National SIM Competitions: SIMWars ACEP 15

       This past week was the national American College of Emergency Physicians (ACEP) national conference.  It was held in Boston, MA, and each year this conference features a simulation competition for residents called SIMWars.  Residency programs from across the US submit an application to compete, and 6 programs are chosen.  They are put up against each other for competition, and the best team remains standing at the end.

ACEP 2015 SIMWars competition, Boston, MA

       Yesterday, last years champions, the Harbor-UCLA EM residency, stepped up to the plate to defend their title.  And man did they ever!  They rose to the occasion, and walked away as second time champions!  Go Harbor!

       I got involved in the planning for SIMWars several months prior to the conference.  After a conference call with the director, we were divided into teams to create cases that would challenge our resident learners in a fun and exciting way.   With topics like Waterhouse-Friedrechson syndrome, lyme carditis, and Anticholinergic poisoning, we threw everything but the kitchen sink at the residents, and they really rose to the challenge.   Working together with my team was very fun, although at times it proved challenging due to time zone differences across California, Chicago and New York.   Our case and case stimuli were reviewed and then made ready for the competition.

        The SIMWars committee met together the night before the competition to work out logistics, such as who would play certain roles during the cases, in which order we would present them, and what props and tools were needed in order for each case to get carried out appropriately.  We also prepared several informative facts about our cases that could be sent out in tweets using the hastag #simwars.   This would allow anyone searching for this hashtag to find all facts, pictures, and comments placed on the feed by participants, audience members, judges and those of us from the SIMWars committee.

ACEP 2015 SIMWars committee

       When the competition began the next morning, the SIMWars committee was excited to get started (see our happy photo to the right).  We served as confederates for our own and each others cases, playing the role of the nurse, family members, and even that of patients themselves!  Moulage was used to create a realistic feel to the cases, and they were made even more challenging for the residents due to belligerent patients and family members.  Some teams were able to handle this quite well, while others were not so good at it.  Either way, all teams got a really good learning experience, and most importantly, we had a lot of fun doing so.  In addition to the experience, hundreds of tweets were sent out along the way with pertinent information to each case.

       Participating in ACEP SIMWars was definitely a fun and educational experience, not just for our participants and the audience, but for the simulation guru, such as myself, as well.   Many of the committee members were fellows and simulation directors from programs all over the US, and all of us eager to teach and learn.  This conference would not have been possible to put on without the interdisciplinary teamwork that occurred among us.  From the basics of case creation, to the recruitment of judges, such as the infamous Scott Weingart.

Most importantly, participating on the SIMWars committee has created a network of new friends who also share the same passion.  So as this years competition came to a close, we are all looking forward to returning to SIMWars and helping to make ACEP 2016 an amazing experience in Las Vegas!

Interest Groups On the Rise... but Start Small

So...... having an interest group on campus turned out to be slightly more challenging than I thought.  The logistics behind getting a group approved on campus was rather tedious.  A constitution must devised and filled out.  Once that is done, students are only allowed to apply during a certain time of the year.  So although we began our group meetings several months ago, we were only formally approved as a campus group mid september last month.

Aside from formalities comes the financial dilemma as well.  Our group was approved for a grand total of $75 dollars in funding!  But hey, that's $75 dollars more than we had last year!

SIMIG SIM-tober Fest staff and faculty: Left: Dr Mark Langdorf,
Center: Dr Julie Sayegh (thats me!), Right: Dr Eric McCoy 

But we continued to meet anyway, and together, came up with the idea of having our first SIMIG conference.  The students were anxious to get started with this, so I entertained the idea of a Halloween themed event.

This week, me and the medical students held our first SIMIG conference!  Called SIM-tober Fest, it included four 30min rotations that consisted of a simulation case, suturing station, IV station, and intubation station.  The event was a success, and  we are hoping to host it annually.

I was very surprised by the way the students really took the reigns in helping to design this event.  I met with them and discussed the logistics.... the simulation case we would run, and the procedure stations that we should incorporate.  I wanted to give them autonomy in putting the rest of the conference together.  The students were ecstatic, and wanted to open the conference to the entire medical school.  However I had to remind them that, with this being our first event,
it was also our first introduction to the rest of the medical school campus, and we wanted to impress!

