Simulationasaneffectiveenvironmenttoteachresuscitation

skillsformedicaltrainees

MohammedAbuAish

EDUC820

Fall2008

NataliaGajdamaschko

Introduction

Difficultieswithresuscitationskillsteaching

Therewasalwaysachallengeinteachingmedicaltraineeshowtodealwith

lifesavingemergencies.Tobeabletodealwithanemergencysituation,the

physicianneedstohavebeenexposedtosimilarsituationinthepasteitherduring

his/hertrainingorearlierintheircareer.Thesuperphysicianwhocandealwith

anysituationevenifhe/sheneverfaceditbeforehasnotbeenbornyet;good

doctorsaretheresultofgoodandbusytrainingprograms,richprevious

experiencesandexcellentmentors.

Mostofthetimethough,whenitcomestolearningtheseskills,themedical

traineesgointoaviciouscyclewhileworkingintheemergencydepartments

WhenasickpatientcomestotheER,thechanceofthemedicalstudentdoingthese

proceduresdependsonhowhe/sheanswersthefamousquestionthatisusually

askedbytheseniorphysicianthatis“haveyoueverdonethisbefore?”

Thestudentsfacesadifficultsituationhere,ifhe/sheanswerswith“No”,the

chanceoftheseniorphysicianallowinghim/hertodotheproceduredecreases

dramaticallyduetotheinherentphysicianandtheethicalresponsibilityofthe

physiciantowardshis/herpatient.

Ifthestudentanswers“Yes”,thechancebecomeshigherbutontheexpense

ofpatientsafetyandstandardsofcareifthisisnotanhonestanswer

Somestudentsgetintothisviscouscycleforlongtimebeforetheycould

breakitsomehow.Ifacedmanystudentsinmycareerwhograduatedfrommedical

schoolwithouthavingthechancetobeintheresuscitationroomevenonce

ItisobviousthenthatMedicalschoolsandhospitalsneedtohavetraining

workshopsandprogramstoovercomethishugegapinmedicalstudentstraining

andherecomestheroleofthecontinuingmedicaleducationandprofessional

developmentdepartmentsineachhospital

Thetraditionalmethodsofcriticalskillstraining

Foryears,MedicalschoolsandhospitalsdependedonAdvancedLifeSupport

Courses(ALS)andworkshopstoteachstudentshowtodealwithcriticalsituations

Usually,seniorinstructors(Physicians,NursesandParamedicspracticinginthe

criticalcarefields(EmergencyMedicine,Intensivecareunitsandtraumaunits)run

theALSprograms

Theusualprocessisthatstudentssignupforthesecoursesthatrunevery3‐

4monthsforadayor2.Thecoursesstartwiththeinstructorsmeetingwiththe

studentstointroducetheplanofthenextdayortwo.ShortvideosandPowerPoint

presentationsarethenpresentedtodiscussdifferentcriticalsituationsand

scenarioswiththesuggestedactionsandinterventions.Theteamthengetsdivided

intosmallergroupsthatgetsassignedtodifferentroomsforhandsonpractice

Theusualequipmentsusedinthesecoursesaresimplesimulationsof

differentbodypartsliketheintubationheadshowninfigure1thatisusedtoteach

studentshowtoperformendotrachealintubation,alifesavingskillthatisan

essentialpartofmedicalstudentstraining.Otherexamplesinclude,theplasticarm

topracticeintravenouscannulationandthesimulatedchestandabdomenfor

surgicalprocedures

Problemswiththetraditionalmethods:

Manystudiesindicatethatwearenotdoingagoodjobwhenitcomesto

criticalskillstraining.Nadel(2000)foundthatPediatricresidentsperformanceon

thePediatricAdvancedlifesupportexaminationwasexcellent(meanscore93.2%)

butwhenitcametoactualperformanceoftechnicalskills,only18%‐33%of

residentswereabletoperformtheseskillscorrectly.White(2000)foundthat

regardlessofexperienceoryearoftraining,Pediatricresidentsperformedwellon

thewrittenexambutpoorlyonskillswith13%failurerateinintubation.

