It’s Hollywood Baby: Simulation Technology and Virtual Environments in Healthcare and Continuing Education

Continuing education can be a blast! While we healthcare professionals often look forward to a weekend “away” or even a week if we can squeeze it in for a continuing education conference or symposium, the excitement usually revolves around the exhibit hall, a vendor educational demonstration or a side trip. However, the future of educational programming is upon us and we may find the educational experience to be more like a visit to Disney World®, taking in a 3-D Hollywood movie or playing on a Wii™.

Step into a virtual hospital or simulation lab on a health sciences campus or log into a serious medical game and you may think that you are aboard the Starship Enterprise. Medical and other healthcare professions students are being educated on the basics of patient care as well as advanced clinical procedures using computer-enhanced mannequins (CEMs) or human patient simulators (HPSs) (figure 1) and 2-and 3-D medical games with electronic patients in virtual environments (figure 2). These technologies are being used to simulate the patient and the patient care environment. With advanced or high-fidelity CEMs, students can listen to vital signs, administer drugs and watch a typical human physiological response play out, perform chest compressions and receive feedback about their technique, draw blood from an arm vein or collect urine via a catheter. Additionally, certain high-fidelity CEMs have wound simulation packages. In some CEMs, these wound simulation or moulage kits can be used to create realistic wounds that can even be connected to the mannequin hydraulic system to produce bleeding. Through computer-aided controls, blood pressure can be controlled and set to produce a venous “ooze” in the wound, an arterial “squirt” or the pulse can be removed in a limb to simulate arterial insufficiency.

Different categories of CEMs exist.1,2 They include low, medium and high fidelity CEMs or HPSs. Each has their merit and can be used for different teaching objectives. Costs are also a consideration as high-fidelity simulators cost significant more than their low and medium-fidelity counterparts. A table comparing features and costs is provided below.

Like CEMs, serious healthcare games allow students to actively experiment with clinical skill performance and decision making without the inherent risk to real patients. The learning process has been termed “successful” failures by many in the simulation field. As a result of the interactive capabilities of these applications, health science centers across the country are rushing to integrate serious gaming into their training paradigms. Serious medical games exist for performing dental implantation surgery, preparing a surgical instrument tray, studying the immune response and for preparing students to manage hospitalized patients. Another example of a serious health game is one being developed by Winston-Salem State University. Physical therapy students will be able to practice patient care skills with electronic patients individually and together (Figure 2).

To fully take advantage of the capabilities of these simulation technologies, applied learning centers such as virtual hospitals are being created. For example, CEMs are being housed in simulation labs that mimic healthcare settings such as an ICU, birthing room or a surgical suite. Depending on the level of financial investment, some centers have created virtual hospitals that contain a number of simulation suites along with control rooms for video recording role playing activities and debriefing rooms for student self-assessment and peer-evaluation. Additionally, full scale patient care scenarios are played out in these environments using teams of students and health care professionals. This interactive learning experience allows group performance to be assessed along with individual performances. As a result, team dynamics can be evaluated along with clinical competence in the delivery of health care services. Because of the potential benefit of these virtual hospitals in providing hands-on skill training for learning new procedures and trouble shooting patient safety issues, healthcare centers are establishing simulation suites or partnering with health science centers and others to build virtual hospital training facilities. A search for the term “virtual hospital” on Google will locate a plethora of these facilities.
However, CEMs and medical games are only two examples of simulation. According to Dr. David Gaba, “Father of Medical Simulation”, there are five categories of medical simulation.1,2

These categories include:
(1) Role playing
(2) Standardized patients
(3) Simple (part) task trainers
(4)Computer-enhanced mannequins (CEMs)
(5) Electronic patients (see Table 1).

Simulation has a role in educating both students and practicing clinicians. Some of the earliest use of simulation can be traced back to teaching medical students about wounds and dermatological conditions.3 The literature indicates that wound simulation has been a part of medical education since at least the Middle Ages when beeswax was used to prepare models of wounds and skin lesions. Wax models of these skin conditions were used to preserve the detail of interesting medical cases in the form of castings and sculpture. Interestingly, wax models representing a wide variety of common and unusual skin lesions were used in dermatology education until the 1940’s when they were displaced by photographic slides.

