Like frontline military personnel, those in medical practice must be fluid in their work and rely on split-second assessments. Often life and death hang in the balance.
Thanks to the valuable and refined teaching tool known as Simulation-based Immersive Medical Training, or SIM, a new generation of physicians is entering medical practice with skills honed by simulated medical-crisis management.
For decades, the United States government has led the way in simulation training for space exploration, computer advancement and in military simulation of soldier-, tank-, and flight-training prior to actual battlefield conditions.
Modern medical simulation is indebted to military medical applications such as casualty assessment, war-trauma response, and emergency evacuation. Scenario re-creation from recorded data and communications between medical teams, and between medical teams and patients, owes its development to combat preparation simulation and analysis.
Perhaps nowhere is SIM more in the public eye today than in the worldwide efforts to isolate, contain, and eradicate the spread of the Ebola virus here and in West Africa. From the Centers for Disease Control and Prevention to TSA security checkpoints in the nation’s airports, simulation exercises and simulation robots are in use to train medical and screening personnel in disease protocols under rapidly changing “combat” conditions.
TRAINING NEXT GENERATION OF NURSES, DOCTORS
What may be less generally known is that medical simulation laboratories are equipping the next generation of nurses and physicians in medical and health-science schools coast to coast.
“We use medical simulation to prepare our students and future doctors for highly dynamic and complex learning environments,” says Joseph DiMeo, DO, Assistant Professor and Chair of Family Medicine at Pacific Northwest University of Health Sciences (PNWU) in Yakima, Washington.“We want them to learn from identifying what they don’t know and by making mistakes in a safe environment without impacting a live patient.”
In the PNWU simulation lab, a class of 135 medical students is broken into teams of four to six students to
complete ten simulations (usually ER-based encounters) over the course of their second year. Students rotate through the roles of leader, scribe, historian, and task performers. Nurses also participate in each simulation, as well as an attending physician/faculty member, a technician who operates the simulation robot/patient, and a person who acts as the “patient’s voice.”
MOCK PATIENT IS A “TALKER”
The mock patient, which DiMeo says is a highly technical piece of machinery, has the ability to talk through the program voiced by a human with a prepared script. The simulation robot is able to manifest all types of abnormal findings affecting vital signs, wounds, heart rate, the skin, and more.
“It’s as if they were at the bedside of an actual patient,” says DiMeo, adding that the students are able to perform all sorts of tasks on the robot, from IV access to catheterization, and from chest tubes to artificial airways. In the spring, “SimMom” gives students basic experience in birthing procedures.
Hands-on training through simulation is essential in developing physician and other medical staff mastery of the components of successful patient interaction, including learning to show respect, effective listening, responding
quickly to patients, and other key encounters that boost care quality, as well as the patient’s overall perception of his or her experience.
It has been no simple task for third-year student Kristi Trickett, who learned to think quickly under high-pressure stress. “When studying the renal system, we had a SIM case of a patient in acute renal failure. We had to use our
early knowledge of pharmaceuticals to determine how to protect his heart, how to appropriately diurese him, and how to order appropriate testing—all in the right order.” This occurred while faculty interjected random challenges such as an agitated spouse who needed calming, or O2 saturations that took a sudden dip.
In Trickett’s renal failure SIM training, the “patient” moaned in obvious distress from stomach pain while team members yelled their findings for the team to absorb:
• Historian: “He has diabetes, has a history of A-fib, and is allergic to penicillin!”
• Team Leader: “Nurse, his fever’s still high. Give him some Tylenol, please!”
• Scribe: “Have we missed anything?”
• Task Performer: “Did you get the Foley in? Another physical please!”
• A Voice Overhead: “The encounter is now over. Please leave the room!”
Each SIM session is followed by a 20-minute debrief with feedback from the team and the observing physician.“Having someone on the microphone responding in real time while we worked away on their robot self in the lab was challenging, and at times even humorous,” says Trickett.
More often, however, the voice from above added to the emotional stress level, especially if a patient “died” on the table. Most student teams experience the loss of at least one robot patient, says DiMeo, and it can be traumatic. “There’s an attachment to the patient. Some in the medical community agonize over this. Should students be exposed to the death of the SIM man? When we ask students whether they learn more when he lives or when he dies, they often respond that as painful as it can be, they learn more from a death.”
“We were all worried that it could happen,” says Trickett, who earned her undergraduate degree in biology/ chemistry from Seattle Pacific University. “The simulated deaths were set up so that two teams could make the same decisions, but in one case the SIM man would react to treatment as expected and survive, while in the
other case the SIM man would become spontaneously unstable and die.
GRIEF, STRESS PART OF SIM EXPERIENCE
“For some students it was stressful and emotional,” she continues. “Someone they cared for died. Others anguished over the thought they did something wrong.” Trickett acknowledges that while it might sound silly to some outside of medicine, she and her fellow students found that facing the fact and the fear of the death of someone in their care, even a robotic patient, was enough to keep them on their toes.
Trickett is convinced SIM training benefits patients, builds physician empathy and understanding, and will also will make her a better family medicine specialist.
“The patient is a human being who can use words of encouragement, [give] regular updates on their condition, and an understanding of what is coming next. In the end, I must not forget that in the practice of medicine, there is always a human patient in the middle of it all.”
It is that holistic approach, especially in osteopathic medicine, which brought third-year student Jarrad Morgan, a graduate of Grinnell College in Iowa, to PNWU. “The focus on the whole person and not just their symptoms, was an enormous draw for me.”
Morgan believes SIM lab training provides great benefit to patients. “It helps produce physicians who already have experience with stressful situations or complex procedures in a controlled environment before they encounter them in their careers or subsequent training. We’ll be able to respond more quickly and effectively.”
In his community medical rotations thus far, Morgan has encountered real patients with similar complaints to what his SIM patients presented last year. “Although not as emergent a situation as I experienced in the SIM lab experience, I knew how to approach the patient, what questions to ask, what symptoms to look for, and what treatment approaches to consider.SIM lab provided the framework for me to improve my understanding of the new material and new situations that come up in rotations."
“This is an improvement to patient safety,” agrees DiMeo, who is also in private practice at Terrace Heights Family Physicians in Yakima.“Simulation allows access to some medical situations that might otherwise take months or years to encounter in practice. In the delivery of babies, for instance, there are a multitude of possible complications in birthing and delivery. Our students get exposed early.”
PNWU is soon to graduate another class into medical residency. The student physicians have begun to see patients, guided by an experienced physician, and soon will be able to go out on their own. DiMeo says that thanks to the simulation exercises, the new physicians have built personal confidence, learned how to build and work together as a team, sharpened their medical decision-making skills, and have already experienced acute care scenarios that have prepared them for real practice. Because PNWU has a mission to educate students interested in primary care among rural and underserved populations, DiMeo is confident their intense SIM lab roleplay
will serve them well.
“Primary care involves a patient from birth to geriatric care,” notes DiMeo, who graduated medical school in 1997 and says it would have been a real advantage to have had a SIM lab as part of his training. “A primary care physician in a day may see all extremes and diversities from cancer to newborns. Basic SIM lab training
prepares doctors for a very broad range of possible outcomes.