The Simulation Story

Approximately 10% of all EMS runs nationwide involve pediatric patients.1 Some studies indicate that for those children under one year of age, direct ALS care during transport is even lower.1 We all know this does not provide enough experience to feel comfortable in an emergency, especially when it involves a child.

     How can we relate our limited experience and practical skills to real-life circumstances? Many healthcare settings are taking this limitation to the extreme by relying on human patient simulation labs, which are as "real" as you get. Patient simulators are models of patients from adult to infant that include respiratory patterns, eye movements and responses, heart sounds and even exchange of gases in simulated technology. The labs, which are equipped to mirror true settings, have become critical in enhancing our way of training and, more important, how we learn and remember critical ideas and concepts.

     Over the last 10 to 15 years, the labs have increased in diversity, use and overall popularity. The benefits of simulation training have only recently been realized.2 Early simulations were utilized for airline pilots and military exercises and have now evolved into medicine.3 Many EMS systems and traditional healthcare professionals have either found funding for new labs or provided funding toward repetitive time in simulation training at local or regional centers that house the simulators.

How Do We Learn?
     When we consider our own cognitive learning styles, many factors are involved. Adults tend to gravitate toward things we are comfortable with or good at. When we learn new information, we do so under conditions that are favorable for us individually. For instance, some like to sit at a desk to put together a project, while others like to sprawl on the floor. Some individuals need more light to study, while others like a more dimly lit area. Sounds, light, temperature and many learning styles all influence the way we gather information, which translates into whether we learn and remember that information. But one facet we cannot overcome is that we are still adult learners, which means we gather much of our information through explanation (didactic) and, for the most part, apply what we have just learned through psychomotor skills (hands-on).

     Didactic learning is the way EMS providers are initially educated. Throughout our advancement in the medical field, we learn a concept (usually in a classroom setting) and then apply it, either on a static manikin or using paper-based scenarios and skill sheets. If we try to apply one without the other, our learning curve diminishes. It is apparent that both serve as conditioners to our learning process.

     In medicine and other specialized fields (e.g., airline industry, military, etc.), much of the attention in education has focused on simulation tools, involving some form of technology that allows providers hands-on experience without causing actual harm. Human patient simulation (HPS), which is already being used by many EMS and healthcare providers, uses simulators that are realistic in both appearance and ability to react to "treatment" based on preprogrammed scenarios.

     Introducing simulation technology into educational programs brings a third component into the mix. Experiential and reflective learning models have been our traditional ways of teaching students. Simulation allows students to combine their own higher-thinking (cognition) and psychomotor (hands-on) skills with emotional variables that can lead to behavior change within their clinical environment.3 The clinical environment created by the educators can also play a part in how effectively or ineffectively treatments are rendered.

Anatomical and Physiological Parameters of HPS
     Although simulators are becoming more advanced, they still retain the basic components: realistic airways, physiologically based parameters, mental status, some neurological functions and anatomical landmarks. Many of the HPS models that provide correct landmark structures allow students to open an airway, ventilate the lungs and intubate. These anatomical and physiological components play a part in respirations and gas exchange, much like we see in our patients. Actual chest rise can be visualized and auscultated for correct procedures, such as BVM or endotracheal intubation. Many simulators can exhibit pulse oximetry, waveforms and end-tidal CO2 readings, as well as colorimetric device color changes. When teaching a condition like anaphylaxis, some simulators exhibit tongue and airway swelling and laryngospasm.

     Pulses can be assessed for strength and quality in the proper locations. Pupils constrict and dilate with light. Procedures can be mimicked, such as cricothyrotomy, needle decompression and chest tubes, all down to the expected rush of air when relieving a spontaneous pneumothorax. Cardiac rhythms can be monitored and arrhythmias defibrillated or cardioverted with real energy levels.

     One component that is indispensable is the drug recognition system. What better place to calculate adult and pediatric doses and watch real-time reactions when a drug is administered? These drug recognition systems recognize the medications you administer, wait for you to calculate a "real" dosage, then respond positively or negatively to your intervention. Some of the high-fidelity simulators know the difference between various drugs and the finite dosages you administer.

Revisiting Team Training
     A familiar old teaching method has recently been added to training: crew resource management. This concept has received increased attention due to medical errors worldwide.4,5 Making a stronger connection in communication, role assignments and identifying potential problems in their treatments are priorities of crew resource management.6-8 Too much medication, procedures done incorrectly and incorrect patient assessments are all precursors to life-threatening mistakes. Many of the groups now using simulators are making strides to improve their teamwork, which ultimately works on minimizing mistakes. They are taking advantage of the ability to condition themselves to many medical and traumatic occurrences in the simulation world before they experience them in reality.

Simulation Lab Training
     Simulation labs provide participants an opportunity to view their own actions (good or bad) and improve upon them. We know from medical research that many of our cognitive skills are lost over months to years of infrequent use.10,11 We also know that many of the skills (as with static manikins) do not allow us to see the consequences of our actions. We provide an assessment or treatment and wait for an instructor to provide an answer. We don't see physical changes in static manikins as a result of our interventions. Simulators are allowing providers to experience those things based directly on their interactions and treatments done in real time. Seeing is truly believing.

