A patient crashing during anesthesia is every team member’s worst nightmare. For most people, reviewing protocols and going to CE is how we prepare for those emergencies. But what if you could actually experience a crisis, in real time, on a patient you know is going to be ok no matter what? Rob Keegan, DVM, DACVAA, has some thoughts on that. 

Keegan taught at Washington State University for 32 years and spent 15 years as the anesthesia section head at WSU’s Veterinary Teaching Hospital, but it was his love of computers that distinguished his classes from others. 

“For quite a few years, I was interested in using computer simulations in teaching,” Keegan said. “Many of the simulations were screen-based simulations: Students would sit in front of a computer and interact with a mechanical ventilator or a variety of anesthesia-related things.” 

Keegan got a National Science Foundation grant to develop a mobile-based electronic fetal monitor simulation for human medicine at the WSU College of Nursing in Spokane. “While I was up there, I got to see their high-fidelity simulation suite. They have a room mocked up just like an OB suite with a sim mom and a sim baby,” he said. 

Sophisticated mannequins like these have become the norm in human medical simulations over the last two decades. Built to scale, “the sim mom is adult-sized, and the sim baby is newborn-sized.” There’s also a sim man.  

The mannequins can blink. They can sweat. Their pupils can change position and size. And medical students can practice everything from hooking up vital signs monitors to participating in a life-like birth with realistic patients and without the fear of causing real damage.  

“I watched a few of their simulations and I was like, this would be amazing if we could do this for our students because they really buy into it and get into it,” Keegan said. But he adds that this amazing technology comes with “an amazing price, too.”  

“For veterinary medicine it’s probably not aligned with what we can do.” 

Keegan dug into the literature and found encouragement. “Almost everyone in the literature said it’s not the degree of technology that you have, but rather it’s how you use the technology, and if it addresses how adults learn, that’s what’s extremely important.” 

Freshly inspired, he adapted some of the screen-based simulations he’d developed previously and turned them into a software-based, immersive  simulation that was far more flexible and adaptable.  

“The idea was to create a platform that was pretty much mannequin-independent and affordable for people, and still had the elements of what was important in simulations to address how adults learn,” Keegan said.  

Even though a mannequin isn’t necessary to run the simulation, they knew it would make it better. He enlisted Lethea Russell, LVT, the coordinator of his simulation lab, to help create their first dog mannequin, which the students nicknamed  “Sketch” because it was kind of sketchy looking. 

Russell’s experience as a veterinary technician assisting in equine orthopedic surgeries for more than 20 years meant that she had seen a lot, learned a lot, and understood firsthand how animals react in surgical situations. She took on another role as well—seamstress.  

Sketch was made from a Walmart stuffed animal. “I know it was around Easter because it had this ‘Happy Easter’ little collar on it,” Keegan recalls.  

Russell “did a little surgery” on Sketch by opening his head and inserting an intubation model. She creates the physical part of the mannequin, including the sewing and inserting surgical models, while Keegan tackles the electronics. He interfaces with the software so that the mannequin’s eye blinks when it’s touched—something normally done to test depth of anesthesia—and to add things like heart sounds and EKG readouts that move across a monitor. Senior students from WSU’s College of Engineering have helped to develop a variety of different technology as well, including a pulse generator and other enhancements.  

“We made the leg move, so we can hit a button and the little motor goes on and the leg goes up and moves in the drape—that’s kind of fun to see the students respond to that,” Keegan said. 

After the first couple years, they replaced Sketch with “Anastasia the anesthesia mannequin,” their second sim dog, which has a “really, really cool-looking mouth and airway that Lethea did.” 

When the full simulation was first offered as an elective course, Keegan told his students, “It’s an experiment; it might suck; it might be horrible, but it works in human medicine.”  

After the six-week course, students didn’t think it sucked. They thought it was pretty useful. 

When it was offered again in following years, every student in the class signed up. “By word of mouth, it got out,” Keegan said. And eventually, the simulation course became part of the core curriculum in anesthesia at the university. 

The insights gained were invaluable. When high-performing students would have difficulty in the simulation, Keegan gained new understanding of how people’s reactions change under stress.  

