Simulation - Applications - in Adult Learning

Disease-a-Month!
Simulation in Healthcare,
Part I: The Future of Medical
Education and Training
Ernest E. Wang, MD, FACEP Christopher Pettineo, BA
Morris Kharasch, MD, FACEP Laura Pettineo, MA
Pamela Aitchison, RN Arthur J. Tokarczyk, MD
Peggy Ochoa, RNC-OB, MS Steven B. Greenberg, MD
Shekhar Menon, MD Stephen Small, MD
Noah DeGarmo, MD Scott Leikin, BA
Sarah Donlan, MD Martha Pettineo, RN
John Flaherty, MD, FACEP Emily C. Singer, MD
James Ahn, MD
Volume 57 Number 11 November 2011

Pages 657-756 ISSN 0011-5029
Disease-a-Month !
Jerrold B. Leikin, MD
NorthShore University HealthSystem
OMEGA, Corporate and Occupational Health Services
Glenview, Illinois
Editorial Board
Raj Rolston, MD
Geisinger Medical Center
Danville, Pennsylvania
John C. Somberg, MD
Rush University Medical College
Rush Presbyterian-St. Luke’s Medical Center
Chicago, Illinois
Michael I. Greenberg, MD, MPH

Drexel University College of Medicine
Philadelphia, Pennsylvania
Martin Lipsky, MD
University of Illinois at Chicago
College of Medicine at Rockford
Rockford, Illinois
Janis Orlowski, MD
Washington Hospital Center
Washington, D.C.
Disease-a-Month !
Volume 57 Number 11 November 2011
Simulation in Healthcare, Part I: The

Future of Medical Education and Training
Ernest E. Wang, MD, FACEP

Division of Emergency Medicine
NorthShore Center for Simulation and Innovation
Evanston, IL
Morris Kharasch, MD, FACEP

Director of Special Projects, Emergency Medicine
Evanston, IL
Pamela Aitchison, RN
Evanston, IL
Peggy Ochoa, RNC-OB, MS

Evanston, IL
Shekhar Menon, MD
Evanston, IL
Noah DeGarmo, MD
Associate Program Director, Emergency Medicine
Evanston, IL
Sarah Donlan, MD
Evanston, IL
John Flaherty, MD, FACEP
Evanston, IL
James Ahn, MD
Section of Emergency Medicine
University of Chicago Pritzker School of Medicine
Chicago, IL
Christopher Pettineo, BA
Evanston, IL
Laura Pettineo, MA
Evanston, IL
Arthur J. Tokarczyk, MD
Department of Anesthesia
Evanston, IL
Steven B. Greenberg, MD
Education Director, Department of Anesthesia
Evanston, IL
Stephen Small, MD
Department of Anesthesia
Chicago, IL
Scott Leikin, BA
Evanston, IL
Martha Pettineo, RN
Evanston, IL
Emily C. Singer, MD
Chicago, IL
Disease-a-Month !
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Disease-a-Month !
Simulation in Healthcare, Part I:

The Future of Medical Education
and Training
Foreword 663
Simulation and Adult Learning 664
Simulation and Adult Learning 664
Types of Simulation 667
Procedural Training 668
Immersive Simulation 668
Adult Learning Theory 670
Development of Expertise (Ericsson) 673
Creating an Effective Learning Environment for Adult Learning 675
Utilizing Simulation
Conclusions 677
References 677
Growth of a Simulation Lab: Engaging the Learner Is Key to 679
Success
Introduction 679
Analysis and Discussion of Contributing Factors 680
Staff 683
Equipment 684
Conclusions 686
References 687
Procedural Simulation 691
Development of Procedural Simulation 691
Current Uses of Procedural Simulation 692
Future Directions 696
References 697
Physiological Stress Responses of Emergency Medicine 700
Residents During an Immersive Medical Simulation Scenario
Introduction 700
Methods 700
Results 702
660 DM, November 2011

