Preparing for the Worst: High-Fidelity Training in Medicine

For Maria, it was an average day on the medical-surgical unit. She had 6 patients with a variety of ailments. Her patients ranged from the 20 year old IV drug user with a forearm abscess, to the 80 year old with an exacerbation of congestive heart failure (CHF). They had kept her busy throughout the morning, but she had managed her time well. She thought that, with any luck, she would have time to sit down and eat a quick lunch. With her break approaching, Maria checked on all of her patients one last time to ensure their needs were tended to. As she walked back down the colorless hallway toward the nurse’s station, her path was suddenly interrupted by a small, elderly woman with silver hair.

“Help!” She exclaimed. “Are you a nurse? I need help!”

“Yes, ma’am. My name is Maria. How can I help you?

“It’s Bob! Something’s wrong with Bob! Please check him out. I’m worried!”

The elderly woman hurried into her husband’s room with the nurse at her heels. As she entered the room, Maria made a number of startling observations. Bob did not appear to be breathing. His body was lifeless and his skin was blue in color. Maria had worked as a nurse for about a year and had provided routine care to countless patients; however, as a newer nurse, she had never experienced an emergency situation. She froze! Her mind racing. “What should I do? What should I do?” She repeated internally. In a panic, she darted across the room, lifted the small plastic window on the wall, and pressed the large, blue “CODE” button. Within seconds a voice echoed from the ceiling, “Code blue room 3102. Code blue room 3102. Code blue room 3102.” Staff from the unit raced into the room with the crash cart. Noticing that Maria was standing motionless and in shock, a young male nurse hurried to the bedside and began administering chest compressions at a rate well above that recommended by the American Heart Association. “Get him on the monitor,” an indistinct voice projected above the rumble of chaos. Over the next three minutes two nurses fumbled with the defibrillator pads and the buttons on the monitor. A quick gaze around the room revealed staff scattered throughout with a general expression of fear and confusion. The room paused as the nurses performed a rhythm check. The patient was in asystole. The young male nurse, visibly exhausted, resumed his ninth set of chest compressions without switching out. By this time, the physician had arrived and began running the code. As he called out orders it became increasingly apparent that no one was quite sure of their role. “Give 1 mg of epinephrine now,” the physician ordered boldly. Again, two nurses moved toward the crash cart to find the medication, both inadvertently slowing the actions of the other. As one nurse receded, the other retrieved a box containing the epinephrine. To prevent delay, these boxes must be opened from a specific side, which is clearly marked. Unaware of this fact, the nurse struggled to open the box for 45 seconds before ripping it down the side. She then struggled to assemble the carpuject prior to administering the medication. As a result, medication administration had been delayed by several minutes. Resuscitation efforts continued in a similar fashion for approximately 25 minutes before being called off.

Throughout this situation, staff demonstrated a lack of knowledge, confidence, and teamwork. Despite countless errors and inadequacies during the resuscitation process, a human life was not lost. The story you just read did not occur on a medical-surgical unit, as the scenario alludes. It occurred in a simulation lab. Instead of informing the patient’s loved ones of their loss and bearing feelings of guilt and failure, members of this team were afforded the opportunity to identify mistakes through debriefing, discuss solutions with the team, and continue practicing scenarios.

What does the literature say about simulation in medicine?

For many years simulation has been a keystone of training in other industries, such as aviation and nuclear power. Despite this, the practice has only recently become widely accepted and utilized in healthcare. Today, most nursing schools, medical schools, and healthcare institutions regularly employ some form of simulation-based learning. According to the Society for Simulation in Healthcare (SSH), simulation-based learning provides four key benefits. These include accessibility and exposure to a vast array of clinical scenarios, a safe environment for students to make mistakes and learn from them, versatility to cater training to participants of all skill levels, and the ability to provide real-time assessment, feedback, and evaluation (Society for Simulation in Healthcare, n.d.).

For maximum benefit, simulation-based learning should be used as an adjunct to other forms of learning. According to Beal, Kinnear, Anderson, Martin, & Wamboldt (2017), simulation- based learning may provide improved skill acquisition and performance outcomes; however, there is no evidence to support any benefit in regard to knowledge acquisition. Instead, this type of training allows participants to transition their knowledge into action. Therefore it is no surprise that increased fidelity, or realism in training, is associated with increased benefit (Beal, Kinnear, Anderson, Martin, & Wamboldt, 2017).

Recent studies have described the growth in simulation-based learning as “sporadic, unequal, and full of discrepancies” (Qayumi et al., 2014). Despite its benefits, the adoption and integration of simulation-based learning faces a number of barriers, with the largest being a lack of resources. High-fidelity simulation is expensive and facilitating this type of training requires adequate space, manpower, equipment, and support. Also, the true value of simulation-based learning in relation to other modalities has not yet been thoroughly investigated in the literature. Therefore, it may be difficult for some healthcare institutions to justify allocation of substantial resources. Globally, online simulation modules are the most commonly utilized form of simulation-based learning. These programs provide a virtual interface for students to gain knowledge and practice skills asynchronously. This type of training is significantly less resource intensive because the need for space, equipment, and personnel is essentially eliminated (Qayumi et al., 2014); however, all simulation-based learning experiences are not created equal. While more affordable and accessible, this style of simulation provides low-fidelity and, as a result, may produce limited results. Despite these facts, researchers project that in the coming years resource allocation and growth in simulation-based learning will continue to increase (Qayumi et al., 2014).

