1. History

2. Modern medical simulation

3. Clinical Skills and Simulations Centers (CSSC) for Medical Simulation

4. Debriefing & Education in Medical Simulation
    Debriefing in Medical Simulation   Simulation, Debriefing, & Education Theory   Debriefing Frameworks   Three-Phase Debriefing Structure    Description    Analysis    Application    Multi-Phase Debriefing Structure    Learning Objectives    Environment    Physical setting    Psychological environment   Evidence & Further Study 

5. Types of Simulations used in Medical Schools and Teaching Hospitals
     Examples of Full-scale Mannequins. See High Fidelity Simulators (HFS)    Examples of Part or Partial Task Trainers^[35]    Examples of Screen-Based Simulations^[36]    Examples of Hybrid Simulation Models  

6. High Fidelity Simulators (HFS)
     Companies that develop High Fidelity Simulators    CAE Healthcare    Simbionix    Gaumard Scientific    Laerdal    Simulab Corporation    Surgical Science    Medical Simulation Technologies    VirtaMed    Organis GmbH    VRmagic    ORamaVR   Examples of High Fidelity Simulators   BabySIM    CAE Fidelis Lucina    CAE Apollo    PediaSim    SimMan3G  

7. Medical Simulation Efficiency in Education

8. Training
    Examples  Advantages 

9. Military and emergency response
    Combat trauma patient simulator  In the classroom 

10. See also

11. References

Medical simulation, or more broadly, healthcare simulation, is a branch of simulation related to education and training in medical fields of various industries. Simulations can be held in the classroom, in situational environments, or in spaces built specifically for simulation practice.^[1] It can involve simulated human patients - artificial, human or a combination of the two, educational documents with detailed simulated animations, casualty assessment in homeland security and military situations, emergency response, and support virtual health functions with holographic simulation. In the past, its main purpose was to train medical professionals to reduce error during surgery, prescription, crisis interventions, and general practice. Combined with methods in debriefing, it is now also used to train students in anatomy, physiology, and communication during their schooling.

History

Modern day simulation for training was first utilized by anesthesia physicians in order to reduce accidents.^[2] When simulation skyrocketed in popularity during the 1930s due to the invention of the Link Trainer for flight and military applications, many different field experts attempted to adapt simulation to their own needs. Due to limitations in technology and overall medical knowledge to a specific degree at the time, medical simulation did not take off as acceptable training until much later.^[1] When the sheer cost effectiveness and training of which simulation was capable surfaced during extensive military use, hardware/software technology increased exponentially, and medical standards were established, medical simulation became entirely possible and affordable, although it remained un-standardized, and not widely accepted by the larger medical community.^[1]

By the 1980s software simulations became available. With the help of a UCSD School of Medicine student, Computer Gaming World reported that Surgeon (1986) for the Apple Macintosh very accurately simulated operating on an aortic aneurysm.^[2] Others followed, such as Life & Death (1988).

In 2004, the Society for Simulation in Healthcare (SSH) formed to assist in collaboration between associations interested in medical simulation in healthcare.^[3]

The need for a "uniform mechanism to educate, evaluate, and certify simulation instructors for the health care profession" was recognized by McGaghie et al. in their critical review of simulation-based medical education research.^[4] In 2012 the SSH piloted two new certifications to provide recognition to educators in an effort to meet this need.^[5]

Modern medical simulation

The American Board of Emergency Medicine employs the use of medical simulation technology in order to accurately judge students by using "patient scenarios" during oral board examinations.^[1] However, these forms of simulation are a far cry from high fidelity models that have surfaced since the 1990s.^[6]

Due to the fact that computer simulation technology is still relatively new with regard to flight and military simulators, there is still much research to be done about the best way to approach medical training through simulation, which continues to remain un-standardized although much more universally accepted and embraced by the medical community. That said, successful strides are being made in terms of medical education and training. Although amount of studies have shown that students engaged in medical simulation training have overall higher scores and retention rates than those trained through traditional means.^[1]

The Council of Residency Directors (CORD) has established the following recommendations for simulation^[1]

1. Simulation is a useful tool for training residents and in ascertaining competency. The core competencies most conducive to simulation-based training are patient care, interpersonal skills, and systems based practice.
2. It is appropriate for performance assessment but there is a scarcity of evidence that supports the validity of simulation in the use for promotion or certification.
3. There is a need for standardization and definition in using simulation to evaluate performance.
4. Scenarios and tools should also be formatted and standardized such that EM educators can use the data and count on it for reproducibility, reliability and validity.

