7 minute read
SimMed NJMS helps learners gain hands-on experience
BY AMANDA CASTLEMAN
The robots get all the glory. Something about a — which could cost up to $100,000—hogs the headlines.
But don’t overlook the whole spectrum of training devices, says Christin Traba, MD’06, MPH, associate professor of pediatrics and executive dean for education. “High-fidelity simulation can be wonderful,” she says. “However, low-fidelity simulation can be just as impactful in the learning process. We strive to utilize all aspects of simulation in training and assessing clinical skills, including manikins, standardized patients, and task trainers for procedural skills.”
Medicine has had abundant time to experiment. Indian practitioners developed leaf and clay models conceptualizing nasal reconstruction in 600 BCE. In China’s Song Dynasty (960–1279 CE), physicians taught acupuncture on life-sized bronze statues. By the 18th century, inventors practiced with fluid-filled glass uteruses and flexible fetuses and tried to mirror cardiovascular physiology. But a century passed before anesthesiologists created the “ancestors” of modern manikins.
The last three decades have been transformative, avoiding 60 to 90 percent of preventable deaths from errors, according to an Institute for Medicine report. And as a bonus, learners pick up skills faster and more effectively.
Today, NJMS deploys many tactics, from interactive scenarios on paper to inflatable infants, “skin” made from silicone or pork, and laparoscopic video towers (think arcade game). The school also has low-fidelity manikins—like those used in CPR training— alongside higher-end ones. And it even uses augmented reality (AR), mixing virtual reality (VR) headsets with real-world spaces and tools.
Some instructors set up manikins in the OR and call codes to elicit real-world, adrenaline-fueled reactions. Others run escape rooms where players discover clues and solve puzzles: a learner-centered, team-based approach. And for peak realness, gynecological and urological teaching associates use themselves as models to instruct and help improve students’ skills, build confidence and reinforce appropriate bedside manners.
Here’s how various programs at NJMS are using this powerful learning technique.
Where Learning Meets Application
The NJMS Clinical Skills Center is a 10,000 square-foot facility that has administered Objective Structured Clinical Examinations (OSCEs) to thousands of students across decades. It includes a sim-training space and 12 exam rooms, which can be configured to resemble an ER, labor and delivery, or a patient’s hospital room with a bed. “Instruction, assessment, and feedback is needed to produce competent clinicians,” says administrative director Maria Laboy, MD. “Providing a safe and controlled venue for these immersive exercises does not come cheap, but is necessary in medical education.”
She adds: “Centers like ours are meant to be judgment-free learning spaces where students are encouraged to ask questions, make mistakes, practice skills, and learn to work as a team. It’s a place where they can share and receive constructive feedback before they interact with real patients.”
Some useful tools include Laerdal’s SimMan 3G PLUS, which average around $80,000 and have interchangeable parts to mimic different ages and genders. Learners can measure its blood pressure and pulse oximetry, deliver medications with real devices and fluids, and train with live defibrillators. The center also has SimBabies, representing ninemonth-olds. Other devices rely on radio tags with smart barcodes to “administer” medications, reducing clean-up. Some models moan, cough or have speakers that trainers can broadcast through.
Scenario programming can provoke certain reactions from the sims. Laboy explains: “Manikins can appear to get better or worse, depending on the team’s actions. Vital sign monitors attached to these manikins provide additional realism. These immersive exercises allow learners to practice in a way that doesn’t harm real patients. In a way, the simulator becomes the guinea pig!”
The center has an AR-compatible task trainer, the CAE Vimedix. A headset shows ultrasound animations of arteries and veins, and can imitate over 200 pathologies. But learners also get hands-on experience with other models, where they can practice skills like inserting IV lines.
“Simulation is embedded in all four years of medical education,” notes Sophia Chen, DO, MPH, assistant professor of pediatrics and associate dean for pre-clerkship education. “It provides a dynamic and interactive environment where students bridge content learned in the classroom with practical application.”
The Transition to Residency course continues this work, explains Sarah Dunn MD, MPP, course director and assistant professor of emergency medicine. Her team adapted a scenario where students manage a SimMan mimicking an undifferentiated critical patient. “They also practice delivering serious news to patient’s families,” she says. When crafting playbooks, Dunn and her team gravitate towards high-risk situations that don’t occur often. “Students should experience being in charge since that’s something they’ll potentially face every day as residents,” she explains.
“Simulation requires suspension of disbelief. You have to enter into a contract where you pretend things are real. Most students accomplish that,” Dunn adds. “In fact, many say it feels realer than they expected.”
Departmental Highlights
Learners can practice complete birthing simulations in obstetrics, gynecology, and reproductive health, notes associate professor Lisa Pompeo, MD. NOELLE manikins allow users to check heart sounds and cervical dilation, correct shoulder dystocia, inspect placentas, manage uterine hemorrhages and resuscitate babies. Pompeo supplements high-tech toys with DIY ones, including faux body parts sculpted from chicken tendons, cow tendons, and car wash sponges with tubing. She explains: “Beef is the easiest to manipulate and feels closer to human tissue. Sites like MedEdPORTAL are good resources for this.” Her department runs multidisciplinary drills with nurses and techs at Rutgers School of Nursing too, stashing a NOELLE in labor and delivery, so learners can practice outside of the NJMS Clinical Skills Center’s hours.
Pediatrics also embraces the “practice makes perfect” ethos, says Kei U. Wong, MD, assistant professor of emergency medicine. “The populations are very vulnerable, and infant, child and adolescent physiologies differ from adults’,” she notes. “Responses also vary
to events like cardiac arrests, intubations and resuscitations, and not all learners have been adequately exposed to those during their clinical training.”
She praises VR and telesimula tion as innovative space-savers, especially for facilities that don’t have pediatric experts. “But we love the hands-on exercises that build muscle memory too,” Wong says. “It’s good to practice skills like placing an IV, because infant veins are so tiny. Simulators can also help highlight racial disparities and teach what veins, burns and eczema look like on different skin colors.”
Her team runs communication drills, including how to de-escalate, as health care practitioners are five times more likely to experience violence than workers overall.
Meanwhile, the Department of Surgery has expanded procedural-based skill-sessions, thanks to efforts by faculty like assistant professor Melissa Alvarez-Downing, MD. Students now practice suturing, catheterization, arterial puncture and nasogastric tube placement. Additionally, the department uses VR to mimic operating-room fires in its 1,100 square-foot simulation lab, explains Daniel Jones, MD, MS, professor and Benjamin F. Rush Jr., MD, Chair of Surgery; and assistant dean of simulation, innovation and scholar-
ship. Fewer than 600 of these blazes ignite annually in the U.S., so they’re rare. But tests showed only 4.4 percent of doctors, nurses and anesthesiologists know how to address the situation. (Pro tip: turn off the oxygen!) Simulation training raised the pass rate to 79 percent.
Future Possibilities
Some faculty dream of a new 5,000 to 10,000 square-foot, north-campus facility in addition to the Clinical Skills Center. “It’s the difference between having a bookshelf in your office versus the library,” Jones says. “This will take a $5 to $10 million infusion from donors first.” In the meantime, he hopes to forge research initiatives with science and engineering faculty to explore the use of VR and artificial intelligence in simulations that lead to safer surgeries.
Since 2010, the Society for Simulation in Healthcare has accredited more than 100 programs across ten countries, a process that requires contiguous and comprehensive centers. Traba says: “NJMS is committed to innovation and simulation, including plans for an updated clinical skills center. As we prepare for the future, we’ll evaluate requirements to be accredited in simulation.”
