Medical simulation is a branch of simulation technology typically related to education and training in medical fields of various industries, but is evolving to also exist outside the boundaries of the education and training sector. It can involve simulated human patients, 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 accidents during surgery, prescription, and general practice. It is now used to train students in anatomy and physiology during their clinical training as allied health professionals with professions that include nursing, sonography, pharmacy assistants and physical therapy. Medical simulation is somewhat unique, as it is currently evolving to function across the medical operations, patient care and clinical space, with the future of medical simulation blurring the line between these sectors of medicine. Advances in technology are advancing geometrically and a McGraw Hill textbook, Medical Simulation, by VanCura and Bisset interfaces the simulator technology with any medically related course of study.
Many medical professionals are skeptical about simulation, saying that medicine, surgery, and general healing skills are too complex to simulate accurately. But technological advances in the past two decades have made it possible to simulate practices from yearly family doctor visits to complex operations such as heart surgery.
An increase in recent emergency and military scenario simulation has helped medical providers in Middle East war zones.
Disaster response is made easier and conducted by better trained individuals due to the rapid availability of simulators in schools, hospitals, military facilities, and research labs.
History
The first uses of medical simulation can be traced back to the first time that a person utilized something other than a patient in order to train, hone, or sustain medical skills. Modern day simulation for training can was first utilized by [anesthesia]] physicians in order to reduce accidents. 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. 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.
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. Others followed, such as Life & Death (1988).
In 2002, the Society for Simulation in Healthcare (SSH) was formed to become a leader in international interprofessional advances the application of medical simulation in healthcare
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. In 2012 the SSH piloted two new certifications to provide recognition to educators in an effort to meet this need.
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. However, these forms of simulation are a far cry from high fidelity models that have surfaced since the 1990s.
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. A thorough 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.
The Council of Residency Directors (CORD) has established the following recommendations for simulation
- 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.
- 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.
- There is a need for standardization and definition in using simulation to evaluate performance.
- 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
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. 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. 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.
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
- Air-way Trainers
- Vascular Access Trainers
- Ultrasound trainers
- Lumbar Puncture Trainers
- Pelvic Trainers
- Mechanical Ventilation Trainers
Examples of Screen-Based Simulations
- ACLS Simulator
- Anatomy Module
- Anesthesia Simulator
- Anesthesia SimSTAT - ASA/CAE Healthcare
- CardioSim
- MicroEKG
- Neonatal Simulator
- SonoSim - Ultrasound simulator
- IS4LearningAuscultation 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
Gaumard
- Victoria Birthing Simulator
- 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®
- TraumaChildâ„¢
- CentraLineManâ„¢
- FemoraLineManâ„¢
- PICCLineManâ„¢
Surgical Science
- LapSim® (Laparoscopy)
- EndoSim® (Colonoscopy, Gastroscopy, Bronchoscopy)
- TeamSim® (OR team training)
VirtaMed
- ArthroSâ„¢
- HystSimâ„¢
- UroSimâ„¢
- PelvicSimâ„¢
Organis GmbH
- TestChest
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." Specifications:
- Automatic responses
- Anatomical features
Simulates:
- 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." Specifications:
- 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
Simulates:
- 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.". Specifications:
- Wireless
- Autonomous physiology
- Affordable
- Automatic physiological responses
- CAE Apollo Prehospital
- CAE Apollo Nursing
Simulates:
- 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." Specifications:
- Oxygen therapy
- Anatomical features: responsive pupils, articulated mandible, exhalation of air and CO2, secretions from eyes, ears, and mouth
Simulates:
- 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
SimMan®3G
SimMan®3G 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.
Specifications:
- 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
Simulates:
- 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." 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."
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. Other statistics include:
- 225,000 deaths annually from medical error including 106,000 deaths due to "nonerror adverse events of medications"
- 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.
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.
- Advanced Cardiac Life Support simulators
- 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 (Low tech)
- Victoria (birthing simulator) (High tech)
- Noelle birthing simulator (High tech)
- Fidelis Lucina female patient simulator (High tech/High fidelity)
- Trauma HAL simulator (High tech)
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.
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. 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.
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. 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.
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). 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. When trainees under the simulated engagement system fire upon each other and register virtual hits, the simulated casualties are moved to the next stage. 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.
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.
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.
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. 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.
See also
References
Further reading
- healthysimulation.com
- dssh.nl
- rightdiagnosis.com
- nap.edu
- saem.org (PDF)
- simghosts.org