The Association of Surgeons in Training has produced recommendations for the introduction, availability and role of simulation in surgical training^[7]

Clinical Skills and Simulations Centers (CSSC) for Medical Simulation

The two main types of medical institutes train people in the latest medical simulations are medical schools and teaching hospitals. According to survey results from the Association of American Medical Colleges (AAMC) simulation content taught at medical schools are done throughout all four years of study while hospitals use simulations during the residency and subspecialty period. Internal medicine, emergency medicine, obstetrics / gynecology, pediatrics, surgery and anesthesiology are the most common areas taught in medical schools and hospitals.^[8]

The AAMC reported that there were six main types of facility location, centralized, decentralized, mobile units, other or a small mixture of centralized & decentralized and centralized & mobile. Most CSSC are owned by the facilities, 84% for medical schools and 90% for teaching hospitals, the majority of simulation centers where housed in a centralized location, 77% for medical schools and 59% for teaching hospitals.^[8] Common medical school CSSC locations contain rooms for debriefs training/scenario, exam /standardized patient rooms, partial task trainer, offices, observation area, control room, class and storage. On average a medical schools CSSC can have around 27 rooms dedicated to training with simulations.^[8]

Debriefing & Education in Medical Simulation

The origins of debriefing can be traced back to the military, whereby upon return from a mission or war game exercise, participants were asked to gather as a group and recount what had happened.^[9] These gatherings had the primary intention of developing new strategies to use in future encounters; these gatherings also provided a learning opportunity for other members of the team who were not present at the events being debriefed.

In the field of psychology, debriefing is used in the processing of traumatic events. Here, the emphasis is on the narrative; in a facilitator-led environment, participants reconstruct what happened and review facts, share reactions, and develop a shared meaning of the events. The aim is to reduce stress, accelerate normal recovery, and assist in both the cognitive and emotional processing of the experience.^[10][11]

In all instances, debriefing is the process by which people who have gone through an experience are intentionally and thoughtfully led through a discussion of that experience.^[20][9] Debriefing in simulation is a critical component of learning in simulation and is necessary to facilitate change “on an individual and systematic level”.^[12][13]{{rp|e287}} It draws from the above-mentioned forms of debriefing, but the emphasis here is on education. Debriefing in education can be described as a “facilitator-led participant discussion of events, reflection, and assimilation of activities into [participants’] cognitions [which] produce long-lasting learning”.^[1] More specific descriptions of debriefing can be found, such as the following in relation to debriefing in healthcare simulations, described by Cheng et al. (2014): “...a discussion between two or more individuals in which aspects of a performance are explored and analysed with the aim of gaining insights that impact the quality of future clinical practice”.^[25]{{rp|658}} Or another regarding debriefing in gaming, by Steinwachs (1992), “…a time to reflect on and discover together what happened during game play and what it all means."^[26]{{rp|187}}

Debriefing in Medical Simulation

Medical simulation is often defined as, “a technique (not a technology) to replace and amplify real life experiences with guided ones, often “immersive” in nature, that evoke or replicate substantial aspects of the real world in a fully interactive fashion”.^[14] This definition deliberately defines simulation as a technique and not a technology, implying that simulation is greater than the technology or tools which it adopts. Also note the use of the word guided in the definition, further implying that the interactions which occur in a simulated environment are not left solely to those persons immersed in the simulation, but that a “guide” also be present. This guide may be virtual in nature, such as prompts from a computer program, or may be physically present, in the form of an instructor or teacher. The human guide is often referred to as a “facilitator”.^[15] It is this facilitator who guides the debriefing which occurs after a simulation scenario has completed.

When these elements are present, the simulation is often referred to as “Instructional simulation,” “Educational simulation,” or “Simulation-based learning”.^[15] Favourable and statistically significant effects for nearly all knowledge and process skill outcomes when comparing simulation AND debriefing versus simulation with no intervention (in healthcare) has been shown.^[16] When applied in a capacity to further professional development, simulation and debriefing may be referred to as “Simulation-based training”.^[17]

Simulation, Debriefing, & Education Theory

The six principles of Experiential Learning Theory align with educational simulation. The six principles are:

1. Engaging students in a process that enhances learning. This includes “feedback on the effectiveness of their learning efforts,” (p. 194) and focus on the process, not the outcome.
2. Students have prior beliefs and ideas. A process which draws these beliefs & ideas out, with the intent of re-examining & re-testing them against a topic in order to accommodate new ideas, will lead to learning.
3. Learning is a process which cycles between reflection and action, feeling and thinking. “Conflict, differences, and disagreement are what drive the learning process” (p. 194); the resolution of these is what leads to learning.
4. Learning happens in interactions between the person and the environment which surrounds them.
5. Learning is more than cognition; it also involves thinking, feeling, perceiving, and behaving.
6. Learning is grounded in constructivist philosophy; “Learning is the process of creating knowledge”.^&91;18&93;{{rp|194}}

