Rural Emergency Medicine Simulation Training and Resource - British Columbia

The 'Dreyfus model' of learning has been applied to many areas of learning including medicine. It employs 5 steps from novice to expert/master. Simulation learning is one aspect of medical learning that can assist in this 'pyramid of learning'.
For physicians the minimum expectation should be for 'competence' with the hope we achieve at 'proficiency' in many areas of our work.
As teachers it should be/ideally be, that we are 'experts' in what we teach.

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The 'essay' below outlines my personal approach to Medical Simulation Teaching.

7 Steps in Emergency Department Simulation Teaching

I have been involved with emergency simulation training for nearly 15 years now, long before the ‘high fidelity’ mannequins and simulation labs were around. Having re-entered the new ‘technical’ world of medical simulation teaching I have been reading and looking at articles on the ‘theory and practice’ of how best to use simulation. Although there is much material out there, I couldn’t seem to find one unified paper or discussion on how I could put this into a compact package that would make sense for me. So, in all humility, I decided I would put down what I think are the fundamental steps to teaching medical simulation.

I believe there are 7 steps to teaching (and learning) emergency medical simulation. They are:
1. Outline your outline
2. Didactic learning.
3. Knowing your environment.
4. ‘Muscle Memory’.
5. Procedure in context.
6. Simulation.
7. Stress inoculation or stress scenarios.

Outline your outline. I believe all learners and teachers perform much better when they know ‘where they are going and how they are going to get there’.  Just having learners read this or have it presented to them before learning I think can help calm anxieties (especially with simulation learning) and create a firm mental framework for the learner so they recognize the steps of their learning, which in turn increases the learning curve.

Didactic learning. So let’s say we are going to teach some medical residents about intubation. Before they start sticking tubes even down mannequins they need to become familiar with many aspects of intubation, the equipment, steps involved etc. This can be done through self-reading, power points, lectures etc. The level of didactic teaching will obviously vary with the level of learning already obtained. However I feel it is better to err on the side of caution and always go back a bit and ‘review’ material that we as teachers may take for granted as the ‘knowledge base’.

Knowing your environment. By this I mean actually being more than just familiar but completely comfortable in knowing where all your equipment is located, in this case an emergency room and knowing how it works. Knowing how to intubate is fine, but is completely useless if you don’t know where the laryngoscope, ET tube, stylets etc are located. And this means not knowing just where the equipment it, but where the ‘spare parts’ are, such as the extra light bulb and batteries are for the direct laryngoscope. I call this ‘owning the emergency room’. I personally feel any doctor working in an ER should know how to  work every piece of equipment in the ER, such as IV infusion pumps, monitors etc. Knowing this not only gives one confidence but one should never assume a nurse is going to be around to do the task. I have watched as IV’s go dry in a trauma and the doctor doesn’t know how to spike a new bag when the nurses are all frantically doing other tasks.  So don't just know your environment, 'own it'.

Muscle memory. So this is where the learner actually physically does the procedure, in this case learning to hold a laryngoscope, suction, introduce the ET tube etc. Depending on the procedure this may need to be repeated only a few times or many times.

Procedure in context. So now the learner has built up some confidence and ‘muscle memory’ in actually learning how to intubate. However in real life medical cases, everything happens in context. The learner must be aware and learn in what order and when to do a particular procedure. As well there are all the ancillary ‘procedures’ that go along with any one distinct procedure. In the example of intubation, there are the ‘pre-intubation’ means of oxygenating a patient, the medications for induction, how they are going to ventilate the patient after intubation. Each one of these ‘contextual’ areas may necessitate separate teaching, simulations as well.

Simulation. So after all that, the learner is ready to actually do a simulation. This can be just a more realistic simulation of the actual ‘procedure’ or it can be within a larger more prolonged simulation scenario. I think there are three ways in which a learner can ‘learn’ within a simulation. The first is watching someone else. Ideally they should watch someone doing the procedure correctly. However even watching other learners, who may not do things perfectly, can help cement things in their mind. Second is visualization. I think this is something medicine in general does not use as much as they should or if at all. Professional athletes use this technique all the time.  Maybe we as physician teachers should start having our medical students and residents ‘close their eyes’ and talk us through how they would do any particular procedure? Finally there is the third and best learning, which is the ‘doing’. In simulations I don’t think a learner should do just one scenario unless they do it perfectly the first time. There should be the opportunity for them to repeat it until it is perfect and they feel totally comfortable doing the procedure. What should happen after a simulations is that there will be ‘debriefing’.  This involves assessing and discussing anything that ‘could have been done better’. I believe that if there are any areas that ‘could have been done better’ then they should be done again until they actually are better.

I haven't mentioned debriefing, but it is an integral part of simulation learning. How it is done can be as important as the actual simulation. Although a debriefing can be very advantageous for learning and can give the learners a clarity and confidence, nothing can do more for learning than as mentioned above, doing the skill or simulation until the learner feels confident actually doing it, not just talking about it.

Stress inoculation or stress scenarios. I am not sure who coined the term stress inoculation, (military?) but it is so apt.  In medical, especially emergency, simulation once the learner(s) have done a simulation ‘perfect’ THEN is the time to add those outside ‘stressors’.  I do agree and believe it is important to put learners through stress, especially when teaching emergency procedures, but only after they have mastered the procedure in the first place. Having a student who has only visualized the vocal cords of a mannequin once or twice and then to  have the bulb not work etc, can destroy any confidence and learning that has been achieved so far. I actually believe it should be the learner who tells the teacher, when they feel they are ready to be ‘inoculated’.

So these are the 7 steps I keep in the back of my mind and try to share with the learners. Medical simulation is stressful even for seasoned physicians. They are being asked to perform in front of their peers and do not want to look stupid. If everyone knows it is going to be a ‘safe’ step by step learning process, the anxiety level goes down and the learning experience goes up. Everyone is happy! Ultimately the patient benefits.

I welcome comments.