In many parts of the world, emergency medicine is just beginning to emerge as a specialty. In Pakistan, for example, it was introduced as recently as 2012. Hands-on training in the management of critically-ill medical and trauma patients is imperative for adequate preparation of board-certified emergency physicians, but accurate simulation can be hard to come by in developing nations. There are very few training programs and dedicated centers for healthcare professionals, and even fewer that have simulation [1]. High-tech simulation equipment is often cost-prohibitive; a mobile, low-tech simulation lab could potentially address the need for advanced training in resuscitation for emergency physicians training in under-resourced hospitals.
Innovation: REDman simulation
RED stands for “resuscitation in the emergency department.” REDman is a hybrid standardized patient/task trainer simulator that includes a red mask used to hide facial expressions. This hybridized approach allows trainees to perform basic physical examination and history techniques on the participating facilitator while learning about diagnosis and management of a diverse range of acute pathologies [2].
Figure 1: Simulation in action. Note the trainee “auscultating” the REDman while two facilitators look on.
The Learners
REDman targets emergency medicine trainees, but can be extrapolated for use with any physician or allied health professional in need of preparation in the management critically ill patients.
The General Group Size
Simulations using REDman require the involvement of 3-4 facilitators and 1 trainee, who participate in front of approximately 20-25 trainees. The case is projected on a screen for all trainees in the room to see. The screen displays key data such as vital signs that change in real-time to reflect progression of the case. When required, the remaining group of trainees are asked to participate by providing input into the patient’s case in order to assist the trainee who is participating in the simulation.
Materials Needed
All the equipment utilized for simulations is low-cost. Refurbished medical supplies or low-fidelity models constructed from basic, readily-available materials can be used.
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REDman: The live patient simulator is played by a physician facilitator. The REDman gear includes straps (tourniquets) at the forearms for securing IV cannulas and a belt at the chest for securing items such as defibrillator pads and chest tubes.
Figure 2: REDman with de-identifying mask, straps at the arms for IV placement, belt at the chest for defibrillator pads, and moulage.
- Defibrillator: For the safety of our simulators and trainees, the defibrillator is a decommissioned unit that is not plugged in or attached to any electronics.
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Laptop and monitor running vital signs: Vital sign simulation software is run on the laptop. One facilitator is responsible for modifying the vital signs in response to clinical interventions by the trainees, or to progress the simulation narrative as necessary. The vital signs are displayed to an attached monitor that is visible by the trainees.
Figure 3: The monitor displays the patient’s vital signs to the participating trainees. The operator interface on the laptop is used to adjust displayed vital signs.
- Makeshift stethoscope: The stethoscope detects properly positioned Near Field Communication (NFC) tags placed on the REDman that can play audio (e.g. heart and lung sounds) into headphones depending on the position of the trainee’s “stethoscope.”
- PowerPoint slideshow: The slideshow projects the details of the case and relevant information such as electrocardiograms and radiographs so the observing group of trainees can see easily.
- Homemade moulage: Moulage can be used to simulate physical exam findings and/or injuries in trauma scenarios.
Figure 4: An example of simulated bullet wounds.
The Technique
The REDman simulation activity typically runs as a day-long workshop focused on critically-ill patient presentations and their respective management. As an example, the simulation activity may begin with a “patient” presenting with undifferentiated shock and respiratory distress. The REDman simulator plays out the role as directed (for instance, acting anxious and short of breath) and may be assisted by a facilitator playing a family member. Another facilitator leads the simulation by verbalizing findings relevant to the case, cuing the candidate if needed, and operating the vital signs interface. An additional facilitator role-plays ancillary emergency department staff and assists the participating trainee in performing tasks such as IV placement and medication administration at the direction of the trainee. For instance, the facilitator can attach an empty normal saline bottle to a makeshift IV cannula to simulate delivering IV fluids, if the participating trainee directs them to do so. The participating trainee must identify various findings on the REDman simulator and corresponding screen and demonstrate proper management. The group of observing trainees observing the scenario is prompted to assist the participating trainee if necessary. After the simulation, the group debriefs. A brief presentation follows based on the topic of the case. This sequence is repeated to cover various other topics as per the outline of the workshop.
Outcome
At the end of workshop, the trainees complete an evaluation form that requests them to grade various aspects of the workshop on a numerical scale, including the methodology of the workshop, the interaction between trainees and facilitators, and the encouragement of the audience
Lessons
- Awareness of audience characteristics and level of expertise is critical for tailoring the simulation experience to their educational needs. Meeting the crowd in advance and learning details about their level of training and discussing their educational needs help to design the simulations adequately.
- Not all simulations go as planned. Candidates may suggest a treatment that deviates from the anticipated course but may not necessarily represent incorrect management, warranting occasional exceptions. The simulation may require real-time modification to account for these scenarios by the facilitator leading the activity, through prompting of the trainees and actors.
- Trainees often feel nervous when approaching the stage, particularly in front of a crowd. Creating a safe learning environment maximizes the educational experience. In order to calm nerves and create a friendly environment, REDman is briefly and humorously introduced on a small slideshow. For trainees that become nervous while performing, clues are given by the facilitators.
Figure 5: A slide from the PowerPoint slide show introducing REDman to the audience.
- Simulations are always a work in progress. There is always something new to learn at a workshop by interacting with the crowd and seeing their response. Reflecting on the experience of each simulation can result in observations that improve future iterations.
Theory Behind the Innovation
Simulation-based learning is rooted in the educational theory of experiential learning which offers an immersive experience through an engaging and enjoyable theme [3]. Trainees learn how decisions produce certain results and this cause-and-effect learning builds a conviction to improve. The trainees debrief afterwards, which assists them in learning what they need to do differently and how the activity translates to real clinical experiences [4].
Closing Thoughts
The REDman workshop has been very well received and several other hospitals have requested to conduct the activity as it offers a unique educational experience and provides a cost-effective alternative to the traditional simulation lab.
Looking for more education innovation? Check the other posts in ALiEM’s IDEA series!
References
- Puri L, Das J, Pai M, et al. Enhancing quality of medical care in low income and middle income countries through simulation-based initiatives: recommendations of the Simnovate Global Health Domain Group. BMJ Simulation and Technology Enhanced Learning 2017;3:S15-S22. DOI: 10.1136/bmjstel-2016-000180
- Martinerie L, Rasoaherinomenjanahary F, Ronot M et al. Healthcare Simulation in Developing Countries and Low-Resource Situations. J Contin Educ Health Prof. 2018 Summer;38(3):205-212. PMID: 30157154.
- Jones F, Passos-Neto CE, Braguiroli OFM. Simulation in medical education: brief history and methodology. PPCR. 2015;1(2):56–63. PMID: 16483328
- Chacko TV. Simulation‐based medical education: using best practices and curriculum mapping to maximize educational benefits in the context of shift toward competency‐based medical education. Arch Med Health Sci. 2017;5:9‐15. DOI: 10.4103/2321-4848.208217.
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