Simulation also aligns with Guided Discovery learning. Developed by Jerome Bruner in the 1960s, discovery learning also stems from the work of Jean Piaget and can be described as a learning environment where there is little to no instructor-guidance.^[23] Guided discovery learning, on the other hand, continues to place learners in a discovery environment, but where an instructor is available to help guide learning via coaching, feedback, hints, and/or modeling.^[23]

Both Experiential & Discovery Learning are based on constructivist philosophy.^[18][23] Broadly, Constructivism is based on the belief that learning is an active process whereby learners make sense of new knowledge by building upon their prior experiences; each person has a unique set of experiences which frame their interpretation of information.^[24]

Debriefing Frameworks

While many models for debriefing exist, they all follow, at a minimum, a three-phase format.^[15][19][20] Debriefing models can be divided into two categories: the “Three-Phase Debriefing Structure,” and the “Multiphase Debriefing Structure”.^[20]

Three-Phase Debriefing Structure

A benchmark in all forms of facilitator-guided, post-event debriefing conversational structures, the three conventional phases of debriefing are: description, analysis, and application.^[15][25][20] Frameworks which make use of the three-phase debriefing format include Debriefing with Good Judgment,^[53] the 3D Model,^[21] the GAS model,^[55] and Diamond Debrief.^[25]

Description

Also labelled as “reaction,”^[26][27][28] "defusing,"^[21] "gather,"^[29] and "identify what happened,"^[12] the description phase of debriefing sees simulation participants describing and exploring their reactions, emotions, and overall impact of the experience.^[15][20] It is the opening phase of systematic reflection, enabled by a facilitator who poses key questions such as:

• “How did that feel?”
• “How did that go?”
• “Can you take us through the scenario as it unfolded?”^[29][20]

A facilitator is to keep asking these questions of the learners until they feel confident that all participants have voiced their understanding of the situation.^[25] The point of the description phase is to identify the impact of the experience, gain insights into what mattered to the participants throughout the simulation, and to establish a shared mental model of the events which occurred.^[27][20][19] A debate in the healthcare simulation community exists regarding the exploration of feelings in the descriptive phase. One camp believes that the descriptive phase should allow an opportunity for participants to “blow off steam,” and release any tension which may have accumulated during the simulation scenario in order for learners to continue the debrief and subsequent reflection without pent-up emotion.^[20][27][21] Others believe that the “venting” phase is not necessary and may explicitly make this statement in their debriefing models, or simply omit any reference to emotions or feelings at all.^[25]

Analysis

The second phase of debriefing is often referred to as “analysis,”^{[15][19][29][28][20]} "description,"^[26] or "discovering".^[21] This is the phase in which the bulk of the time of debriefing is spent, with a focus on participant performance, rationales, & frames.^{[26][25][27][12]} It is meant to be a time of reflective practice on what actually occurred during the scenario, and the reasons why events unfolded as they did.^[28][20] The analysis phase uncovers the decision-making process behind observed actions.^[21] Common questions posed, or statements made, by a facilitator during this phase include:

• “Tell me about [insert performance/event here, i.e. teamwork] during the scenario.”^[20]
• “What went well? Why?”
• “What made things challenging?”
• “Why do you think that happened?”

Participant performance is a key component during the analysis phase. However, performance can often be a difficult topic to broach with participants, as criticism or constructive feedback often incur negative feelings. There exists a framework for questioning named “Advocacy-Inquiry,” or the “debriefing with good judgment” approach, which aims to reduce negative experiences in medical simulation debriefing.^[28]

Advocacy Inquiry. The use of advocacy-inquiry (AI) questioning is highly encouraged by nearly all authors of debriefing models.^{[26][27][28][21]} Advocacy-inquiry consists of pairing “an assertion, observation, or statement” (advocacy), together with a question (inquiry), in order to elicit the mental frameworks – or schema – of both the facilitator and the participants.^[28]{{rp|53}} In phrasing questions this way, participants are made aware of the facilitator’s own point of view in relation to the question being posed. Note that the use of AI is most encouraged when a facilitator has a judgment about something which was observed during the simulation scenario. Using AI eliminates the tone of judgment as well as the “guess what I’m thinking” which can occur when asking questions.

Application

The third and final phase of three-phase debriefing structures is most commonly referred to as “application,"^[15][25] or "summary".^{[26][27][29][28]} Participants are asked to move any newly acquired insights and/or knowledge gained throughout the simulation experience forward to their daily activities or thought processes.^{[15][25][19][28][20]} This includes learning which may have occurred during the previous phases in the debriefing process. Common questions posed, or statements made, by a facilitator during this phase include:

• “What are you going to do differently in your practice tomorrow?”^[25]
• “What new insights have you gained?”
• “What one thing will you commit to doing differently after this?”

