What to do when things go wrong: A simulation for high-volume hemorrhage control

During stressful events, unprepared surgical trainees facing cognitive overload may struggle to perform. In this study, we evaluated learner experiences and performance using a novel model to simulate intraoperative crisis.

We developed a curriculum to practice psychomotor, leadership, and stress-management skills. Surgical residents and fellows used a novel simulator replicating major abdominal hemorrhage. Participants were assessed for the successful vascular repair of the simulated venous injury, the volume of blood loss, and performance using Objective Structured Assessment of Technical Skills and the Non-Technical Skills for Surgeons Scale. Participants completed measures of stress and cognitive load. We conducted focus groups and individual interviews followed by qualitative analysis.

Twenty-three residents and 10 fellows participated in 3 sessions. Seven of 23 residents and 8 of 10 fellows completed the simulation within 20 minutes (P = .02). Blood loss exceeded 1,000 mL in 74% of residents and 60% of fellows. Objective Structured Assessment of Technical Skills scores averaged 3.4 (standard deviation, 0.8) per category in residents and 3.9 (standard deviation, 0.99) in fellows (P = .01). There were no differences in Non-Technical Skills for Surgeons Scale, stress, or cognitive load scores. Thematic analysis revealed that nontechnical and technical skills were interrelated in their contribution to performance, response to a crisis should be methodical to tame chaos, and stress levels were qualitatively related to experience and performance.

A novel simulation of major abdominal hemorrhage provided an appropriate challenge for junior surgery residents, and the superior performance of fellows provides evidence of validity. The evaluation identified opportunities to engage fellows to build their nontechnical skills.