The following article was written by Dr. Sarah Foohey who is an emergency physician in Mississauga, Ontario. She completed medical school at McMaster and her family medicine residency and EM fellowship at the University of Toronto. Since completing her training in 2018, Sarah has lead the exam preparation sessions for the University of Toronto EM residents. She is also passionate about simulation education. Most recently, Sarah has helped develop an in situ simulation program at Credit Valley Hospital designed to improve the department’s readiness during the COVID-19 Pandemic.
Why create a virtual resus room?
Physical distancing restrictions during the COVID-19 pandemic have dramatically impacted medical education, challenging educators around the world to create interesting, novel ways to engage learners remotely.1-4 Virtual alternatives to in-person simulation sessions have been of particular interest. From discussion with other educators, it seems like many programs have shifted to a model of sim that involves talking through challenging cases. This strategy is excellent for medical content review but misses the hands-on, interactive, nervous energy of simulation that makes it so valuable. This is why we set out to create the Virtual Resus Room.
The infrastructure of the Virtual Resus Room is simple, using separate audio and visual inputs. The visual portion is provided by a shared Google Slide that has been designed to feature the essential components of a resuscitation room. Every participant and facilitator will have the same slide open on their computer – so it can be interacted with in real time. Audio is provided using Zoom, or the teleconferencing program of your choice. Through this, the facilitators can present the case and provide pertinent verbal updates. The team members can communicate to delegate roles, verbalize when they have completed tasks, and brainstorm together.
How was it done?
This project was initially developed as an educational tool for the University of Toronto Canadian College of Family Practice – Emergency Medicine (CCFP-EM) residents. The first case we ran with this group was a pediatric patient with diabetic ketoacidosis who ultimately developed cerebral edema, became hypoxic, and required intubation. This case was modified from a similar one that we found on emsimcases.com.
In a case like this, with multiple concurrent orders required, the team lead had to use effective role delegation to divide the tasks at hand. One resident was responsible for medications, selecting the ordered medication from the medications tray on a separate page, then dragging it into the “medication given” box to simulate its administration. Another resident was responsible for airway, and initially had to choose the appropriate method and rate of oxygen delivery. Eventually, they had to prepare to intubate the child, first selecting the appropriately sized airway equipment from the airway tray and then verbalizing the steps involved in this procedure. The resident responsible for charting helped keep track of all orders, medications administered, and tasks completed.
As the case progressed, the facilitators updated the patient’s vital signs in response to the learners’ actions and provided prompts to convey changes in clinical status. They also revealed physical exam findings and investigations as prompted by the residents’ questions and orders. For example, a video of a child with Kussmaul breathing was shown when the residents asked about the patient’s appearance.
In this experienced group of residents, clear role delegation and closed loop communication made the case run smoothly. One resident responsible for medications expressed that they were struggling with having too many orders at once, giving the team lead the feedback they needed to avoid the order stacking that can occur in these complicated cases. One team lead asked another resident to consult their preferred treatment algorithm for DKA, delegating this task so they didn’t lose situational awareness. During the debrief, it was clear that the case had allowed the learners to practice these types of crisis resource management skills, even in this remote environment.
Challenges encountered
Of course, an online simulation cannot supplant an in-person setting but rather can be used to supplement or temporarily replace in-person simulation in times when it cannot be held. It was sometimes challenging to communicate using Zoom, since only one person could be talking at one time and a concerted effort had to be made not to interrupt one another. In addition, although video was used, this didn’t allow for the eye contact and non-verbal cues that improve communication during resuscitations. As a facilitator, confidently running the simulation required a thorough understanding of both the case progression and how to interact with the new interface, which we accomplished by having facilitators do a full trial run of the case in advance of the session.
Summary and next steps
The next step will be to continue developing more cases and to use the Virtual Resus Room model to lead online simulation sessions for additional groups of learners. In upcoming weeks, it will be trialed in the emergency medicine clerkship curriculum at both McMaster University and the University of Toronto. I would love to share this project and work to improve it with any interested educator. The cases we have developed and trialed are available online at virtualresusroom.com.
Simulation has been a cornerstone of my medical education, preparing me for life as a staff physician more than any other learning modality. Until it is safe for us to be back together in the close quarters of the Sim Lab, my hope is that the Virtual Resus Room can provide a fun, engaging, and high yield alternative approach.
References
- Ferrel MN, Ryan JJ. The impact of COVID-19 on medical education. Cureus [Internet]. 2020 Mar [cited 2020 May 31]; 12(3): e7492. Available from: https://www.cureus.com/articles/29902-the-impact-of-covid-19-on-medical-education doi:10.7759/cureus.7492
- Pather N, Blyth P, Chapman JA, Dayal MR, Flack N, Fogg QA, et al. Forced disruption of anatomy education in Australia and New Zealand: An acute response to the Covid-19 pandemic. Anat Sci Educ [Internet]. 2020 Apr [cited 2020 May 31]; Available from: https://anatomypubs.onlinelibrary.wiley.com/doi/full/10.1002/ase.1968 doi:10.1002/ase.
- Rose S. Medical student education in the time of COVID-19. JAMA [Internet]. 2020 Mar [cited 2020 May 31]; Available from: https://jamanetwork.com/journals/jama/fullarticle/2764138 doi:10.1001/jama.2020.5227
- Sahi PK, Mishra D, Singh T. Medical education amid the COVID-19 pandemic. Indian Pediatrics [Internet]. 2020 May [cited 2020 May 31]. Available from: https://pubmed.ncbi.nlm.nih.gov/32412913/
EM Sim Cases 
This is outstanding! I’d love more details on the how-to’s of creating this. It is informative but looks within reach of low resource settings! Thanks so much for the post.
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