Note that the summary here is not always in terms of re-stating the major points which were visited throughout the simulation & debrief, but more so emphasize the greatest impact of learning. The summary may be done by either the facilitator or the participants – debriefing models differ in which they suggest. In the latter, the participants summarize what was of most value for them.^[26][25][12] A summary by the facilitator consists of re-stating key learning points which occurred throughout the debrief.^[26][21][27]

Multi-Phase Debriefing Structure

While all debriefing models include the phases of the three-part debriefing structure, there are several with additional phases. These additions either explicitly call out specific features which may be included in the three-part debriefing model, such as reviewing learning objectives, or provide additional process recommendations, such as immediately re-practicing any skills involved in the original simulation scenario.^[12][27] Examples of multi-phase debriefing structures include the Promoting Excellence and Reflective Learning in Simulation (PEARLS) framework,^[26] TeamGAINS,^[27] and Healthcare Simulation After-Action Review (AAR).^[12]

Learning Objectives

As with any other educational initiative, learning objectives are of paramount importance in simulation and debriefing. Without learning objectives, simulations themselves and the subsequent debriefs are aimless, disorganized, and often dysfunctional. Most debriefing models explicitly make mention of stating learning objectives.^{[26][25][27][12][21]}

The exploration of learning objectives ought to answer at least two questions: What competencies – knowledge, skills, and/or attitudes – are to be learned, and what specifically should be learned about them?^[15] The method of debriefing chosen should align with learning objectives through evaluation of three points: performance domain – cognitive, technical, or behavioural; evidence for rationale – yes/no; and estimated length of time to address – short, moderate, or long.^[26]

Learning objectives may be predetermined and included in the development of a simulation scenario, or they may be emergent as the scenario unfolds.^[26][15] It can be challenging for the novice facilitator to adapt to emergent learning objectives, as the subsequent discussion may be purely exploratory in nature with no defined outcome. Conversely, the discussion may lead to a specific area of expertise which neither the facilitator nor participants are familiar with. In such situations, the facilitator and participants must be flexible and move on to the next objective, and follow-up with the debriefing of the emergent outcome at a later time.

Environment

The debriefing environment consists of two main features: the physical setting, as well as the psychological environment.

Physical setting

When choosing a space in which to debrief, one must consider whether the scenario which unfolded was a complex case. Complex cases usually involve heightened emotions, interdependent processes, and require more time spent debriefing. As such, it is recommended that these types of debriefings occur in a separate room from where the simulation scenario took place. This allows for a release of tension as participants move from one place to another and encounter new surroundings.^[15] Note, however, that it is important to remind participants not to begin debriefing during the walk to the new room. The momentum of the simulation leads participants to begin debriefing with one another as soon the scenario has finished.^[30] However, in order to establish a shared mental model with all participants, debriefing must occur in a fashion whereby all participants can hear one another and have a chance to respond. This is difficult to accomplish while walking down a hallway, or in any disorganized fashion.

The location of the debriefing is ideally somewhere comfortable and conducive to conversation and reflection, where chairs can be maneuvered and manipulated.^[15][12] It is recommended that, during the debriefing, the facilitator(s) and/or participants be seated in a circle.^[30] This is done so that everyone can see each other and increase group cohesion. Furthermore, the use of a circle implies equality amongst the group, and decreases any sense of hierarchy which may be present.

Psychological environment

Establishing psychological safety and a safe learning environment is of utmost importance within both the simulation and the debriefing period.^{[26][15][28][31][20][21]} As simulation participants often find the experience stressful and intimidating, worried about judgment from their peers and facilitator(s), establishing safety must be done from the outset of the simulation event.^[32] Note that psychological safety does not necessarily equate to comfort, but rather that participants “feel safe enough to embrace being uncomfortable…without the burden of feeling that they will be shamed, humiliated, or belittled”.^[31]{{rp|340}}

It is recommended that establishing safety begin in the pre-brief phase^[31] by alerting participants to the “basic assumption.” The basic assumption, derived from the Centre for Medical Simulation at Harvard University (n.d.), is an agreed upon, predetermined mental model whereby everyone involved in the simulation & debrief believe that all participants are intelligent, well-trained, want to do their best, and are participating to learn and promote development.^[33][20] Additionally, Rudolph et al. (2014) have identified four principles to guide the formulation of a psychologically safe environment:

1. Communicate clear expectations
2. Establish a “fiction contract”
3. Attend to logistic details
4. Declare & enact a commitment to respecting learners & concern for their psychological safety^&91;31&93;

Included in these principles is the notion of confidentiality. Explicitly reminding participants that their individual performance and debriefing reflections are not meant to be shared outside of the simulation event can help foster participation. Confidentiality builds trust by increasing transparency and allowing participants to practice without fear.^[15][31]

