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PubMed2003

Simulation and management games for training command and control in emergencies.

The aim of our project was to introduce and implement simulation techniques in a problematic field of increasing health care system preparedness for disasters. This field was chosen as knowledge is gained by few experienced staff members who need to disperse it to others during the busy routine work of the system personnel. Knowledge management techniques ranging from classifying the current data, centralized organizational knowledge storage and using it for decision making and dispersing it through the organization--were used in this project. In the first stage we analyzed the current system of building a preparedness protocol (set of orders). We identified the pitfalls of changing personnel and loosing knowledge gained through lessons from local and national experience. For this stage we developed a database of resources and objects (casualties) to be used in the simulation in different possibilities. One of those was the differentiation between drills with trainer and those in front of computers enable to set the needed solution. The model rules for different scenarios of multi-casualty incidents from conventional warfare trauma to combined chemical/toxicological as well as, levels of care pre and inside hospitals--were incorporated to the database management system (we used Microsoft Access' DBMS). The hardware for management game was comprised of serial computers with network and possibility of projection of scenes. For prehospital phase the possibility of portable PC's and connections to central server was used to assess bidirectional flow of information. Simulation software (ARENA) and graphical interfase (Visual Basic, GUI) as shown in the attached figure. We hereby conclude that our system provides solutions which are in use in different levels of healthcare system to assess and improve management command and control for different scenarios of multi-casualty incidents.

Computer Simulation↗

PubMed2006

"Hemodynamic efficacy" of two endoscopic clip devices used in the treatment of bleeding vessels, tested in an experimental setting using the compact Erlangen Active Simulator for Interventional Endoscopy (compactEASIE) training model.

BACKGROUND AND STUDY AIMS: Hemoclip therapy is a well-established procedure in the treatment of gastrointestinal bleeding. Although new products are provided periodically by the industry, comparative investigations are lacking. We compared two different hemoclip devices in an experimental setting, assessing them using objective hemostatic parameters. MATERIALS AND METHODS: We compared two disposable clip devices (Olympus HX-200L-135 (n = 40) vs. Wilson-Cook Tri-Clip (n = 40)) in an experimental setting using the compact Erlangen Active Simulator for Interventional Endoscopy (compactEASIE) training model equipped with an upper gastrointestinal-organ package for bleeding simulation. This was a randomized, prospective, controlled trial. Four investigators with different levels of endoscopic experience applied ten hemoclip devices of each type to the spurting vessels, the clips allocated using a randomized list for each investigator. The efficacy of hemostasis was determined by continuous measurement of the pressure within the afferent vessel before and after clip application and calculation of the relative reduction of vessel diameter by the clip device. The system pressure was recorded over the period from 1 minute before to 1 minute after clip application. A secondary end point was a subjective assessment of the whole clip application procedure by the endoscopist and the assisting nurse, using a visual analog scale (0 - 100, with 100 representing the best experience). RESULTS: A total of 39/40 clips of each type were applied successfully. Both clip devices led to a significant increase in system pressure, representing significant relative reduction of vessel diameter (Olympus 5.4 +/- 7.5 %, p < 0.001; Cook 4.9 +/- 8.0 %, p < 0.001). Overall, there was no significant difference between the two devices ( P = 0.756). However, the investigator with the least experience in endoscopy (< 100 procedures) produced significantly inferior results compared with the other three investigators, who had performed between 2000 and 6000 procedures each ( P < 0.05). We found no evidence of a learning curve from the intra-observer results. The devices received good, but not significantly different, overall ratings by the endoscopists (Olympus 69 +/- 24 vs. Wilson-Cook 65 +/- 16) and by the assisting nurses (Olympus 77 +/- 9 vs. Wilson-Cook 70 +/- 22). CONCLUSIONS: Using an established cadaveric training model, no significant difference was found between the two types of hemoclip devices with respect to their "hemostatic efficacy". However, the experience of the endoscopist appears to play a major role in successful clip application. The use of a feedback mechanism in emergency endoscopy training, using continuous intravessel pressure monitoring, may substantially enhance the efficacy of training, resulting in a similar improvement in clinical results.

