Simulation as an effective environment to teach resuscitation skills for medical trainees Mohammed Abu Aish EDUC 820 Fall 2008 Natalia Gajdamaschko
Introduction Difficulties with resuscitation skills teaching There was always a challenge in teaching medical trainees how to deal with life saving emergencies. To be able to deal with an emergency situation, the physician needs to have been exposed to similar situation in the past either during his/her training or earlier in their career. The super physician who can deal with any situation even if he/she never faced it before has not been born yet; good doctors are the result of good and busy training programs, rich previous experiences and excellent mentors. Most of the time though, when it comes to learning these skills, the medical trainees go into a vicious cycle while working in the emergency departments When a sick patient comes to the ER, the chance of the medical student doing these procedures depends on how he/she answers the famous question that is usually asked by the senior physician that is “ have you ever done this before?” The students faces a difficult situation here, if he/she answers with “No”, the chance of the senior physician allowing him/her to do the procedure decreases dramatically due to the inherent physician and the ethical responsibility of the physician towards his/her patient. If the student answers “Yes”, the chance becomes higher but on the expense of patient safety and standards of care if this is not an honest answer
Some students get into this viscous cycle for long time before they could break it some how. I faced many students in my career who graduated from medical school without having the chance to be in the resuscitation room even once It is obvious then that Medical schools and hospitals need to have training workshops and programs to overcome this huge gap in medical students training and here comes the role of the continuing medical education and professional development departments in each hospital The traditional methods of critical skills training For years, Medical schools and hospitals depended on Advanced Life Support Courses (ALS) and workshops to teach students how to deal with critical situations Usually, senior instructors (Physicians, Nurses and Paramedics practicing in the critical care fields (Emergency Medicine, Intensive care units and trauma units) run the ALS programs The usual process is that students sign up for these courses that run every 3‐ 4 months for a day or 2. The courses start with the instructors meeting with the students to introduce the plan of the next day or two. Short videos and Power Point presentations are then presented to discuss different critical situations and scenarios with the suggested actions and interventions. The team then gets divided into smaller groups that gets assigned to different rooms for hands on practice The usual equipments used in these courses are simple simulations of different body parts like the intubation head shown in figure 1 that is used to teach
students how to perform endotracheal intubation, a life saving skill that is an essential part of medical students training. Other examples include, the plastic arm to practice intravenous cannulation and the simulated chest and abdomen for surgical procedures
Problems with the traditional methods: Many studies indicate that we are not doing a good job when it comes to critical skills training. Nadel (2000) found that Pediatric residents performance on the Pediatric Advanced life support examination was excellent (mean score 93.2%) but when it came to actual performance of technical skills, only 18%‐33% of residents were able to perform these skills correctly. White (2000) found that regardless of experience or year of training, Pediatric residents performed well on the written exam but poorly on skills with 13% failure rate in intubation. A close analysis of the learning environment explains many of the shortcomings of such way of training
Most of these training courses take places in classes in hotel meeting rooms or auditoriums, Instructors give a didactic talks followed by a day or two of small groups practice. A close look to the learning environment clearly show how they are really different from the actual world, doctors do not usually deal with emergencies in a fancy meeting halls when every one is fully dressed and holding his/her cup of coffee and sitting on a chair listening to lectures Other problems with these workshops are the consistency and continuity of training, it is difficult to imagine that the knowledge and skills learned in these short 2 day workshops will be retained for the whole year without repeated exposure or training, unfortunately, due to organizational difficulties, these workshops take place infrequently every few months Even if we assume that this is a good way to teach the physical skills, a bigger problem remains unsolved, that is, teaching the trainee how to deal with the emergency as a whole. Emergencies are never an isolated head to intubate or an arm to cannulate, it is a whole patient to treat, care for and respect. It is a whole environment to get used to and it is a team to lead
What else can be done? The ideal alternative would have to be interactive, stimulating, challenging and afterall relevant to the medical student. High Fidelity Patient Simulation is proposed to fill these criteria
The use of Simulation in Medicine is not new. Peter Safard introduced the first Medical simulated manikin called Resusci‐Anne in 1960. This adoption of simulation in Medicine came after the success of simulation technology in the field of airlines industry but came after 38 years of the first flight simulators that was introduced in 1922 Flight Simulators by Edward Link (Grenvik and Schaefer, 2004) Much was dine since the sixties, the medical simulation has reached a highly sophisticated and almost realistic nature but unfortunately, the adoption of these technologies did not go in the same directions that went with the flight simulators not only due to high costs but due to the different educational philosophies and ideologies in medical schools that was built strongly on behavioristic psychology model that focused on teacher‐centered education for centuries more than student‐ centered education and apprenticeship. In this model, the knowledge is divided to smaller chunks for the student to master each separately not as a whole; the separation of the intubation head from the rest of the body is a classic example of such an approach. Recently, new trend started to appear or better said, “reappear” in Medical education. More emphasis on students‐centered education and on the importance of context, learning environments and teamwork is starting to reshape the medical school curricula. Problem based learning is an example of how small group discussions in medical schools have changed from being run by senior tutors to be run exclusively by medical students (Smith 2007).