Evidence & Further Study

There exists a paucity of quantitative data regarding the effectiveness of debriefing in medical simulation,^[15][16][34] despite Lederman’s 1992 seminal Model for the Systematic Assessment of Debriefing.^[19] Nearly every article reviewed had a cry for objective studies regarding the effectiveness of debriefing, whether it be comparing: the myriad options of conversational structures,^[20] debriefing models,^[27] or the comprehensive 5 W’s of Who – debriefer, What – content & methods, When – timing, Where – environment, and Why – theory.^[34]

Currently, there are critical limitations in the presentation of existing studies, a sparsity of research related to debriefing topics of importance, and debriefing characteristics are incompletely reported.^[34][16] Recommendations for future debriefing studies include:

• Duration of debriefing
• Educator presence
• Educator characteristics
• Content of debriefing
• Structure & method of debriefing
• Timing of debriefing^[16]

and/or:

• Who: debriefer number & characteristics
• What: the purpose of the debrief, formative vs summative assessment, individual vs team debriefing, method of debriefing, content covered, mechanics, etc.
• When: duration, post-event vs during-event vs delayed, etc.
• Where: in-situ, separate room, hospital, learning centre, etc.
• Why: theoretical underpinning of the debriefing model chosen & rationale
• PICO: population, intervention, comparator, outcome^[34]

Current research has found that simulation training with debriefing, when compared with no intervention, had favourable, statistically significant effects for nearly all outcomes: knowledge, process skill, time skills, product skills, behaviour process, behaviour time, and patient effects. When compared with other forms of instruction, simulation and debriefing showed small favourable effects for knowledge, time & process outcomes, and moderate effects for satisfaction.^[16]

Types of Simulations used in Medical Schools and Teaching Hospitals

There many different types of simulations that are used for training purposes. Some of the most known are the use of mannequins (referred to by the simulation company METI as Human Patient Simulators, or HPS for short) and standardized patients.

As seen in the chart titled "Types of Simulation Used in Medical Education" retrieved from the AAMC article, medical schools are leading the way when it comes to the use of standardized patients, but teaching hospitals and medical schools are close when it comes to full-scale mannequins and partial task trainers.

Examples of Full-scale Mannequins. See High Fidelity Simulators (HFS)

Examples of Part or Partial Task Trainers^[35]

• Air-way Trainers
• Vascular Access Trainers
• Ultrasound trainers
• Lumbar Puncture Trainers
• Pelvic Trainers
• Mechanical Ventilation Trainers

Examples of Screen-Based Simulations^[36]

• ACLS Simulator
• Anatomy Module
• Anesthesia Simulator
• Anesthesia SimSTAT - ASA/CAE Healthcare
• CardioSim
• MicroEKG
• Neonatal Simulator
• SonoSim - Ultrasound simulator
• IS4Learning - Auscultation simulator

Examples of Hybrid Simulation Models

• Standized Patients and Full-scale Manniquins
• Full-scale Manniquins/Part or Partial Task Trainers

High Fidelity Simulators (HFS)

Companies that develop High Fidelity Simulators

CAE Healthcare

• Lucina (maternal/fetal)
• Athena (high fidelity standard female simulator)
• iStan
• METIman
• Apollo
• HPS
• Caesar
• PediaSim
• BabySim
• ECS
• National Research Council - Institute of Clinical Physiology (IFC-CNR)

Simbionix

Gaumard Scientific

• Victoria Birthing Simulator^[37]
• Noelle Birthing Simulator
• HAL series

Laerdal

• SimMan 3G
• SimMan Trauma
• Sim Junior
• Sim Mom
• Sim Baby
• SimNewB
• "Harvey" the Cardiopulmonary Patient Simulator

Simulab Corporation

• TraumaMan
• TraumaChild
• CentraLineMan
• FemoraLineMan
• PICCLineMan

Surgical Science

• LapSim (Laparoscopy)
• EndoSim (Colonoscopy, Gastroscopy, Bronchoscopy)
• TeamSim (OR team training)

Medical Simulation Technologies

• TEEmothy
• Harpoon Medical Training Simulator

VirtaMed

• ArthroS
• HystSim
• UroSim
• PelvicSim

Organis GmbH

• TestChest

VRmagic

• Eyesi Surgical (Anterior and Posterior Segment Eye Surgery)
• Eyesi Indirect (Indirect Ophthalmoscopy)
• Eyesi Direct (Direct Ophthalmoscopy)
• Earsi Otoscope (Otoscopy)

ORamaVR

• ORama-THA (hip arthroplasty)
• ORama-TKA (knee arthroplasty)
• ORama-Suturing (basic surgical skills)
• ORama-Dental (basic dental implant surgery)

Examples of High Fidelity Simulators

BabySIM

The BabySIM is a realistic, 16 pound model of an infant with correct physiology and generated reactions to medical interventions.