I cautioned the group that perhaps we should limit the number of students we allow to participate.  This worked out great for several reasons:

1. It gave us control over teaching.  I wanted to limit the event to 24 people.  Realistically, having more than that many people in the same room makes teaching SIM and debriefing rather difficult.  I wanted this to be a learning experience in addition to fun. 
2. It allowed us to utilize our resources wisely.    Because most of the SIMIG members are 2nd year medical students, they did not know how to intubate, suture or start IVs.  I met with them several weeks in advance to teach them these skills.  This allowed the students to practice until the day of the event, so that they could become the teachers. We did get some faculty members to volunteer to supervise the event (shown in the photo above), but having small student groups would prevent my novice teachers from getting overwhelmed if they had to be on their own. 
3. It made a 2 hour conference possible.  Lets face it... conferences are fun.  But they are even more fun when they are informative, interactive, and can be done in a short period of time.  We wanted are participants to get a good taste of what simulation has to offer, and small groups made 30min rotations possible.  
4. It made our event seem exclusive.   Within 24 hours, all 24 spots were filled, and we had several others on the waiting list to attend the event.

Overall, the event was a success and a big hit with the students.  Please enjoy some video footage of our event below.  

Have you put together any simulation conferences?  How was your experience?  What do you think about our SIM-tober Fest?   Please share your comments below! 

Simulation Research: The TeleSIM project

As with all reliable educational modalities, simulation has been validated as an effective tool for teaching in medical education.  Many articles have shown that through the use of procedural task trainers, high-fidelity human simulators, and standardized patients, it has been shown to improve patient safety, the number of clinical errors made, and interdisciplinary teamwork and communication.^{1, 3, 6-7}

But what about locations who can't afford to run a simulation center or purchase the costly simulation mannequins?  Are they doomed to be left without being able to practice their skills prior to caring for patients?

To address this question, a group of surgeons at the University of Toronto came up with the idea of using low-cost multimedia resources, such as Skype, to provide simulation education and training to remote areas of around world.  This novel concept was given the name "Telesimulation," and has been shown in several studies to be an effective alternative to traditional self-practice and lectures alone.^{2, 4-5}  These studies, however, mainly use laparoscopic surgical trainers as the educational medium provided.  Please watch the video to the left to get a better understanding of telesimulation and how it is currently being used.


As even in the US, cost is a big factor in determining funding for medical education, we are attempting to prove the effectiveness of telesimulation to standard high-fidelity simulation.  This study is innovative because there have only been a few small studies using telesimulation, and are based mostly on training laparoscopic surgery.  We are using our medical students that rotate through the emergency department as our subjects.  If we are able to prove that there is no difference in learning between telesimulation and standard high-fidelity simulation, we can bring telesimulation to large and remote audiences who would not have access otherwise!  Wish us luck!

To download a Skype account for your program, click this link!


References: 

