1. METHODS Dicing with Death Charing Cross Hospital, Imperial College Healthcare NHS Trust, Fulham Palace Road, London, W6 8RF, UK A Major Haemorrhage Training Tool INTRODUCTION A Major Haemorrhage can be stressful for laboratory staff, especially when they are encountered rarely. It was felt that a tool was required which would increase familiarity and therefore confidence. The challenge was to make each occurrence of the exercise different without set up time and effort, “Dicing with Death” is based on the dice/board adventure game Dungeons and Dragons. There are a set of predefined responses to dice rolls which determine the circumstances of the Haemorrhage, this means that each exercise is unique. The results of the dice rolls can be modified to reflect the needs of different hospitals. Keywords: Major Haemorrhage, Simulation, Dungeons, Dragons, Training, Action Learning, Confidence, Reflection EXERCISE DESIGN There are 2 roles in the exercise, the Dice Master who must be a BMS, and the Architect who can be any laboratory worker including managers. The cost is minimal, only paperwork and time is required (the die came from a Christmas cracker). There is no set up time, and no requirement for input or supervision from a Training Officer or Senior BMS. The die outcomes have been set up to reflect the types of patient seen at Charing Cross but also to cover rare circumstances. The 2 sample (group check) rule is also incorporated. The inspiration for the format came from watching The Big Bang Theory. REFLECTION The Reflective Sheet completed after the exercise allows the participants to consider good and bad practice, and whether the exercise has increased their familiarity and confidence in dealing with Major Haemorrhages. It then asks for any good ideas that could be shared with the rest of the laboratory. It also asks for comments which may help improve the exercise itself. The Reflective Sheet may be used as evidence of CPD. All participants have expressed an increase in confidence in managing Major Haemorrhages and enjoyed the exercise. CONCLUSION The Dicing with Death exercise works well as it appears to be able to provoke original thought. The role play nature of the exercise uses Action Learning which is one of the more robust methods of training. The overall objective of increased familiarity and confidence in the laboratory management of Major Haemorrhages has been achieved. REFERENCES ‘ The Wiggly Finger Catalyst’ (2011) The Big Bang Theory, Episode 5, 4. E4, November 2011 BCSH 2010. Guidelines on the use of irradiated components. http://www.bcshguidelines.com. BCSH 2004. Transfusion guidelines for neonates and older children, including 2005 and 2007 amendments. http://www.bcshguidelines.com. BCSH 2004. Transfusion guideline for the use of fresh-frozen plasma, cryoprecipitate and cryosupernatant, including 2005 and 2007 amendments. http://www.bcshguidelines.com. ACKNOWLEDGEMENTS Many thanks to Alfred Andrade, Jaymini Patel, Malalai Sadiqzai, Parul Patel, and Lloyd Noble Quotes from participants – taken from Reflective Sheets There are 8 phases of the exercise which lasts a total of 30-45 minutes. After each section there are questions requiring the participants to think about what is special or unusual about the circumstances, and reflect on what they could do to be proactive. There are 4 documents required; - The SOP which explains the procedure - The Architect Sheets which provide a narrative and give the responses to the dice rolls - The Dice Master worksheet on which the die outcomes and the reflections are recorded - The Reflective Sheet for use after the exercise The causes of Major Haemorrhage in Section 1 reflect patient types seen at Charing Cross Hospital. Many of these involve underlying coagulopathies, requiring the BMSs to be aware of issues surrounding these types of patients. From Section 6 onwards the die may dictate that the exercise stops as the bleeding is controlled, or the patient did not survive. The latter reflects that sometimes patients do not survive in spite of everyone’s best efforts. This is often the main cause of anxiety amongst laboratory staff and can weigh on the minds of BMSs for weeks after the event. The 8 sections of the exercise are 1 – Initial contact and patient demographics 2 – Transfusion history and sample availability 3 – Initial request for components 4 – Real time stock level review 5 – Baseline Full Blood Count and Coagulation results 6 – Fresh Full Blood Count results 7 – Fresh Coagulation results 8 – Something extreme Laboratory staff playing Dicing with Death “It is good practice to make decisions in advance” Band 6 BMS “It is a really good exercise, it should be done once every month with all members of staff” Band 6 BMS “Very good exercise for people on every level” Band 4 AP “Yes [I felt more familiar with the protocol], improved my confidence in dealing with different situations” Band 6 BMS “Very good as it makes you think on your gut” Band 6 BMS “Yes [I have more confidence], after this simulation we had an MH in A&E/Theatre and everything was handled according to plan” Band 6 locum BMS “It is a very good way of learning, refreshes your knowledge of information” Band 6 BMS “I love it” Band 6 BMS “Fantastic!!!” Band 6 BMS Architect Sheet - Page 1Architect Sheet - Page 2 KATY VEALE BSc(hons), MSc, FIBMS