“Total Immersion” Simulation…..!!

The Auckland Rescue Helicopter Trust (ARHT) works with multiple agencies, including NZ Defence, and has the good fortune from time to time to train alongside these groups.

On the 14th May we were invited to train in the ultimate in-situ simulation venue – the Royal New Zealand Navy Damage Control School with the RNZN Sea Safety Training Squadron. This involved fire training and vessel damage control (for this read blocking lots of holes letting water into a ship simulator…!)

Present were 5 ARHT crewman, our physical instructor, and several representatives from the New Zealand Police Search and Rescue unit.  I went along as the HEMS medic representative and to get an idea of how in-situ simulation is conducted in other services.  It was the epitome of a multidisciplinary team!

We started with the Fire-Fighting Training Unit (FFTU). After instruction of the use of the differing methods of fighting fires, donning fire-retardant suits, gloves and masks we firstly made up our own foam fire extinguishers, then used them on a gas fire. We also did the same on oil and diesel fires with fire blankets, CO2 extinguishers and lastly dry powder extinguishers.



We then moved on to the Damage Control Training Unit (DCTU).  After some brief instruction on ‘shoring up’ methods (how to block leaks in the ship), we moved into the unit for a tour before the real fun began. The DCTU is a faithful recreation of a section of a ship three decks high.  It is used to train Navy personnel in Damage Control (leak stopping and removal of flood water) and casualty evacuation. The DCTU uses hydraulics to simulate the rocking motion of a ship at sea; this enables students to experience the problems which can arise from the combination of motion and free surface water.

navy                                                               (The Simulator is is the background of this picture)

I was appointed team leader for my team of 7 – I was reliably assured this was due to me being small (5′), mouthy and Irish… It was a rather daunting prospect.  Even with the training and experience I have in a leadership capacity; I was now leading a team of people in something that I had no prior experience or knowledge of.  Add in the team-mix as described above, then lock us all in a confined space, with freezing cold water pouring (under massive pressure) in through multiple holes in the walls, roof and floor, plus darkness, smoke, noise and the motion of a rocking ship – doubly daunting…

Not surprisingly it was extremely difficult to keep overall situational awareness – I did most of the team leading being “hands –off”, but with my backside blocking a leak in the wall!  Despite this the team worked together brilliantly. We had allocated roles beforehand.  There was great use of closed loop communication, once a job was done those free returned to the team leader for further task allocation.  We managed to shore up all the major leaks in the engine room (where we started) then moved to help the second team out in the mess hall with further leaks.  We finished in waist deep water (waist deep if you were 6ft tall that is…!).

Escape was though an overhead hatch, weighed down by water from leaks in the decks overhead – again great teamwork was put to use getting the stronger team members up a rope ladder first to open the hatch against pressure and then help the rest up through the subsequent torrent of water.

There are cameras all through the DCTU – everything was filmed, the footage is then usually viewed in a de-briefing session following the scenario.  Unfortunately due to time constraints we didn’t manage to see the footage from our exercise.

A few colleagues were wondering what exactly an emergency medicine / HEMS doctor was doing on a Navy damage control exercise as (to quote) “it’s not something you’ll ever need to do… the ED is hardly going to sink…”.  However I feel there were multiple comparisons to this training and what we do every day in the workplace, be that in the ED or on the helicopter.  In-situ simulation aside, today proved an invaluable crisis resource management and team-building exercise for the ARHT group.  14 people from different services, with differing physical attributes and prior experience working together in a completely alien environment, doing something they have never done before…  It suddenly dawned on me this was no different to your usual gnarly trauma resuscitation crew on an ED night shift, except with maybe a few more lives at stake!

For more insight into how other high-performance services train to mitigate for the “fallibility of the human mind under great pressure” and how this can be translated into healthcare, see this post from the blog Resus Room Management. This has a link to the BBC Horizon documentary “How to avoid mistakes in Surgery” where Kevin Fong (a well-known Anaesthetist and Intensivist from the UK) explores human factors in medicine.

I would like to thank the instructors from the RNZN Sea Safety Training Squadron and also ARHT crewman Ati Wynyard for organising this very worthwhile training day.

ARHT Surgical Airway Skills Session

One of the challenges of resuscitation and pre-hospital medicine is that there are multiple high-risk but rarely performed procedures that clinicians must be ready to perform. The difficulty is that we may go our entire careers and only perform them once or even more likely never. However, the difference from success and failure for these procedures can mean life or limb. Consequently we must remain competent despite the challenges with practice.  There is an excellent article that articulates these issues by Cliff Reid & M Clancy which I highly recommend reading (for anyone interested in the topic).

(a primer video I integrated into a recent cric teaching session to get our participants into the mood!)

