“CRM and SBT… just another set of acronyms in the world of medical education? Don’t we already have enough??
Not quite! Rather, Crisis Resource Management (CRM) is a complementary approach to Simulation Based Training (SBT). It can enhance current ongoing medical simulations or provide foundation for a vigorous curriculum when launching new simulation programs.
WHAT IS IT?
Crisis Resource Management is the ability to translate medical knowledge to real world actions, in the setting of an emergency.
Rather than a separate entity from medical simulation, CRM principles can be looked at as a way to focus and shape medical simulation curriculum and especially the objectives of each case to focus upon development of critical skill-sets that contribute to optimal team function and success during crisis.”
Recently I had the pleasure of attending a superb AWLS course in Queenstown. The course was run by a group of intrepid clinicians who decided several years ago to import AWLS from the United States. You can read about the group (and more importantly, book a place on the course!) here:
Wilderness medicine is in may ways the ultimate in prehospital care – it involves providing care to patients in an frequently austere environment with often very limited personnel, equipment, and communications. For emergency department doctors like myself, it also separates us from the security of readily accessible diagnostic investigations.
At its core wilderness medicine represents the same pathologies as emergency medicine, although environmental issues are obviously more common than in our urban ED and regional HEMS (check out this article about some recent lightning strike patients treated in Waikato ED!). The challenges encountered by treating clinicians however are very different, and solutions rely on communication, improvisation, adaptation, clinical judgement, and common sense… plus (of course!) duct tape and a pocket knife.
The course itself included a variety of teaching formats including interactive lectures, group discussions, practical skill stations, and in-situ simulation. The organizers successfully arranged significant rainfall on one of the simulation afternoons – ever tried running a trauma resuscitation in the rain under a tarpaulin? (Credit is also due here to some of the local medical students, who were quite willing to become hypothermic for the sake of medical education)
Without giving away too much of the detail on the course, here are some examples of the material covered:
Single rescuer rolling a trauma patient with cervical spine control:
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Improvised rope sling carry for patient unable to walk
Improvised cervical collar
C-spine immobilization with Sam splint/backpack, alternatively device for restraining combative ED consultant – Logan Stuckey from Nambour
Splinting of fractured femur with ski pole
In situ simulation: Body on the shore – what will you do?
Pre-hospital external warming device (at least, that was the explanation given)
You are in ED when an R40 is received that a young victim of road trauma is enroute. She is hypoxaemic, tachycardic, hypotensive, and combative, and has facial, chest and limb injuries including a mangled upper limb and femoral shaft fracture.
ETA is 5 minutes.
Oh dear. What to do…
Try using the highest fidelity simulator available to you (your imagination) to plan what you might do to prepare for the arrival of this very unwell patient.
In particular, which procedures might be needed? (hint, below is a list of procedures, with internet links, which you may wish to be familiar with PRIOR to her arrival…Another good source of info for procedures is the text book by Roberts and Hedges. We have a copy at staff base, but I believe if you are on the training program this book is subsidized, so is essentially FREE to you. Get a copy from Medical Books, just down the road from AED.)
Be positive! Good luck!
Please note, we probably won’t cover all of these procedures on 30 July.
CRICOTHYROTOMY (thanks to Petro)
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RAPID RHINO INSERTION
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CHEST DRAIN INSERTION (thanks to Mark Gardener)
CHEST DECOMPRESSION AND DRAIN INSERTION – click HERE for many links – LifeInTheFastLane: Own The Chest Tube!
FINGER THORACOSTOMY – Needle versus knife for chest decompression, podcast by Scott Weingart HERE (or click HERE for full show notes and references)
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LIMB TOURNIQUET APPLICATION
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I/O INSERTION
(suggest watching from the 10 minute mark for landmarks)
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PELVIC SLING APPLICATION
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DONWAY FEMORAL SPLINT APPLICATION
(Somewhat weird Smurfs-in-snow version, takes 3 minutes. In the ED we would advocate removing ski boots prior to application…)
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E-FAST ULTRASOUND EXAM
(Some good views demonstrated, although I don’t agree with their comments about not visualising the kidney in the perisplenic view)
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ARTERIAL LINE INSERTION
(check this out from 2.10 until 4.40)
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CENTRAL LINE INSERTION
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PERICARDIOCENTESIS
(Not really applicable in trauma, but still…Also, I think we would generally leave a catheter in situ)
“CRM and SBT… just another set of acronyms in the world of medical education? Don’t we already have enough??
Improving care in ED 