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, 2013. 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 13th, 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.
• 93.25% of the participants were comfortable using a team approach.
• 87.50% of the participants felt certain they could perform the
procedure/techniques for an emergency thoracotomy following the hybrid
simulation.
• 81.25% 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 interdepartment 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???