1.  Aggarwal, R., Mytton, O. T., Derbrew, M., Hananel, D., Heydenburg, M., Issenberg, B., … Reznick, R. (2010). Training and simulation for patient safety. Quality and Safety in Health Care, 19(Suppl 2), i34–i43. http://doi.org/10.1136/qshc.2009.038562
2.  Henao, Ó., Escallón, J., Green, J., Farcas, M., Sierra, J. M., Sánchez, W., & Okrainec, A. (2013). [Fundamentals of laparoscopic surgery in Colombia using telesimulation: an effective educational tool for distance learning]. Biomédica: Revista Del Instituto Nacional De Salud, 33(1), 107–114. http://doi.org/10.1590/S0120-41572013000100013
3. Issenberg S, McGaghie WC, Hart IR, & et al. (1999). SImulation technology for health care professional skills training and assessment. JAMA, 282(9), 861–866. http://doi.org/10.1001/jama.282.9.861
4.  Mikrogianakis, A., Kam, A., Silver, S., Bakanisi, B., Henao, O., Okrainec, A., & Azzie, G. (2011). Telesimulation: an innovative and effective tool for teaching novel intraosseous insertion techniques in developing countries. Academic Emergency Medicine: Official Journal of the Society for Academic Emergency Medicine, 18(4), 420–427. http://doi.org/10.1111/j.1553-2712.2011.01038.x
5. Okrainec, A., Vassiliou, M., Kapoor, A., Pitzul, K., Henao, O., Kaneva, P., … Ritter, E. M. (2013). Feasibility of remote administration of the Fundamentals of Laparoscopic Surgery (FLS) skills test. Surgical Endoscopy, 27(11), 4033–4037. http://doi.org/10.1007/s00464-013-3048-7
6. Okuda, Y., Bryson, E. O., DeMaria, S., Jacobson, L., Quinones, J., Shen, B., & Levine, A. I. (2009). The Utility of Simulation in Medical Education: What Is the Evidence? Mount Sinai Journal of Medicine: A Journal of Translational and Personalized Medicine, 76(4), 330–343. http://doi.org/10.1002/msj.20127
7.  Satava, R. M. (2010). Emerging Trends that Herald the Future of Surgical Simulation. Surgical Clinics of North America, 90(3), 623–633. http://doi.org/10.1016/j.suc.2010.02.002
8. UHN Toronto. 2010, April 26.  UHN pioneers telesimulation training worldwide.  Retrieved from https://www.youtube.com/watch?v=wwx1BUzwGNA

Running the SIM exeperience

Image 1: Simulation set up for medical students with human
simulator. 

So as a simulation fellow, with hopes of soon becoming a simulation director, I am responsible for running simulation lab for my residents every month.  In order to do this, you have to develop cases and ensure that they are written and executed in a realistic way.  This insures that you get what is called learner "buy-in." one of the most challenging things to accomplish in simulation in my book.   I find that for those who have never been in simulation lab, the buy-in component comes a little easier.  But for the residents, who do simulation monthly, getting them to buy into the feigned realism can be a little bit tricky.

Image 2: Simulation set up for the OR.

What helps in this situation is the way that you write the case.  Give them something they haven't seen before or that will challenge them while caring for the simulated patient.  This takes the feeling of familiarity away from the situation, even though they are there monthly.  This challenge is what will keep them on their toes.

In addition, keep in mind that it becomes difficult to replicate the actual findings of what occurred with a patient, such as becoming lethargic and unresponsive.  One can mimic wounds, scars and physical findings with moulage, the sounds of fainting, or becoming very sick with vomiting through the human simulator, provide an emesis basin of blood or vomit, or even get the simulator to seize....  But often times because the simulator has limitations with real-time movement, you may want to consider the use of a standardized patient instead.  At times, I have played the role of the patients as a standardized patient.  Although I think this worked a little better as far as realism is concerned for the residents, I wasn't quite sure it was as effective as I had hoped because they are familiar with who I am and my role as an educator.

To solve this problem, I decided to start a standardized patient volunteer program with the medical students who are part of our simulation interest group.  In this way, having an unfamiliar body playing the role of the patient would contribute to the realism of the case.  Not only this, but it gives the students more of a sense of ownership to the simulation interest group as well, and helps to build their curriculum vitae with volunteer and educational opportunities.  

Image 3: The debriefing room 

Aside from case development, the biggest part of simulation is the debriefing portion at the end.  Its very important that there be a type of evaluation system for the learner.  Dive into the emotional component of the case.  Be sure to ask the learners to summarize the case, to ensure understanding.  Ask about their feelings regarding the case... did they feel that they did well?  What did they not do well?  Would they have done anything differently?

Image 4: Real time image of a simulation
session during UC Irvine Simulation
Instructor course. 

Once this evaluation portion is complete, ask the learners about what they know about the topic.  Do they know the presenting signs and symptoms?  Are they familiar with the management of that particular disease?  Do they know who appropriate consult services are that should become involved in the patients care, and the to which part of the hospital the patient should be admitted, ie the telemetry floor vs the ICU?

Some instructors use this discussion component of debriefing as the only method of learning.  Others, such as myself, like to supplement the debriefing session with a brief lecture outline the signs and symptoms, diagnosis, treatment and management of the particular illness, pitfalls, complications, etc, to reinforce the learning experience.  However you chose to conduct your debriefing, always remember that the most important component is asking the students how they felt, and challenging them to discuss what they already know and how they would alter their care in the future.

