December 2017 | Issue 33
A simulation in real life

byline nicholas lee (Custom).jpgBy Nicholas Lee, Class of 2019


It was the second day of my first Year 4 clinical posting in Emergency Medicine. I was out riding the ambulance with the paramedic team. The week before was filled with simulation, skills practice and Team-Based Learning sessions in preparation for our posting. The ambulance was a new environment for me and the “turn-out” alarm never failed to set my heart racing.

The alarm sounded: we were called to respond to a patient with drowsiness.

When we got to the house and saw the elderly man lying on his bed, the paramedic’s instinct alerted her that his condition was particularly serious. She picked up her pace and we assessed him quickly. He had been sick for a few days, getting drowsier over time. His family called 995 when he became unresponsive.

Suddenly the patient stopped breathing. The paramedic immediately reached for the bag-valve-mask resuscitator. I checked the patient’s carotid pulse and she noticed I was struggling to feel one. “You can’t feel the pulse?” she asked and checked to confirm.

The patient was in cardiac arrest. “Do you want me to start CPR?” I asked reflexively. We quickly assessed his rhythm with the AED (automated external defibrillator) and found that he was in pulseless electrical activity (PEA). The AED pronounced, “No shock advised”. Someone from the team leaned over the patient and commenced chest compressions. The paramedic secured the airway with an LMA (laryngeal mask airway) and instructed me to insert an IV line while the medic in the team quickly prepared adrenaline and primed the line.

“Ma’am, your father’s heart has stopped,” the paramedic said to the patient’s worried daughter. “We are going to do everything we can for him.” We rushed him to the hospital, taking turns to do chest compressions, “bagging” (ventilating a patient with the bag-valve-mask resuscitator) and adrenaline injections. Once we reached the hospital, the Emergency Department (ED) team took over. Unfortunately, the patient was later pronounced dead.

I spent the rest of the week reflecting on my first cardiac arrest. Two things really stood out. Firstly, I was surprised that I managed to retain my composure working with the ambulance team. I can be very nervous when faced with difficult or unexpected situations. A cardiac arrest is something I had never encountered, and instead of feeling lost, I remained composed and was able to focus. I knew the sequence of the resuscitation.

Secondly, I was glad that I contributed to the team. I was the most junior member and I had only known them for six hours, but they made me feel welcome. 

My mind returned to the week before, when we had our ACLS (advanced cardiac life support) simulation. We had worked in small teams to manage different scenarios, played the role of leaders, doctors and nurses to manage a range of critically ill patients in the resuscitation room. The scenarios were rigorous and realistic, and we were left to manage the ‘patient’ – a high-fidelity mannequin – independently, with our tutor supervising and facilitating the session at arm’s length.

I have taken simulation for granted as a part of my curriculum and previously held the sentiment that it is not very realistic. What I learnt from this experience changed that: simulation bridges the divide between reading ACLS in the textbook to its deployment on a real cardiac arrest patient. Managing a patient independently in the simulated resuscitation room helped me to translate algorithms into actions, identify and correct my knowledge gaps, and build my confidence before interacting with real patients and other members of the healthcare team: work-based learning and applied knowledge that would stand me in good stead when faced with a cardiac arrest.

I grew a lot through the opportunity to take charge and make mistakes as part of my training, and to take responsibility for “patients” in a simulated setting before becoming a house officer on night calls. This newfound competency was also key to enabling me to integrate and apply my skills in the setting of a new and unfamiliar team. Having been well-trained individually meant that we worked well as a team even without having worked together before. It afforded a fluidity and synchrony in the team dynamics.

This is analogous to sports, where teams do not practise and improve by just playing the game over and over again. They break up the practice and sport into smaller drills that do not represent the whole sport, but grow specific skills and qualities discretely to improve the individual and come together to integrate such that the team’s overall competency is greater than the sum of its parts.

Simulation is the discrete training that may be tempting to write off as unrealistic, but has been integral to my medical training. I am grateful for the opportunity to learn through simulation, and much more for the dedicated faculty who have invested much of themselves to form and mould me as a medical student, with simulation just one of the many means. My gratitude also goes to the paramedic team who inspired me with their professionalism and who were in every way, an exemplary team of healthcare providers.