Table 2.

Complication cards for “Simulation Roulette”

Acute hemorrhage Complexity: Moderate Appropriate patients: Anyone undergoing invasive surgery Setting: Intraoperative Instructions: Several minutes after beginning the simulation, blood pressure begins to decrease to 85/50 mmHg and heart rate increases to 115 bpm. Report that suddenly one liter of blood is in the suction canister and the surgeons say the patient is “oozy.”	Scoring items State the most likely differential diagnosis depending on the circumstances. Consider coagulopathy or platelet dysfunction. Communicate with surgical team. Administer adequate fluid resuscitation (e.g. 3xEBL in crystalloid or 1xEBL in colloid or blood products). Determine whether pharmacologic therapy or transfusion is indicated (discuss any patient factors that would alter the transfusion threshold).
Seizure Complexity: Moderate Appropriate patients: Any Setting: If GA: Prior to induction or after extubation depending on most likely context If Regional/MAC: Anytime (could be presentation of local anesthetic toxicity as well) Instructions: Suddenly, the patient develops twitching in arm that proceeds to grand mal seizure and loss of consciousness. HR increases to 150 bpm, BP increases to 200/110, and SpO2 decreases to 93%. For advanced trainees: SpO2 stays at 93% for one minute then starts dropping over next minute to 50%. STAT Plausibility Consult: Oops – it turns out the patient had a few seizures several years ago, but didn’t keep taking the medications because they meant he couldn’t drive.	Scoring items State diagnosis. Discuss possible causes (e.g. neurological, pharmacological, metabolic). Administer oxygen, support airway as needed with mask (or bag-valve-mask). Administer pharmacologic treatment of choice (e.g. benzodiazepine if SpO2 stable, succinylcholine if SpO2 dropping). Order chemistry profile if metabolic disruption is a likely cause. State appropriate next steps depending on context (e.g. head CT). Indications for proceeding with intubation: history of full stomach, elevated ICP, emergency surgery, falling SpO2.
Acute elevation in ICP Complexity: Moderate Appropriate patients: Could be any, with a little creativity Setting: After extubation Instructions: One minute after extubation the patient has altered mental status, RR slows to 5 breaths per minute, BP rises to 180/98, HR decreases to 45. STAT Plausibility Consult: Did your patient just have a ruptured aneurysm? They can happen in otherwise healthy patients with very little warning.	Scoring items State problem. State differential diagnosis (e.g. Bleeding? Obstruction? Elevated cerebral blood flow?). Intubate, state CO2 goal of mild hypocapnia, consider mannitol. State appropriate next steps depending on context (e.g. surgical exploration, head CT, or ICU)
Pulmonary Embolus Complexity: High Appropriate patients: Any Setting: Middle of a case (GA most plausible) Instructions: Suddenly there is an acute drop in CO2 to 10 mmHg, drop in BP to 70/30 mmHg, elevation in HR to 130 bpm, and over next few minutes decrease in SpO2 to 80%. STAT Plausibility Consult: Did your patient have an occult malignancy? Recent trans-oceanic flight? Lower extremity trauma?	Scoring items State problem (especially: recognize the significance of the drop in ETCO2). State differential diagnosis (thrombolic event, fat embolus, or air embolus depending on context). Auscultate lungs, treat with 100% O2, epinephrine, fluid bolus. Consider interventional radiology, TEE.
Pulmonary Edema Complexity: Moderate Appropriate patients: Any long case Setting: Intraoperative or Postoperative. Could be towards end of long case with lots of fluid (or inadvertent fluid overload by break relief). Instructions: Gradually the SpO2 decreases to 92% (but returns to 97% with 100% O2), lung sounds have crackles, lung compliance gets worse at same time.	Scoring items State problem State differential diagnosis (cardiogenic or non-cardiogenic) Auscultate lungs, recognize significance of crackles Attempt ETT suction, recruiting maneuvers, consider diuretic
Low urine output Complexity: Low Appropriate patients: Any case where it is plausible to have a urinary catheter Setting: End of long case where provider is taking over from another provider; or PACU Instructions:  Report that there is no urine in the foley bag. Charted UOP is 20 ml over the past 2 hours. Pick the most likely option depending on the patient: Option 1: Hypovolemia (HR 95, BP 90/55, low CVP) Option 2: Low Cardiac Output (HR 50, BP 90/55, high CVP, +/− lungs with crackles) Option 3: Post-renal obstruction	Scoring items State problem. Identify differential diagnosis (e.g. pre-renal, intra-renal, post-renal), state most likely diagnosis in this patient. Perform physical exam (quality of heart sounds, quality of pulse); troubleshoot urinary catheter. Pick appropriate treatment (e.g. fluid vs. diuretic vs. wait-and-see). Plan follow-up (e.g. check urine in next hour vs send to ICU).