When all is said and done, your outcome will be successful!

Are you a simulation fellow, director or instructor?  How do you conduct your simulation sessions?  What works for you?   Please share your comments below! 

Making Simulation Task Trainers

Over the course of the month, I wanted to get the students from my interest group involved in some hands-on simulation.  We began the creation of a simulated, low cost, metallic corneal foreign body removal task trainer, and the students loved being apart of the experience!

I came up with the idea after realizing that although relatively simple, removal of a corneal foreign body is a very scary task!  I mean, come one, using a needle attached to a syringe to pick a piece of metal out of someones eye?!

After months of contemplation and research, I compiled a list of house hold items required to put the task-trainer together.  Using affordable, easy to access materials is not an uncommon practice in simulation, as many of the high-tech trainers can run anywhere from thousands to hundreds of thousands of dollars, or are just not even in existence yet.

Before you begin this process, there are a few ways you can ensure the success of your outcome.

Come up with a novel idea.  Like with the process of developing my foreign body task trainer, I looked into whether this resources was already available.  I found an article that suggested a way for residents to practice this technique is by gluing an agar plate to a wall, and embedding several metal foreign bodies into it.  Then allow the resident to push a slit lamp up to the wall and use a needle and syringe to pick out the metal objects.  However effective this may be, it definitely was not as realistic.
First, you want to ensure that you are fulfilling a need at your facility.  Ask yourself, 'is something like this already available?'  'Do the residents or medical students need this kind of training?'  Where I trained for residency, we saw this quite a bit.  However, it is a rare event at UC Irvine, and I felt it would be a disservice to the residents to not teach them how.  Even if this presents many times to your ED, allowing the residents to practice this maneuver prior would prove effective in regard to patient safety and resident confidence while performing the procedure.

Do a cost analysis to determine whether its worth the time and effort to start to build.  Is it easier to invest your time and resources in the development process, or would it be more affordable to just purchase a pre-made version what you are looking for?


Ensure that it works... test it out!  Myself and the students who created this trainer did have a lot of fun picking out the metal foreign body.  However, we do plan to have our emergency medicine residents use the model for training purposes.

Please enjoy the final product of our task-trainer.  How realistic do you think it looks?  Share your thoughts in the comment section below! 

              

Forming Interest Groups… Introducing the first ever UC Irvine Simulation Interest Group

As a new fellow at the only simulation fellowship in southern California, I felt it was important to spread the word about the power of medical simulation education.  After months of planning, I sent out an email to our medical students to gauge their interest in forming a simulation interest group.  I received about 15 responses, and then got the ball rolling!  Introducing the first ever UC Irvine School of Medicine Medical Student Simulation Interest Group! 

UC Irvine School of Medicine Medical Student Simulation Interest Group
Featured in this photo: Front row, left: Dr Cameron Ricks, Simulation Center Director, Assistant Professor Department of Anesthesia; Front row right: Dr Eric McCoy, director of Emergency Medicine Simulation Fellowship, Assistant Professor Department of Emergency Medicine 

A few weeks ago, we had our first simulation interest group meeting, and it was a total success!  I wanted to share with you some of the highlights of the meeting, in case you are looking to do the same at your own facility.  In order to make the group successful, I urge you to consider the 7 following steps:

1.  Obtain and Introduce the supporting faculty and staff.  

a.     Ensure that prior to starting your group, you have faculty and staff support who will sponsor, mentor and dedicate time to ensuring the growth, development, and persistence of your group.  For me as a fellow, I have 2 supporting faculty members, Dr Eric McCoy (right, behind me in the photo) the emergency medicine fellowship director, and Dr Cameron Ricks (left), the director of anesthesia simulation and the simulation center at UCI.  

b.   Give the students some background information about you and other staff members, and your motivation behind the group.  I wanted the students to know about my background in education, and why academic medicine was so important to me.  I also wanted them to understand why I chose to complete a fellowship in simulation education, as by providing both emotional and hands-on components to learning, I feel it is one of the most effective ways to teach.

c.     This introduces a feeling of mentorship to the students.  Let them know you are there for their benefit and education, and that all ideas for the group regarding education, research and community service are open to discussion.

