Session Stewart

7/31/2019 Session Stewart

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Simulation has a long history...


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Photos LTC(ret) M. Synovitz


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Current Sims at

Altus Air Force BaseOklahoma

Photos LTC(ret) M. Synovitz


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The military has also been a majordeveloper of medical simulation

technology


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My first introduction tomedical simulation was

the EFMB....

3 continuous days ofsimulation, testing, and

performance...


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The CombatCasualty CareCourse is a military

introduction tosimulation for RNs

and MDs on active

duty


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Military Health SystemsDigital SimulationTraining Currently Available

MC4/SA (Medical Communications for

Combat Casualty Care/Situational Awareness)CHCS (Composite Health Care System)CHCSII-T (Composite Health Care System

II-Theater)TRAC2ES (TRANSCOM Regulating and

Command & Control Evacuation System)DMLSS (Defense Medical Logistics

Standard Support)DMLSSAM (Defense Medical Logistics

Standard Support-AssemblageManagement)

TCAM (TAMMIS Customer AssistanceModule)


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Oklahoma

We are particularly blessed withdisasters

Tornadoes Heavy weather

Ice Storms

Floods

Wildfires


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So... How do weteach readinessfor this!

We havechosen severalmethods...

Picher tornado, 2008


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Simulations Are Ideal ForDisaster Training


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HSEEP

Describes two major types of exercise Discussion based

Discussion-based exercises familiarize participants

with current plans, policies, agreements andprocedures, or may be used to develop new plans,policies, agreements, and procedures.

Operations based

Operations-based Exercises validate plans, policies,agreements and procedures, clarify roles andresponsibilities, and identify resource gaps in anoperational environment.


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HSEEP Exercises

Discussion

Seminars

Not really a simulation or exercise

Workshop Also not really simulation or exercise


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Simulations

Table top exercises

Very good for identification of potentialproblems in the emergency operationsplans

Useful for training key leadership andmanagement to plan and work together.


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Tabletop Simulations

Duncan OK, 2009


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Tabletop Simulations

Duncan, OK, Jan 27-28 2010(and they were better prepared, we think!)


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Games

A game is a simulation of operations thatoften involves two or more teams, usuallyin a competitive environment, using rules,data, and procedure designed to depict an

actual or assumed real-life situation.


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ACLS Games...


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Ground TruthVideo Game


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Text

EMDM Disaster Preparedness Game


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Operational Simulations

Individual (small groups) simulations

Teach procedures that you cant usually

do - and may not be able to find theopportunity to see/do.

Example - organophosphate poisoning

treatment.

Often used in training responders todisasters


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Simulations

Drills

Small team simulations:

Very good for unit cohesiveness, trainingfor scenarios that are not often seen.


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Functional Exercise

A functional exercise examines thecoordination, command, and control

between various multi-agencycoordination centers

A functional exercise does not involve

any "boots on the ground."

(Often difficult to differentiate from table-top exercises)


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Full scale exercises:

A full-scale exercise is a multi-agency,multi-jurisdictional, multi-disciplineexercise involving functional (e.g., jointfield office, emergency operation

centers, etc.) and "boots on the ground"response (e.g., firefightersdecontaminating mock victims).


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Full scale exercises:

Useful for ensuring that agencieswork/play well together.

Useful for identification of command

structure problems VERY expensive!


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Tulsa Airport 2010

Lots of people, lots of volunteers, and lots of vehicles.


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Tulsa Airport 2010

Plane crashes are especially tough tosimulate because most don't actuallyhappen on runways. Instead, theyusually occur in remote areas, andthat makes it difficult for so manyemergency vehicles to respond soquickly.


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Tulsa Airport 2010

23 Agencies,304 casualties,and an airplane

Photos, Channel 6, KOTV


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We also use medicalsimulations...


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It may be used forboth individuals and

teams

M di l Si l i


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Medical Simulationin Emergency Medicine

ABEM was the first medical specializationboard to adopt simulation within their oral

board examinations... from the first ABEMboard in 1980.

These oral examinations are a far cry

from the high fidelity simulations nowavailable.


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Doctors Trained On Patient Simulators exhibit SuperiorSkills

Beth Israel Medical Centre

New Virtual Reality Surgery Simulator honesSurgeons' Skills, Improves Patient Safety

Oregon Health & Science University School of Medicine

Clinical Simulation Technology Used To ImproveCommunication Of Medical Teams

Washington University School of Medicine

Science Daily

Medical SimulationIn Disaster Medicine... Works


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Role Playing

Like ABEM oral examinations

Task trainers

Computer patient

Manniquin simulators

Medical Simulation


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Benefit of Simulators

Student can practice key skills in a safeenvironment

Teacher can break down the task intocomponents

Student can receive immediate feedback

Teacher can create the same situation toassess performance repeatedly


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Benefits of Simulators

Simulators are great for teaching andassessing:

Procedural skills

Treatment/interventions

Invasive monitoring

Allowing mistakes.


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Simulations in DM

Focus on medical management

Crisis resource management skills arereinforced

Increased complexity

Can be videotaped for review andreflection

What will you do differently next time?


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Limitations

Not great for:

2-way communication skills

Treating the patient as a person

Students tend to treat the sim as adummy.

Representing family/staff/other teammembers


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Hardware & InfrastructureAre NOT inexpensive.

We have over $1x106investedin our equipment

Medical Simulation


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Manpower and Training

Are also NOT inexpensive.

Medical Simulation


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The Usual Training Model

S1D1T1

See One

Do One

Teach One


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S1D1T1S1D1T1

Often used in surgical training

Frequently used for procedures inother specialties.