Acloseanalysisofthelearningenvironmentexplainsmanyofthe

shortcomingsofsuchwayoftraining

Mostofthesetrainingcoursestakeplacesinclassesinhotelmeetingrooms

orauditoriums,Instructorsgiveadidactictalksfollowedbyadayortwoofsmall

groupspractice.Acloselooktothelearningenvironmentclearlyshowhowtheyare

reallydifferentfromtheactualworld,doctorsdonotusuallydealwithemergencies

inafancymeetinghallswheneveryoneisfullydressedandholdinghis/hercupof

coffeeandsittingonachairlisteningtolectures

Otherproblemswiththeseworkshopsaretheconsistencyandcontinuityof

training,itisdifficulttoimaginethattheknowledgeandskillslearnedintheseshort

2dayworkshopswillberetainedforthewholeyearwithoutrepeatedexposureor

training,unfortunately,duetoorganizationaldifficulties,theseworkshopstake

placeinfrequentlyeveryfewmonths

Evenifweassumethatthisisagoodwaytoteachthephysicalskills,a

biggerproblemremainsunsolved,thatis,teachingthetraineehowtodealwiththe

emergencyasawhole.Emergenciesareneveranisolatedheadtointubateoran

armtocannulate,itisawholepatienttotreat,careforandrespect.Itisawhole

environmenttogetusedtoanditisateamtolead

Whatelsecanbedone?

Theidealalternativewouldhavetobeinteractive,stimulating,challenging

andafterallrelevanttothemedicalstudent.HighFidelityPatientSimulationis

proposedtofillthesecriteria

TheuseofSimulationinMedicineisnotnew.PeterSafardintroducedthe

firstMedicalsimulatedmanikincalledResusci‐Annein1960.Thisadoptionof

simulationinMedicinecameafterthesuccessofsimulationtechnologyinthefield

ofairlinesindustrybutcameafter38yearsofthefirstflightsimulatorsthatwas

introducedin1922FlightSimulatorsbyEdwardLink(GrenvikandSchaefer,2004)

Muchwasdinesincethesixties,themedicalsimulationhasreachedahighly

sophisticatedandalmostrealisticnaturebutunfortunately,theadoptionofthese

technologiesdidnotgointhesamedirectionsthatwentwiththeflightsimulators

notonlyduetohighcostsbutduetothedifferenteducationalphilosophiesand

ideologiesinmedicalschoolsthatwasbuiltstronglyonbehavioristicpsychology

modelthatfocusedonteacher‐centerededucationforcenturiesmorethanstudent‐

centerededucationandapprenticeship.Inthismodel,theknowledgeisdividedto

smallerchunksforthestudenttomastereachseparatelynotasawhole;the

separationoftheintubationheadfromtherestofthebodyisaclassicexampleof

suchanapproach.

Recently,newtrendstartedtoappearorbettersaid,“reappear”inMedical

education.Moreemphasisonstudents‐centerededucationandontheimportanceof

context,learningenvironmentsandteamworkisstartingtoreshapethemedical

schoolcurricula.Problembasedlearningisanexampleofhowsmallgroup

discussionsinmedicalschoolshavechangedfrombeingrunbyseniortutorstobe

runexclusivelybymedicalstudents(Smith2007).

HighFidelityPatientSimulation(HFPS)isbeingadoptedmoreandmoreby

medicalschoolsandteachinghospitalstotrainmedicalstudentshowtodealwith

criticallyillpatients.Hugeamountofresearchispublishedclaimingthatmedical

traineesretainmoreskillsandknowledgeaftertraininginthesimulated

environmentthanafterthetraditionaltraining(Fiedor2004,Halamek2000,Hunt

2008,Issenberg1999,Kory2007,Lighthall2006,Long2005,McFetrich2006,

Perkins2007,Schwartz2007andSteadman2006).Detaileddiscussionofthese

quantitativestudiesisbeyondthescopeofthispaper.

Inthenextfewparagraphs,IwilldiscusswhyIbelieveHFPSisfarsuperior

tothetraditionalmethodsofcriticalskillstrainingfromapurelypedagogicalpoint

ofview

Descriptionofthescene

AtVancouverGeneralHospitalCenterofExcellence,theSimulationcenteris

builtcarefullytosimulatetheactualresuscitationroomenvironment.Every

Thursday,thetraineesworkingintheEmergencyDepartment(Medicalstudentsad

residents)cometothiscenterfor4hours.Igivethemashortorientationaboutthe

resuscitationroomexplainingtothemwheretofindthingsthatmaybeneeded

duringtheresuscitationprocessandintroducethemtoourpatient“Billy”whois

lyingonthebedfullydresses,blinkingandsmilingandrespondingtotheirgreetings

bytalkingtothem(thevoicecomesfromthebuiltinmicrophoneinsideBillywhois

controlledbymycolleagueinthecontrolroom.Peopleinthecontrolroomcansee

thetraineesbutthetraineescannotseethem).Thesceneisequippedwithmonitors,

X‐rayviewingboxandaphonetocallforhelp.Thereisacartfullofdrugsand

intubationequipmentsclosetothebedandawhiteboardfixedtothewallinfront

ofthebed.Thisisalldesignedtosimulatetheactualtraumaroominourhospital.

