Flowcharts, tickboxes and more

Expanding on the idea of improving my focus as the sim provider on measurable objectives, I have been thinking about how I write scenarios and looking at how others do it. I recently came across two disparate but well done examples.  the flowchart idea is from the Oxford Deanery simulation scenarios, using flow charts to give options about how easy to hard the scenario progresses to.


The other detailed tickbox approach which uses an internal cascade of modifiers and triggers is from emsimcases.  Is this approach too cluttered – the OCD part of me likes the many tickboxes to ensure I am assessing objectives as ways of measuring progress towards the goals of the simultion.


Encouragingly both of these cases are available as a creative commons licence – great work FOAMed teams!



Objectives in scenarios

With a recent scenario we realised in debrief that we are not using PPE.  Participants are not putting on gloves or glasses before engaging in the scenario.  I then realised on reflection that as the sim provider, I am not identifying this in the scenario and the reason I am not identifying this is poor creation of objectives in the sim scenario.  Goals are the attainable, relevant aims for the scenario. Objectives are the measurable items that confirm the goals are being attained.  I have also seen this called “expected care”, such as in this template for scenario design from SMACC Chicago 2015. gant-nitrile

This then flows onto other items in the scenario, time to CPR, time to AED, checking pad contact and other markers of quality care.  Especially as an occasional sim provider,  creation of checklists in the scenario writing should help me ensure we are actually meeting goals and then objectives.

In scenarios from the simtech, objectives are further broken down into Knowledge/Skills/Attitude & Behaviours.  This seems like a great approach however a significant ramp up in being able to observe and record this all across a scenario.

Thinking about this more overnight, I also need to bring in different objectives for different members of the team.  Being medical, this is my focus however integration with goals/objectives for reception and nursing would make this work more applicable to them and hopefully foster engagement.

in situ simulation as orientation

One powerful facet of in situ simulation that self-evidently cannot be done elsewhere is orientation to a new practice/clinic. Today I was covering foreign body removal with the two new registrars who have just rotated in to our clinic one week ago.

Rather than collect all the items needed for the tutorial myself,  it is more useful for them to find the eye box, loupe, amethocaine, flouroscein and bring them to the room. Then run through the examination, foreign body removal and disposition as a short scenario with a debrief. Now the registrar has had some practice on a task trainer and is orientated to the practice resources.

The eyes in place, last piece of tape about to be applied

The task trainer was made with peeled grape eyes with 100’s & 1000’s (cake sprinkles) as FB that leach out a food colouring “rust ring”.  The grapes were held in place with modelling clay and tape.  The tape has been partially folded back on itself to create an eyelid that can be everted. Ey1

CRM/human factors eBook from Canada as FOAMed

CoverThis short eBook of 90pages is packed with digested information on working memory, situational awareness, communication approaches and teamwork tips.


There is an interview with one of the editors Peter Brindley on the RAGEpodcast.  Thanks to the Royal College of Physicians and Surgeons in Canada for making this available online in the spirit of FOAMed.

Role cards

In an idea taken from Dr Jonathan Gatward’s site mobilesim, I modified his two minute action cards for our GP setting.

My modification of Gatward’s hospital based cards for a collapse/CPR scenario

The idea behind the cards is to force team roles onto participants as a way to shake up what may be established hierarchies in the team.  In our setting, the registrars look to the senior GPs to lead scenarios.  By giving them a particular card, I hope to prepare them for that role in the team and provide some quick aid memories to that role.

This seemed to work very well and I will continue to use this to create some rotation of roles in the team.

You can download my cards as pdf or powerpoint from dropbox here.

Nursing and Medical Students in interdisciplinary simulations – a good paper

One of the benefits of ISS I appreciate in general practice is getting GP’s and registrars working with the practice nurse, reception staff in an impromptu multi-disciplinary team when we practice our simulations.  This is quite the difference from often working away in our own areas of the practice, interacting only on single tasks.


This study from Sweden was conducted with simulation laboratory sessions involving both nursing and medical students concurrently.  Scenarios were common ward problems – confusion, breathing problems and vasovagals with the two groups having to work together.  Their debrief flow was vent / what went well / what did not go well / what to change, so a sort of Pendelton’s sandwich however with that vent at the front to get all the jumbled thoughts and feelings out first.  I plan to try this next time with explicitly asking learners to ‘vent” at the start of the debrief and then use a more structured debrief (I tend to use diamond).

OD in the car park!

Last month I attended a real OD in the carpark at our GP clinic. The unresponsive man’s friends notified our reception that he had dropped and I attended, gave some basic airway support, IM nalaxone and then handed over to Victoria Ambulance. I attended that with my Conover-style everyday pack but other doctors were talking about what to do for another OD or multiple casualties, could the emergency trolley get there, how many people would we need –  so I offered to organise an in situ simulation to explore these questions.

Simple Laedal Little Annie with opportunity store clothes sewn around towel leg/arms. Bluetooth speaker inside with stertorous breathing MP3

Props were syringes with some flash back blood in the hub, pharmacy bags and drug baggies.

The staff were all given warning – unexpected sim I do not feel would really work in the GP setting. I generally run these in the registrar teaching time so I know they are free and the supervisor teaching them.  I then also block out the practice nurse for that first 30min of the day and notify the reception staff. I put up signs at reception and for this one in the car park around it “Medical Emergency Training” so no one is alarmed.  As other people report about in situ simulation, patients are interested and respectful of you demonstrating skills upkeep in the usual clinical space.

Before hand, I provide a preamble to the staff about the focus of the scenario and some background. Opiate Overdose in the Practice. Then I write or adapt my running sheet as a reminder about manipulating the blue tooth speaker, monitor vital signs or other changes.

We ran the team through – two registrars, one GP supervisor, the practice nurse and myself as the simulation educator.  A quick clean up and then debrief in the tea room  saw us use the first 30minutes of the day very fruitfully.