Cashing out by buying in – How expensive does a mannequin have to be to call a simulation “high fidelity?”

This critique on simulation fidelity was written by Alia Dharamsi, a PGY 4 in Emergency Medicine at The University of Toronto and 2017 SHRED [Simulation, Health Sciences, Resuscitation for the Emergency Department] Fellow.

How expensive does a mannequin have to be to call a simulation “high fidelity?”

mannequin

That was the question I was pondering this week, as our SHRED theme this month is simulation in medical education. In my 4th year of residency at University of Toronto, most of my simulation training has been in one of our two simulation labs, using one of our three “high fidelity” mannequins. However, even though the simulation labs and equipment have been very consistent over the past few years, I have found a fluctuating attentiveness and “buy-in” to these simulation sessions: some have felt very real and have resulted in a measurable level of stress and urgency to improve the patient’s (read: mannequin’s) outcome while others have felt like a mandatory hoop through which to jump in order to pass a rotation.

It should not come to anyone’s surprise to note that in Emergency Medicine, simulation is a necessary part of our development as residents. Simulation based medical education allows trainees to meet standards of care and training, mitigates risks to patients, develops clinical competencies, improves patient safety, aids in managing complex patient encounters, and protects patients [1]. Furthermore, in emergency medicine, simulation has allowed me to practice rare and life-saving critical skills like cricothyroidotomies and thoracotomies before employing them in real-time resuscitations. Those who know me will tell you when it comes to simulation I fully support its use as an educational tool, but there does still seem to be an ebb and flow to how much I commit to each sim case that I participate in as a learner.

During a CCU rotation,  I was involved in a relatively simple “chest pain” simulation exercise. As the circulating resident, I was tasked with giving the patient ASA to chew. In that moment I didn’t just simulate giving ASA; I took the yellow lid from an epinephrine kit (it looked like a small circular tablet) and put it in the mannequin’s mouth asking him to chew it. I did not think much of it until our airway resident was preparing to intubate, and the whole case derailed into an “ airway foreign body” scenario—to the confusion of the simulationists sitting behind the window who didn’t know how that foreign body got into the airway in the first place. Why did I do that? I believe it’s because I bought into the scenario, and in my eyes that mannequin was my patient, and my patient needed the ASA to chew. The case of a chest pain—although derailed into a difficult airway case by my earnest delivery of medications—was in the context of a residency rotation where I was expected to manage the CCU independently overnight. That context allowed me to buy-into the case because I knew these skills were transferrable to my role as a CCU resident. My buy-in has had less to do with the mannequin and the physical space and everything to do with how the simulation fit into the greater context of my current training.

There has been discussion amongst simulationists that there should be a frame shift away from fidelity and towards educational effectiveness: helping to engage learners, providing framework and context to aid them in suspending their disbelief, and providing structure to apply the simulation to real-time resuscitations in order to enhance learner engagement [2]. The notion of functional fidelity is one that resonates with me as a budding simulationist; if a learner has an educational goal and is oriented to how the simulation will provide the context and platform to learn that goal, the learner may more easily “project fidelity onto the simulation scenario.” That is, the learner will buy-into the simulation [2].

 So how do we facilitate buy-in?

We can start by orienting learners meaningfully and intentionally to the simulation exercises. [3] This can be accomplished by demonstrating how the concepts from the simulation are transferrable to other contexts which can allow the learners to engage on a deeper level with the simulation and see the greater applicability of what they are learning [2].  We can’t assume learners understand why or how this exercise is applicable to them. A chest pain case for a senior resident in emergency medicine has very different learning outcomes than the same case for an off service junior resident rotating through the ER; the same can be said for a resident primarily working in the hospital or working in an outpatient clinic. Tailoring case objectives to learners specifically provides an opportunity to provide relevant skills to learners in the context of their training, giving them a reason to buy-in to the scenario session. Moving beyond “to learn…” or “to outline the management of…”, I would advocate that specifically outlining objectives for the level and specialties of participating learners will help them see the employability of the skills they gain in the simulation.

