Translating Learning into Action
Anesthesiologists at Penn State Hershey Medical Center routinely respond to Code Blues. By the time they arrive, the patient typically already has vascular access and is ready for cardiopulmonary resuscitation (CPR). One day last May, Jonathan A. Anson, MD, Assistant Professor of Anesthesiology, answered the code call. When he arrived, the patient was receiving chest compressions for pulseless electrical activity. However, despite numerous attempts, staff was unable to obtain intravenous (IV) access or administer Advanced Cardiac Life Support medications. Knowing that this patient needed immediate vascular access if the patient was going to survive cardiac arrest, Dr. Anson obtained an intraosseous (IO) needle and placed an IO line in the patient’s tibia. Next, he administered epinephrine and fluid to the patient and quickly achieved a sustainable cardiac rhythm with a return of peripheral pulses.
Dr. Anson had never before placed an IO line. He only knew how to because he took a simulation-based practice performance and assessment activity as part of the Maintenance of Certification in Anesthesiology® (MOCA®). “The MOCA training just popped into my head. I remembered the emphasis on high-quality CPR without interruption and IO access if you can’t get quick IV access,” he said. “I wasn’t even sure we had IO needles on our code carts, but they were in the drawer with the other IV supplies. Now I know where they are located throughout the hospital.”
Dr. Anson, who became Board Certified in Anesthesiology in 2010 and is now involved in MOCA to meet the requirements of the ABMS MOC process, took the simulation later that year. The combination of the simulation training and his knowledge of the American Heart Association (AHA) guidelines for CPR and emergency cardiovascular care, which advocate early use of IO access if IV access is unobtainable, gave Dr. Anson the confidence to attempt the procedure on a real patient. Describing the encounter as “surreal,” Dr. Anson was impressed that he remembered the skills he learned during the simulation because of the time that had lapsed since taking the course. He credits that with the simulation lab itself. “The simulation was very low tech; simple leg and bone models and IO needles,” he said. “But I didn’t realize how life-like the simulation was until I did the procedure for real. If I had just read how to do this in a book I would not have retained any of the information a year and a half later.”
Dr. Anson has walked away from this encounter not only with new life-saving skills, but also a profoundly different view of the ABMS MOC process, and MOCA, in particular. “Initially, I thought it was something that I had to do and I was just trying to check off a box on the list. I had low expectations,” he continued. “But this experience has taught me that there is value in the MOC process. Physicians should really look at these activities, such as the simulation, as opportunities to learn. It’s not an assessment as are many of the traditional pass-fail exams we’ve taken along the way. Tests assess for competency whereas the goal of the simulation is to identify gaps in our practice and find ways we can improve, rather than just demonstrate that we are minimally competent.”
Moreover, the skills that Dr. Anson learned are relevant for anesthesiologists of all ages. “I’m not very far removed from my residency, having finished in 2009, a year before the AHA guidelines came out. But there was still a gap in my training,” he said. “The simulation is as equally applicable to me having just finished my residency as it is to an anesthesiologist who has been practicing for 30 years.” Furthermore, the simulation offers an opportunity to learn these skills without having to practice on real patients.
Dr. Anson was so impressed with the simulation that it spurred him to learn more about the adult-learning theories that support it. Last fall, he became an instructor in the MOCA course offered at Penn State Hershey.
For those who question the value of the MOC process, Dr. Anson said this: “I’m an analytical person, so I like definitions. A common definition of ‘value’ is quality divided by cost. Looking at the quality of the course, there’s really no comparison between it and a traditional exam. With MOCA, you get personalized, individualized attention at a very affordable cost.”