Introduction

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.

 

Template

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

 

Didactics:

• 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

2. Decision making

                                                               i.      Recognises and articulates problem

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

3. Communication and Teamwork

                                                               i.      Keeps team informed about situation

                                                             ii.      Seeks and listens to advice of team members

                                                            iii.      Clearly communicates plan

4. 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
	BIS

 

 

Other equipment required:

 

X	Anesthesia Machine	X	ETT
X	Anaesthetic Pumps		LMA
	Brochoscope		Laryngoscope
X	Defibrillator
	Hotline
	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
Preparation
Simulation
Debrief

 

 

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.

 

STATE 1

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)

 

STATE 2

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

 

Trigger: 1 minutes

 

STATE 3

There is ST elevation, moderate hypotension and increasing CVP.

 

(Candidate should check grafts / consider inotropes)

 

Trigger: 3 minute

 

STATE 4

Profound hypotension and ST elevation

 

INTERVENTION

Recommence CPB / IABP

 

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

 

STATE 5

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