Cadaver↗

PubMed1994

Simulated patients in assessing consultation skills of trainees in general practice vocational training: a validity study.

Although simulated patients are increasingly used in medical education, little research has been carried out on their validity. Validity in this case defines the relationship between performance with a simulated patient and performance with a real patient. One of the objectives of this study was to determine the validity of the use of simulated patients in assessing the consultation skills of trainees in vocational training at the Department of General Practice, University of Utrecht, The Netherlands. A check-list with a rating scale was used to assess the consultation skills of trainees at the department with simulated patients as well as in their training practices with real patients. The simulated and the selected practice cases were patients with complex multi-conditional problems like low back pain, headache and chest pain. The consultation skills were subdivided into four groups: the patient-centered approach, the non-somatic approach, communication skills and interpersonal skills. The measurement of skills, in particular of consultation skills, is very difficult. A description is given of the way the research group solved this problem. The analysis was performed by determining the sensitivity and predictive value of the assessment of a simulated encounter with a routine practice encounter. A difference existed in the assessed level of consultation skills in the simulated encounter compared to the level in the training practice. In simulation the level of consultation skills was higher than in day-to-day practice. This difference can reflect the difference between competence and performance. Competence is defined as what a doctor is capable of doing and performance as what a doctor actually does in day-to-day practice.(ABSTRACT TRUNCATED AT 250 WORDS)

Clinical Competence↗

PubMedDate not supplied

Ankle disk training influences reaction times of selected muscles in a simulated ankle sprain.

Ankle disk training has been used as an exercise in sports medicine clinics to help protect against ankle sprains. This study investigated the effects of ankle disk training on the contraction pattern of the anterior tibialis, posterior tibialis, peroneus longus, and flexor digitorum longus muscles in a simulated ankle sprain. Twenty adults were recruited and divided into a control group and an experimental group. A platform with a trapdoor was used to simulate a lateral ankle sprain. Electromyographic data were recorded from each subject in pretraining and posttraining tests. The experimental group underwent ankle disk training for 8 weeks between the pretraining and posttraining tests. In the pretraining test, the four muscles started to contract simultaneously; in the posttraining test, the contractions of the anterior and posterior tibialis muscles were delayed. This delay favors the correction of excessive ankle inversion. This study examined the effects of one form of proprioceptive training on muscle reaction times, and its results may explain why such training can help protect against ankle sprains.

Adolescent↗

PubMed2000

Computers in radiology. The sedation, analgesia, and contrast media computerized simulator: a new approach to train and evaluate radiologists' responses to critical incidents.

BACKGROUND: Awareness and preparedness to handle sedation, analgesia, and contrast-media complications are key in the daily radiology practice. OBJECTIVE: The purpose is to create a computerized simulator (PC-Windows-based) that uses a graphical interface to reproduce critical incidents in pediatric and adult patients undergoing a wide spectrum of radiologic sedation, analgesia and contrast media complications. MATERIALS AND METHODS: The computerized simulator has a comprehensive set of physiologic and pharmacologic models that predict patient response to management of sedation, analgesia, and contrast-media complications. Photorealistic images, real-time monitors, and mouse-driven information demonstrate in a virtual-reality fashion the behavior of the patient in crisis. RESULTS: Thirteen pediatric and adult radiology scenarios are illustrated encompassing areas such as pediatric radiology, neuroradiology, interventional radiology, and body imaging. The multiple case scenarios evaluate randomly the diagnostic and management performance of the radiologist in critical incidents such as oversedation, anaphylaxis, aspiration, airway obstruction, apnea, agitation, bronchospasm, hypotension, hypertension, cardiac arrest, bradycardia, tachycardia, and myocardial ischemia. The user must control the airway, breathing and circulation, and administer medications in a timely manner to save the simulated patient. On-line help is available in the program to suggest diagnostic and treatment steps to save the patient, and provide information about the medications. A printout of the case management can be obtained for evaluation or educational purposes. CONCLUSION: The interactive computerized simulator is a new approach to train and evaluate radiologists' responses to critical incidents encountered during radiologic sedation, analgesia, and contrast-media administration.

Adult↗

PubMed2001

Screen-based anesthesia simulation with debriefing improves performance in a mannequin-based anesthesia simulator.