This simulator was created for life-saving infant care practice. "BabySIM can produce heart, bowel and breath sounds, including bilateral chest excursion and seesaw breathing."^[38]

• Automatic responses
• Anatomical features

• Bulging fontanel capability
• blinking eyes with variable pupil size and the ability to tear
• Cooing and crying
• Secretions from the ears, eyes, and mouth
• Responds to airway trauma or obstruction: esophageal, nasal and oral intubation, and BVM ventilation and laryngoscopic procedures
• Responds to chest compressions, defibrillation and pacing, needle decompression, chest tube insertion and intraosseous insertion

CAE Fidelis Lucina

This pregnant patient simulator is meant for child birthing simulations and is a Maternal Fetal Simulator. It was created for practice with normal deliveries, emergency deliveries, as well as births with complications. "Fidelis Lucina is the only childbirth simulator with validated maternal-fetal physiology. The physiological modeling allows learners to monitor and manage both patients without instructor intervention."^[39]

• Multiple birthing positions
• Feedback post-delivery from the simulator's arterial and venous blood gas values that give one-minute and five-minute APGAR scores based on users performance

• Static and dynamic cervices that dilate, efface, and station
• Fetus that automatically descends and rotates
• Fetus with soft and firm areas true to life
• Fetus that responds when stimulated with suctioning with an open mouth and nose
• Fetus with attached umbilical cord and attached placenta that is able to be positioned

CAE Apollo

The CAE Apollo simulator (formerly METIman) is the most advanced and realistically-looking of all CAE simulators. Apollo can withstand indoor and outside training simulations and has a large variety of training in many areas. "Apollo's easy to use learning features are designed for teaching basic nursing and prehospital skills.".^[40]

• Wireless
• Autonomous physiology
• Affordable
• Automatic physiological responses
• CAE Apollo Prehospital
• CAE Apollo Nursing

• Suction airway secretions with variable airway resistance
• Aspirate and infuse fluids
• Cricothyrotomy/tracheostomy and bronchial occlusion
• Pacing and CPR compressions
• Responds to defibrillation
• Bilateral chest movement
• Suction airway secretions with variable airway resistance
• Palpable pulse
• Responds to needle thoracentesis and chest tube placement

PediaSim

The PediaSim was created for pediatrics in need of critical care. It is a simulation of a six-year-old child. "PediaSim offers the integrated METI physiology in a smaller practice patient with full trauma features for both nursing and emergency response." "PediaSIM HPS is specifically designed for risk-free practice of anesthesia, respiratory and critical care. With true respiratory gas exchange, PediaSIM HPS inhales oxygen and exhales CO2, interfaces with real clinical monitors and responds to oxygen therapy. The optional anesthesia delivery system allows the lungs to uptake or excrete nitrous oxide, sevoflurane, isoflurane and other anesthetic gases. PediaSIM HPS also responds to drug administration with a unique Drug Recognition System that uses barcode technology. New Simulated Clinical Experiences (SCEs) are now available for anesthesia, allied health, Pediatric Advanced Life Support (PALS) and PALS Europe."^[41]

• Oxygen therapy
• Anatomical features: responsive pupils, articulated mandible, exhalation of air and CO2, secretions from eyes, ears, and mouth

• Responds to clinical interventions: chest compression, pacing, defibrillation, needle decompression, and chest tube insertion
• Airway trauma features: upper airway obstruction, laryngospasm and bronchial occlusion for intubation
• BVM ventilation and needle cricothyrotomy

SimMan3G

SimMan3G is a full size lifelike mannequin that allows for simulation of different medical conditions to help train those that would need to treat those issues in the real life. The mannequin works wirelessly and it is self-contained, allowing it to be used in realistic settings like a hospital, ambulance or military combat environment.^[42]

• Quality CPR feedback
• Wireless Monitor - Completely wireless and self-contained, optional wired connectivity and power
• Secretions
• Drugs and Event Recognition
• Eye Signs
• Vascular Access
• Chest Decompression and Chest Drain

• Airway complications
• Breathing complications
• Circulation Features
• CPR
• Eye movement
• Convulsions
• Bleeding and Wounds

Medical Simulation Efficiency in Education

According to a study conducted by Bjorn Hoffman, to find the level of efficiency of simulation based medical training in a hi-tech health care setting, "simulation's ability to address skilful device handling as well as purposive aspects of technology provides a potential for effective and efficient learning."^[43] More positive information is found in the article entitled, "The role of medical simulation: an overview," by Kevin Kunler. Kunkler states that, "medical simulators can be useful tools in determining a physician's understanding and use of best practices, management of patient complications, appropriate use of instruments and tools, and overall competence in performing procedures."^[44]

Training

The main purpose of medical simulation is to properly educate students in various fields through the use of high technology simulators. According to the Institute of Medicine, 44,000 to 98,000 deaths annually are recorded due primarily to medical mistakes during treatment.^[45] Other statistics include:

• 225,000 deaths annually from medical error including 106,000 deaths due to "nonerror adverse events of medications"^[46]
• 7,391 deaths resulted from medication errors

If 44,000 to 98,000 deaths are the direct result of medical mistakes, and the CDC reported in 1999 that roughly 2.4 million people died in the United States, the medical mistakes estimate represents 1.8% to 4.0% of all deaths, respectively.^[47]

A near 5% representation of deaths primarily related to medical mistakes is simply unacceptable in the world of medicine. Anything that can assist in bringing this number down is highly recommended and medical simulation has proven to be the key assistant.

