 18.8


Cardiovascular:                         Full flow, laminar CPB, aortic inflow cannulae and single RA venous drainage, no vent

                                                MABP 62mmHg, CVP 2mmHg, SR 88bpm



Genitourinary:                            Urinary catheter 500mls in bag






Patient Status

Student learning outcomes or actions desired and trigger to move to next state



Pre Sim room



Team Brief




Stable on CPB

Learner Actions:


Clear introductions with names and roles

Outline of case and intended procedure



Familiarisation and orientation with operative field

Assessment of current physiological values

Communication with surgical, scrub, perfusion, anaesthetic personnel




Teaching Points:

  • Identify all team members / roles
  • Situational awareness










Stable on CPB

Learner Actions:

  • Prepare to wean from CPB
  • Communicates with anaesthetist, pefusionist
  • Pre wean checks complete
  • Team content with plan
  • Clearly communicates plan and actions



Teaching Points:

  • Decision making
  • Communication/Teamwork


Trigger: Completion of checks and agreement with anaesthetist / perfusionist



Stable off CPB

Learner Actions:

  • Post CPB checks



Teaching Points:

  • Communication



Trigger:  1 minutes



Unstable Learner Actions:

  • Recognises changing physiology
  • Communicates with and encourages input from team





Teaching Points:

  • Situational awareness
  • Communication


Trigger: 1minute

4. More unstable Learner Actions

  • Gets attention of team
  • Verbalises problem, options and plan
  • Remains calm
  • Makes appropriate decision and action
Teaching Points:




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