BACKGROUND: Previous investigations have established the need for improved training for management of anesthetic emergencies. Training with inexpensive screen-based anesthesia simulators may prove to be helpful. PURPOSES: We measured the effectiveness of screen-based simulator training with debriefing on the response to simulated anesthetic critical incidents. METHODS: Thirty-one 1st-year clinical anesthesia residents were randomized into 2 groups. The intervention group handled 10 anesthetic emergencies using the screen-based anesthesia simulator program and received written feedback on their management, whereas the traditional (control) group was asked to study a handout covering the same 10 emergencies. All residents then were evaluated on their management of 4 standardized scenarios in a mannequin-based simulator using a quantitative scoring system. RESULTS: The average point score for the simulator-with-debriefing group was 52.6 +/- 9.9 out of 95 possible points. The traditional group average point score was 43.4 +/- 5.9, p = .004. CONCLUSIONS: Residents who managed anesthetic problems using a screen-based anesthesia simulator handled the emergencies in a mannequin-based anesthesia simulator better than residents who were asked to study a handout covering the same problems. Computer simulations with feedback are effective as a supplement to traditional residency training methods for the management of medical emergencies.

Anesthesiology↗

PubMed2004

Construct validity for the LAPSIM laparoscopic surgical simulator.

BACKGROUND: The skills required for laparoscopic surgery are amenable to simulator-based training. Several computerized devices are now available. We hypothesized that the LAPSIM simulator can be shown to distinguish novice from experienced laparoscopic surgeons, thus establishing construct validity. METHODS: We tested residents of all levels and attending laparoscopic surgeons. The subjects were tested on eight software modules. Pass/fail (P/F), time (T), maximum level achieved (MLA), tissue damage (TD), motion, and error scores were compared using the t-test and analysis of variance. RESULTS: A total of 54 subjects were tested. The most significant difference was found when we compared the most (seven attending surgeons) and least experienced (10 interns) subjects. Grasping showed significance at P/F and MLA (p < 0.03). Clip applying was significant for P/F, MLA, motion, and errors (p < 0.02). Laparoscopic suturing was significant for P/F, MLA, T, TD, as was knot error (p < 0.05). This finding held for novice, intermediate, and expert subjects (p < 0.05) and for suturing time between attending surgeons and residents (postgraduate year [PGY] 1-4) (p < 0.05). CONCLUSIONS: LAPSIM has construct validity to distinguish between expert and novice laparoscopists. Suture simulation can be used to discriminate between individuals at different levels of residency and expert surgeons.

Clinical Competence↗

PubMed2002

Cardiopulmonary resuscitation training for undergraduate medical students: a five-year study.

BACKGROUND: Cardiopulmonary resuscitation (CPR) training for undergraduate medical students and junior doctors has been noted to be poor in the past. Attempts have been made over the last decade to improve CPR training for all health professionals. AIM: This study aimed to determine if CPR training for undergraduate medical students in a single institution improved after initial concerns in 1992, and to observe trends in CPR training over five years. METHODS: Prospective single centre observational cohort survey by means of a 2-page self completed questionnaire to final year undergraduate medical students at the University of Glasgow (1993-97 inclusive). RESULTS: Mean annual response rate 58% (range 48%-67%). 99% of responders had been trained in basic life support during undergraduate training. The use of simulated arrests for training increased significantly. CPR training was concentrated in the first and final years. Training in all aspects of advanced life support increased, as did the students' confidence in these techniques. Student satisfaction with the amount of basic life support training increased very significantly and there was a small, but significant increase in student satisfaction with advanced life support training. Overall confidence at the prospect of being a member of the resuscitation team on qualification did not increase. CONCLUSIONS: There has been a sustained improvement in CPR training at this institution since 1993. Improvements in the training of specific advanced life support techniques does not lead to improved overall confidence in using these skills on qualification. Advanced life support training requires further expansion.

Cardiopulmonary Resuscitation↗

PubMed2002

Development and validation of virtual driving simulator for the spinal injury patient.

