Newest addition to the ARHT simulation equipment!

Sim and Choppers

One of my medical education interests is looking at how we train and practice rarely performed procedures. For these situations, simulation offers an excellent method of training. The challenge, however, is recreating the fidelity of such situations since many rarely performed procedures are quite invasive.  Often we’ll start the training with a task-trainer like model and then progress to a full size manikin. Task-trainers are simulation models specifically designed for one type of procedure. 

In emergency and pre-hospital medicine, the cricothyroidotomy is among the most invasive, time critical yet rarely performed procedures. In addition to the potential technical challenges of this procedure, the decision to perform a cric might be even more difficult.  Identifying a “can’t intubate, can’t ventilate” scenario and then to “pull the trigger” may be one of the hardest cognitive leaps we face in resuscitation.  For example, last week, in the  Auckland emergency department we ran an…

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Does every patient who gets pre-hospital needle decompression need a chest tube?

The authors of a recent study tried to answer this question. The authors evaluated patients who got needle decompression in the field using prospective, observational methodology (though I wonder if truly prospective given the lack of data). Anyways, they noted that in their population very few patients (5/52 decompressions) escaped without requiring a follow-up chest tube. Only 1/15 penetrating trauma patients did not get a chest tube.  A few important questions remain including how many of the needle decompressions actually reached the pleural cavity or the technique used for decompression (appears later in Q&A that it was probably anterior axillary line). 

The authors conclude to have a low threshold for chest tube insertion based on CXR however, not shockingly a CT chest will provide more information. This study certainly doesn’t support withholding a chest drain if needle decompression is performed in the field. There was a nice suggesting by another surgeon who commented they leave all the needles in place during CT scan to see if it actually reached the pleural cavity. For the stable patient that doesn’t need immediate intervention, this is probably sound advice. Wait for the CT then make decision based on clinical and radiographic data.

There should probably be further study on this topic but for now, this is all we have! Here’s the abstract below.

Is routine tube thoracostomy necessary after prehospital needle decompression for tension pneumothorax? KM Dominguez et al. Am J Surg 2013; 205(3): 329-332 


Thoracic needle decompression is lifesaving in tension pneumothorax. However, performance of subsequent tube thoracostomy is questioned. The needle may not enter the chest, or the diagnosis may be wrong. The aim of this study was to test the hypothesis that routine tubethoracostomy is not required.


A prospective 2-year study of patients aged ≥18 years with thoracic trauma was conducted at a level 1 trauma center.


Forty-one patients with chest trauma, 12 penetrating and 29 blunt, had 47 needled hemithoraces for evaluation; 85% of hemithoraces required tube thoracostomy after needle decompression of the chest (34 of 41 patients [83%]).


Patients undergoing needle decompression who do not require placement of thoracostomy for clinical indications may be assessed using chest radiography, but thoracic computed tomography is more accurate. Air or blood on chest radiography or computed tomography of the chest is an indication for tube thoracostomy.

The importance of simulation in usability testing and hazard identification


Auckland ED is conducting a lot of simulation training currently, with a recent focus on airway management.

Last week a teaching session was delivered by Sam Bendall (an Auckland HEMS doctor) on ‘intubation as a team sport’, which covered human factors in ED airway management and included the use of adjuncts like airway checklists. While Auckland HEMS has an RSI checklist, a similar tool has not been finalized for Auckland ED – this is under consideration currently. Following that teaching session, several airway checklists had nonetheless made their way into our resuscitation areas.

High-fidelity simulation training took place this afternoon, led by Sam, Mike Nicholls (another HEMS doctor), and Nancy Mitchell (Nurse Educator).

The first scenario involved a relatively junior team undertaking an emergent RSI. They performed admirably, and the outcome in practice would have been safe and successful. As an observer however, it was apparent that an airway checklist would have contributed to their confidence and comfort levels. (My personal opinion is that we should start using a checklist for ALL ED RSIs, independent of team seniority)

While watching the simulation I spotted a checklist taped to a whiteboard on a side wall. I assumed that was the airway checklist, and thought ‘that’s a clever position – it means the airway assistant can read out the checklist immediately prior to the RSI. They haven’t used it, I must bring this up at the debrief’.

At the end of the debrief, I inspected what I thought was the airway checklist, and found this:

HCA checklist

It wasn’t an airway checklist at all, but a restocking checklist!

The actual airway checklist was here…


Tray following RSI (this is NOT how we set up!) Airway checklist bottom left

taped to the top of the airway trolley (logical) but unfortunately covered up by the airway tray, which is removed from the trolley and placed on top when setting up for airway management. This is a good example of a latent hazard.

I found a second copy of the checklist taped to the desk at the entrance to the resus bay – this is where the scribe (usually one of the senior nurses) stays during a resuscitation:

photo(2) copyAlthough this desk is frequently cluttered with paperwork during a resuscitation, accessing the checklist would be a simple matter, and would be done so by a senior person.

After looking at the positioning of these checklists, I came to two conclusions:

1) Simulation is a powerful tool for testing the usability of a new item or technique and identifying hazards

When considering logistics/ergonomics/equipment what actually happens in real life may differ from what we envisage mentally when we introduce something new. Simulation introduces stress, time-urgency, ergonomic elements and personnel elements that can rapidly reveal whether something new is going to be useful or not, or whether its introduction has inadvertently created hazards

2) We need to actively manage the environment we work in

When confronted with a critically ill patient, it is easy to focus on the scenario in front of us (there is usually quite enough to think about there!) and accept the physical environment as it is. By going a step further and ACTIVELY managing our environment to improve logistics and ergonomics we can increase our chances of a good outcome. This can occur both BEFORE we are confronted with a patient (eliminating the latent hazard above, for example) and DURING a resuscitation. This is particularly important in the pre-hospital setting, where both the relatively unforgiving helicopter and roadside environment provide a range of challenges not encountered in a resuscitation bay. As doctors I believe we have a lot to learn from our paramedic colleages in this area.

(NB – if someone becomes angry because that restocking checklist mysteriously disappears this week, I had NOTHING to do with it, nothing at all)