We can also use those specific objectives and context we start the simulation session with to foster a more directed debrief. The post-simulation discussion should not only cover medical management principles but also specific discussion about what learners would do if they encountered a similar situation in their specific work environment (clinic, ward, etc), transferring the learning out of the simulation lab and into real world medical practice.

If we are going to see simulation as a tool, let’s see it as one of those fancy screwdrivers with multiple bits, and stop trying to use the screwdriver handle as a hammer for every nail. No one mannequin, regardless of how expensive and how many fancy features it has, can replace the role of a thoughtful facilitator who can help learners buy-into the simulation. If facilitators take the time to orient the learner to their specific learning objectives and then reinforce that context in the debrief discussion, they can increase the functional fidelity of the session and aid learners in maximizing their benefit from each simulation experience.

 

Citations 

  1. Ziv, A., Wolpe, P. R., Small, S. D., & Glick, S. (2003). Simulation-Based Medical Education. Academic Medicine, 78(8), 783-788. doi:10.1097/00001888-200308000-00006
  2. Hamstra, S. J., Brydges, R., Hatala, R., Zendejas, B., & Cook, D. A. (2014). Reconsidering Fidelity in Simulation-Based Training. Academic Medicine, 89(3), 387-392. doi:10.1097/acm.0000000000000130
  3. Issenberg, S. B., Mcgaghie, W. C., Petrusa, E. R., Gordon, D. L., & Scalese, R. J. (2005). Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review. Medical Teacher, 27(1), 10-28. doi:10.1080/01421590500046924

 

Aortic Dissection

This case was written by Dr. Martin Kuuskne who is one of the editors-in-chief at EMSimCases and is an attending Emergency Medicine Physician at University Health Network in Toronto.

Why it Matters

Aortic Dissection is one of the most deadly causes of chest pain for the emergency physician. Its presentation, methods of diagnosis, management and complications are varied and demand critical thinking, clear communication and teamwork. This case highlights the following points:

  1. The key elements of the history, physical exam and initial investigations that support the diagnosis of aortic dissection.
  2. The importance of managing hypertension in the setting of aortic dissection, including specific blood pressure and heart rate targets.
  3. The need to set priorities dynamically as a patient becomes unstable and requires ACLS care.

Clinical Vignette 

You are working the day shift at a tertiary-care hospital. A 66-year-old female is being wheeled into the resuscitation bay with a history of a syncopal episode. No family members or friends are present with the patient.

Case Summary

A 66-year-old female with a history of smoking, HTN and T2DM presents with syncope while walking her dog. She complains of retrosternal chest pain radiating to her jaw. She will become increasingly bradycardic and hypotensive, requiring the team to mobilize resources in order to facilitate diagnosis and management of an aortic dissection.

Download the case here: Aortic Dissection

First EKG for the case: Sinus tachycardia

(EKG Source: http://i0.wp.com/lifeinthefastlane.com/wp-content/uploads/2011/12/sinus-tachycardia.jpg)

Second EKG for the case:

mobitz-1-stemi

(EKG Source: http://hqmeded-ecg.blogspot.ca/2012_09_01_archive.html)

CXR for the case:

(CXR Source: https://radiopaedia.org/articles/aortic-dissection)

VSA Megacode

This case is written by Dr. Cheryl ffrench, a staff Emergency Physician at the Health Sciences Centre in Winnipeg. She is the Associate Program Director and the Director of Simulation for the University of Manitoba’s FRCP-EM residency program; she is also on the Advisory Board of emsimcases.com.

Why it Matters

Leading a resuscitation is a core skill of an Emergency Physician. More often than not, we know very little about the patient’s history before orchestrating a team of nurses, respiratory technicians, residents and other team members to provide resuscitative care. Assessment of the cardiac rhythm and pulse allows us to start with ACLS algorithms in order to hopefully obtain return of spontaneous circulation (ROSC), initiate post-ROSC care and arrange for the appropriate disposition of the patient This case, which is geared toward junior learners, highlights the following:

  • The importance of resource allocation during a prolonged resuscitation
  • Managing the resuscitation team, ensuring effective communication and recognizing compression fatigue.
  • Providing high quality ACLS and post-ROSC care
  • Recognizing STEMI as the cause of the cardiac arrest and initiating disposition for percutaneous coronary intervention (PCI)

Clinical Vignette

A 54-year-old male police officer presents to the ED with chest pain. He played his normal weekend hockey game about two hours ago. He has been having retrosternal chest pain since the game ended. It improved with rest, but has not resolved completely. It is worse after walking into the department. He now feels dizzy, short of breath, and nauseous.

