Saint Louis University (SLU) St. Louis, Missouri

Saint Louis University (SLU) St. Louis, Missouri Christine M Werner, PhD, PA-C, RD1 Gary S Gottesman, MD, FAAP, FACMG1 1Department of Physician Assist...
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Saint Louis University (SLU) St. Louis, Missouri Christine M Werner, PhD, PA-C, RD1 Gary S Gottesman, MD, FAAP, FACMG1 1Department of Physician Assistant Education,

Doisy College of Health Sciences

Wesley Q Burch, EMT, Education Specialist2 Anthony J Scalzo, MD, FAAP, FACMT2 2Emergency Medicine Simulation Laboratory,

School of Medicine

Educational Goals & Objectives: At the conclusion of this session, participants will be able to: ◦ Define clinical simulation technology ◦ Describe various systems of clinical simulation training ◦

Identify core competencies clinical simulation training can provide in:

 Trauma skills  Critical decision-making  Communication skills

Terms: 

Clinical Simulation = Medical Simulation = Simulation-Based Education

Definition by David Gaba (1):  Instructional process that substitutes real patient encounters with artificial models, live actors or virtual reality patients Goals:  Replicate patient case scenarios in a realistic environment for purpose of feedback & assessment 

Predictable, consistent, standardized, safe, reproducible

1. Gaba DM. The future vision of simulation in health care. Qual Saf Health Care. 2004; 13(Suppl 1): i2-i10.

General Advantages

(2, 3)

◦ Hands on training in a “safe” environment  Not compromising patient safety ◦ Opportunity for repetitive practice to master a given skill ◦ Improves educational experience ◦ On-going training opportunities 2. Kunkler K. The role of medical simulation: an overview. Int J Med Robotics Comput Assist Surg. 2006;2:203-210. 3. Okuda Y, et al. The utility of simulation in medical education: what is the evidence? Mt Sinai J Med. 2009;76:330-343.

Specific Advantages for PA students ◦ Intimidation factor of “ER” setting, especially if their 1st rotation ◦ Lack of Level 1 trauma centers in St. Louis area  8 students/year

◦ Enhancement of ER clinical experience  Assisting with codes  Using BLS & ACLS training with confidence  Understanding of the process

Disadvantages (2-4)

◦ Cost  Initial  Operational  Maintenance  Additional equipment (supplies, monitors, carts, etc) ◦ Resources  Physical (space, utility-electrical, additional equipment)  Compression unit is LOUD  Staff support (programming simulator, teaching, monitoring the students)  Knowledge of maintaining additional equipment  Cardiac monitors  Ventilators  Crash cart  Defibrillator

4. Cherry RA and Ali J. Current concepts in simulation-based trauma education. J Trauma. 2008;65:1186-1193.

Task Trainers

Full procedure trainers

◦ Train a specific task/skill ◦ Individual body parts (LP, phlebotomy arms) ◦ Visual (eye models), audio (auscultation models), tactile (breast , pelvic models) ◦ Sophisticated systems (laparoscopic, airway, colonoscopy)

Full body mannequin trainer

◦ High-fidelity ◦ #procedures capabilities ◦ Computerize controlled with programmable physiologic responses ◦ Wired (METI) HPS (Human Patient Simulator) or wireless (ex: METI ®iStan) 5. Kneebone R, et al. The human face of simulation: patient-focused simulation training. Acad Med. 2006; 81:919-924.

Ears: can leak blood or spinal fluid

Neck: trachea with realistic anatomical landmarks Pulses: pulses can be palpated at: • Carotids • Radials • Brachials • Femorals • Dorsalis pedis Gender: transferable

Eyes: blink & automatically respond to light stimuli

Mouth: speaks, tongue can swell, airway can close Thorax:

- heart sounds • regular • irregular • arrhythmias - Lungs • breath sounds • create pneumothorax

Limbs: transferable 6. Dilg M. Battlefield ready. UNIVERSITAS Saint Louis University. Summer 2009: 16-19. 7. ER meets MASH in the new simulation lab. Saint Louis University Newslink. 2009: February.

Learning opportunities identified from the Gulf War: ◦ Need to better prepare active military medical personnel for trauma care in the battlefield ◦ “Peacetime”  Active duty medical personnel are typically stationed @ non- level one trauma medical center  Lacked opportunity of trauma care training  Especially in battlefield scenarios 8. Croley WC and Rothenberg DM. Education of trainees in the intensive care unit. Crit Care Med. 2007;35(suppl.):S117-121. 9. Lighthall GK and Barr J. The use of clinical simulation systems to train critical care physicians. J Intensive Care Med. 2007;22(5):257-269.