Discussion 703
Conclusions 705
References 705
Use of Mannequin-Based Simulators in Anesthesiology 706
Introduction 706
History of Anesthesia Simulators 707
Current Anesthesia Practice 709
Future Course of Anesthesia Simulation 712
References 713
Critical Care Simulation 715
Introduction 715
Technical Skills 718
Nontechnical Skills 718
Scoring Systems 719
Patient-Related Outcomes 720
Future Goals of Critical Care Simulation 720
Conclusions 720
References 721
Simulation Applications in Emergency Medical Services 723
Introduction 723
EMS Training 724
Disaster Preparedness 726
Future Roles of Simulation in EMS Training 731
Conclusions 732
References 732
High-Fidelity Simulation—Emergency Medicine 734
Background 734
Current Use of Simulation in Emergency Medicine 736
Future Directions in Emergency Medicine 740
References 741
Simulations in Internal Medicine 744
Background 744
Advanced Cardiac Life Support 744
Airway Management 745
Procedures 746
Physical Examination Skills 749
Communication Skills and Clinical Reasoning 750
DM, November 2011 661

Identification of Systemic Problems 752
The Future of IM Simulation 753
References 755
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Foreword
The field of medical simulation has exploded since the days of manne-
quin-based cardiopulmonary resuscitation instruction decades ago. It is
now an essential element for not only medical student/resident education
but also enhancing the practices of nursing, emergency medical techni-
cians, and other allied health personnel. The development of high-fidelity
mannequin simulators (ranging from neonatal, to adult, to obstetrical
simulators) has literally revolutionized the approach to surgical tech-
niques, resuscitation, and disaster management, to name a few specific
areas.
Dr. Wang and colleagues oversee one of the premiere medical simula-
tion centers in the country. They present a comprehensive overview of
this modality that proves to be a valuable resource for the primary care
physician.
Jerrold B. Leikin, MD
Editor-in-Chief

Simulation and Adult Learning
Simulation and Adult Learning
Simulation is a technique—not a technology—to replace or amplify real
experiences with guided experiences that evoke or replicate substantial aspects
of the real world in a fully interactive manner.1
(David Gaba)
Simulation has been embraced by the medical community as an
important method for improving clinical training and patient safety.
Practitioners of simulation, or “simulationists,” use a recipe consisting of
clinically important medical cases, lessons learned from other high-reliability
organizations and industries, computer-driven full-body manikin simulators,
realistic procedural task trainers, and a dash of theatre to create memorable
learning experiences that can be transferred directly to patient care. As Kyle
and Murray have succinctly observed, “Clinical simulation is pretend for the
purpose of improving behaviors for someone else’s benefit.”2
Medical simulation had existed primarily in task trainer and full-body
low-fidelity forms until about 10-15 years ago. The first human patient
simulator, Sim One, was developed in the late 1960s at the University of
Southern California by J.S. Denson and Stephen Abrahamson and
featured in National Geographic and Life magazines.3-5 However, med-
ical simulation as a discipline really gained momentum during the 1990s
to 2000s because of the convergence of several key factors:
1. Dr. David Gaba’s vision of immersive simulation—in 1988, Gaba and
DeAnda described the first production of the first immersive simula-
tion environment in their seminal work, “A Comprehensive Anesthe-
sia Simulation Environment: Re-creating the Operating Room for
Research and Training.”3 Dr. Gaba fabricated the anesthesiologist’s
“physical, as well as mental, task environment”3 using an intubation/
thorax mannequin and a variety of electronic inputs to replicate
electrocardiograms and invasive pressures, pulse oximetry, tempera-
ture, and blood pressure. The authors described the use of scripts to
present anesthesia scenarios that could be controlled by the simulation
Dis Mon 2011;57:664-678