These life-saving, rarely performed procedures happen to be an interest of mine. It’s a fascinating exercise in education and cognition to maintain competence in performing these procedures yet have virtually no real-life patient practice. The likely result is that clinicians are not competent or they do not remain competent in performing them. More optimistically, some clinicians will maintain their skills through simulation. However, I would bet that a survey of most staff emergency physicians would reveal virtually no hands on practice of many of these life-saving procedures. One of the most talked about and important of these procedures is the surgical airway (or cricothyroidotomy). This is only performed when a patient who requires emergency airway management but they cannot be intubated or ventilated. For most of us, we’ll go through our careers never performing one. But every time we intubate a patient, there’s a risk that this scenario could develop and we’ll have to act accordingly.

At ARHT last week, I ran an inter-professional session for the paramedics, doctors and crewman on surgical airway performance (or cricothyroidotomy). The goal was to integrate our new cricothyroidotomy task trainers into the educational curriculum and combine them with some group discussion and simulation. For those looking to do replicate the event or simply looking for ideas, I will outline our session.

In addition to the introduction of our new task-trainers we also used this opportunity to review our performance of surgical airway. From an educator’s perspective, the most important step for success of this session is preparation. Those who know me, know that I’m not a detail oriented person but planning for everything from big picture stuff to the smallest detail can make a huge difference. In an effort to encourage the sharing of information (FOAMed) I’ll describe our itinerary.

Before the session I sent 2 emails. Our group is relatively new to the flipped classroom, or sending material first then promoting discussion within the classroom/learning site. Something I took home from SMACC 2013 is start with videos (easy to digest material) if you’re implementing a flipped classroom approach for the first time. A follow up email was sent with the videos again and this time along with 2 articles:

  1. Cricothryoidotomy bottom-up training review: battlefield lessons learned
  2. Emergency Surgical Airway: 24 successful cases leading to a simple “scalpel-finger-tube” technique 


  • The learning outcomes were outlined
  • The MOST important aspect was to outline the ground rules and expectations. In our case, we were not using this session as an evaluation but instead as an opportunity to practice and engage our entire team. If you are evaluating learners, let them know!
  • We used  both task trainers and simulation to ensure an environment that promotes psychological safety  and learning for all participants

Content Presentation (using powerpoint)

  • I kept this short – about 20min so that everyone remained engaged (some of our doctors have fairly short attention spans!)
  • Review the indications (contraindications…not really any), complications and considerations in performing a surgical airway
  • Review the controversies regarding surgical airway (more to come on this in a later post)
    • preferred technique (surgical vs. percutaneous)
    • vertical vs. horizontal incision
    • team positioning
    • Integrated 2 videos – the impact of engaging the audience is impressive…especially when you have the luxury of using some pretty amazing footage
No better way to encourage participation than some pointing and asking people directly! (not my finest picture during a lecture...)

No better way to encourage participation than some pointing and asking people directly! (not my finest picture during a lecture…)

Task Trainers

  • We had 3 stations of task trainers with inter-disciplinary teams (paramedic, doctor, crewman)
  • Teams rotated every 15 minutes
  • Station 1 – pediatric needle airways
  • Station 2 – open/surgical cricothyroidotomy using a variety of tools & instruments
  • Station 3 – participants were blindfolded, relying on their tactile sense and team communication to complete the procedure
Our cric station set up. A variety of equipment that allowed participants to try various methods

Our cric station set up. A variety of equipment that allowed participants to try various methods

Our crew practicing a surgical airway on a task trainer

Our crew practicing a surgical airway on a task trainer

Several participants trying out a needle jet ventilation technique

Several participants trying out a needle jet ventilation techniqu

Brainstorming session

  • While we already have a cric kit in our packs, we used this opportunity to discuss the equipment that participants used in the task-trainer session
  • Then we packed a cric kit following this discussion (based on consensus) for a team to use in the next section – an outdoor simulation
  • This usablity testing allowed participants to directly observe their decisions for kit composition in practice!


  • 3 volunteers (crewman, doctor, paramedic) representative of our duty crew at ARHT
  • Participated in a simulation of a patient with a trapped patient, unable to be extricated and deteriorating mental status and respiratory status. There was considerable
Debriefing after the manikin was successfully rescued from under the trailer! He got a cric and was ventilated by our team! Disclaimer...no manikins were harmed during this educational session (except a few cuts to their necks)

Debriefing after the manikin was successfully rescued from under the trailer! He got a cric and was ventilated by our team! Disclaimer…no manikins were harmed during this educational session (except a few cuts to their necks)


  • Debriefing of the simulation and the entire day
  • We used this opportunity to ask participants what equipment, methods and preferences they would like integrated into our standard operating procedure

This entire process included usability testing for participants – allowing them to use different techniques & equipment they may otherwise not try.  This also provides an additional opportunity for inter-professional education that is extremely important for such a high risk, rarely performed procedure. Proper planning and training for all team members involved will only make the process better.