Simulation in EMS: Real solutions for medics

The need to create realistic environments is driving technology to new levels of realism

Simulation in medical education continues to evolve as the technology improves and the science behind the practice becomes clearer. Simulation education is simply not a fad; there is real purpose behind its use. Let's explore its tenets, the role it occupies in education and how it relates to real world practice.

Brief history
Simulation is not new; we've been doing it since we were children. Making a "gun" out of your thumb and index finger is a classic example of "pretending" a real object. In more concrete terms, simulation has existed in a variety of occupations since the late 1920s when aviation produced its first flight simulator.

Medical educators began looking at medical simulation in the late 1980s. However, initiatives to incorporate simulation into medical education were sporadic.

Industry-wide efforts began in earnest after the release of the Institutes of Medicine 1999 report, To Err is Human, highlighting medical practice errors in healthcare institutions nationwide.

One of the recommendations of that report was to move away from using live patients as "trainers" and incorporate highly realistic, controlled training equipment and environments to allow new practitioners to develop and refine assessments, skills and procedures in a safe environment.

While the word "simulation" might be associated with very expensive, highly technical equipment, the simple fact is that it doesn't require a lot of money to implement. Medical simulation can be conducted in a variety of ways in order to accomplish the educational or training goal.

Standardized patients
Many of us have used each other as "pretend patients" during scenarios, sometimes using a script or directions to recreate a specific condition. While useful, the use of a standardized patient brings it to another level.

In this situation, a person is specifically prepared and trained to act in a very specific manner. Highly detailed instructions are provided so that the actor can react to the interactions with the healthcare provider in a realistic way.

A standardized patient may have makeup or moulage applied to mimic conditions such as pale skin color or diaphoresis. Broken bones, burns and other traumatic injuries can be applied.

The main purpose of using a standardized patient is to help the provider learn how to assess and interact with the patient. Since the patient is a live human being, few skills and invasive procedures can be performed; these can be simulated using task simulators.

Task simulators
Task simulators are designed for exactly that – to help the learner acquire a specific skill or technique. Recall learning on a CPR manikin, an airway head or an IV arm, and you have the general idea.

These devices range widely in terms of realism. The need for realistic conditions depends on what the educator is trying to achieve. If it is the initial acquisition of a specific skill, what is needed is a device that possesses the essential features of the actual anatomical condition that it is attempting to simulate.

For example, an airway head designed for initial skill acquisition will have the basic anatomic landmarks present, such as the teeth, tongue and soft tissues of the posterior pharynx, larynx and glottic opening.

A moveable mandible and neck will be needed to perform basic airway maneuvers. There should be some type of feedback device that indicates the task is being performed successfully, such as inflating lungs or balloons, or chest rise.

As importantly, the device should be sturdy enough to withstand hundreds, even thousands of repetitions as beginning students practice and improve the basics of the task.

However, once the essential task has been acquired, more sophisticated task trainers can be used to force adaptations of the task itself.

Carrying through the previous example, changing the airway "architecture" will help the learner refine his/her basic technique.

Injecting small amounts of air into bladders that are located within the manikin can cause its airway to become more narrow, or its neck more rigid, or displace the epiglottis anteriorly, all in an effort to make airway placement for difficult.

Patient simulators
Like task simulators, patient simulators come in a wide range of complexity and realism. Low fidelity simulators have essential aspects of the human body and often come with limited interactivity.

For example, a simple ALS manikin may allow an EMS team to defibrillate, gain intravenous access and deliver medications, and insert a variety of advanced airways during a simulated cardiac arrest.

The instructor or operator may have limited ability to control certain aspects of the simulator's physiology, such as lung sounds, pulse rate and blood pressure readings.

Contrast low fidelity manikins with high fidelity simulators. These mimic many of the body's anatomic and physiologic parameters.

Eyes blink, pupils dilate; the chest rises and falls with each breath. Skin turns pale and diaphoretic on command. High fidelity simulators speak, either with "pre-canned" speech clips or transmitting an actor's voice remotely.

High fidelity simulators also record data, which can be essential to the learning process. External video cameras and microphones record what the student or team are doing from one moment to the next.

Internal sensors monitor critical tasks, such as the volume of air being provided per manual ventilation, when an advanced airway is place or when an electrical shock is delivered.

High fidelity simulators can also be programmed with sophisticated scenarios. Once initiated, the simulator can run on its own, with little input from an instructor or operator. Complex algorithms allows the simulator to "decide" what the next logical step should be, based upon the information it receives from its sensors. In essence the learner is working directly with the "patient" while the instructor can observe the interactions without worrying too much about controlling the scenario.

High fidelity simulators can be "tetherless," meaning that there are no wires or tubes connected to it. On board compressors and wireless control can allow the simulator to be used almost anywhere; this is especially useful in the EMS environment, which is quite different from the four walls of a hospital room.

The simulation environment
While it might seem great to be able to use high fidelity simulators in all types of training, it's not as simple as it seems, or as necessary. In many scenarios they are great learning tools.

But high fidelity simulators are expensive, costing $40,000 or more to purchase. Maintenance and repair is expensive. Learning how to operate the devices can be complicated and tedious.

Meanwhile, other lower cost, less realistic simulator devices can work fine, if you know what you are trying to achieve. For example, simply placing the airway trainer onto the floor after the student learned the basic steps would better simulate the true work environment of a patient lying on the floor.

Moving the simple ALS manikin onto a gurney and into the back of an ambulance can have the students learn how to operate with its tight confines.

The implication is this: simulation is what you make of it. Training in situations that mimic real life allows the learner with basic knowledge to be able to integrate that information in a realistic manner.

Simulation environments can scale up or down, depending on what the training goal is. In full scale simulations, the instructor creates the environment that essentially removes the teacher from the situation, so the student learns how to operate more autonomously, yet safe from inflicting harm if a mistake is made.

High fidelity simulations recreate the working conditions (back of a moving ambulance), using equipment in a realistic manner (manikin, standardized patient, jump kits, actual invasive procedures), and under real life conditions (outside, in the rain, at night).

Making these conditions realistic promotes not only critical thinking and decision making skills, but also teamwork, coordination and leadership skills.

The need to create safe, realistic environments to practice and refine critical tasks and procedures is driving simulation to new levels of realism and interactivity. It continues to be the role of the instructor to utilize the technology wisely, so that the training goal can be accomplished effectively. 

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