0011-5029/2011 $36.00 ! 0
doi:10.1016/j.disamonth.2011.08.017

operator to react dynamically to the actions of the students. Addition-
ally, key actors, such as the circulating nurse and the surgeon, were
played by the simulation director. The paradigm of creating a realistic
environment where the students were required to interpret the moni-
tored data and physically perform tasks simultaneously forced subjects
to “reallocate time and attention” and perform as if it were a real
situation. They combined the scenario experience with video debrief-
ing to create a reflective learning process. The described benefits of
simulation included “(1) there is no risk to a patient; (2) scenarios
involving uncommon but serious problems can be presented; (3) the
same scenario can be presented sequentially to multiple subjects; (4)
errors can be allowed which in a clinical setting would require
immediate intervention by a supervisor; (5) if desired, the simulation
can be halted for teaching and can be restarted to demonstrate different
techniques; and (6) recording, replay, and critique of performance are
facilitated using the simulator.”3
2. The founding of the Society for Simulation in Healthcare in 2004 “to
represent the rapidly growing group of educators and researchers who
utilize a variety of simulation techniques for education, testing, and
research in health care.”6 This society has facilitated interaction
between multiple specialties and disciplines within the medical-related
professions, including physician, nursing, allied health paramedical
personnel, and industry. Additionally, the organization has had inter-
national influence and has successfully brought simulationists from
around the world together to promote advancement of simulation-
based training and education.
3. The pioneering work on expert-performance conducted by Dr. K.
Anders Ericsson over the last two decades transformed the way
medical educators think about how clinicians acquire clinical compe-
tence and, indeed, how medical expertise is defined. His concept of
“deliberate practice” (DP), where training is focused on improving
particular tasks, was central to the development of a unique simula-
tion-based experiential learning pedagogy that has been adopted by
physicians across many disciplines.7,8 Dr. Ericsson was able to
successfully translate his findings across multiple nonmedical domains
to the medical community and encourage the use of simulation for
training and assessment. “Research on medical expertise and simula-
tion training in technical procedures and diagnosis provide exciting
opportunities for establishing translational research on the acquisition
of superior (expert) performance in the clinic by capturing it with
representative tasks in the laboratory, reproducing it for experimental
analysis, and developing training activities, such as deliberate practice,
that can induce measurable improvements in performance in the
clinic.”9
4. The Institute of Medicine publication, “To Err is Human: Building a
Safer Health System,” released November 1, 1999, highlighting the
prevalence of medical errors in the health care system, brought patient
safety to the forefront of the medical and lay consciousness and
generated action to define and implement new methods to systematically
design safety into all processes of care.10 Simulation-based training was
proposed as a core method for creating learning environments to measure
and improve the understanding of the nature and frequency of errors. “Use
Simulations Whenever Possible” was recommended to health care orga-
nizations and teaching institutions for “training novice practitioners,
problem solving, and crisis management, especially when new and
potentially hazardous procedures and equipment are introduced.” The
report also recommended that the use of Crisis Resource Management
techniques, modified from the aviation industry’s Crew Resource Man-
agement systems, in dynamic settings, such as the emergency department
and operating rooms, to improve communication and reduce error “should
be more widely applied.”10
5. The timely development of commercially available full-body high-
fidelity manikin simulators at the turn of the millennium allowed for
the actualization of the visions of Dr. Gaba and the Institute of
Medicine and has since fueled widespread implementation of immer-
sive simulation-based training on multispecialty and multidisciplinary
levels. Laerdal Medical (Wappinger Falls, NY) launched SimMan, its
adult-sized portable high-fidelity manikin in 2002. It has since devel-
oped its infant simulator, SimBaby, in 2005 and SimNewB, its
