An Interview With William F. Dunn, MD, on Patient Simulators

Recently prehospital intubation has come under fire as having the potential to cause more harm than help. There are a variety of possible explanations for these findings, perhaps the most important being experience, education and training. Healthcare providers are often dependent on real-life events for training in particular procedures, and acquiring the experience to become proficient can be problematic. However, the rapid development of patient simulator technology is changing that, offering medical providers more opportunities to train on difficult or crucial procedures in safe and controlled settings without endangering patients.

The Society of Critical Care Medicine (SCCM) recently released Simulators in Critical Care Education and Beyond, the first textbook for critical care medicine simulator education (www.sccm.org/press_room/press_releases/May252004.asp), edited by William F. Dunn, MD, associate professor of medicine and co-director of the Mayo multidisciplinary critical care fellowship at the Mayo Clinic in Rochester, MN. Having just returned from a visit to the Israel Center for Medical Simulation (MSR) at the Chaim Sheba Medical Center in Tel Hashomer and the fifth annual International Meeting on Medical Simulation (IMMS) in Miami, FL, which he co-chaired in January, Dunn shared his thoughts with EMS Magazine about the use of this technology in prehospital education.

Patient simulators are obviously a great boon to training medical providers in new procedures. What is currently being done in the EMS or prehospital environment with this technology?

A lot is being done. Simulators are being used extensively at many institutions to train EMTs and emergency personnel. Michael Gordon, MD, associate dean for research in medical education at the University of Miami, is in charge of a major simulation education initiative there. EMTs and paramedics across the state of Florida train at their facility, using simulators. Other institutions having serious programs in simulation-based education include Stanford, the University of Toronto and Massachusetts General Hospital (Boston), among others. Recognize, though, that the simulator is just a dummy, despite the technology—the real depth of the learning experience comes from the instructional aspects, debriefing after an exercise, and so on.

Probably the forte of manikin simulators (as opposed to other varieties) is their use in team training. As such, a large number of EMT programs, fire departments, etc., use manikin simulators for training their prehospital teams in initial stabilization and transport of patients. In fact, both Laerdal and METI, the largest suppliers of high-tech manikins in this country, sponsor large meetings to facilitate “train-the-trainer” type courses geared to EMS users.

Additionally, SCCM sponsors the annual International Meeting on Medical Simulation (IMMS) to share the state of the art. This society is multispecialty in orientation, and growing rapidly in scope and influence because of the increasingly recognized need for medical education reform utilizing simulation methods.

Beyond manikins, simulation techniques include “standardized patients,” using actors to facilitate training in triage, communication skills, diagnoses, etc., and “task trainers,” which are machines that train individuals for specific technological processes, for example, ultrasound imaging, diagnostic peritoneal lavage, endoscopy, etc. The entire technological field is growing rapidly. Representative companies include Simbionix, Simulab, Mentice, Limbs & Things, Immersion and others.

No one wants a patient to sustain an injury as a result of his or her actions. Are patient simulators “real enough” that they would help prevent accidents and unnecessary injuries in the emergency setting?

Much engineering has gone into the creation of realistic manikin airways for training. This is the standard of education in an increasing number of institutions. The airways are dynamic. However, having a manikin only is never the answer—“It’s the curriculum, stupid!” That is, it’s the training by human instructors around the experience of the manikins that makes the difference. Specifically, because of the improving fidelity of simulators, this entire field can be expected to quickly move to quantifiable proficiency standards, in the hope of raising professional performance standards.

How important is the fidelity of a simulation—that is, its realism—to training effectiveness?

Quite. We are providing an educational experience to simulate the real experience of caring for a human being. The closer we have apples and apples, within an environment of high-quality education, the more reliable the educational product will be.

What kinds of conditions are these new devices able to simulate—do they come with different “packages” of symptoms?

They are both prepackaged into scenarios and programmable for locally created scenarios. Regarding manikin simulators, there are interactive demonstrations on the Laerdal and METI websites that break it down for you (www.laerdal.com and www.meti.com).

Since the manikin can actually “die” if you deliver the wrong procedure—or poorly execute it—the training is more powerful than pretending with a co-worker or imagining with a static manikin. But these devices are costly and may be unavailable to many EMS agencies. How can organizations on a limited budget access this technology?

The real cost for ANY program is not the simulator—it’s the people who run them, and perhaps the required space, if dedicated space is used. High-quality practice and research is expensive—do we think that high-quality education should happen for free? Institutions that raise this concern generally don’t really have a financial problem; they have a prioritization problem. What we’re talking about is raising the standards for care (including within an educational framework) for human beings. Shouldn’t this be a priority?

How can EMS agencies justify or mitigate the cost of training with simulators?

All that is required is some creative thinking and local collaboration/communication, most of the time. A local champion is helpful. Lots of things are funded locally after recognition of community self-interest—especially in the name of patient (or public) safety. We have to think big on this, and really get the vision.

Can you talk about any models that emergency departments can learn from to help them utilize this incredible tool?

The Israeli model—a national single center of training in a virtual hospital setting—is unique in a way, due to the geopolitics of the Middle East. Nonetheless, it offers insights into mechanisms of providing high-quality experiences/courses in regional simulation-based education.

Having a central program highly dedicated to the creation of scenarios and excellence in educational simulation-based curriculum can be extremely helpful, obviating every individual EMT program, fire department, etc., from reinventing the wheel. Having such a regional system can also facilitate both community philanthropy in covering capital costs and business planning to cover operational costs.

How does the use of patient simulators compare to our system’s more traditional “apprentice” or probie/preceptor model of medical training as a “best practice” for fostering experiential learning?

I wrote about this in my introduction to the book—according to the Institute of Medicine, every year approximately 100,000 patients may die unnecessarily due to adverse events in U.S. hospitals under the current apprentice system. I think that’s pretty clear. In short, the use of simulation-based education in the area of potential patient risk represents a revolution in education, which will likely replace, in some circumstances, the apprentice model. The aviation analogy is this: When a pilot trains on a new aircraft, all the training happens in a simulator. The first time he flies the real plane, it’s with real passengers, not an empty plane. In that industry, at least, simulation is considered a robust “experiential learning” platform.

Several articles in Simulators in Critical Care Education and Beyond seem to take a tone of persuasion. Is their use controversial? What’s the downside?

The only downside is that change creates grieving in any venue. But this technology is underutilized. There has been generally poor dissemination of information about the potentials of simulation-based education outside the anesthesiology community, where the manikin simulators were developed. This was the reason for the book.

Any controversy might hinge on the paucity of information showing absolute proof of saved lives through this kind of training in a randomized, scientific study mechanism. However, it’s unrealistic to think this will be quickly feasible, though increasing evidence of shortened learning curves is accumulating. To put this in perspective: There has never been a randomized, controlled trial demonstrating the effectiveness of simulation-based education in commercial aviation. Would you be willing to take your next flight with a pilot who had never been in a flight simulator taking the controls in hand for the first time? Similarly, let’s limit our training of healthcare workers on people as much as possible.