High Fidelity Patient Simulation (HFPS) is being adopted more and more by medical schools and teaching hospitals to train medical students how to deal with critically ill patients. Huge amount of research is published claiming that medical trainees retain more skills and knowledge after training in the simulated environment than after the traditional training (Fiedor 2004, Halamek 2000, Hunt 2008, Issenberg 1999, Kory 2007, Lighthall 2006, Long 2005, McFetrich 2006, Perkins 2007, Schwartz 2007 and Steadman 2006). Detailed discussion of these quantitative studies is beyond the scope of this paper. In the next few paragraphs, I will discuss why I believe HFPS is far superior to the traditional methods of critical skills training from a purely pedagogical point of view Description of the scene At Vancouver General Hospital Center of Excellence, the Simulation center is built carefully to simulate the actual resuscitation room environment. Every Thursday, the trainees working in the Emergency Department (Medical students ad residents) come to this center for 4 hours. I give them a short orientation about the resuscitation room explaining to them where to find things that may be needed during the resuscitation process and introduce them to our patient “Billy” who is lying on the bed fully dresses, blinking and smiling and responding to their greetings by talking to them (the voice comes from the built in microphone inside Billy who is controlled by my colleague in the control room. People in the control room can see the trainees but the trainees cannot see them). The scene is equipped with monitors,
X‐ray viewing box and a phone to call for help. There is a cart full of drugs and intubation equipments close to the bed and a white board fixed to the wall in front of the bed. This is all designed to simulate the actual trauma room in our hospital. After this orientation, I vanish to the control room, and start running the first scenario, suddenly Billy will start screaming and moaning and complaining of chest pain. The team members start to react initially in a chaotic way but later they start organizing themselves, some one will be in charge but the rest of the team all contribute with their physical efforts and with their ideas Billy is connected to a sophisticated computer system that is programmed to make Belly as interactive and reactive as possible. If students give the wrong drug, Billy will respond in a similar way that a real patient will do. If the mistake is catastrophic Billy will die unless the team treat him aggressively with other therapies After running 4 scenarios, The whole team sit at the end of the day and discuss how things went and room for improvement for next week, senior instructors join the team for this discussion but they leave the discussion almost entirely for the trainees unless a major misconception needs to be corrected
Pedagogical analysis of the simulated learning environment Authentic environment A major difference between the simulated learning environment and the traditional workshops is that the simulated environment is not a hotel meeting room but rather a special unit, usually inside the hospital, that is, very well prepared and equipped to simulate the real trauma room, every monitor and screen, every piece of equipment and even the drugs used are a copy of the actual work environment. This great emphasis of the authenticity of the learning environment has its great roots in educational psychology. The Situated Cognition theory (Brown, Collins & Duguid, 1989) states that education is better achieved with Authentic practices and real life stories rather being bound to classes and textbooks. Lave and Wenger (1991) work on situated Learning: Legitimate Peripheral Participation emphasized the importance of the discourse that takes place in these
learning environments to make meaning. Knowledge is created from participation in this authentic socio‐cultural context Different levels of participation The simulated environment is deliberately made as real as possible, which causes new comers to feel initially overwhelmed with the complexity of the scenarios. It is common to see the student not saying a word on his/her first day our center even with our reassurance at the orientation session that this environment is not designed to evaluate the student and grade him/her but rather designed to support learning. Gradually with repeated exposure, the new comer starts to move up the ladder of expertise to be an effective member of the resuscitation team. Every student is encouraged to take the leadership of the team at some point. Some students achieve this stage earlier than others but they all will eventually reach it. The gradual movement up the ladder of expertise has been long talked about by the famous psychologist Lev Vygotsky (1978) as the in his famous work on the “Zone of Proximal Development” which constitutes the difference between what the learners can achieve with help from what they can achieve without support. This difference is the learner’s journey to expertise in our example. Vygotsky work on ZPD did not state that the learner should be exposed to impossible situations but rather to difficult or challenging situations that they initially need help‐ or what was later called “scaffolding” by other psychologists‐ to achieve. This is exactly the case here, as all the trainees are medical students and