neonatal simulator, in 2008. Medical Education Technologies, Inc
(METI) (Sarasota, FL) debuted their Emergency Care Simulator in
2003, and BabySIM, their infant simulator in 2005. Gaumard Scien-
tific (Miami, FL) produced the first high-fidelity birthing simulator,
dubbed “NOELLE,” with its own neonate, “Newborn HAL.”
The result of the confluence of these developments has been the progres-
sive, almost viral spread of medical simulations across disciplines. As
technology continually improves and simulationists become more sophisti-
cated with their scenario orchestration, there has been an increase in the
realism of simulation and the opportunity to practice in simulated environ-
ments. The positive impact is now being described in terms of real patient
outcomes.11-13
There is one critical point to remember when discussing the efficacy of
simulation training: in order for our students to really learn, we have to
ensure that a proper learning environment is created for them. This
principle is the real basis for effective simulation-based training and
resides in adult learner-centered educational principles. The remainder of
this article describes the types of simulation currently available, the
framework for simulation-based training, and the educational pedagogy
that serves as the foundation for medical simulation with adult learners.
Types of Simulation
Simulation has traditionally been divided into low and high fidelity.
Low-fidelity simulation classically refers to task-trainers designed for
procedural training, such as airway heads, IV arms, static cardiopulmo-
nary resuscitation manikins, and the like. High-fidelity simulation refers
to full-body software-controlled manikins with dynamic mechanical
features, such as airway obstruction (laryngeal occlusion, tongue swell-
ing, or trismus), heart sounds, lung sounds (wheezing, rales, crackles,
absence of breath sounds), bowel sounds, central and peripheral pulses,
and seizure simulation. Most can accommodate a wide variety of
procedures, such as bag-mask ventilation, endotracheal intubation, crico-
thyrotomy, tube thoracostomy, and placement of a Foley catheter. The
most fully featured simulators can detect anesthesia gases, sweat, and
tear; produce mydriasis/miosis; and have the ability to register medication
administration and dosage. Specialty high-fidelity manikins include
neonatal simulators and a pregnancy simulator that has all the features of
high-fidelity manikins, but also can deliver an infant.
Experienced simulationists know this categorization is often arbitrarily
simplistic, and with technological advance, these categories are becoming
more blurred. Low-fidelity trainers are becoming more realistic with each
generation. Central line torsos now can provide anatomically realistic
ultrasound images so that ultrasound-guided central line placement can be
practiced. Trainers have been developed for lumbar puncture training
with interchangeable modules to simulate an obese or elderly patient, thus
increasing the difficulty level. By combining low-fidelity task trainers in
an immersive environment while a standardized patient interacts with the
participants, we can turn a low-fidelity simulator into a high-fidelity
experience. Likewise, a “high-fidelity” full-body manikin simulator can
be reduced to a simple airway task trainer or cardiopulmonary resuscita-
tion manikin if the simulation does not provide all the accessory stimuli
(patient voice, nursing confederate communication, storytelling) or if the
software capabilities are not used properly. As virtual reality and
computer simulation becomes increasingly immersive and mainstream, it
may be that these modalities will provide the most realistic simulation
experience in the future.
Procedural Training
A multitude of task trainers are available to teach procedural skill
acquisition in a variety of areas. A partial list includes noninvasive airway
management, endotracheal intubation, surgical airways, difficult airway
adjuncts, cardiac defibrillation and pacing, tube thoracostomy, central line
placement, intravenous and intraosseous initiation, drug administration,
lumbar puncture, birthing, and ultrasound, among others. Procedural
simulation is covered in-depth in the article by Ahn and Menon in this
issue.
Immersive Simulation
Immersive simulation is a planned educational activity where a learner
or group of learners take part in the care of a simulated medical patient in
an environment where the theatrical presentation is realistic enough for
the participants to feel immersed in the surroundings, suspend disbelief,