We developed a virtual reality (VR) driving simulator in order to safely evaluate and improve the driving ability of spinal injury patients. The simulator is composed of an actual car, a beam projector, and a large screen. For the interface of our driving simulator, an actual car was adapted and then connected to a computer. We equipped the car with hand control driving devices especially adapted for spinal injury patients. A beam projector was used so that the subjects could see the virtual scene on a large screen set up in front of them. The virtual environment (VE) consisted of 18 sections (e.g., a speed-limited road, a straight road, a curved road, a left turn) and each section was linked naturally to the next. The subjects selected for this trial were 10 normal drivers with valid driving licenses and 15 patients with thoracic or lumbar cord injuries who had prior driving experience. For evaluation, five driving skills were measured, including average speed, steering stability, centerline violations, traffic signal violations, and driving time in various road conditions such as straight and curved roads. The normal subjects manipulated the gas pedal and the brake with their feet, while the patients manipulated a hand control with their hands. After they finished driving the whole course, the participants answered the questions such as "How realistic did the virtual reality driving simulator seem to you?" and "How much was your fear reduced?" In this study, we found that the difference in manipulation method (i.e., the patient group's hand control versus the normal driver's foot controls) does not seem to influence relative performance in the VR driving simulator, though training to improve the use of hand controls in the VR driving simulator would be useful to reduce the fear that the patients feel while driving.

Adult↗

PubMed1995

A novel variable-gravity simulation method: potential for astronaut training.

Zero gravity conditions for astronaut training have traditionally used neutral buoyancy tanks, and with such tanks hypogravity conditions are produced by the use of supplemental weights. This technique does not allow for the influence of water viscosity on any reduced gravity exercise regime. With a water-foam fluid produced by using a microbubble air flow together with surface active agents to prevent bubble agglomeration, it has been found possible to simulate a range of gravity conditions without the need for supplemental weights and additionally with a substantial reduction in the resulting fluid viscosity. This new technique appears to have application in improving the simulation environment for astronaut training under the reduced gravity conditions to be found on the moon or on Mars, and may have terrestrial applications in patient rehabilitation and exercise as well.

Astronauts↗

PubMed1988

Recent advances in computer image generation simulation.

An explosion in flight simulator technology over the past 10 years is revolutionizing U.S. Air Force (USAF) operational training. The single, most important development has been in computer image generation. However, other significant advances are being made in simulator handling qualities, real-time computation systems, and electro-optical displays. These developments hold great promise for achieving high fidelity combat mission simulation. This article reviews the progress to date and predicts its impact, along with that of new computer science advances such as very high speed integrated circuits (VHSIC), on future USAF aircrew simulator training. Some exciting possibilities are multiship, full-mission simulators at replacement training units, miniaturized unit level mission rehearsal training simulators, onboard embedded training capability, and national scale simulator networking.

Aviation↗

PubMed2005

Validation of computer-based training in ureterorenoscopy.

OBJECTIVES: To evaluate the outcome of training both urological novices and experts, using the recently developed UroMentor (Simbionix Ltd, Israel) trainer, that provides a realistic simulation of rigid and flexible ureterorenoscopy (URS). SUBJECTS AND METHODS: Twenty experienced urologists (total number of previous flexible URSs 21-153) were monitored during simulated flexible URS for treating a lower calyceal stone, and the outcome was correlated with individual experience. A score was compiled based on the variables recorded, including total operation time, stone contact time, complications such as bleeding or perforation, and treatment success. A further five urological residents with no endourological experience were trained on the UroMentor in rigid URS for ureteric stone treatment. Their acquired clinical skills were subsequently compared to those of five urological residents who received no simulator training. RESULTS: All 20 experienced urologists disintegrated the stone on the simulator, and the score achieved was related to their personal experience; there was a significant difference in performance in those with < 40 and > 80 previous flexible URSs. For the five urological residents with no endourological experience, simulator training improved their skills, and comparison with urological residents who had received no simulator training showed advantages for the trained residents. After being trained on the simulator, the group performed better in the first four URSs on patients. CONCLUSIONS: Individual experience correlates with individual performance on the simulator. Simulator training was helpful in improving clinical skills. Although the distribution of computer-based simulators is limited by high prices, virtual reality-based training has the potential to become an important tool for clinical education.