Case Summary

A 54-year-old male police officer presents to the ED complaining of chest pain for two hours that started after his weekend hockey game. He is feeling dizzy and short of breath upon presentation. He will have a VT arrest as he is placed on the monitor. He will require two shocks and rounds of CPR before he has ROSC. He will then loose his pulse again while the team is trying to initiate post-arrest care; this will happen several times. Finally, the team will maintain ROSC. When an ECG is performed, it is revealed that the patient has a STEMI and the team will need to call for emergent PCI.

Download the case here: VSA Megacode

ECG for the case found here:

anterolateral

(ECG source: http://cdn.lifeinthefastlane.com/wp-content/uploads/2011/10/anterolateral.jpg)

Post Intubation-CXR for the case found here:

normal-intubation2

(CXR source: https://emcow.files.wordpress.com/2012/11/normal-intubation2.jpg)

Tumour Lysis Syndrome

This case is written by Dr. Donika Orlich; a PGY5 Emergency Medicine resident at McMaster University who completed a fellowship in Simulation and Medical Education last year.

Why it Matters

Tumor Lysis Syndrome is a constellation of metabolic disturbances that can occur as a potentially fatal complication of treating cancers, most notably leukemias or solid rapidly-proliferating tumours. This case highlights the following:

  • The identification and management of severe hyperkalemia
  • The need to consider Tumour Lysis Syndrome as a diagnosis and order appropriate metabolic tests
  • Recognizing and initiating the treatment of severe hyperuricemia
  • Communicating with family members effectively during the treatment of a critically ill patient.

Clinical Vignette

A 72-year-old male presents to the emergency department complaining of general weakness for 2 days.  His wife called EMS and he was a STEMI patch to your hospital. He has been placed in the resuscitation bay.

Case Summary

A 72-year-old male is brought in as a “code STEMI” to the resuscitation bay. He was recently diagnosed with ALL and had chemotherapy 3 days ago for the first time. The patient is severely hyperkalemic, which must be initially recognized and treated, hypocalcemic and hyperuricemic as a result of Tumour Lysis Syndrome and the metabolic derangements must be stabilized until emergent hemodialysis is arranged.

Download the case here: Tumour Lysis Syndrome

ECGs for the case found here:

ecg90406-hyperkalaemia-pr-lengthens

(Source:  http://lifeinthefastlane.com/ecg-library/basics/hyperkalaemia/)

normal-sinus-rhythm

(Source:  http://cdn.lifeinthefastlane.com/wp-content/uploads/2011/12/normal-sinus-rhythm.jpg)

CXR for the case found here:

CXR

Unstable Bradycardia

This case was written by Dr. Martin Kuuskne from McGill University. Dr. Kuuskne is a PGY5 Emergency Medicine resident and one of the editors-in-chief at EMSimCases.

Why it Matters

High-degree AV blocks (second degree Mobitz type II and third degree AV block) rarely respond to atropine and necessitate the utilization of electromechanical pacing, IV chronotropic agents or both. This case highlights the following points:

  1. Anticipating for the deterioration of patient with an unstable bradycardia by early pacer pad placement and initiating transcutaneous pacing
  2. The use of IV chronotropic agents in the treatment of severe bradycardia
  3. Recognizing PEA in the deteriorating bradycardic patient

Clinical Vignette 

A 78-year-old male from a long-term care facility is being transferred to the emergency department for decreased mental status.

Case Summary

A 78-year-old male presents to the emergency department with an unstable bradycardia. The patient deteriorates from a second degree, Mobitz Type II-AV block into a third degree AV block requiring ACLS protocol medications, transcutaneous pacing, and ultimately transvenous pacing until definitive management with a permanent pacemaker can be arranged.