and manage the scenario as if the patient were real.
Doerr and Murray describe the “Simulation Learning Pyramid” that
serves as the foundation for creating effective simulation-based experi-
ences. The 4 elements of the pyramid are (1) the simulation plan; (2) the
simulation; (3) the debriefing; and (4) transference.14 Alinier has decon-
structed the components of simulation even further and has devised a
“Sequence to play the game known as Clinical Simulation” (Table 1).15
The simulation plan is a script designed by the instructors comprising
the following elements: (1) predefined learning goals and objectives; (2)
a description of how the case will play out, including plans for appropriate
responses from the simulator to the participants’ actions; (3) scripts for
actors who play the voice of the simulator, the confederates (family
member, nursing, prehospital provider, consultants, etc) as the learners
are guided through the simulation. Included in the plan should be a
method for setting the stage for the exercise and creating a safe learning
environment as part of the introduction (Table 1).
There are numerous methods and environments for creating immersive
simulation. Simulation centers are but one example. In situ simulation,
where the scenario is executed in the clinical work area—such as the
emergency department, intensive care unit, medical floor, ambulance,
helicopter, or a moulaged field response— can provide an equal experi-
ence and has its own advantages. Participants manage the simulated
TABLE 1. The “Sequence to play the game known as Clinical Simulation”
(1) Welcome the participants and create a friendly, supportive atmosphere
(2) Introduce the faculty
(3) Presession evaluation to determine baseline knowledge, skills, and attitudes
(4) Explanation of session plan
(5) Ice-breaking activity recommended if participants do not know each other
(6) Explanation of the basic simulation rules, the philosophy
(7) Introduction to the patient simulator and simulation environment
(8) Basic “warm-up” scenario for the whole group
(9) Clarification discussion
(10) Separation of participants into groups—“hot seat” and observers
(11) Scenario execution
(12) End scenario
(13) Facilitate debriefing
(14) Summarize the important learning points
(15) Switch groups
(16) Repeat steps 11-14 for subsequent scenarios
(17) Conduct an overall session debriefing
(18) Postsession evaluation
(19) End session
Adapted from Alinier G. Chapter 76 —Learning through play: simulation scenario ! obstacle
course " treasure hunt. In: Kyle RR, Murray WB, editors. Clinical Simulation: Operations,
Engineering and Management. London: Elsevier/Academic Press, 2008. p. 745-9.
patient in their actual environments and perform tasks with their own
equipment, allowing for increased realism, and possibly enhanced trans-
fer of the experience into actual clinical care.
In addition to the physical space, providing stimuli—monitors, sounds,
laboratory data, electrocardiogram, radiologic studies, nursing, family, and
consultants— creates realism. Adding task trainers so that participants have to
perform the actual procedure during an immersive simulation can provide
additional performance measurement and imbue the learner with enhanced
self-efficacy when a similar scenario presents during actual patient care.
Adding standardized patients to interact with the learners allows for even
more interaction and can train or assess communication skills.
Debriefing is a critical exercise in the simulation experience. The
students use this as a time for critical reflection on the simulation.
Facilitators guide the students through the management of the case by
discussing the learning objectives and providing diagnostic feedback on
the students’ performances. Key insights from simulation-based training
are derived during this important exercise. We want our learners to
appreciate the positive aspects of their performance even when the
outcome is not what they had hoped to have, but also to understand where
they need to improve by providing constructive, directed feedback. Often,
the participants will volunteer what they feel they need to improve on
without prompting.
Measurement of transference should ideally be determined before
implementing a simulation curriculum to determine its relative effective-
ness and to see if the lessons learned are incorporated into actual clinical
care and with what frequency. This type of information can be used as
feedback to make adjustments to improve on the simulation plan, the
simulation, and the debriefing.
Adult Learning Theory