Unexpected difficult airway Complexity: Moderate to High Appropriate patients: Any Setting: Beginning of case Instructions: Create a can ventilate/cannot intubate scenario in a case that mandates an ETT (or make sure the LMA doesn’t work properly). Advanced: Let the scenario progress to cannot ventilate/cannot intubate.	Scoring items State problem. Prior to induction, take appropriate precautions if patient is likely to be difficult ventilation (e.g. positioning, airway adjuncts immediately available, avoiding long-acting muscle relxants). Follow difficult airway algorithm and demonstrate rapid progression to surgical airway in case of cannot ventilate/cannot intubate. Extra credit: Draw the ASA Difficult Airway algorithm
Aspiration Complexity: Low Appropriate patients: Any Setting: If GA: Immediately after intubation If Regional/MAC: After administration of sedative drugs Instructions: SpO2 drops to 90%, HR 95, BP increase by 10%, increased airway pressure, report that there was a lot of yellow fluid suctioned from back of mouth (and ETT/LMA, if in place). STAT Plausibility Consult: Your outpatient stopped at a fast food restaurant and ate a turkey biscuit on the way into the hospital. Or your inpatient, it turns out, had an unrecognized ileus from days of being on narcotics.	Scoring items State problem Discuss differential diagnosis of wheezing and decreased SpO2 after intubation; discuss risk factors for aspiration. Auscultate lungs, suction ETT. Decide on appropriate post-operative care (PACU or ICU, need for antibiotics, duration of monitoring, whether a CXR is indicated).
Local anesthetic toxicity Complexity: Low to High Appropriate patients: Regional technique Setting: During block placement (epidural or regional), following negative test dose of local anesthetic with epinephrine (could create peaked T wakes on monitor as only initial sign). Instructions: Patient reports feeling funny, lips tingling, HR 100, BP 80/50. Advanced: Proceed to full cardiovascular collapse: BP drops to 60/20, HR increases to 130 then progresses to PVCs, VTach, Vfib.	Scoring State problem. Ensure appropriate monitoring and airway support, place patient on 100% oxygen. If cardiovascular collapse: call for help, administer IntraLipid, support with ACLS, prepare for cardiac bypass/ECMO.
Power failure Complexity: Moderate Appropriate patients: Any Setting: Any time Instructions: Power to whole OR goes out	Scoring items Continue to appropriately monitor the patient. Find flashlight. Ensure important equipment is plugged into “emergency” outlets.
Fire in the operating room Complexity: Moderate Appropriate patients: Any Setting: Any time Instructions: If plausible, have the ETT catch on fire. If not, have the drapes catch on fire with cautery (e.g. could be MAC case with face mask O2).	Scoring items If ETT fire: Remove tube, reintubate, examine airway for damage If drapes: remove O2, remove drapes, use fire extinguisher (drapes are water-resistant) Discuss factors increasing risk of fire (fuel such as alcohol prep solution, ignition source such as cautery, oxygen) Plan for next steps, e.g. intubation? ABG? ICU?
Failure to emerge from general anesthesia or sedation Complexity: Low Appropriate patients: Any case with “emergence” Instructions: Provider takes over near the end, right after taking a break (during which it is possible that the break relief gave–but did not chart–additional sedative drug/relaxant). If GA case: Patient does not move at end of case, but HR goes up to 120 and BP goes up to 145/90 (residual neuromuscular blockade scenario). If sedation case: Patient does not regain appropriate level of alertness. Advanced: Patient is actively agitated and delirious.	Scoring items State problem. State differential (neurological, metabolic, pharmacologic causes). Search for causes: check for level of neuromuscular blockade, check patient temperature, consider checking electrolytes. As appropriate: identify and treat residual neuromuscular blockade/sedation/agitation.
