October 1997
Volume 61 |
Number 10
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| Uses of Simulators
for Education and Training in Nonanesthesia Health Care Domains |
Daniel B. Raemer, Ph.D.
Deborah M. Barron, M.D.
Realistic simulators are creating a paradigm shift in education
and training throughout all of medicine. The tongue-in-cheek adage
of "see one, do one, teach one" is gradually becoming
an inapplicable metaphor as the number of inpatients and their
length of stay decrease and as financial structures underscore
the high cost of teaching in the clinical environment. Restrictions
on the use of animal laboratories for teaching clinical skills
and concepts are also mandating consideration of alternatives.
As realistic simulators have begun to permeate anesthesia education,
other medical and allied health specialties are piloting the use
of this technology in their new educational constructs. We will
highlight some of the programs emerging in nonanesthesia fields
that use the mannequin-based realistic patient simulators pioneered
in anesthesia.
Physiology and Clinical Medicine
A number of simulation centers have used their patient simulator
to enhance lectures on cardiovascular and respiratory physiology,
clinical pharmacology and basic physical diagnosis. Medical students
at various levels of training at Pennsylvania State University,
the Universities of Pittsburgh and Florida, and Harvard, Vanderbilt
and New York Universities are offered programs that replace sessions
once taught in the animal laboratory. Studies of the effectiveness
of learning using this hands-on modality are ongoing at Harvard.
In addition to anesthesia training, the University of Florida
uses its simulator as part of the physiology course for biomedical
engineering students as well.
The majority of simulation centers offer opportunities for simulator-based
education to medical students during their anesthesia or surgery
clerkships. The response has been overwhelmingly positive as students
are able to actually implement their clinical plan without stress
to the patient or health care system. These programs foster career
interest in the fields of anesthesiology and surgery and enhance
understanding in the medical community at large of the roles of
anesthesiologists and others on the surgical team.
Acute Care Medicine
Advanced cardiac life support (ACLS) has been traditionally taught
using part-task simulators having capabilities limited to cardiopulmonary
resuscitation training and cardiac rhythm identification. However,
the recognition that quality "code management" goes
beyond ACLS training has led the Boston group to begin a mock
code program involving the entire hospital response team. This
program is organized by the resuscitation committees of the regional
hospitals and involves medical and surgical house staff, nursing,
respiratory therapy and anesthesia.
Each month for two days, the patient simulator is moved to an
actual patient room in one of the hospitals. Appropriate paperwork,
facilities and supplies for a particular patient are created to
promote realism. The active code teams are given pagers and told
that they will be called to participate in a "mock code"
sometime during the two days. Approximately three mock codes per
day are called, and one of the teams is summoned for each. The
team response to the simulated patient's cardiopulmonary arrest
and complications is videotaped. A 45-minute, facilitated review
of the tape is immediately conducted for the participants. Medical,
equipment and team dynamics issues are discussed.
Penn State, University of Pittsburgh and Washington University
in St. Louis, Missouri, use their simulator to introduce management
principles to critical care medicine residents. Since critical
care patient management requires integration of multiple services,
these simulator-based courses include surgeons, internists, anesthesiologists
and nurses. Placement and function of cardiovascular monitoring
lines, clinical decision-making and dealing with complex patients
are emphasized.
The Stanford group has begun a program with neonatology to provide
crisis resource management training to neonatology fellows and
pediatric residents. Resuscitation of newborns in the delivery
room is the focus. As expected, this course has generated interest
in team training for the entire labor, birth and recovery team.
Radiology
Radiologists, especially interventional specialists, are increasingly
facing complications such as contrast media reactions, oversedation,
airway reactivity and cardiac failure. At the Boston center, radiology
residents attend a mandatory half-day session in crisis management.
Modeled after the Anesthesia Crisis Management program, radiology
residents are paired with a technologist and registered nurse
and presented with simulated acute crises. A mannequin simulator
set in a mock computerized tomography scanner suite is used to
provide context to the team. Appropriate patient history and order
forms, films and equipment are used whenever possible to maintain
realism.
Using post-hoc videotape debriefing, issues of leadership, calling
for support, communicating within and outside the team, utilization
of emergency equipment and resources, and avoiding fixations are
stressed.
Surgical Teams
A number of centers have gone beyond isolated teaching of anesthesia
practitioners to involve the entire surgical team. The simulator
in Basel, Switzerland, has been used for monthly crisis management
training of regular surgical teams for three years. The simulator
operating room suite is adjacent to the regular O.R.
The day prior to the scheduled case, "Wilhelm Tell"
appears on the operating schedule, and a surgical team and anesthesia
team are expected to work up the patient history and plan. The
case is conducted with the surgical team operating on porcine
intestines and the anesthesia team administering a general anesthetic
to the patient simulator. A crisis such as a oxygen pipeline failure
is introduced during the procedure, and the O.R. team is expected
to respond appropriately and efficiently. The case is videotaped
and reviewed with an emphasis on "team dynamics."
The Toronto Sunnybrook Hospital Simulator Center is also conducting
surgical team crisis management exercises. The center has been
evaluating acceptance of this teaching modality for the past year
in an ongoing study.
The Pittsburgh simulator group has been conducting an annual
obstetrical team crisis management training program. This exercise
focuses on OB crisis such as the pre-eclamptic patient arriving
from the emergency department with seizures, post-partum hemorrhage,
amniotic emboli and difficult airway. Both staff and resident
obstetricians and anesthesiologists participate.
Emergency Medicine
A number of simulator centers, notably those in Stanford, California,
Rochester, New York, and St. Louis, Missouri, have programs for
emergency medicine physicians. At Washington University, a day-long
program is offered for emergency department attending staff on
rapid sequence intubation. After learning about the medications,
indications and technique, participants practice on the simulated
patient. As the day progresses, the patient is made more clinically
complex.
Similarly, emergency department residents are taught the fundamentals
of airway management on a variety of simulated patients, including
ones with emphysema, trauma and drug overdose. Stanford's program
emphasizes crisis resource management for a mixed group of emergency
physicians, surgeons and anesthesiologists.
Allied Health Professionals
Emergency medical technicians, respiratory therapists, Med Flight
crews and ambulance teams have benefited from simulator training
at various locations, including University of Florida at Gainesville,
Pennsylvania State University at Hershey and Mount Sinai Hospital
in New York. These programs have emphasized airway management
principles and practice. Some pharmacology is taught via the simulator
to the allied health professionals specific to their needs in
the field.
Youth Programs
Several simulator centers have donated their time to educate
and inspire high school students, especially from the inner cities,
on health issues and health care careers. Penn State University
has a frequent program for youth in the Hershey area. Young students
are exposed to the comparative physiology of the "couch potato"
versus the "athlete" using the simulated patient!
The Future of Simulators
Applications for the "anesthesia" simulator in other
medical domains are expanding rapidly. Very strong interest from
both the medical schools and postgraduate programs is likely to
result in a change in the culture of teaching.
As programs and curricula develop and as the technology continues
to leap forward, the physiologically based patient mannequin simulator
will be a cornerstone in the training of physicians for knowledge
base, skills and practice.
Daniel B. Raemer, Ph.D., is Associate Professor
of Anesthesia at Harvard Medical School, Boston, Massachusetts.
E-mail the author.
Deborah M. Barron, M.D., is Staff Anesthesiologist
at Brigham & Women's Hospital and a Clinical Instructor at
Harvard Medical School, Boston, Massachusetts
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