Examples

The following is a list of examples of common medical simulators used for training.^[48]

• Advanced Cardiac Life Support simulators^[49]
• Partial Human Patient Simulator (Low tech)
• Human Patient Simulator (High tech/ High fidelity)
• Hands-on Suture Simulator (Low tech)
• IV Trainer to Augment Human Patient Simulator (Low tech)
• Pure Software Simulation (High tech)
• Anesthesiology Simulator (High tech)
• Minimally Invasive Surgery Trainer (High tech)
• Bronchoscopy Simulator
• Battlefield Trauma to Augment Human Patient Simulator
• Team Training Suite
• "Harvey" mannequin^[50] (Low tech)
• Victoria (birthing simulator) (High tech)^[37][51]
• Noelle birthing simulator (High tech)^[52]
• Fidelis Lucina female patient simulator (High tech/High fidelity)^[53]
• Trauma HAL simulator (High tech)^[54]

Advantages

Studies have shown that students perform better and have higher retention rates than colleagues under strict traditional methods of medical training. The table below shows the results of tests given to 20 students using highly advanced medical simulation training materials and others given traditional paper based tests. It was found that high technology learning students outperformed traditional students significantly.^[55]

In addition to overall better scores for medical students, several other distinct advantages exist not specifically related to training.

• Less costly
• Time efficient
• Less personnel required
• Many automated processes
• Ability to store performance history
• Track global statistics for many linked medical simulators
• Less medical related accidents

Military and emergency response

One of the single largest proponents behind simulators has always been the United States government. Billions (and perhaps trillions, at this point) of dollars have been spent in the name of advancing simulators for space exploration, computer advancements, medical and military training, and other projects funded for research by the government. The Department of Defense (most notably, the Army) is one of the largest fund producers for simulation research, training, and support. As such, most simulators tend to be created for military purposes including soldier, tank, and flight training in combat situations. In terms of medical simulation, military applications have played a large part in its success and funding. Some examples of scenarios useful for medical applications include casualty assessment, war trauma response, emergency evacuations, training for communications between teams, team/individual after action assessment, and scenario recreation from recorded data. Medical simulation of combat trauma through the use of moulage applied to soldiers, dummies or fake body parts to emulate casualties, helps to provide a realistic combat environment while having the benefit of lessening psychological trauma and PTSD when exposed to the real thing.

Combat trauma patient simulator

The Combat Trauma Patient Simulation Program is perhaps the largest in terms of processes and people involved at any given time. According to Kincaid, Donovan, and Pettitt, the CTPS program has been created in order to assess and analyze the feasibility of simulation in a battlefield environment.^[57] Combat casualties, massively destructive outbreaks, chemical spills, gas leaks, and other forms of large scale negative events can be accurately simulated in a safe, inexpensive, and relatively small environment.^[58]

One of the rather large advantages to such a massive simulation of intertwining processes is the fact that people ranging from the field medics all the way up to the hospitals located in key military bases receive proper training for potential casualty prevention. The process of simulation begins with the Point of Injury and leads into Casualty Collection Points, Ground Medical Evacuations, Medical Aid Stations, and finally Hospitals.^[57] Another advantage is that all casualties can be monitored through high-tech computer software and GPS receivers located in medical vehicles and in key medical clothing. By monitoring such data, leaders can be aware of which areas in the flow needs to be sped up, slowed down, moved to a different format, or removed completely. The flow between the Point of Injury and Hospital is required to be uninterrupted if a successful goal is to be met.

Live field exercises are another benefit of the CTPS program. By allowing many individuals to engage in a "live fire" simulation, people can become acquainted with the processes involved in transferring duties among teammates in order to keep the flow moving between locations. While there is the chance of these simulations not inspiring true dedication into the actions of some participants because it is not necessarily a real disaster, the truly dedicated individuals will shine in their ability to remedy the destruction. Leaders can spot weaknesses and strengths in the participants of the simulation without worrying about every single piece of the simulation. In a real disaster, leaders would need to concentrate on individual success, team success, and overall progression. Alternatively, in a simulation of exactly the same event, the leaders could ignore certain areas in order to concentrate on the individuals involved in order to analyze weaknesses. Overall, the CTPS program is beneficial to everyone involved due to cost savings, risk reduction, personnel safety, enhanced effectiveness, and reduction of the learning curves.

