Emergency Department Thoracotomy: A Hybrid Simulation With A Clinical Outcome

Actual ED Thoracotomy Footage

Relevance: At Riverside Methodist Hospital, emergency thoracotomies are not an everyday occurrence. Emergency thoracotomies are more common in urban hospitals. Training on this high stakes, technical skill only occurs when such a case presents to the ED. Because of the rarity and the speed at which this skill needs to be demonstrated, true training on emergency thoracotomies is minimal. Therefore, alternate training methods and frequent skill practice opportunities are of the highest importance. Like any skill that doesn’t get used often, they can be lost or forgotten.

Target Audience: General surgery residents, emergency department physicians, registered nurses, and other emergency department staff.

Measurable Objectives: Fabricate a team approach to emergency department thoracotomies. Educate general surgery residents in identifying the indications and procedures for emergency department thoracotomies. Decrease the plethora of confusion and anxiety associated with performing emergency thoracotomies. Increase understanding of roles and responsibilities and general knowledge of equipment and procedures related to emergency thoracotomy management.

Background: The hybrid simulation was created by Ohio Health Experiential Learning and was a culmination of resources from both Doctors Hospital and Riverside Methodist Hospital. Due to the necessity of inter-department and interdisciplinary communication and management of resources needed to effectively perform this procedure. Experiential Learning Medical Director, Trauma Program Manager, Emergency Department Coordinator, Emergency Department Charge Registered Nurse, and the General Surgeon worked collaboratively to develop the educational content and coordinate this training. The team was facilitated by an Experiential Learning Simulationist as Project Lead. Initial program development began on November 20, Planning took copious meetings and required a team effort to build and implement. Successful implementation and execution of the thoracotomy lab occurred only three weeks following our first meeting. The event took place on December 13 th, 2012.

Methods Participants included 30 general surgery residents, 3 physicians, and four registered nurses. Following the lecture and discussion, residents participated in a trauma scenario allowing each to assess and treat the simulated patient. During this lab time, residents were able to properly identify the indications and procedure to successfully perform an emergency thoracotomy. For the third portion of this session, residents were split up into five groups; each group with a combination of graduate residency years. Groups rotated from the Center to the Riverside Methodist Hospital Trauma Bay, where they were able to carry out an actual thoracotomy on a cadaver. This session allowed residents to simultaneously practice, the procedure and identify the exact location of necessary equipment.

Methods Continued: The cadaver practice was video-casted live from the Emergency Department to the Center for observation, discussion, and debriefing. Training scenario for simulator and cadaver practice: Middle aged male brought into the Emergency Department by EMS. The patient sustained multiple gunshot wounds to the epigastic area and needs assessment and treatment.

Findings: 93.75% of the participants felt confident that they are able to recognize the indications for a thoracotomy % of the participants were comfortable using a team approach % of the participants felt certain they could perform the procedure/techniques for an emergency thoracotomy following the hybrid simulation % felt the hybrid simulation enhanced their ability to apply the course objectives. Overall, 81.25% felt the course met their learning needs. Using the cadaver was helpful; however, participants commented that a fresh thorax would be more realistic in this type of training. Performing the thoracotomy in the trauma bay versus an anatomy lab made it more realistic. Approximately 5 days following the training, one resident, who attended the lab, actually performed an emergency thoracotomy after learning that the attending emergency physician would not be able to respond.

Findings Continued: Emergency Department Nurses felt more comfortable locating proper equipment and helping with the overall procedure. ED RN’s gained self efficacy from not being notified in advance about the lab and having to take their appropriate role immediately. The attending physicians felt that the hybrid simulation was an effective and creative method to teach residents this low frequency, high stakes skill.

Resident Statement: The resident stated “while placing lines in the trauma room, the patient lost his blood pressure and all pulses. He was immediately intubated and a quick decision was made to perform an emergent thoracotomy. During the procedure, one blade from the chest retractor fell off; however, I was able to correct it without delay. The resident recounted that he heard the instructor’s voice in his mind throughout the procedure.” As a result of the procedure, the patient regained a blood pressure and pulses and was rushed into the operating room.

Conclusion: Training using hybrid simulation, in a controlled learning environment, can create a comfortable atmosphere for technique and process practice regarding infrequently used skills. Specific emergency situations such as thoracotomies, offer minimal opportunity for practice and instruction, yet require immediate, often unsupervised action. This training has proven to be beneficial for all participants. It provides the ability to efficiently recognize case sensitive indications and procedures, as well as, help to build an inter- department team with effective communication processes. As demonstrated through the resident experience, this type of training presents a chance to save a life; transferring information learned through hybrid simulation into real clinical outcomes.

Questions???