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Thoughts From A Clinician

Thoughts from a Clinician:DO YOU DRESS REHEARSE?

 december 2011 rotator 3 ICC Simulation




Any professional actor, actress, or performer will tell you the most important part of their job is the dress rehearsal.  It makes sense…right?  They go, in full costume garb, and perform as if there’s a full audience, with one major exception – there are no paying customers watching!  They do this to perfect, in every way, their show; assuring that the customer will be fully satisfied.  This logic also applies to the critical care provider.  Are you doing it?  I challenge the current provider to ask themselves – Am I “dress rehearsing”?  If yes, then “how often” and under what circumstances?  If not, why not?  Are we practicing for the main stage?  Let’s put on our EMS shades and take a look at how this applies to us.  Current providers are the performers; our stage – the patient’s living room; the audience – our patients.  Stop and think about this…and then continue reading!

Too much training is still being done without simulation.  The value added component of simulation is nearly immeasurable, especially for the critical care provider.  As common place as it has become, simulation still gets the hairy eyeball from some.  Perhaps the pushback comes from cost of simulation or simply the available resources to do simulation training (1).  How do we combat this kind of pushback in our own shop?  How do we influence the training and education to assure that simulation is included?  Do we start weekly or monthly “dress rehearsals?”

One myth, I suspect, is that in order to do “engaging” critical care simulation it needs to be done in and with a high fidelity scenario and manikin.  This is simply not true.  According to Sydney Area HEMS Education Coordinator, Cliff Reid, MD a lot of simulation is about stimulating the mind to believe what is happening (2).  The correct phrase for this simulation is called “stress inoculation” training.  This has been done very well for many years by the military and is starting to make its way into civilian EMS.  For example, the military has done stress inoculation training to ensure that all Soldiers, Sailors, Airmen, and Marines are able to function fully despite extreme stressors.  In essence, the extreme stress replaces the “high fidelity” capability of the manikin; essentially eliminating the need for a very expensive high fidelity simulator (3).  Simply put, use what is available at your station and in your training area – and then pour in several gallons of stress.  Watch the “simple” simulation unfold as it becomes a high stakes, reality based inferno of experiential potential.

Some might ask what the recipe is for the “stress”.  I might offer that “stress” comes in two parts; first, the scenarios must be believable and relatable; second, there needs to be specific benchmarks that the crew must hit in order to complete the simulation.  It may help to have co-workers as actors who play the part of stressed family members.  Perhaps you could throw a difficult airway on top of the patient in extremis.  These are just a few examples of the difficulties they may experience in the field – bringing added stress to the already-stressed mind.  Keep in mind, the end goal is not to focus on the mistakes, but rather talk about the opportunities for improved growth and development.  Stress first; debrief last!

Remember the dress rehearsal analogy?  Let’s get back to it.  During rehearsal, there are almost always stage hands, directors, assistants, etc. hanging around, watching and perfecting their role in the performance; the point is, the actors are being watched – by their own peers.  For the critical care provider, this is no different.  Typically, simulations are run with and among your colleagues.  The fear of failure, in front of peers, can be paralyzing.  Suck it up cupcake.  Get over it.  As understandable as this, it holds no place among us.  A wise man once said, it is better to screw up in front of each other during a training session, than to underperform for a patient during their time of distress.  Each simulation training is an opportunity to learn, grow, and improve as a clinician; and as an organization. 

Simulation training is a valuable tool and should be implemented within your organization.  This is applicable to ground, air, or intra-hospital.  Go ahead; do your scenarios; add some stress; and track the results.  Wear your uniform, use your equipment, and work with your partners.  This is your dress rehearsal for your big stage event - taking care of the sickest of the sick.  We need to be prepared to provide the best patient care…always.  I promise you will see a difference.

Always reach out to other resources to see what they can offer you and how you can be better prepared for patient care (4).  If resources are needed to do this in your service, let us know how we can help.  With that thought, take care and as always think like a clinician. 


Mora A, Tsai-Nguyen G, Columbus C. 213. Critical Care Medicine. 2015;43:54-55. doi:10.1097/01.ccm.0000474041.11341.66.          

Naumann DN, Bowley DM, Midwinter MJ, Walker A, Pallister I. High-Fidelity Simulation Model of Pelvic Hemorrhagic Trauma: The Future for Military Surgical Skills Training? Military Medicine. 2016;181(11):1407-1409. doi:10.7205/milmed-d-16-00008.


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