Simulation Transformation

Are you ready to aid a patient experiencing acute contrast medium reaction?

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When I began my career, use of ionic contrast medium seemed to prompt several contrast reactions each day.

Patients were typically treated with antihistamine, a bronchodilator, and in some cases epinephrine. These adverse events were so common that after a few months I rarely became nervous at the prospect of treating such individuals.

Over time, the use of nonionic contrast material greatly reduced the frequency of these events, and my skills for managing them began to wane. Like most radiologists, I dutifully enrolled in didactic sessions to refresh my memory as to the treatment of these events. However, over the ensuing years, even these education sessions began to seem insufficient in preparing us to treat these acute situations.

When I came to Massachusetts General Hospital a few years ago, I was pleasantly surprised to learn of a viable and robust contrast medium reaction education program and simulation training that had been put in place a few years prior. Led initially by Bethany Niell, MD, and subsequently by Gloria M. Salazar, MD, this program reinvigorated my confidence in managing contrast medium reactions by producing real-world simulation exercises that came as close to reality as I could imagine.

Simulation in health care is not new. It is well understood that participatory learning helps build on prior knowledge when encountering an actual situation. Moreover, debriefing following this simulation allows participants to reflect on their knowledge and performance and identify gaps for future improvement. Contrast medium reactions are rare but important medical events for which high-fidelity simulation can improve team-based skills and performance.

In our department, all staff members related to clinical radiological care — including technologists, nurses, residents, fellows, and radiologists — participate in simulation training. Online education materials are reviewed prior to the simulation, and exercises are focused exclusively on real-world clinical scenarios that these practitioners may encounter in routine practice.

A high-fidelity mannequin is the focal point of the simulation exercise. The mannequin is connected to a laptop behind an opaque screen. An operator controls the vital signs and speaks to the medical staff as if the mannequin were speaking directly to them. The simulation room is equipped with a patient monitor and all the other accoutrements that one would find in a CT scanner suite. The practitioners assume their real-world positions prior to initiation of the clinical scenario. For example, the radiologists are working in a reading room adjacent to a scanner and receive a phone call from a technologist informing them of the patient's difficulty following injection of IV contrast material. The radiologists enter the room and must manage the clinical problem at hand. All practitioners in our department are required to repeat simulation training annually, and most believe it is a practice well worth their time.

Having managed many contrast reactions in my youth, I found the simulation exercise to be as stressful as any actual crisis. The simulation staff go to great lengths to replicate the chaos and confusion that sometimes accompany a medical emergency. In a recent simulation, I was flummoxed by one of our radiology nurses who was playing the role of floor nurse accompanying the patient to the CT scanner. As the simulated patient's wheezing began to intensify, the nurse said repeatedly that the patient has these symptoms on the floor 'all the time' and is just given Benadryl. Immediately, I began to question my judgment as this seemingly battle-hardened nurse knew the patient much better than I did. Fortunately, sticking to my guns proved to be the right response; aggressive therapy enabled him to turn the corner.

Earlier this month, I invited William T. Thorwarth Jr., MD, FACR, CEO of the ACR to experience simulation training firsthand. Drawing on his many years of experience as an interventional radiologist and previously as an emergency room physician, Dr. Thorwarth demonstrated expert ability to manage a contrast reaction, bringing his simulated patient back from the brink of disaster with the careful evaluation of the clinical condition and administration of the appropriate therapy.

While we haven't yet realized a plan to extend the benefits of simulation training more broadly, I'm hopeful that we can find a way to bring this experience to a national audience. In the meantime, I encourage radiologists to seek opportunities for simulation training in their practices. After all, an ounce of prevention is worth a pound of cure.

BrinkBy James A. Brink, MD, FACR, Chair

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