     One of the more impressive ways to teach critical thinking skills is working through a problem (simulation) and reviewing (debriefing) it right after: What was done right, and what may need to be repeated or corrected? Debriefing is a proven way of letting students recognize their strengths and weaknesses, and this can be extended to the team's strengths and weaknesses.3 Traditional didactic courses spend much of the time reviewing lectures or including static manikin training only. In many of these same courses, the comprehensive testing or review at the end of the class involves a one-on-one scenario where students must remember patient information, condition and treatment throughout the testing period. This not only makes it difficult to learn key points, it allows us to become mediocre in our treatment and learning styles. Working as a team on a "patient" provides you with real-time feedback, making you realize the intricate things you tend to forget while completing paper scenarios. Some simulation labs videotape providers during team treatments to point out their strong and weak areas. This is all summarized during the debriefing. As adult learners, it is key for us to not only comprehend our skills, but to retain them for longer periods of time.

     Results from previous research on using human patient simulators looked at participant satisfaction. Studies done in various settings tend to prove that participants in simulator labs feel better prepared and are more relaxed when dealing with common and uncommon situations.7 In particular, those labs that simulate both patient and environment have the most success in making participants feel the reality of a situation. Simulated environments range from hospital emergency departments and military combat zones to surgical suites or the backs of ambulances. Placing simulators in these social and physical conditions allows participants to "feel" the impact of crying family members, bystanders providing medical care when EMS arrives, or even space constraints in the back of the ambulance.

Research and Technology
     The National EMS Research Agenda and the Institute of Medicine recognize areas that can be strengthened in our own communities.5,13 One consistent recommendation is for general prehospital research. As a whole, EMS providers need to improve on advancing "high-quality EMS-related research to drive improvements in patient outcome."12 Furthermore, "vast amounts of money are being spent for patient care with little rigorous evaluation of the effectiveness of that care."12 Much of the research being done on use of patient simulators is strictly hospital-based; however, that research shows that we can all probably improve upon our patient care, and we can begin making improvements through the use of simulation technology.3

     Early research from the airline industry demonstrated that pilots who attended simulation training performed with more confidence.4 Anesthesiology has incorporated human patient simulators and subjected anesthesiologists to possibilities they may or may not see in real patients.9 EMS has just begun the move to integrate simulators into its curricula.13 Much research is still needed on the relationship between human learning and simulation technology. Although the present focus on participant satisfaction is still key to further advancement in simulation, the ultimate goal is to provide a conducive environment for adult learners to comprehend and retain pertinent information.

Conclusion
     Depending on what simulation technology is needed, purchasing a simulator and transforming a lab into a specific environment can cost hundreds of thousands of dollars. Many EMS agencies that use simulation training are finding help through grants, state EMS funding and other local forms of financial assistance. Much of the training involves contracting with local or regional simulation centers, which in itself cuts expenses if you pay hourly or per-person rates for training your personnel.

     The trade-off is more critical training, which leads to a marked improvement in skills and learning to deal with stressful situations in close-to-real stressful environments. Learning more and feeling more comfortable in real-life situations will vastly improve our overall patient care. Keeping our perspective on how we learn, what our goals are and what our resources may be will be the key to improving our own personal confidence and creating a model to follow. If we have an environment in which we can train as a team, get direct feedback from the "patient" and learn from a formal review (debriefing), we can hopefully reduce medical errors.

References

1. Suruda A, Vernon DD, Reading J, et al. Prehospital emergency services: A population-based study of pediatric utilization. Inj Prevention 5:294-297, 1999.
   
2. VonLubitz DK, Carrasco B, Levine H. Simulation-based medical education: Advanced distributed learning as a tool for the future. MedSMART Inc., 2002.
   
3. DeVita MA, Schaefer J, Lutz J, et al. Improving medical emergency team (MET) performance using a novel curriculum and a computerized human patient simulator. Quality and Safety in Health Care 14:326-331, 2005.
   
4. Helmreich RL, Merritt AC, Wilhelm JA. The evolution of crew resource management training in commercial aviation. Int J Aviat Psychol 9(1):19-32, 2000.
   
5. Kohn LT, Corrigan JM, Donaldson MS, eds. To err is human: Building a safer health system. A report of the Committee on Quality of Health Care in America, Institute of Medicine. Washington, DC: National Academy Press, 2000.
   
6. Cohen SG, Bailey DE. What makes teams work: Group effectiveness research from the shop floor to the executive suite. J Manag 23:239-290, 1997.
   
7. Morey JC, Simon R, Jay GD, et al. Error reduction and performance improvement in the emergency department through formal teamwork training: Evaluation results of the MedTeams project. Health Serv Res 37(6):1553-1581, 2002.
   
8. Holcomb JB, Dumire RD, Crommet JW, et al. Evaluation of trauma team performance using an advanced human patient simulator for resuscitation training. J Trauma: Inj, Infec & Crit Care 52(6):1078-1086, 2002.
   
9. Gaba DM, Howard SK, Fish KJ, et al. Simulation-based training in anesthesia crisis resource management (ACRM): A decade of experience. Simulation & Gaming 32(2):175-193, 2001.
   
10. Kaczorowski J, Levitt C, Hammond M, et al. Retention of neonatal resuscitation skills and knowledge: A randomized controlled trial. Family Medicine 10:705-711, 1998.
    
11. Ward P, Johnson LA, Mulligan NW, et al. Improving cardiopulmonary resuscitation skills retention: Effect of two checklists designed to prompt correct performance. Resuscitation 34(3):221-225, 1997.
    
12. Sayre MR, White LJ, Brown LH. National EMS Research Agenda. Prehosp Emerg Care 6(3 Suppl):S1-43, 2002.
    
13. Hall RE, Plant JR, Bads J, et al. Human patient simulation is effective for teaching paramedic students endotracheal intubation. Acad Emerg Med 12:850-855, 2005.