2.    Get to know your students, and their motivation behind joining the group.

a.     The most important reason for this is to ensure that the students are going to be dedicated to keeping the group running successfully, both now and in the years to come.

b.     It is also important to initiate a feeling of camaraderie among the group, understanding their backgrounds and interests, and learning who they are as a person will help to make a better collaborative whole.

3.    Set your goals and objectives for the group

a.     Make sure you let the students know what is expected for the group, and what will make the group thrive. One of the best ways of doing this is by creating a group statement of purpose.  For us, it was fulfilling a presence of education and learning, community service, and research for our group.  The students were very happy with this as our defining theme.  Initially you may need to guide this step, as I did, because after all, you are the developer of the group.    Ask the students how they would like to redefine or state these goals and objectives, as it allows them to take ownership of the group.

4.     Create specific rolls that should be fulfilled

a.     For our group, I knew from preplanning, that there were specific roles I wanted the students to fill.  Take a look at the following list and description of these roles as an idea for your own group.

                                               i.     President: to initiate and run group meetings, discuss agenda items, etc

                                             ii.     Vice President: to aid the president in the above and serve in his/her absence

                                            iii.     Faculty Liaison:  I knew that having a large group of student would be tough for me to manage, so I wanted to assign a role to one student who would serve as the voice for the collective group.  This person would be the “go-to” for the students, as well as for me if there was a particular message I needed to get out to the group.

                                            iv.     Web Master: As a student of a multi-media masters program, for me having our own group webpage was key.  There will always be one student in the group interested in IT, and will help with web page development, announcements, calendar, and web site maintenance.  There are several free programs available for this, such as word press.  Speak with your facilities IT department to inquire about web space domains for getting your site up on the web.

                                             v.     President/VP of Community Service:  With a strong community service background, I knew that this was something that I wanted to pursue.  As health care providers who have been granted the opportunity to get into and through medical school, I wanted the students to know the importance of giving back to and educating the community.

                                            vi.     President/VP of Education: Although running cases in the simulation lab is very fun and exciting, not educating the students to the power of simulation would be doing them a disservice.  I wanted the students to understand the educational value of simulation in education. By assigning the role of President or VP of education, you can work with a few students to develop a small group of lectures that could be taught each meeting to enhance the knowledge base of the students to what simulation is. 

                                          vii.     President/VP of Research: As with all institutions of higher learning, research is a big component to medical education.  As a new field in medicine, the opportunities to conduct simulation-based research are endless.  Student input is also useful for developing new projects.

5.    Allow the students to take the reins

a.     Allow the students to self-assign roles.  They know their own strengths and weaknesses, and this will allow for a more collaborative environment without resentment toward the group leader.  Surprisingly the students were very quick to decide the role they wanted to fulfill.

b.     Allow the students to choose what they want the group to achieve.  For our group, it was conducting simulation-based workshops for the school of medicine.  They also wanted to work with other interest groups, such as the emergency medicine interest group, surgery and ultrasound interest groups, to form collaborative workshops, conferences, and lectures. 

6.      Set up monthly meetings to discuss new ideas and actions for the group

a.     The group needs to know that they have your support, and that there is vested interest in making the group thrive.  Consider monthly faculty/student meetings, and monthly student group leader meetings to keep your interest group on a track to success.

7.      Choose a day specific to your group and make it yours

a.     As a new group, we wanted to gain credibility on campus at UC Irvine.  Our group came up with the idea of putting on a conference called “SIMtober Fest.”  It would be a half day event where students immerse themselves in medical simulation high-fidelity cases, task trainers, and education. 

These are only my suggestions, but there is a wealth of information available on the web about how to start an interest group.   Hopefully you found this resource and its links helpful. 

References: 

1. Goals and Objectives image. Retrieved May 29, 2015 from https://micajeho.files.wordpress.com/2012/08/meta_sprint_time_scrum.jpg

Already started an interest group?  Share your experiences below!