2003 – 2004  Collaboration between Saint Louis University (SLU) School of Medicine (SOM) & Air Force medical personnel  Center for Sustainment of Trauma & Readiness Skills “C-STARS”  2 week trauma care training program (year round)  Air Force, Air Force Reserve, Air National Guard, physicians, nurses, medics (16/2 wk session)  Medical simulation training  Rotated in the SLU ER with trauma surgery team

2004 – 2008 ◦ Robert D. Bell, ◦ PA-C, Lt Col, MOANG Associate Program Director of C-STARS ◦ Initiated PA & other allied health students into the trauma lab  One room (battlefield)

 Intro sessions  Non-graded trauma lab scenarios (phase 2)  Challenging times to set up  6:00 pm, 6:00 am, availability of technician & Bob

2009 ◦ Partnership between SLU SOM & C-STARS

 Simulation Laboratory  One of three corporative programs in the U.S.A.  Dedicated to SLU medical & healthcare professional students & hospital employees in addition to C-STARS

One full time technician ◦ Scheduling ◦ Training ◦ Operation One “trauma” suite ◦ ◦ ◦ ◦ ◦ ◦

Adjacent video room Cardiac monitor Crash cart Defibrillator Ventilator TV screen  Case presentation  Radiographs  Laboratory results

Larger Room “Emergency Room” ◦ 3 Beds with  1 Adult HPS  1 Peds Patient Simulator  1 Adult Emergency Care Simulator

◦ Instruction units for     

Triage training Mass causality training Advanced airway management Chest tube thoracostomy Central line catheterization

The EM simulation curriculum developed at SLU focuses on: ◦ Educational competencies: • • •

Basic Life Support (BLS) Protocol Advanced Cardiac Life Support (ACLS) Protocol Primary & Secondary Trauma Surveys

◦ Clinical competencies: • • •

Focused physical examination Critical decision making Team communication skills

In 2009: Incorporated in didactic training 

Essentials of Emergency Medicine & Cardiology Courses • Introduction to the Simulation Lab • Equipment • Mannequin •

Airway management • Oxygen masks • Intubation devices • Ventilator protocol

• Chest tube thoracostomy • Log roll/safety measures during assessment •

Expected & unexpected physical findings • Breath sounds • Cardiac sounds • Cardiac rhythms • Other organ/system findings

 

2-3 opportunities to practice as a team in the trauma lab over the course Review a “good” & “not-so-good” trauma case

Practicum • Assigned teams of 4-5 students • 20 minutes to stabilize patient • One assessment score per team • Initial assessment BLS • Primary survey • Secondary survey • Accuracy of stabilization plan • Communication skills • Professional conduct

Create a database of cases

Considerations for differential ◦ ◦ ◦ ◦

Mechanism of injury Duration of exposure/event EMS initiatives Pertinent medical history    

Allergies Medications Last time eaten Information that can effect outcomes

◦ Baseline vitals – borderline stable

Consider what your students report/log during clinical rotations

Sky the limit…

Examples ◦ GSW after fist fight ◦ MVA (many dif mechanism of injuries) ◦ Fall injuries (height from fall, how landed, etc)  Tree  Deck/steps

◦ Boating accident ◦ Bicycling accident

CASE #5: Deck Injury: Mr. Grill You are the trauma team on-call in a local ER. You are called to the ED to see a 38 y/o man who fell down his deck stairway of 15 steps. EMS reports he was grilling on the upper deck & went after a flipped hot dog. EMS reported him to be alert but not oriented. His initial visits in the ambulance were: BP: 90/58 bilat

P=120, reg, reg


T˚=97.0 F

Pulse Ox=91%

Emergency Medicine Rotation 

Post Rotation Trauma Lab Practicum • • •

Students on EM rotation work as a team Trauma case scenario 15 minutes to stabilize patient

One assessment score per team • • • • • • • •

Initial assessment Primary survey Secondary survey Provide at least 3 differential diagnoses ACLS protocol Accuracy of stabilization plan Professional communication skills Professional conduct

Immediate feedback of their performance

Faculty-guided video debriefing ◦ ~20 minutes ◦ Done in both didactic & clinical year curriculum ◦ Self reflection/evaluation     

What did they do well What could they have done better Team effort Communication Skills

2009 ◦ 1st year for didactic & clinical year training

Class of 2010 ◦ 1st class to evaluate impact of didactic & clinical curriculum

◦ Evaluation (N=29) still one more rotation  94% strongly agreed trauma lab helpful  78% comfortable assisting with a code  64% comfortable with emergency medicine 

Increase in students pursuing emergency medicine as career choice upon graduation

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