6 e-Letters

  • The ethical imperative of psychological safety in healthcare. In response to the Manifesto for healthcare simulation practice.

    We read the Park et al. Manifesto for healthcare simulation practice1 with great interest and present this commentary to prompt continued discussion.

    The effects of the pandemic are widespread throughout healthcare and health professions education. In the Manifesto, the authors implore simulationists to “adopt a commitment to comprehensive safety, to advocate collaboratively and to lead ethically.” They emphasize working remotely and fear that some simulationists’ “calls for safety are overlooked or even disregarded by their own institutions.” We emphatically agree that healthcare simulationists should inform clinical and educational leaders about safety, collaborative advocacy, and ethics during the current pandemic and in its aftermath.

    The article suggests that standardized patients (SPs) may not have an empowered voice to speak up if they feel unsafe in the learning environment and that SPs should have the same psychological safety as learners and patients. We agree with the authors that psychological safety for all simulationists, learners, and clinicians is imperative to the health and wellbeing of learners and patients.

    The Quadruple Aim of healthcare suggests a thriving, well-trained, and fulfilled workforce provides better care for patients.2 In this unusual time, there is an essential tension among the competing priorities of professional safety, service, duty, and satisfaction. We simulationists have spent decades demonstrating how rigo...

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  • Remote OSCE for final years at University of Buckingham due to Covid-19 pandemic

    We were interested to read about your use of a Web-OSCE to enhance clinical skills training via Zoom for third year medical students in Qatar. In the UK, medical schools have also been forced to change teaching and assessment practices due to Covid-19 and at University of Buckingham we have held a summative OSCE online for three final year medical students.
    The main cohort of final year students was able to take a shortened, amended OSCE in March 2020 before lockdown with the transfer to a non-clinical site and the use of simulated patients instead of real patients. However three students needed to take the resit OSCE at the end of May and due to the social distancing and the fact students had in some cases returned to their home countries and could not fly back to the UK, we decided to convert this to a remote OSCE (rOSCE).
    We used Microsoft Teams as the online platform due to its versatility and availability; it is free to download and works on most computer hardware. Each student was assigned a ‘channel’ on the Team and allocated an invigilator. Unlike the experience in Qatar, the students remained in the channel and the assessors and simulated patients circulated and we were able to run eight 15-minute stations in this way. As in Qatar and other settings (1) it was not possible to test practical procedures or clinical skills however these had been assessed at other points in the course. We were able to assess high level skills in these final year students...

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  • Simulation For Clamping of The Endotracheal Tube In COVID 19

    We read with interest the article by Ahmed O et al1 regarding simulation training during the coronavirus pandemic. We would like to congratulate the authors for the same. The time since simulation training has been introduced for learning anaesthesia skills, it has increased the success rates when the procedures are performed on patients after practicing on simulators. We would like to stress on the point that although simulation training improves the success rate for all procedures, but special recommendations which have been specially added for anaesthesia management during the present pandemic needs extra attention like donning doffing of the PPE kit and clamping to unclamping of the ETT (points 17-20)
    It is a well known fact that clamping of the ETT increases airway resistance and changes the dynamic compliance of the lung.2 If the total process of clamping till unclamping is prolonged, it can lead to adverse effect on the lung dynamics, in an already compromised COVID 19 patient, showing ARDS type features. If the total time of clamping is increased the cuff needs to be deflated prevent the increase in airway resistance, thereby increasing the chances of secretion drooling and hampering the whole purpose of clamping. It is essentially important to complete the whole procedure within a short time span. In present COVID situation the results may not be as anticipated as number of assistants will be limited, and anxiety of operator will be high. Simulation will be...

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  • Simulation COVID-19 Intubation Checklist

    We read with interest the report by Ahmed et al1. "Anaesthesia simulation training during coronavirus pandemic: an experience to share". The authors developed A metric-based checklist steps of induction of GA, tracheal intubation, intraoperative management, tracheal extubation and patient recovery in the context of treating patient with covid-19. A supplemental video was used as learning method for the involved health workers. Although the investigators initiate that their clinicians improved their performance during simulation training, they could not consistently addressing all concerns. 1) it is not clear at what flow rate O2/min that preoxygenation should be delivered. Defining such flow is crucial to minimize viral transmission2. 2) the preparation/management between two cases of COVID19, ( e.g soda-lime canister changes; the necessary time pause between cases…),was not notified in their training sessions. Adding such guidance to the checklist would ensure more supplementary protective measures.
    On the other hand, the video showed nicely all training steps, including the using of the glidescope as videolarungoscope (GVL) tool for endotrachel intubation. It is well known that due to the curvature of the GVL blade, a stylet must be used to position the endotrachel tube (ETT) tip at the glottic opening especially in suspected difficult airway3,4. The using of stylet facilitate a quick-pass first-attempt tracheal instrumentation5 .However, in the record...

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  • On-line lessons learned post Covid-19: mater artium necessitas

    We read with interest the article, Preparing and responding to 2019 novel coronavirus with simulation and technology-enhanced learning for healthcare professionals: challenges and opportunities in China (1) echoing the old adage ‘necessity is the mother of invention’ in relation to remote-site clinical education. Disruption to all levels of education have sparked initiatives as described by Li et al and have exposed the stark lack of a global coordinated mitigation plan. Lessons learned during the current crisis will re-shape our view of traditional clinical teaching theory and delivery. Distance learning is likely to become the norm in the post Covid-19 era and innovative simulation tools are set to enhance these platforms (2).

    Our experiences in ophthalmology reinforce the notion that pedagogy follows technology in producing robust, validated and clinically relevant higher level education in the surgical specialties (3). We foresee a growing global imperative to ensure continued development of cost-effective, accessible, high quality alternatives to on-campus face to face clinical learning to supplement, and in some cases supplant current programmes. These are likely to include asynchronous discussion boards, reflective e-portfolios, remote site assessments and developing home microsurgical simulators (personal communication, Brennan P). Covid-19 has revealed, on a global scale, both our human frailties and resilience.

    Notwithstanding the tragic human tol...

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  • Shoulder Dystocia Simulation Can Change Outcomes

    We congratulate Kim et al on developing a shoulder dystocia training program that included video instruction, a didactic portion and a simulation training session including force measurement, followed by a study aimed at evaluating the impact of the training on actual clinical outcomes.1 Their observed two-fold increase in shoulder dystocia incidence is consistent with some other studies,2, 3 and more in line with prospective clinical studies that report an incidence of ~ 4% among term vaginal deliveries.4, 5 It further suggests improved recognition of shoulder impaction in the final stages of delivery in the clinical setting following simulation-based training.

    Ultimately, the patient safety goal of shoulder dystocia simulation training for should be the reduction in shoulder dystocia-associated brachial plexus injuries. We would be interested to learn if there was a higher correlation between brachial plexus injuries and shoulder dystocia after training than before.

    Compared to other force training studies, Kim et al did not find a similar decrease in brachial plexus injuries.6-8 We offer a hypothesis as to why that might be.

    We believe that demonstrating what 100 N feels during simulation, even with admonishing the trainee not to use that much traction, is not effective at reducing injury. One reason is that memory of that much traction once experienced is short-lived, and clinicians tend to underestimate the traction they apply during a difficu...

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