Clinical Competence↗

PubMed2001

Development and evaluation of an epidural injection simulator with force feedback for medical training.

Performing epidural injections is a complex task that demands a high level of skill and precision from the physician, since an improperly performed procedure can result in serious complications for the patient. The objective of our project is to create an epidural injection simulator for medical training and education that provides the user with realistic feel encountered during an actual procedure. We have used a Phantom haptic interface by SensAble Technologies, which is capable of three-dimensional force feedback, to simulate interactions between the needle and bones or tissues. An additional degree-of-freedom through an actual syringe was incorporated to simulate the "loss of resistance" effect, commonly considered to be the most reliable method for identifying the epidural space during an injection procedure. The simulator also includes a new training feature called "Haptic Guidance" that allows the user to follow a previously recorded expert procedure and feel the encountered forces. Evaluations of the simulator by experienced professionals indicate that the simulation system has considerable potential to become a useful aid in medical training.

Computer Simulation↗

PubMed2004

Achieving house staff competence in emergency airway management: results of a teaching program using a computerized patient simulator.

OBJECTIVES: Patient simulation is emerging as a training technique in the field of medicine. It has particular application in training responses to high-risk, low-frequency clinical events, of which a typical example is in-hospital cardiac arrest. A critical element of response by the cardiac arrest team is initial airway management. In teaching hospitals, medical interns are first responders to in-hospital cardiac arrests. Our objective was to design and test a program using a computer-controlled patient simulator to train medical interns and demonstrate their competence in initial airway management. DESIGN: Prospective, randomized, controlled, unblinded trial. SETTING: Internal medicine residency training program in an urban teaching hospital. PARTICIPANTS: All 50 starting internal medicine interns in July 2002, all Advanced Cardiac Life Support certified in June 2002. INTERVENTIONS: All interns were tested in initial airway management skills and then were randomly assigned to receive either immediate or delayed individualized training using a computer-controlled patient simulator. The computer-simulated training process consisted of a scenario of respiratory arrest. The interns were challenged with the scenario twice following testing. The interns were debriefed extensively and given hands-on training by the attending using the simulator until they achieved perfect performance. MEASUREMENTS AND MAIN RESULTS: Initial airway management was divided into specific scorable steps. Individual step scores and total scores were recorded for each intern on initial and repeat testing. For 10 months following simulator training, intern airway management skills were scored in actual patient airway events. Despite recent Advanced Cardiac Life Support training and certification, all starting medical interns demonstrated poor airway management skills. The immediate training group showed significant improvement in initial airway management when tested before and 4 wks after training. In contrast, the delayed training group showed no significant improvement. Direct observation of interns in actual initial airway events revealed excellent clinical performance. CONCLUSIONS: Individualized training of medical interns using a computer-controlled patient simulator is an effective means of achieving and measuring competence in initial airway management skills. The improvement appears to be transferable to the bedside of real patients.

Adult↗

PubMed2004

New aspects on critical care medicine training.

Recently, three fundamental changes have been introduced in medical education, all of particular importance to critical care medicine: (1) clinical teaching and medical practice now emphasize evidence-based medicine, (2) patient safety aspects are increasingly stressed, and (3) use of simulation in medical training is spreading rapidly. In 1999, the disturbingly high frequency of life-threatening or even lethal medical complications was emphasized by the Institute of Medicine in the book To Err Is Human. The Institute of Medicine recommended establishing interdisciplinary team training programs incorporating efficient methods such as simulation. Although simulation has been used by the aviation industry and the military for several decades, only during the past decade has this become a teaching method in medicine. Currently, two full-scale computerized simulators are available: METI, provided by Medical Education Technologies, Sarasota, Florida, and SimMan, manufactured by Laerdal Medical, in Stavanger, Norway. The simulation center at the University of Pittsburgh Medical Center was established in 1994 and has grown quickly to its current large facility, where, in academic year 2003 to 2004, approximately 8000 healthcare professionals were trained on the SimMan. Courses taught include clinical procedures and decision making in perioperative medicine, acute medicine, pharmacology, anesthesiology, airway management, bronchoscopy, pediatric versus adult crisis management, critical events in obstetrics, and crisis team training. Advantages of simulation training over traditional medical education methods include (1) provision of a safe environment for both patient and student during training in risky procedures, (2) unlimited exposure to rare but complicated and important clinical events, (3) the ability to plan and shape training opportunities rather than waiting for a suitable situation to arise clinically, (4) the ability to provide immediate feedback, (5) the opportunity to repeat performance, (6) the opportunity for team training, and (7) lower costs, both direct and indirect. Within the next decade, use of computerized simulators for evidence-based education and training in medicine is expected to develop considerably and spread rapidly into a very important domain of medical schools throughout the entire world.