residents who presumably have similar capabilities but with different levels of confidence and skills Acquisition of cultural tools During the simulation scenarios, the student will get to use different tools similar to what he/she will use in real life. The student will use the same monitors that is used on the actual trauma room, he/she will use the same defibrillators, x‐ rays, syringes, drug bottles and intubation equipments. Being familiar with these tools clearly differentiate an expert physician from a novice one All these tools are considered “Cultural tools” because they are used in the medical culture and the acquisition of these cultural tools is what leads to professional development. Vygotsky’s concept of “cultural tools” in cultural‐historical constructivism theories goes beyond physical equipments though; it includes every thing in the learning environment that can be used by the learner to move across the zone of proximal development. In the simulated environment these tools include: the nurses, the language used to communicate and all other artifacts in the scene. A holistic approach In the simulated environment, the student is encouraged to work with other team members to reach a shared understanding of the case. Every member is encouraged to think loud to express what he/she thinks. This allows the team leader to correct the common misunderstandings and misinterpretations of the novice
team members. It also helps the team leader remember important concepts that he/she may miss or forget during the resuscitation process, a phenomenon that can happen in stressful critical situations. Coming from a cultural‐historical constructivist view, I believe that this collaborative learning to make meaning of the resuscitation process is far more superior to the segmented learning that happens with indivisula learners playing alone with a small piece of plastic to learn individual skills. This shared meaning making is what makes the simulated environment very similar to the real world, the world in which the physicians is only one member of the team dealing with a critically sick patient. Distributed cognition: In any trauma room, being familiar with the way the room is designed and the locations of different tools in the room is an important factor in the speed of access and the ease of intervention once a critically ill patient arrive to that scene, this is what explains why even a very senior physician may have difficulties managing his first few patients after moving to a new emergency room. For this reason we try to simulate every aspect of the real trauma room in the simulated environment, this means arranging the drugs and equipments in the same carts and with the same pattern as in the real trauma room. Even the phones in the simulated environment are the same brand we have in the real trauma room. Cognitive psychology call these efforts “ reducing extrinsic cognitive load” which indicates that by having things organized in a fixed pattern in the trauma
room, we reduce the cognitive efforts of trying to find things during stressful situations to being just focused on solving the patient problem Other psychologists go beyond this explanation to a much bigger concept, Hutchins theoriy of Distributed cognition (1995) view the simulated environment as a whole “functional system” in which cognition becomes not only intrinsic to the physician but also shared by the surrounding artifacts, In this environment, every piece becomes important and becomes part of what Hutchins would have called “ the Trauma Room Memory” Whether we think about it from the cognitive science aspect or from the socio‐historic views, we clearly can see how the simulated environment, if set properly to simulate the actual world, can help the learner retrieve previous knowledge faster ad more efficiently during actual life scenarios. Conclusion: HFPS has lot yet to offer to the field of Medical Education, the rich authentic environment that simulate the real world can support medical trainees learning and development. There is much more “knowledge” about a critical emergency than what can be written in any textbook, every mistake matters, every thing in the scene has a meaning and only by being in the scene, we could figure or “share” this meaning
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