Supplemental Digital Content 1.
LAST SIMULATION SCRIPT
Neal
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You are about to undertake a simulation exercise that involves the anesthetic
management of a patient under your care.
You are also being asked to participate in a study that coincides with this simulation
exercise. If you elect to participate in the study, you will be randomized to one of two
patient management groups. If you elect not to participate in the study, you will still
undergo the simulation exercise, but without randomization.
If you enroll in this study, your performance will be paired with a study participant
number that is not linked to your identity.
If you wish to participate in the study, you must read an IRB consent form and give your
verbal consent to be enrolled in the study protocol.
Neal
Brian is here to assist you. He will provide you with whatever equipment, drugs, or other
assistance that you require. You should interact with him as you normally would in the induction
room. Should you require further personnel, they will be provided.
Please verbalize the actions that you are taking. Please verbalize your thought processes;
otherwise the scorers are unable to accurately determine your responses to the simulation.
The attending anesthesiologists in the room are here to either run the simulation or to document
your actions during the simulation. They cannot assist you in the management of this patient.
The simulation will be recorded only to provide backup documentation should the scorers have a
question regarding your performance. Once these questions are clarified, the video will be
erased.
Hsiung
Your patient is a 73 yr old man who is scheduled for total hip arthroplasty.
The patient sustained an anterior MI 3 years ago, which was complicated by CHF. He currently
reports no angina or dyspnea. Recent cardiac echo is unchanged from one year ago; ejection
fraction is 45%. A recent dobutamine stress test revealed no inducible ischemia. The patient
takes no anticoagulants. The remainder of the patient’s past history and physical examination are
unremarkable.
The patient is in the induction room and has consented to spinal anesthesia with a single-shot
femoral nerve block.
Supplemental Digital Content 1.
Request
Prompt If Not Done or
Verbalized
Pre-Checklist Description of Femoral Nerve Block
Hsiung: Describe how you
will prepare the patient for
FNB
Hsiung: Describe how you
Halpern:
will perform the FNB
 What will you inject?
 What volume /
concentration?
 Describe how you will
inject the local anesthetic
Early Subjective Symptoms and Hemodynamic Changes
Hsiung: The FNB has been
completed. Now describe how
you will prepare the patient
for spinal anesthesia
Simulate
Hsiung:
 Patient becomes restless;
“I feel weird”
 BP and HR increase
 Ventricular dysrhythmias
begin
Hsiung: What is your working
diagnosis?
Given Checklist if Randomized to Receive It
Neal: Give checklist if
randomized to that group
Seizure
Halpern: Ask for dose of all
drugs
Ventricular Tachycardia with Pulse
Seizure stops with treatment
VT with pulse
Halpern:
 Ask for dose of all drugs
 Lidocaine?
 Esmolol?
 Lidocaine?
Ventricular Fibrillation
Halpern:
 Ask for dose of all drugs
 Vasopressin?
 While waiting for lipid,
would you like to give
propofol?
VF persists despite Rx
Supplemental Digital Content 1.
Lipid Emulsion Now Available
Please describe how you will
Halpern:
administer it
 What lipid concentration?
 Bolus dose?
 Would you like to start an
infusion?
 What dose?
What would you like now?
Halpern:
 Repeat lipid bolus?
 Change infusion?
Patient Stabilizes / Transfer to ICU
Hsiung as Intensivist
Consultant:
 Continue infusion (min)?
 What is max dose?
 Monitor—where and how
long?
VF persists despite lipid
emulsion
Subject:
COMPLETES STANDARDIZED SURVEY OF OPINIONS REGARDING CHECKLIST
Neal:
ASK OPEN-ENDED QUESTIONS BEFORE DEBRIEFING
All:
DEBRIEF