The pediatric emergency department (ED) was in the midst of its early morning ritual. There were no patients waiting to be seen. I wanted to help wake up the residents with a simulated pediatric code. As I set up our SIM Baby, I decided to simulate a respiratory arrest. This infant would be very sick and difficult to save.

As our faculty and residents filtered out of Morning Report, our clerk made the overhead call: “Pediatric Code Pediatric ED, Pediatric Code Pediatric ED.”

Our response team came running: physicians, nurses, respiratory therapists, a clinical pharmacist, and ancillary staff. The momentary surprise, and relief, that it was a SIM case quickly transitioned into the serious clinical demands of responding to an infant on the brink of death. Tools were retrieved, commands were issued, medications were called for and administered. Team members worked while others observed. In the end, despite the team’s best efforts, the SIM patient could not be rescued. Death was pronounced, there was a moment of silence, and a grieving mother was provided support.

The simulation and our clinical performance went, well, okay. It demonstrated that there were areas for improvement. As we debriefed, we talked openly and constructively about what we might have done differently. The discussion provided an opportunity to process not only the intricacies of a pediatric code but also our visceral responses to the death of a young child.

The debriefing engendered a sense of ownership, teamwork, and collaboration. We shared an experience that produced very real effects and emotions. Some team members verbalized being grateful for an opportunity to practice and learn this way, as simulation education is relatively new to our department. As we packed away the equipment, we sensed that our time had been well spent. There was a sense of appreciation.

It was probably a half hour later, although it seemed much less.

“Respiratory therapist to the ED stat” was heard overhead. My first thought was someone didn’t get the message. The simulation was over. At that moment, a mass of people burst through the door with a pale and lethargic 13-month-old infant who was barely breathing. We could not have been more prepared.

The team showed up and jumped into action with a level of confidence and coordination that soothed the distraught parents at the bedside. The Broselow tape went down; the same tools and medications were now actually needed. The baby was intubated, resuscitated, and stabilized. There were some very harrowing moments but we kept to our algorithms. We kept our cool. The infant was stabilized.

The sense of accomplishment shared by the team was evident in our hugs, tears, and smiles. We shook our heads with grateful disbelief that we had practiced the simulated case minutes earlier. Our performance was obviously enhanced by the previous simulation.

Simulation education has evolved during the past decade in both technique and as a standardized tool for resident assessment. Simulation enhances cognitive and procedural skills and engenders confidence in those skills in a stress-free environment. The use of simulation education has been adapted by the ACGME in assessing core competency in resident training for the advancing emergency medicine resident. As per the SAEM’s Simulation Task Force: “Medical simulation promises to revolutionize health care education, and emergency physicians are actively participating in the development of this field.”

Every member of our ED team experienced the real and enduring benefit of simulation education that unforgettable morning.

By the way, our 13-month-old was extubated the next day and is doing fine!