A number of simulation technologies are used to educate students and clinicians alike about wound management practices. For example, role playing and standardized patients can assist with patient interview skills, symptom recognition and navigating complex psychosocial issues. Wounds can be simulated on human actors using a moulage kit and these wounds can be evaluated and a treatment approach formulated. However, it is difficult to simulate associated impairments such as arterial insufficiency or to safely practice certain procedures such as debridement.

Another simulation approach that is used in teaching wound management practices today is the partial task trainers (models of human body parts with simulated wounds). Examples of this simulation approach include the pressure ulcer and diabetic foot ulcer models. These partial task trainers can be used to teach wound staging and to demonstrate certain wound dressing applications. However, they do not have a programmable physiology so higher level simulations such as variable, bounding or absent pulses cannot be simulated along with active bleeding.

In contrast, CEMs and electronic patients allow students and health care professionals to actively practice wound management clinical skills that are not possible on humans or partial task trainers. High fidelity CEMs are capable of a broad range of physiological responses that allow for a more robust simulation of wound management practices. Simulated wounds may be attached to some high fidelity CEMs (Figure 5) and the CEMs can be programmed to exhibit specific types of pulse rates, blood pressures, and particular bleeding patterns such as a venous ooze or an arterial squirt as discussed previously. Other features that can be used to teach wound management include venous refill (simulated via a blue laser light) and skin coloration changes such as cyanotic nail beds.

Manufacturers of CEMs also provide moulage kits (figure 3 and 4) that can be used to create realistic injuries. As mentioned previously, simulated wounds may be connected to the internal hydraulics of the CEM so that active bleeding of the character desired may occur in the wound bed. Additionally, different colored solutions may be used to simulate venous or arterial blood along with purulence or serous fluid.

Moulage kits can also be self-prepared rather than purchased. Materials that can be used to create wounds include eggplant, Silly Putty®, glue, and Crayola Model Magic®. Acrylic paints can be used to create the look of purulence, eschar or slough and red and purple lipstick can be used to simulate bruising or the look of a deep tissue injury. Petroleum jelly, cornstarch and oatmeal can create the look of fibrotic or alligator skin. Inflammation can be simulated by placing a hotpack under the CEMs synthetic skin and likewise arterial insufficiency can be simulated by using a cold pack under the skin. Toothpaste mixed with green or yellow acrylic paint is a great way to create a thick purulence while Ooze® can be used to simulate slough. Floam® can be used to create hardened eschar that can be debrided with a scalpel or a low frequency ultrasound device.
Additionally, wounds can also be simulated using animation. Animations of patients and their wounds are created along with various wound care applications. Students or healthcare providers can evaluate these wounds and then select and apply treatments in a virtual environment.

Conclusion:
In conclusion, education in the health sciences is rapidly evolving and is taking advantage of the variety
of simulation technologies that are available for interactive learning. These technologies are also being rapidly adopted for health provider continuing competency and continuing education programs.

The various forms of simulation have many advantages including promotion of skill acquisition through hands-on learning and immediate assessment of performance through self, group and video-directed feedback.

As wound care clinicians and educators, it is important for us to realize the opportunities that exist for enhancing our learning experiences and teaching endeavors. Keep your eyes open for a virtual hospital. One may be coming to your community soon or a serious medical game may make its way into your facility. Learning has never been such fun!

Teresa Conner-Kerr, PT, PhD, CWS, CLT is Professor and Chair in the Department of Physical Therapy at Winston-Salem State University. She is dually certified in wound and lymphedema management with over 15 years of clinical experience.
She is currently funded to establish a virtual hospital and serious medical game to address rehabilitation training needs.

Sharon Prybylo, PT, DPT is Director of Clinical Education and Clinical Assistant Professor in the Department of Physical Therapy. She has 38 years of experience in orthopedic physical therapy and currently serves as the clinical simulation coordinator for the department.