The 2nd year resident isfrequently teaching the 1st yearresident


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In Disaster Medicine

If youve seen three disasters of the samekind,

you are either in the wrong part of theworld

very unlucky

Or both.

S1D1T1 doesnt work well in this situation.


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We also have invested in the

AMA sponsored NDLS as atraining method to help introduceresponders at multiple levels to

disaster medicine


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ADLS

At the conclusion of this ADLS course thestudent will be able:

Identify the Critical Need to Be Prepared forNatural Disasters and Events involving:chemical, biological, nuclear, radiological, and

explosive incidents.

Define all-hazards: and list possibleetiologies


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ADLS

Identify the components of the DISASTERparadigm and apply the paradigm using both theM.A.S.S. and the

ID-me BDLS triage model

Meet the Acute Care needs of patients involvedin either a public health emergency or a natural

disasterRapidly and effectively become part of the publichealth system


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ADLS

Demonstrate the ability to participate in a

coordinated, multidisciplinary, mass casualtyincident using personal protective equipment

Demonstrate the use of elements ofdecontamination site selection and the operation ofbasic chemical and radiological detection.


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ADLS

Demonstrate the ability to operate within theIncident Command System and exerciseleadership competencies related to emergency

preparedness and response.

So... How do we teach this?


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ADLS

ADLS makes use of interactive scenarios and

drills in which the participants treat simulated

patients in a disaster.

Through the use of high fidelity mannequins thestudent can gain experience in treating

conditions that they would normally not treateven with years of experience.

Our friends


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Our friends....help us Teach ADLS


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Management ofMass Casualtyfrom Explosion


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Hemorrhagic feverContaminated patient

M di l Si l ti


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Provides the opportunity to train on unusualmedical problems.

Problems that you wont (hopefully)see

Problems that require unusualresources

Problems that require unusualequipment or personal protective gear.

Medical SimulationIn Disaster Medicine

M di l Si l ti


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Also provides a balance between the emotionalload associated with the crisis experience andthe professional lessons that can be learned.

We can stress the provider without the risk ofoverload.


M di l Sim l ti


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Also.

Provides professionals with the skills tocope competently with those mistakes

that could not be prevented

Reduces occurrences of errors in reallife

The military has clearly shownthat we play just like we train


Medical Sim lation


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In order for this to work....

Trainees must have some ability to invoke a

Suspension of Disbelief



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During training, we need to avoidMONITOR Focus

Looking at the monitor to prompt the next clinicaldecision!


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Feedback

Students are asked how they thought thescenario went

Leading questions probe the studentsthought processes

A hidden benefit of


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A hidden benefit offeedback

The immediacy of the post simulation reflectivelearning process may provide trainees with

snapshot of their abilities in certain clinical areas

For some = impetus for further self assessment/newlearning in those areas that are perceived as being lessthan optimal or below expectation

For some this =

Medical Simulation
http://images.google.com/imgres?imgurl=http://shsd.k12.ar.us/happenings04-05/october/redribbonweek/Smiley-face.gif&imgrefurl=http://scientificactivist.blogspot.com/2006_03_01_archive.html&h=317&w=313&sz=47&hl=en&start=1&um=1&tbnid=V7EmKwWiIO9V1M:&tbnh=118&tbnw=117&prev=/images?q=smiley+face&um=1&hl=en


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Is Resource Intensive and Time Consumingfor both Trainers & Trainees


Medical Simulation


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Initial exposure raises awareness

Repeated exposure to simulationimproves performance

High Impact

But does will it translate into improved clinicaloutcomes?


Medical Simulation


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Reliability Validity

Predictive validity

Medical SimulationVerification of Competency


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2008 Academic Emergency MedicineConsensus Conference on the Science of

Simulation

Objective methods and measures to demonstratesimulator training actually improves patient safety

Effective feedback of information from errorreporting systems into simulation training toimprove patient safety

Methods and outcome measures to demonstrateteamwork improves disaster response

..


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Others experiences...

Abrahamson SD, Canzian S, Brunet F. Usingsimulation for training and to change protocol duringthe outbreak of severe acute respiratory syndrome.Critical Care 2006;10(R3):

Schwid HA, Rooke GA, Ross BK, Sivarajan M. Use ofa computerized advanced cardiac life supportsimulator improves retention of advanced cardiac lifesupport guidelines better than a textbook review. CritCare Med 1999;27:821-824.

AND MANY MORE....


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Weve done this a few times...... Since the inception of OIDEM in 2006...

Weve trained 211 students in Advanced

Disaster Life Support in 4 classes peryear.

But... we dont just do ADLS for disaster

training

We have bi-monthly simulation trainingsessions for our residents

Medical Simulation In Disaster


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...

Weve doing team training with nursingstudents in Emergency Procedures.

We help the Urban Search and RescueTeams with their disaster exercises anddrills.

We help with Advanced Trauma Life

Support procedure training.

We work with both rural EMS agencies,EMSA, and Tulsa Fire Department

Medical Simulation In DisasterMedicine

S


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Weve been active in all of the disastertraining shown in this slide set...

Including HSEEP training.

We BELIEVE in using trainingsimulations in disaster medicine.

Medical Simulation In DisasterMedicine


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Our friends help us teach in ways thatliving people just cant...

in places or situations we cant put living

people...

and react to agents that we cant use on

living people...


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Thank you....


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Charles Stewart MD EMDM, MPH(candidate)

Professor of Emergency MedicineDepartment of Emergency Medicine

Director, Oklahoma Institute for Disasterand Emergency Medicine

[email protected]
mailto:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]

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Session Stewart

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