Computer Simulation↗

PubMed1982

A comparison of resident performance on real and simulated patients.

Although simulated patients have been increasingly used in medical education, the validity of this procedure--that is, the relationship between performance on a simulated patient and performance with a real patient presenting a similar clinical problem--has not been adequately addressed. The study on which this article is based was an attempt to examine this question. Four actual patients with chronic stable findings were used in the study; four simulated patients were then programmed to present the same problem. A sample of 10 residents in family and internal medicine interviewed and examined all eight patients. The order of the presentation of the cases was balanced. No significant differences emerged in number of questions on history and physical examination or in the diagnoses and investigations considered by residents. Residents elicited significantly more historical data from the simulated patient; however, this was found to be due to a single case in which the real patient suffered from a neurological condition characterized by loss of memory. Residents correctly identified 67 percent of the patients as real or simulated against a chance figure of 50 percent. The implications of the study for training of simulated patients are discussed.

Clinical Competence↗

PubMed2001

Does training in a virtual reality simulator improve surgical performance?

BACKGROUND: The development of computerized surgical simulators in a virtual reality environment demands models for proper validation. Recent investigations have shown that a virtual reality simulator (MIST-VR) is a reliable tool for the assessment of laparoscopic psychomotor skills and that it improves the automation of the so-called fulcrum effect. Therefore, we set out to determine whether training with the MIST-VR would improve the surgical performance of surgically inexperienced medical students and to see if results obtained in the simulator would correlate with surgical performance. METHODS: A total of 29 medical students were randomized into two groups. One group received preoperative MIST-VR training. Both groups then performed a simulated laparoscopic appendectomy in a pig. The operations were videotaped and examined by three independent observers. RESULTS: There was no significant difference in performance between the two groups. The performance with the MIST-VR correlated with the results in surgery. CONCLUSION: A method that can measure surgical skill, based on the scoring of independent observers who view videotaped performances, seems to be reliable. MIST-VR did not improve the surgical skills of the subjects, but the results with MIST-VR did predict surgical outcome.

Clinical Competence↗

PubMed2004

Simulation in undergraduate medical education: bridging the gap between theory and practice.

OBJECTIVE: To evaluate the use of simulation-based teaching in the medical undergraduate curriculum in the context of management of medical emergencies, using a medium fidelity simulator. DESIGN: Small groups of medical students attended a simulation workshop on management of medical emergencies. The workshop was evaluated in a post-course questionnaire. SUBJECTS: All Year 4 medical students allocated to the resuscitation rotation during the first half of 2002. MAIN OUTCOME MEASURES: Student perceptions of learning outcomes, the value of the simulation in the undergraduate curriculum and their self-assessed improved mastery of workshop material. RESULTS: A total of 33 students attended the workshop and all completed questionnaires. Students rated the workshop highly and found it a valuable learning experience. In all, 21 (64%) students identified teamwork skills as key learning points; 11 (33%) felt they had learnt how to approach a problem better, particularly in terms of using a systematic approach, and 12 (36%) felt they had learnt how to apply their theoretical knowledge in a clinical setting better. All 33 students were positive about the use of simulation in their training; 14 students wrote that simulation should be used more or should be mandatory in training; 5 students commented positively on the realism of the learning experience and a further 5 said they valued the opportunity to learn new skills in a safe environment. CONCLUSION: This study demonstrates that medical students value simulation-based learning highly. In particular, they value the opportunity to apply their theoretical knowledge in a safe and realistic setting, to develop teamwork skills and to develop a systematic approach to a problem. A medium fidelity simulator is a valuable educational tool in medical undergraduate education.

Attitude of Health Personnel↗