Download the case here: Bradycardia

First EKG for the case:

http://lifeinthefastlane.com/quiz-ecg-014/

Second EKG for the case:

3rd AVB

http://www.emedu.org/ecg/searchdr.php?diag=3d

CXR for the case here:

CXR

http://radiopaedia.org/

Bedside Ultrasounds for the case:

Intra-abdominal Sepsis

This case was written by Dr. Martin Kuuskne from McGill University. Dr. Kuuskne is a PGY5 Emergency Medicine resident and one of the editors-in-chief at EMSimCases.

Why it Matters

Although recent literature has challenged the use of protocolized care in the management of sepsis, this case highlights the key points that are crucial in early sepsis care, namely:

  • The recognition of sepsis and identifying a likely source of infection
  • The initiation of broad-spectrum antibiotics in the emergency department
  • Hemodynamic resuscitation with intravenous fluids and vasopressor therapy

Clinical Vignette 

You are working a day shift at a community hospital emergency department. You are handed a chart of a patient presenting with abdominal pain. You recognize the following vital signs: Heart rate 120, blood pressure 85/55, respiratory rate 20, and O2 Saturation 95%.

Case Summary

A 60-year-old male presents with a four-day history of abdominal pain secondary to cholangitis. The patient presents in septic shock requiring intravenous fluid resuscitation, empiric broad-spectrum antibiotics and vasopressor support and suffers a PEA arrest prior to disposition to advanced imaging or definitive management.

Download the case here: Cholangitis

ECG for case found here: 

Sinus tachycardia

(ECG source: http://cdn.lifeinthefastlane.com/wp-content/uploads/2011/12/sinus-tachycardia.jpg)

CXR for case found here: 

CXR

Ultrasound for case found here:

http://www.pocustoronto.com/wordpress/?p=264

Ruptured AAA

This case was written by Dr. Martin Kuuskne from McGill University. Dr. Kuuskne is a PGY5 Emergency Medicine resident and one of the editors-in-chief at EMSimCases.

Why it Matters

Rupture is the most common and critical complication of an abdominal aortic aneurysm (AAA). It usually occurs into the retroperitoneum where bleeding may be temporarily limited and allows an opportunity to intervene. This case highlights three important aspects of managing a patient with a AAA rupture.

  • The use of a targeted ultrasound protocol in undifferentiated shock.
  • The concept of permissive hypotension in the treatment of a critical hemorrhage.
  • Rapid stabilization with blood products and organization for the transfer of a critically ill patient to the operating room.

Clinical Vignette 

You are working an evening shift at a tertiary care emergency department. You receive a call from a paramedic to alert you to the arrival of a 70-year old male who had a syncopal episode and was then found to be obtunded by his daughter. The patient is now in the resuscitation bay.

Case Summary

A 70-year-old male presents to the emergency department after a syncopal episode and then found to be obtunded by his daughter. He is hypotensive and tachycardic on arrival secondary to a AAA rupture into the retroperitoneal space. He requires intubation and fluid resuscitation with blood products to avoid a PEA arrest secondary to hypovolemia.

Download the case here: Ruptured AAA

ECG for case found here: 

Preintubation CXR for case found here: 

CXR

http://radiopaedia.org/images/220869

Postintubation CXR for case found here: 

Ultrasounds for case found here:

Opioid Overdose with ARDS

This case was written by Dr. Martin Kuuskne from McGill University. Dr. Kuuskne is a PGY4 Emergency Medicine resident and one of the editors-in-chief at EMSimCases.

Why it Matters

Opioid toxicity is a clinical diagnosis that should be rapidly recognized and managed. This case highlights four important aspects of a patient presenting after an opioid overdose:

  • Maintaining and addressing a wide differential diagnosis for the comatose patient.
  • Indications for and dosing of naloxone in the treatment of opioid toxicity.
  • Preoxygenation and intubation of a patient in the setting of significant hypoxemia.
  • Recognition of heroin associated acute respiratory distress syndrome (ARDS), a rare complication of opioid toxicity.

Clinical Vignette 

You are working in a community centre emergency department. A 34-year-old male is being brought into the resuscitation bay by EMS after being found unconscious in an alley-way by bystanders who called 911. The patient was given O2 by facemask and no other therapies en-route.