“Students struggle because they’re immersed in it, and there’s so much emotion involved in this whole thing that they just have a hard time. They get overwhelmed. We would see this all the time on their first couple of surgeries. It’s too much. It’s overload for them,” Keegan said. 

And if it’s happening in the classroom, chances are good that it is happening in the real world. 

“The nice thing is that there’s four of them [at one time in the simulation]. They can stop the simulation, pause, take a time out, and talk about what’s going on.”  

Which led to another key insight: When students work together, they perform far better. He found that when students were tested individually, the class averaged 65% correct answers, compared with 95% right answers when problems were approached collectively. 

“The power of peer teaching is incredible,” Keegan said. 

“Anesthesia is a team sport” 

Unlike in academia—where each student is assessed individually—in the real world, veterinary medicine, and anesthesia in particular, is a team sport. Beyond the classroom work being done at WSU, Keegan has taken his simulation on the road to the IVECCS conference, the AVTE Technician Educator Conference, and to some private practices. Midmark is working with Keegan to sponsor more in clinic simulation CE for working veterinary professionals.  

Whether he’s working with second-year veterinary students or professionals in a clinic, one thing remains true about the simulation, he says: “Where most of the learning occurs is in the debrief afterwards.”  

Modeled after military debriefs, where soldiers convene after a mission to tell the story of what happened from their perspective for the benefit of everyone’s learning, these debrief sessions show that even highly experienced and skilled practitioners can be surprised by blindspots in their perception. This means communication breakdowns are likely happening in real life too, and the simulation gives practice teams the chance to identify them in a less risky environment. 

“There’s a lot of stuff that goes on that when you’re in the simulation you don’t see and you don’t realize because you’re in the moment,” Keegan said. It’s great for improving communication between the veterinarian doing surgery and the technician doing anesthesia.  

For example, a timid new technician might hesitate to alert the surgeon of what’s happening out of fear of interrupting. “If a lead falls off, I shouldn’t be afraid to talk to the surgeon and say, ‘look I need to do this’—and the technician has to know that the surgeon might be involved in something delicate so they’ll need to wait two or three minutes before they can get to it.” 

Immersive simulations like this are relatively new in veterinary medicine, but Keegan sees them as a critical tool for training veterinary teams. After three decades at WSU and at a time when many would consider retirement, Keegan is starting a new position at the University of Arizona where the entire veterinary anesthesia curriculum is problem-based and team-based learning. Simulation is a natural fit and is embraced and integrated throughout the U of A curriculum.  

“The research around education has just exploded in the last 10 or 15 years. For hundreds of years the professor sat up there and lectured. They were doing that in the 1700s. Although it seems  very efficient, it’s probably not the best model—it doesn’t address how people learn.”  

And he’s equally passionate about sharing this technology with working veterinary practices. 

“We’re really not doing anything that human medicine hasn’t been doing for 10 or 15 or 20 years. But we’re doing it in a way that’s affordable and accessible. Basically, to make this thing run, you just need a stuffed animal you can buy at Walmart, a laptop, and a computer monitor, and you could pretty much do it anywhere.”  

Attendees of AAHA’s Connexity conference in Scottsdale, Arizona, next month will get a unique opportunity to experience this simulation in person. 

Now that he’s living in Arizona, Connexity 2021 is right in Keegan’s backyard. He’ll be joined at the conference by Lethea Russell, LVT, now the Coordinator of WSU’s Clinical Simulation Center, as well as Andreza Conti-Patara, DVM, from Oklahoma State, and Sallianne Schlacks, DVM, from the University of Arizona, two DVM specialists who also have simulation teaching experience. The simulation is being offered twice on Wednesday, September 22 as a preconference workshop in two identical sessions. Regardless of anything else that happens, Keegan said, one thing is for sure: “That venue in Scottdale is amazing,” he said.   

Mastering the “Uh oh!”: Real-Life Anesthesia Crises in Simulated Surgeries is being offered to a limited number of guests at Connexity on Wednesday, September 22. Preregistration is required, as well as an additional fee of $200. Sign up now. Sponsored by Midmark. 

Photo credit: © Rob Keegan