Team based Simulation
Leading a resuscitation team in the management of a critically unwell patient is an essential skill of an emergency physician, and this is assessed in the simulation station. Typical domains are Medical Expertise, Teamwork and Collaboration, and Prioritisation and Decision-making.
Important information about the Sim stations is found in the "OSCE Simulation Stations" document available on the ACEM Fellowship Examination Resources site.
The Sim station is usually in the context of the candidate arriving as the ‘Consultant in Charge’ to assist and lead the care of a patient in a dynamic and evolving situation as would occur if they were ‘called in to help’. Thus, candidates may be required to provide care at any stage of the patient’s ED journey where a ‘problem’ could occur.
It is likely you will be tasked with leading the resuscitation, and have a team of staff (e.g. a registrar and a nurse) to assist you. The confederates will be real ED staff (not actors), so will have some experience. Usually they will have instructions to follow commands, and have certain prompts to keep the station moving (“I can’t feel a pulse!”), but will have limited ability to prompt you. They are usually competent to perform most procedures under your direction, including cannulation, insertion of IO and intubation. Occasionally the confederates will ask you to confirm your instructions – this does not necessarily mean you have made an error, but would be normal practice in a real resus (e.g. most nurses will be expected to check a dose before it is given).
The simulated patient will respond like a real patient in that their condition will deteriorate or improve depending on their management. In acute cases, vital signs may change and you will be told of these changes. You may ask for vital signs at any time. Subsequent laboratory investigations will realistically reflect deterioration or improvement of the case. The response of a simulated patient to changes in therapy is usually more rapid than in real life.
You will be tested on both how you manage a clinical scenario and how you lead a team. Your communication and professionalism are just as important as your medical knowledge.
Some topics you should practise include:
Advanced life support
Special circumstances (pregnant, newborn, tox, hypothermia)
Standard intubation – need to be slick at this – may form part of any simulation
Difficult intubation or Can’t Intubate/Can’t Ventilate situation
Complications post-intubation e.g. cardiac arrest, hypotension, sudden hypoxaemia, trouble shooting ventilation problems
CVS emergencies e.g. cardiogenic shock, massive PE, tension pneumothorax, tachyarrhythmias (unstable wide or narrow complex); bradyarrhythmias (including pacing)
Haemorrhagic shock (e.g. massive GIT, PPH) with Massive Transfusion Protocol activation
Seizures , including eclampsia
Precipitous birth, including PPH.
Trauma – e.g. severe head injury, haemo/pneumothorax, penetrating chest injury, severe pelvic trauma, abdominal trauma, spinal injury/neurogenic shock
Tox emergencies e.g. TCA or CCB overdose, snake bite
Paed scenarios – e. g. head injury, anaphylaxis, asthma, APLS, choking, seizures, septic shock, SVT, trauma, neonatal resuscitation
Prepare the team for the arrival of a patient
Lead the team in the assessment and management of a patient
Lead the team in the resuscitation and stabilisation of a patient
Rapidly establish clinical priorities
Provide effective and timely interventions
Manage post-resuscitation care
Take a phone call to discuss referral at the end of the scenario
Domains that have been tested in recent OSCEs
Medical Expertise: Assessment
Seeks evidence of time critical diagnoses when performing assessment
Identifies important historical details (red flags) diagnostic of an important condition
Recognises signs on physical examination that indicate high risk of imminent deterioration
Creates a focused investigation plan that confirms or excludes time critical diagnoses
Correctly interprets the results of an investigation within the scenario.
Generates a relevant list of differential diagnoses after synthesising clinical information found on initial assessment
Medical Expertise: Management
Outlines an overall plan for resuscitating a patient
Correctly chooses time critical interventions based on assessment
Recognises and expedites any specific intervention essential to resuscitation
Adapts and initiates standard therapies to that patient, including drugs, fluids, gases, and monitoring
Anticipates and manages common complications during and after a procedure.
Identifies risks of deterioration in the patient
Presents the salient points about the patient’s care in a structured handover
Teamwork and Collaboration
Introduces self and purpose as duty consultant and team leader, performs introductions of team members and confirms roles and skills
Summarises the current situation, highlights important points and provides a management plan
Encourages open team communication by verbalising plan and inviting feedback
Issues instructions clearly and appropriately with a time limit for completion i.e. to specific team member/s
Uses appropriate communication techniques to negotiate an appropriate outcome for the patient
Shares the ‘mental model’ with the team e.g. summarises the current situation, states desired clinical endpoints, outlines plan and priorities
Presents the salient points about the patient’s care in a structured handover
Prioritisation and Decision Making
Highlights high-risk features identified during initial patient assessment
Summarises and prioritises the key issues that must be addressed during and following the emergency encounter
Prioritises chosen treatment options to create an appropriate escalating treatment plan
Provides a rationale to explain and justify decisions about ongoing treatment and disposition decisions
Makes safe and timely decisions for a complex or critical patient presentation
Anticipates and prepares for multiple potential problems
Demonstrates continued situational awareness with increased task loading.
Prioritises a differential diagnosis list to determine the most likely diagnoses in a patient
Manages multiple problems simultaneously by prioritising treatment options
ACEM OSCE report feedback
Common themes for candidates who performed well:
Appeared to have practised running a team in simulation
Demonstrated a considered plan for medical management
Managed the immediate issue, then recognised the need for second line therapy
Managed the team well and gave clear instructions in a calm manner
Provided a succinct and clear summary after the 6-minute mark
Provided a wider differential diagnosis
Assumed leadership and gave clear directions for stepwise use of strategies to manage the patient’s airway and ventilation.
Were organised with clear plan but were flexible to incorporate new information
Used multiple strategies to improve the patient’s condition and adapted these strategies to the specifics of the patient.
Demonstrated a structured approach to the management of the patient
Showed a high standard of ALS/defibrillator/resuscitation care, including reversible causes
Able to work very well with their team, perhaps as a result of ‘human factors’ such as use of names and encouragement
Knew the drug doses for paediatric resuscitation and the specific therapies for the overdose
Common themes for candidates who performed below expected level:
Inadequate medical knowledge
Did not read or apply the station’s Candidate Instructions
Did not address one or more areas of competing priorities
Became fixated on less relevant issues and consequently made poorly prioritised decisions
Lacked a well-developed differential diagnosis
Lack of stepwise, systematic approach
Did not know the correct second-line treatment
Failed to prioritise or adequately apply strategies to address both airway and ventilation
Said what they ‘would or might do’ but did not effectively act on or apply these strategies
Knowledge of common drug doses and equipment sizes was below standard.
Failed to adequately follow ALS algorithms or correctly identify the cause of the arrest
Demonstrated inadequate prioritisation at the start of the arrest
Poor team leadership and communication skills.
It is important you can place yourself “in the moment” to make this scenario as real as possible, as it will improve your performance.
Practise, practise, practise!
Film yourself as this will identify areas of weakness that you are not aware of
You should know and follow as closely as possible the most recent resus algorithms for adults and children.