Case Summary

A 34-year-old male was found unconscious in an alleyway by bystanders who called EMS. The patient presents with a clinical opioid intoxication requiring naloxone administration. The patient also presents with acute respiratory distress syndrome (ARDS) secondary to heroin use requiring airway support, intubation and mechanical ventilation.

Download the case here: Opioid Overdose with ARDS

Preintubation CXR for case found here: 

Pre-intuabtion

(CXR source: http://www.radiology.vcu.edu/programs/residents/quiz/pulm_cotw/PulmonConf/09-03-04/68yM%2008-03-04%20CXR.jpg)

Postintubation CXR for case found here:

Post intubation

(CXR source: http://courses.washington.edu/med620/images/mv_c3fig1.jpg)

ECG for case found here: 

EKG

(ECG source: http://www.emedu.org/ecg/images/sb_1a.jpg)

Lung ultrasound for case found here: 

How to develop targeted simulation learning objectives – Part 2: The Practice

In part 1 of this two part series (https://emsimcases.com/2015/04/21/how-to-develop-targeted-simulation-learning-objectives-part-1-the-theory/), we used the revised Bloom’s taxonomy to describe an approach to developing simulation-based learning objectives by targeting a specific, complex knowledge domain and a higher level cognitive process.

Now that we know the theory behind making targeted simulation learning objectives, what kind of learning objectives should be included in a team-based resuscitation simulation scenario?

Team based simulation can be used to learn and assess a variety of different components of resuscitation skills. These simulated events display the knowledge, skills and attitudes of learners in a controlled setting. What makes simulation different from other traditional models of learning is that it combines components of crisis resource management (CRM) with medical knowledge and skills into a complex educational event. Keeping this in mind, while developing objectives for a simulated scenario, it helps to separate the CRM and medical knowledge objectives. A separation of these two key components allows for targeted feedback directed at specific areas of the learners’ performance and aids in their assessment.

A common pitfall in the development of objectives for a simulated case is including too many of them! While there are a multitude of soft skills as well as medical decisions being made during the simulated event, both the learners and assessors benefit from having a limited amount of clear objectives. Debriefing after a simulation is critical for the learning experience and having too many objectives may dilute the main teaching points of the case. As an example, at the McGill University Emergency Medicine residency program, we aim for 2 CRM based objectives and 3 medical knowledge objectives. While this is in no way the rule, we have found that tailoring the case to a smaller number of clear and well-developed objectives allows for productive and high yield debriefing sessions.

Learning Objectives for a Tricyclic Antidepressant Overdose Case

Learning Objectives for a Tricyclic Antidepressant Overdose Case

As discussed in a previous post (https://emsimcases.com/2015/04/07/crisis-resource-management/), the main components of CRM include communication, leadership, resource utilization, situational awareness and problem solving.1 A case can be specifically tailored toward a CRM objective or vice versa. For example, an objective focusing on resource utilization and triage can guide the development of a simulated case with two patients in a resource-limited setting. Conversely, a simulated STEMI case can include an objective focusing on leadership and the team leader maintaining a global perspective of the case. There are no guidelines on which CRM based objectives to include, but ensuring that your cases utilize different CRM components allows your learners to focus on a few important skills at a time and ensures that your learners are exposed to each component of CRM in a simulated setting.

Medical objectives encompass the core medical content that the simulated case was designed to address. When developing the medical objective, remember to focus on a higher cognitive process, such as “applying” over “remembering”, and a higher-level knowledge domain, such as “procedural knowledge” that includes skills and algorithms. Again, there is no limit to what medical objectives you can include, as long as they are well developed and specific. When developing the medical objective for the case, it may help to take a step back and ask yourself “what do I want my learners to take away from this case?” It also helps to consider the training level of the learners, where simulation fits within your full educational curriculum as well as your setting and to develop the objectives accordingly. As an example, an airway case may contain an objective on the choice of an induction and paralytic agent for intubation for junior learners, whereas an objective on a “can’t intubate, can’t ventilate” situation may be more suitable for senior learners.