Personal Experience with simulation-based learning

Recently, I was provided the opportunity to personally experience high-fidelity, simulation-based learning. During the summer, I relocated to a new area and began working for a new organization. Coincidentally my Advanced Cardiac Life Support (ACLS) certification was about to expire. During the orientation process I was informed that recertification was only offered through a two day course at the institution’s simulation center. I must admit that my initial reaction was one of fear and anxiety. Who wants to act out scenarios in front of others? Or even worse, make a mistake in front of others? To participate in this type of training one is required to subject themselves to a certain level of vulnerability. Despite these feelings, I tried to maintain a positive outlook.

On the first day of class, I promptly arrived to the simulation center and provided the required paperwork at the front desk. I was then escorted down a long, dark hallway lined with large windows, peering into what resembled hospital rooms. Most of the rooms were inhabited by 5 to 6 individuals in ceil blue scrubs and a patient in the bed. I continued on to a small classroom in the back of the building. The class was filled with 10 nurses representing a wide range of ages, backgrounds, and levels of experience. At the front of the class stood our instructor, a spry, 30 something paramedic with a strong sense of humor. We received a quick overview of our day, which would be half didactic and half simulation.

 After the didactic portion of the course, the instructor guided us into the simulation room to meet the “patient” and get familiar with the layout of the equipment. Upon entering and getting a closer look, I noticed that the room closely mimicked those that you would see on a true hospital floor. We briefly explored the crash cart and discussed the SimMan®, which was laying in the bed, breathing, and blinking periodically. When the instructor asked, “who wants to be team leader in the first scenario?” all eyes averted toward the ground. During the first few simulations, the lack of confidence among the participants quickly became apparent. A number of issues rooted in communication also presented themselves. One example was the coordination of pulse/rhythm checks and switches between those providing chest compressions. In an ideal situation, those doing chest compressions are expected to switch after five sets of CPR, which should take approximately 2 minutes. Similarly, pulse and rhythm checks are to occur every 2 minutes; however, during the first few simulations the team leader found it difficult to manage time and would arbitrarily call for rhythm checks. This threw off the timing of switches between those providing CPR and resulted in a number of delays and inconsistencies. As a group, we identified this issue and discussed potential solutions. We decided that those providing chest compressions would verbally indicate when they were starting their fifth cycle of CPR, thus prompting the team leader to call for a pulse/rhythm check at the completion of the cycle. To our surprise, this method worked flawlessly. Over the course of the day, we became more familiar with the equipment, the algorithms, and the responsibilities and expectations of one another.

On the second day of class, students each had the opportunity to act as the team leader for one last practice scenario and then participated in a graded simulation. We ran each of these scenarios quickly and efficiently. Looking back to the first day, the level of progression was truly unbelievable. Our initial silence was replaced with clear and efficient communication, a strong sense of support and teamwork was evident, and our reluctance to participate had transformed into a strong sense of confidence in the leadership role.

The true strength of this training was how closely it paralleled reality. Inside the simulation room it was just us, the patient, and the equipment. The instructor remained outside the room and acted as the patient’s voice and provided vital details relating to the scenario through the intercom system. There was no pretend. If we were hooking the patient up to the monitor, we got the defibrillator and/or ecg pads and put them on. If we wanted to administer supplemental oxygen, we found the delivery device and put it on. If we were giving medications, we actually drew them up and delivered them through a peripheral IV. The realism of this training allowed us to actually experience the situation in a safe environment. Debriefing following scenarios was also extremely helpful and allowed us to identify issues, problem solve as a group, and grow closer as a team.

On the second day, I left the simulation center feeling empowered. I experienced a level of self-confidence in taking charge during an emergency situation that I had not felt before, and it has stuck with me. This experience left me wanting more. If you have the chance to experience high-fidelity, simulation-based learning, do yourself a favor and seize the opportunity!

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References

Beal, M., Kinnear, J., Anderson, C., Martin, T., & Wamboldt, R. (2017). The effectiveness of medical simulation in teaching medical students critical care medicine: A systematic review and meta-analysis. Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare, 12(2), 104-116. Doi:10.1097/SIH.0000000000000189

Society for Simulation in Healthcare. (n.d.). About Simulation. Retrieved from https://www.ssih.org/About-SSH/About-Simulation

Qayumi, K., Pachev, G., Zheng, B., Ziv, A., Koval, V., Badiei, S., & Cheng, A. (2014). Status of simulation in health care education: An international survey. Advances in Medical Education and Practice, 5(1), 457-467. Doi: 10.2147/AMEP.S65451