Laryngospasm/Negative pressure pulmonary edema Complexity: Moderate Appropriate patients: Any Setting: After extubation, or anytime during mask case Instructions: Induce complete laryngospasm that does not respond to positive pressure. Advanced: After successfully treating the laryngospasm, the patient has persistent requirement for O2 in the recovery room, RR 30, SpO2 100% on O2 but 89% on room air.	Scoring items State problem Discuss possible causes (e.g. concurrent aspiration, secretions in oropharynx, light anesthesia) Treat with positive pressure ventilation and when this fails, proceed to succinylcholine/rocuronium as appropriate. Advanced: Identify negative pressure pulmonary edema, order chest x-ray, check arterial blood gas (pH 7.48, pCO2 30, pO2 150 on simple face mask), identify significant A-a gradient in this setting
Rhabdomyolysis Complexity: Low to Moderate Appropriate patients: Any long GA case Setting: At end of case or in PACU/ICU Instructions: Report that the patient has brown-colored urine. Advanced: Tachycardia, hypotension, PVCs, hyperkalemia, metabolic acidosis. STAT Plausibility Consult: Perhaps the patient had undiagnosed mitochondrial myopathy and some lower extremity weakness (an admittedly rare, but possible, confounder)? Or an unfortunately severe response to trauma?	Scoring items State problem. State differential diagnosis. Check Creatine Kinase level. Rule out malignant hyperthermia (no temperature increase or increased CO2) Treat hyperkalemia (insulin/glucose, bicarbonate) Institute treatment with fluids at high rate, identify risk of renal failure and need for ICU in severe cases
Medical error made by other Complexity: Low Appropriate patients: Regional or MAC case (awake patient) Setting: Intraoperative, after returning from a break. Instructions:  Upon returning from break relief, the provider is told “They made incision. I gave the Ancef while you were gone.”  The patient, who is only mildly sedated, says “Wait, is that a cephala-something? I’m allergic to anything that has a ‘cef’ in it. I’m feeling kind of short of breath, actually. And itchy all over.”  The patient proceeds to have an allergic reaction consisting of rash and mild wheezing, easily treated with anti-histamines and inhaled albuterol.  After, the patient is angry and demands to know: how could this happen? And, What could you do to prevent this from happening again?	Scoring items Identify and treat allergic reaction. Demonstrate appropriate rapport with patient; express regret that it happened without assigning blame; identify sources of error; identify an action plan for quality improvement.
Belligerent patient Complexity: Low Appropriate patients: Any Setting: Prior to induction, you are wheeling the patient into the room (you have just given a small amount of midazolam) and the surgical team is not present yet. The OR nurses are busy. Instructions: The patient is acting drugged, demented, or deranged – but it is not clear if she is crazy or just mad. Either way, she refuses to get on the bed and says you have no business forcing her to, and furthermore, she’s calling the cops. She screams when you touch her IV and is taking back her consent for surgery and actively trying to leave. No one is coming to your help despite the obviously deteriorating situation.	Scoring items State problem, and rule out medical causes for delirium/agitation. Demonstrate effective interpersonal skills: Must politely yet firmly enlist aid of recalcitrant team. Address ethical issues of proceeding with case despite refusal of patient (who has been sedated).
Abbreviations: ABG – Arterial blood gas ACLS – Advanced Cardiac Life Support ASA – American Society of Anesthesiologists BP - Blood pressure BPM - Beats per minute CT - Computed tomography scan CVP – Central Venous Pressure CXR – Chest X-ray EBL - Estimated Blood Loss ECMO – Extracorporeal membrane oxygenation ETCO2 – End-tidal carbon dioxide ETT - Endotracheal tube	GA - General Anesthesia HR - Heart rate ICP - Intracranial pressure ICU – Intensive Care Unit LMA – Laryngeal mask airway MAC - Monitored anesthesia care OR – Operating room PACU – Post-anesthesia care unit PVC – Premature Ventricular Complex RR – Respiratory rate SpO2 - Oxygen saturation by pulse oximetry TEE – Transesophageal echocardiography UOP – Urine output