In March of 2010 we carried out an MH drill at my institution. It was an important exercise and we learned several important lessons. Having never performed a formal multidisciplinary MH drill there were numerous logistic considerations that went into the development of the drill and actual performance of the drill. In this blog I will describe the steps that we took to conduct a successful MH mock drill.
First a few words about my institution. We are a large teaching hospital with 18 ORs in the main hospital, a large OR and PACU staff, residency training programs in Anesthesiology and General Surgery (among others). We also have a very active nursing and medical education department and have had some experience with manikin simulation although no centralized simulation center. One of our nurse educators has been using the manikin simulator extensively in training nursing personnel throughout the hospital. Each week the anesthesia and surgery departments have a morning conference at which time the OR and PACU have their in-service program so only emergency surgery is performed. We therefore settled on an early morning drill.
Prior to the actual date of the drill, I gave a talk to the OR personnel and had previously spoken to the surgery and anesthesiology staffs on many aspects of MH. I used many of the slides in the MHAUS drill kit. One of the nurses videotaped the lecture and showed it to the OR personnel on the off-shifts.
In my first meeting with the four nurse educators, we decided that our first drill would be announced and planned. We decided that we would solicit about 10 volunteers from the OR staff to participate in the drill along with two surgeons (one resident and one staff) two anesthesia residents, and one anesthesia technician. Because the entire staff could not fit into one OR, we made room for about 20 staff to stand or sit on the side of the OR as observers and to have the entire drill videotaped. We are again fortunate to have excellent media support for this, but given the modern capabilities for audiovisual recording this could have been done by one of the staff or a volunteer, although the quality might not have been as high. The main purpose of the video was for the debriefing session.
The next decision was the scenario of the drill and to define the goals of the exercise.
The main goal was to train the OR team to respond quickly and in a coordinated manner to an MH crisis. We wanted the OR nurses to be active participants in managing an MH crisis rather anticipating needs rather than waiting to be asked to perform a task. Surgeons, anesthesiologists and OR personnel all have to work together to insure a successful outcome. Other goals were to gain experience in mixing dantrolene, to enhance communication among team members, and to detect problems that might inhibit or obstruct the successful treatment of an MH crisis.
We chose to have the MH crisis begin in the middle of a lengthy breast reconstruction being done with general anesthesia using a laryngeal mask airway (LMA) and a potent volatile anesthetic. The patient had no family or personal history of MH nor other medical problems. We prepared in advance the results of a blood gas analysis and electrolytes that would be drawn during the procedure.
We would have to have the manikin programmed to develop signs of MH, including temperature rise, output of cola colored urine, increased jaw muscle tone along with the other signs of MH. Working with our nurse who uses simulations regularly we worked out a rough timeline for the crisis.
We briefed the anesthesiologists, anesthesia technician and the surgeons on their roles in the scenario without being prescriptive.
We then had to make sure that we had dantrolene available to mix for the scenario. With the assistance of JHP pharmaceuticals we secured several vials of Dantrium IV for injection to be used in the scenario. Other facilities might be able to secure expired Dantrium from their pharmacy prior to return to the company.
The nurse educators then had to work with the volunteer staff to identify the roles they were to play. For this they used the task cards contained in the MHAUS mock drill kit, modified slightly for the institution.
We included representatives from the PACU in the drill because they had to be prepared to manage the patient once the crisis was passed, but did not include ICU personnel.
We could have also included a portion of the drill where the surgeon/anesthesiologist and OR nurse would have spoken to the “family” of the patient who experienced the crisis, but decided that that could wait for another time.
One logistic issue is what term to use when the drill was announced and whether the overhead paging system would be used. We decided to use the overhead page and to announce “MH in OR 1”.
All of these decisions required three meetings and as well as discussions with our media person and the others on the team. The manikin programming had to be set up and trialed in advance and because the manikin we use weighs about 200 pounds help had to be obtained to move the manikin on the day of the drill. In addition, the drill had to be completed in less than one hour in order to make room for the regular OR schedule to begin.
On the day of the drill, our video team and simulator expert arrived very early to get everything in order. I gave a brief explanation to the OR staff of the need for the drill and what we were planning to accomplish. Each of the participants identified themselves to each other and explained what they were going to do in the drill. For example, one person was tasked with getting ice to place on the patient. Most of the OR team was in an adjoining OR and able to view the OR where the drill was taking place via broadcast of the event into the second OR. Had that not been possible, the event would have been videotaped for discussion at a later time.
We originally hoped to run the drill, review what happened and run it again, but we did not have time because of the logistics of staging the drill.
The actual MH drill went smoothly enough, but we learned a few things that we did not anticipate. When a call was going to be placed to the MH hotline, it was discovered that the phone in the OR did not give access to an outside line. So, fortunately a cell phone was used. Communication of events as the drill proceeded was sometimes difficult because of the many people in the OR and background noise of many people trying to tell others what they were doing. We found that it was essential to have a second anesthesiologist because nurses not trained in ACLS were not permitted to inject medications intravenously and the first anesthesiologist was communicating with the hotline as well as changing anesthetics (the technician had to set up a propofol infusion). In order to open the top drawer of the MH cart we were using, the seal on the cart had to be broken and a latch flipped over. The nurse did not realize that the latch had to be flipped and therefore, had to ask one of the assistants to obtain a foley catheter which was in the top drawer. Fortunately the dantrolene was not in the top drawer. These problems were subsequently corrected.
The participants did manage to diagnose the MH event, to have the MH cart brought in the OR (as well as the cardiac arrest cart, which was not in the script), administer dantrolene, call the hotline, draw arterial blood gases and electrolytes, and treat hyperkalemia. Because the case was being done with an LMA, the anesthesiologist had to intubate the patient and struggled a bit with jaw stiffness. The patient survived!
It so happened that the next week a grand rounds program for both the anesthesia and surgery departments had been arranged, but at the last minute the speaker cancelled. We therefore took the opportunity to have the OR team join the anesthesiologists and surgeons to review the video and discuss what went right and what could be improved.
The discussion was again videotaped for replay for nurses on the off-shifts.
Those of us who planned the drill found it to be a useful exercise in team training and making the OR staff more familiar with the management of MH and the need for coordinated efforts among all the clinicians who work in the OR.
Furthermore we realize that the drill needs to be repeated periodically in order to prepare more members of the OR staff for managing an MH crisis, although in the future the drill would be run with a subset of the OR staff rather than the entire OR staff trying to view the drill in real time.
Finally after doing the announced drill several times, it will be time to do an unannounced drill.
In addition, we will add components to include discussion of MH with the family and include advice for them for follow up care as well making sure PACU and ICU personnel were aware of the continuing care of the MH patient.
Of course I am biased having played a large role in preparing the MHAUS mock drill kit, but I found that having a suggested scenarios and detailed task cards allowed us to organize, plan and conduct an effective MH drill in preparation for the real thing. In addition the video contained in the kit allowed the organizers to have an idea of how a well run drill would take place.
Team training is complex and requires planning, coordination and constant reevaluation. Malignant Hyperthermia is a perfect example of why the OR team needs to have a plan and drill in managing a complex, emergent medical emergency. We learned much and realize that these drills need to organized at least once per year, particularly with a large OR staff.
If you have conducted an MH drill and wish to share your experiences with others, please fee free to do so.
In the next blog I will give you a review of the MHAUS scientific conference in Pittsburgh.