TRAINING and EDUCATION
How I Teach
“How I Teach” is ASH Clinical News’ forum for sharing best practices
in teaching hematology to medical students, residents, and fellows.
We invite essays providing insight into teaching and modeling
clinical practice (history-taking, the physical exam, informed
consent, giving bad news), successful research mentoring, diseasespecific tips, or more general advice. In this issue, Alexandra P.
Wolanskyj, MD, discusses not only the “how” but the “why” of
providing simulation-based training of procedural skills to fellows
and other advanced-level providers – highlighting the patient
safety dimension to the simulation of intrathecal chemotherapy.
FROM THE HUDSON
RIVER TO THE
HEMATOLOGY WARDS
Why Simulation of Intrathecal
Chemotherapy Can Save Lives
et’s start with two case examples:
1. “Mr. M” is a 36-year-old male with newly
diagnosed B-cell acute lymphocytic
leukemia (ALL) who presents with
diplopia, a classic feature of central
nervous system (CNS) involvement. During his first
of several planned intrathecal (IT) chemotherapy
sessions, he undergoes placement of the lumbar
spinal needle under fluoroscopic guidance. Freeflowing cerebrospinal fluid was not attainable despite
several adjustments by the radiologist and an x-ray
confirming accurate placement at L3-L4 vertebrae.
A dilemma ensued: Should the methotrexate (MTX)
be instilled? Mr. M had received platelets, been fully
consented, and was ready on the neuroradiologist’s
table. A decision had to be made; the procedure
would be aborted. An MRI later revealed that he had
congenital narrowing of his spinal canal below the
L2 vertebra. The next day, his IT chemotherapy was
successfully performed above L2 with free-flowing
cerebrospinal fluid and with no side effects. He went
on to have an uneventful hospitalization.
2. “Mrs. J” is a 55-year-old female with standard-risk
B-cell ALL who presents for her first IT chemotherapy
with MTX through an Ommaya reservoir. This had
been placed because of extensive prior lumbar spinal
surgery following a motor
vehicle accident and repeated
painful and unsuccessful
lumbar punctures. Within a few
minutes following instillation
of the MTX, Mrs. J begins to
complain of a headache and
her right arm began to twitch
leading to full tonic-clonic
seizures. Aggressive maneuvers
are initiated, but she quickly
loses consciousness, lapses
into a coma, and succumbs
within 24 hours due to rapid
neurological deterioration
despite full support.
Alexandra Wolanskyj, MD (left), and learners in the intrathecal chemotherapy lab.
ASHClinicalNews.org
What happened? What are the
lessons learned? What could
have been the outcome had we
plunged ahead with Mr. M, a
recent patient on the hematol-
ogy ward? What was missed for Mrs. J, a recent patient
in the simulation center during an IT chemotherapy
procedural workshop?
Despite a comprehensive checklist in hand, the fellow
had failed to notice that the small vial labelled “15 mg of
MTX” contained a light amber – not pale yellow–colored
fluid and missed this case of an MTX overdose (see the
photo on page 66).
So, here’s how and why I teach simulation-based training for IT chemotherapy.
Getting It Wrong is Typically Fatal
Over the last several decades, many cases of accidental
IT overdoses of MTX and systemic toxicities have been
reported. These overdoses result in seizures, respiratory failure, coma, and death. Numerous reports of inadvertent IT
administration of parenteral drugs have also been described
with dozens of cases involving vincristine, as well as a few
reports with a variety of other drugs, such as daunorubicin,
asparaginase, vindesine, doxorubicin, and dactinomycin.
Nearly all cases have been fatal or resulted in severe
irreversible neurologic impairment, and, sadly, these
cases predominantly occur in the pediatric population.1
Most recently, three fatal reports of mistaken IT bortezomib infusion have been described in adults. The overwhelming conclusion one can draw from these tragic yet
avoidable errors is the need for greater safety processes
and adequate training of all members of the health-care
team involved in these high-risk procedures.
Simulation in High-Risk Environments Saves Lives
Simulation has been used since the early 1900s in the
military, and for more than 50 years in pilot training
and law enforcement. Captain Chesley “Sully” Sullenberger set his maimed Airbus down on the Hudson
River in a perfectly executed emergency landing in
ASH Clinical News
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