CTPS contains many different technologies and smaller simulations within the rather gigantic "mother" simulation. Because the smaller simulations are potentially developed by separate companies (at times even competing companies), the interfaces have the high chance of being non-communicative or are simply incompatible without some sort of translation between the competing interfaces. All of this integration is made possible through a highly researched and deeply developed High Level Architecture containing interface modules to link up incompatible parts of the complete CTPS process.^[59]

The simulation federates (subsystems) of the CTPS involves the Lockheed Martin MILES system, the Operational Requirements-based Casualty Assessment system (ORCA), the Jackson Medical Simulation library (JMSL), and the Human Patient Simulator (HPS).^[57] By combining these systems together, trainees can be contained to their respective areas of study while also studying the possible hindrances between stages of transition.

Beginning the military casualty treatment simulation is the MILES engagement simulator, which accurately simulates gunfire and other combat engagements.^[60][61] When trainees under the simulated engagement system fire upon each other and register virtual hits, the simulated casualties are moved to the next stage.^[60][61] At first glance, this system may seem similar to entertainment driven laser tag centers found within urban cities of the United States. But after a deeper look, the overall training that a user would go through involves much more than pointing, shooting, and laughing at the outcome. Proper combat procedures can be taught to single users, team based squads, or larger squads. Obvious advantages to this approach include reductions in physical harm to trainees, increase in physical realism by tagging individuals as "dead," and providing immediate feedback to users who score a hit. While the MILES training system is not necessarily a medically based simulation; however, it is completely necessary to begin the process into medical procedures. Without proper combat engagement, realistic casualties and injuries cannot be simulated and cannot be transferred into the beginning medical stages in a manner that would provide meaning to a medical trainee.^[59][60][61]

The next stage involves casualty assessment based on results driven by simulated engagements under the MILES system. Any and all casualties are transferred to the ORCA stage, given initial wound assessments, put into an initial medical state (severe, critical, dead), and finally passed on to the JMSL. Under the JMSL, all casualties generated by MILES and assessed initially by ORCA are sent through transition phases in order to accurately simulate a casualty progressing to a more and more deadly state while awaiting treatment under average circumstances.^[59]

After casualties have been generated, processed, and sent through various stages, actual training under a medic or doctor can be attained through the HPS. By using a physiologically realistic test dummy, users can treat a patient and receive immediate, accurate feedback regarding the results. Using this approach, users can engage in proper medical training as if a live patient was being used without subjecting the patient to physical harm in the case of accidents. From a financial standpoint, the entire system offers a cheaper alternative to throwing untrained medics into a potentially hazardous and live situation. On the job training simply does not cut it when it comes to lives and equipment on the line.^[59]

In the classroom

There are many other medical systems that exist in forms other than "live fire" and "on the field" exercises. Simulation-Based Medical Education is one form that allows students to learn for educational purposes in a classroom. SBME works well with all forms of classroom learning such as lectures, problem solving, in hospital teaching, and other traditional forms of education.^[62] Several advantages appear while using this approach such as patient safety, higher knowledge retaining, teamwork, competence, and skill at the bedside.

One of the most prominent versions of SBME that stands out is Adobe Flash based medical simulations and animations. While textbooks are sufficient for certain diagrams and process flow explanations, certain high quality animations created in Adobe Flash are extremely beneficial when it comes to learning. Some of the advantages to Flash-based medical simulations and animations include a visually animated representation of blood flow within a body or other physiological processes occurring within the body that would otherwise seem awkward or impossible to understand through static images. A rather annoying disadvantage to these animated approaches stems from the fact that they are extremely costly to create in terms of time and money. Some of the better animations require teams of people equal in size to major movie productions when it comes to after effects.

The newest progression of medical simulation, is the application of simulation to the medical operations, patient care and clinical sectors of medicine. This evolution, can be seen with respect to the application of holographic simulation within the area of Virtual Health (VH), most known as telehealth with holographic simulation capability integrated into the delivery of healthcare through health information technologies to remote locations where medical care is not readily available. As described earlier regarding medical simulation in general, the operational, patient care and clinical use of simulation will most likely travel the same road of acceptance and integration into the medical community. Additional capabilities are expected to help drive this use of simulation to become common, such as Artificial Intelligence (AI), and unmanned medical platforms. The recent introduction of virtual-reality surgical simulators is also gaining ground amongst high quality medical simulator tools.^[63]

See also

• Simulation
• Military simulation
• Simulated reality
• Simulation language
• List of discrete event simulation software
• List of computer simulation software
• Multiple Integrated Laser Engagement System
• Web based simulation

References

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