Defining learning objectives for your simulated scenarios is key for case development, debriefing and, ultimately, learning. Using theory, we can create targeted objectives that optimize the learning time spent in the simulated setting. Breaking up the objectives into CRM and medical knowledge while limiting the total number of objectives can help focus both the learner and educator on the teaching points from the case. Through careful consideration of learning objective development, simulation can be used to both fill potential gaps in you educational curriculum and to enhance the resuscitation skills, CRM skills and medical knowledge of your learners.

Take Home Points

1) Divide simulation objectives into CRM or medical objectives

2) Limit the number of objectives for each case

3) Apply theory to develop targeted and specific objectives to align them with the teaching strategy of simulation

4) Diversify your CRM objectives throughout your simulation curriculum

5) For medical objectives, ask yourself “what do I want my learners to take away from this case?”

6) Consider the training level, full training curriculum and setting when developing medical objectives.

  1. 1) Hicks CM, Kiss A, Bandiera GW, Denny CJ. Crisis Resources for Emergency Workers (CREW II): Results of a pilot study and simulation-based crisis resource management course for emergency medicine residents. Can J Emerg Med. 2012;14(Crew Ii):354-362. doi:10.2310/8000.2012.120580.

Case progression: states, modifiers and triggers

In order for a simulated scenario to run smoothly, the case progression needs to be planned for in advance. This involves determining which states the patient simulator progresses through, how modifiers may change features of those states and what triggers will be used to change between states. A working understanding of these terms makes developing cases a lot easier.

State

During a simulated resuscitation scenario, the patient progresses through multiple states. The state represents the overall condition of the patient simulator during a specific period of time. I like to think of a state as a constellation composed of the vital signs and the patient status (which includes the general appearance and relevant physical exam findings) that we can present to the learners. While case progression usually follows a linear route through different states, this is not the rule; the case may skip or jump to a different state depending how it is developed (see figure 1). Each state should be represented by a characteristic title.

Screen Shot 2015-03-22 at 12.58.55 PM

Figure 1. An example of a case progression. States 1 through 4 represent a linear progression. State 5. V-fib, is a possible simulator state, depending on the leaners’ actions. The green arrows represent unspecified triggers.

Modifier

A modifier is a learner action that induces a change to the patient simulator, but not enough to transition between states. These changes can affect either a vital sign or a component of the patient’s status, but usually not both. An example of a modifier would be the application of a 100%-non-rebreather mask to a patient in an “Acute Pulmonary Edema” state. As a modifier, this learner action would cause an increase in the patient simulator’s O2 saturation from 84% to 89%. However the state, “Acute Pulmonary Edema”, would not change. It would continue to be represented by sinus tachycardia at a rate of 120, a blood pressure of 180/105, a respiratory rate of 28 and a patient status represented by respiratory distress (accessory muscle use, pursed lipped breathing etc). A modifier can manifest its change instantly or over a specified amount of time (ex. increase the O2 saturation from 84% to 89% over 10 seconds).

Trigger

A trigger is an event that causes a change in the simulator state. I describe triggers as being either active or latent. Active triggers are represented by a learner action (ex. needle thoracostomy) or a specific combination of learner actions (ex. ≥2 methods of active cooling) while latent triggers are usually time-based (ex. 3 minutes). Active triggers are key to the progression of the case and make for great learning points during debriefing because they define important medical management decisions. Latent triggers are used to automatically progress the case. Like a modifier, a trigger can also be manifested instantly or over a specified amount of time.

EMSimCases case progression template

Figure 2. An example of a state, modifier and triggers using the EMSIMCASES case progression template

Figure 2. An example of a state, modifier and triggers using the EMSIMCASES case progression template

The EMSimCases template uses a table to display and facilitate case progression while running a simulation scenario (see Figure 2). The patient state is described in the first column with its title and vital signs. The patient status (general appearance and relevant physical exam findings) is described in the second column. A full physical exam is described in another section of the template. The third column lists possible learner actions. The fourth column contains the modifiers and triggers for that state.


Any simulation educator can tell you that no matter how much planning goes into case development, learners will always surprise you with an action that you did not predict. This highlights the importance of being able to adapt the case progression to unforeseen learner actions on the fly. However, if you develop cases with a logical progression of states, account for possible modifiers and how they will change features of those states and, lastly, define the triggers that will transition between states, your simulation scenario will be as smooth and realistic as ever.