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!