Afterthisorientation,Ivanishtothecontrolroom,andstartrunningthefirst

scenario,suddenlyBillywillstartscreamingandmoaningandcomplainingofchest

pain.Theteammembersstarttoreactinitiallyinachaoticwaybutlatertheystart

organizingthemselves,someonewillbeinchargebuttherestoftheteamall

contributewiththeirphysicaleffortsandwiththeirideas

Billyisconnectedtoasophisticatedcomputersystemthatisprogrammedto

makeBellyasinteractiveandreactiveaspossible.Ifstudentsgivethewrongdrug,

Billywillrespondinasimilarwaythatarealpatientwilldo.Ifthemistakeis

catastrophicBillywilldieunlesstheteamtreathimaggressivelywithother

therapies

Afterrunning4scenarios,Thewholeteamsitattheendofthedayand

discusshowthingswentandroomforimprovementfornextweek,senior

instructorsjointheteamforthisdiscussionbuttheyleavethediscussionalmost

entirelyforthetraineesunlessamajormisconceptionneedstobecorrected

Pedagogicalanalysisofthesimulatedlearningenvironment

Authenticenvironment

Amajordifferencebetweenthesimulatedlearningenvironmentandthe

traditionalworkshopsisthatthesimulatedenvironmentisnotahotelmeeting

roombutratheraspecialunit,usuallyinsidethehospital,thatis,verywellprepared

andequippedtosimulatetherealtraumaroom,everymonitorandscreen,every

pieceofequipmentandeventhedrugsusedareacopyoftheactualwork

environment.

Thisgreatemphasisoftheauthenticityofthelearningenvironmenthasits

greatrootsineducationalpsychology.TheSituatedCognitiontheory(Brown,

Collins&Duguid,1989)statesthateducationisbetterachievedwithAuthentic

practicesandreallifestoriesratherbeingboundtoclassesandtextbooks.

LaveandWenger(1991)workonsituatedLearning:LegitimatePeripheral

Participationemphasizedtheimportanceofthediscoursethattakesplaceinthese

learningenvironmentstomakemeaning.Knowledgeiscreatedfromparticipationin

thisauthenticsocio‐culturalcontext

Differentlevelsofparticipation

Thesimulatedenvironmentisdeliberatelymadeasrealaspossible,which

causesnewcomerstofeelinitiallyoverwhelmedwiththecomplexityofthe

scenarios.Itiscommontoseethestudentnotsayingawordonhis/herfirstdayour

centerevenwithourreassuranceattheorientationsessionthatthisenvironmentis

notdesignedtoevaluatethestudentandgradehim/herbutratherdesignedto

supportlearning.Graduallywithrepeatedexposure,thenewcomerstartstomove

uptheladderofexpertisetobeaneffectivememberoftheresuscitationteam.

Everystudentisencouragedtotaketheleadershipoftheteamatsome

point.Somestudentsachievethisstageearlierthanothersbuttheyallwill

eventuallyreachit.Thegradualmovementuptheladderofexpertisehasbeenlong

talkedaboutbythefamouspsychologistLevVygotsky(1978)astheinhisfamous

workonthe“ZoneofProximalDevelopment”whichconstitutesthedifference

betweenwhatthelearnerscanachievewithhelpfromwhattheycanachieve

withoutsupport.Thisdifferenceisthelearner’sjourneytoexpertiseinourexample.

VygotskyworkonZPDdidnotstatethatthelearnershouldbeexposedto

impossiblesituationsbutrathertodifficultorchallengingsituationsthatthey

initiallyneedhelp‐orwhatwaslatercalled“scaffolding”byotherpsychologists‐to

achieve.Thisisexactlythecasehere,asallthetraineesaremedicalstudentsand

residentswhopresumablyhavesimilarcapabilitiesbutwithdifferentlevelsof

confidenceandskills

Acquisitionofculturaltools

Duringthesimulationscenarios,thestudentwillgettousedifferenttools

similartowhathe/shewilluseinreallife.Thestudentwillusethesamemonitors

thatisusedontheactualtraumaroom,he/shewillusethesamedefibrillators,x‐

rays,syringes,drugbottlesandintubationequipments.Beingfamiliarwiththese

toolsclearlydifferentiateanexpertphysicianfromanoviceone

Allthesetoolsareconsidered“Culturaltools”becausetheyareusedinthe

medicalcultureandtheacquisitionoftheseculturaltoolsiswhatleadsto

professionaldevelopment.

Vygotsky’sconceptof“culturaltools”incultural‐historicalconstructivism

theoriesgoesbeyondphysicalequipmentsthough;itincludeseverythinginthe

learningenvironmentthatcanbeusedbythelearnertomoveacrossthezoneof

proximaldevelopment.Inthesimulatedenvironmentthesetoolsinclude:the

nurses,thelanguageusedtocommunicateandallotherartifactsinthescene.

Aholisticapproach

Inthesimulatedenvironment,thestudentisencouragedtoworkwithother

teammemberstoreachasharedunderstandingofthecase.Everymemberis

encouragedtothinkloudtoexpresswhathe/shethinks.Thisallowstheteamleader

tocorrectthecommonmisunderstandingsandmisinterpretationsofthenovice

teammembers.Italsohelpstheteamleaderrememberimportantconceptsthat

he/shemaymissorforgetduringtheresuscitationprocess,aphenomenonthatcan

happeninstressfulcriticalsituations.

Comingfromacultural‐historicalconstructivistview,Ibelievethatthis

collaborativelearningtomakemeaningoftheresuscitationprocessisfarmore

superiortothesegmentedlearningthathappenswithindivisulalearnersplaying

alonewithasmallpieceofplastictolearnindividualskills.Thissharedmeaning

makingiswhatmakesthesimulatedenvironmentverysimilartotherealworld,the

worldinwhichthephysiciansisonlyonememberoftheteamdealingwitha

criticallysickpatient.

Distributedcognition:

Inanytraumaroom,beingfamiliarwiththewaytheroomisdesignedand

thelocationsofdifferenttoolsintheroomisanimportantfactorinthespeedof

accessandtheeaseofinterventiononceacriticallyillpatientarrivetothatscene,

thisiswhatexplainswhyevenaveryseniorphysicianmayhavedifficulties

managinghisfirstfewpatientsaftermovingtoanewemergencyroom.Forthis

reasonwetrytosimulateeveryaspectoftherealtraumaroominthesimulated

environment,thismeansarrangingthedrugsandequipmentsinthesamecartsand

withthesamepatternasintherealtraumaroom.Eventhephonesinthesimulated

environmentarethesamebrandwehaveintherealtraumaroom.

Cognitivepsychologycalltheseefforts“reducingextrinsiccognitiveload”

whichindicatesthatbyhavingthingsorganizedinafixedpatterninthetrauma

room,wereducethecognitiveeffortsoftryingtofindthingsduringstressful

situationstobeingjustfocusedonsolvingthepatientproblem

Otherpsychologistsgobeyondthisexplanationtoamuchbiggerconcept,

HutchinstheoriyofDistributedcognition(1995)viewthesimulatedenvironmentas

awhole“functionalsystem”inwhichcognitionbecomesnotonlyintrinsictothe

physicianbutalsosharedbythesurroundingartifacts,Inthisenvironment,every

piecebecomesimportantandbecomespartofwhatHutchinswouldhavecalled“

theTraumaRoomMemory”

Whetherwethinkaboutitfromthecognitivescienceaspectorfromthe

socio‐historicviews,weclearlycanseehowthesimulatedenvironment,ifset

properlytosimulatetheactualworld,canhelpthelearnerretrieveprevious

knowledgefasteradmoreefficientlyduringactuallifescenarios.

Conclusion:

HFPShaslotyettooffertothefieldofMedicalEducation,therichauthentic

environmentthatsimulatetherealworldcansupportmedicaltraineeslearningand

development.Thereismuchmore“knowledge”aboutacriticalemergencythan

whatcanbewritteninanytextbook,everymistakematters,everythinginthescene

hasameaningandonlybybeinginthescene,wecouldfigureor“share”this

meaning

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