Adult learning theory serves as the foundation for simulation-based
training. It is well known that adults learn differently than children because
of age, maturity, and life experiences. Their learning tends to be more
self-directed and independent. During the 20th century, a growing body of
educational theories and concepts has been developed to describe how adults
learn best. Effective medical simulation-based training applies these theories
in practice to promote effective acquisition and retention of clinical skills.
Malcolm Knowles, widely considered one of the world’s leading
scholar-practitioners in the development of adult learning theory, devel-
oped a conceptual framework for adult learning that he termed “andra-
gogy.”16 Principal to this framework are several assumptions about the
nature of adult learners that must be considered when developing
educational programs for them. These assumptions about adult learners
are as follows16,17:
1. Adults need to know why they need to learn something before

undertaking the effort to learn it. This has been termed “the need to
know.” Adults who take the initiative to learn based on this have been
observed to spend considerable energy exploring the benefits they will
receive learning it and the negative consequences of not learning it.
2. Adults have a self-concept biased toward independent and self-
directed learning. Adults feel responsible for their own lives and their
own learning. They resist or resent activities labeled as “education”
that they feel is imposed on them.
3. Adults have acquired a great deal of life experience. Life experiences
are a rich source of learning and have helped shape adults’ self-identity
more deeply than in children.
4. Adults value learning that helps them cope with the demands of their
everyday life. This has been termed “the readiness to learn” and argues
that adults become most willing to learn those things that are
immediately applicable.
5. Adults are more interested in life-centered (also referred to as
problem-centered or task-centered) approaches than subject-centered
approaches to learning. Adults are more willing to learn things that are
relevant and applicable to real-life situations.
6. Adults are more motivated to learn by internal drives than external
ones. The most potent motivators for adults are internal pressures, such
as the desire for increased job satisfaction, self-esteem, quality of life,
or self-efficacy.
Based on these assumptions, Dr. Knowles formulated the following
seven strategies to facilitate adult learning16,17:
(1) Establish an effective learning climate where learners feel safe and
comfortable expressing themselves;
(2) Involve learners in the mutual planning of curriculum and methods;
(3) Have learners diagnose their own needs to promote internal motiva-
tion;
(4) Encourage learners to devise their own learning objectives;
(5) Encourage learners to identify resources and devise strategies for
using resources to meet their learning objectives;
(6) Support learners in carrying out their learning plans;
(7) Involve learners in self-evaluation to promote and develop skills for
critical self-reflection.
John Dewey, considered the most influential educational theorist of
the 20th century, brought the concept of experiential learning to higher
education. He theorized that all learning has a purpose at its endpoint.
The initiation of learning begins with an impulse or experience.18 In
order for learning to occur, the impulse must then involve observation
of the surrounding condition. Observation, to Dewey, meant not acting
immediately on the impulse, but reflecting on the experience and
comparing it to prior experiences. “Knowledge of what has happened
in the past in similar situations in the past, a knowledge obtained
partly from recollection and partly from the information, advice, and
warning of those who have had a wider experience”18 is considered in
conjunction with the observations. Judgment combines observation
and knowledge into an interpretation of the significance of the
experience. Judgment translates the meaning of the experiences into
the purpose—a desire to change or to create a plan of action for future
similar experiences.
David Kolb, an organizational psychologist who was heavily influ-
enced by Dewey, developed his now famous learning cycle (Fig 1) to
FIG 1. Kolb’s learning cycle. (Adapted from Kolb DA. Experiential Learning: Experience as the
Source of Learning and Development. Englewood Cliffs (NJ): Prentice-Hall, 1984.) (Color
version of figure is available online.)
describe the learning process “whereby knowledge is created through

the transformation of experience.”19 He considered learning the major
process of human adaptation. The major tenets supporting his theory
on learning include: (1) it is best conceived as a process, not in terms
of an outcome; (2) it is a continuous process grounded in experience;
(3) it requires the resolution of conflicts between dialectically opposed
modes of adaptation to the world; (4) it is a holistic process; and (5)
it involves transactions between person and the environment.19
Experiential learning as a process, according to Kolb, involves more
than learning a set of facts or ideas (outcomes). Ideas are not immutable
elements, but are continuously changed and reformed as a person
experiments and reflects on the experiences they produce: “All learning is
relearning.”19 Learning is a continuous adaption and resolution of the way
a person conceptualizes the world and what a person actually experiences
in the world.
Learners, if they are to be effective, need four different kinds of
abilities—concrete experience abilities (CE), reflective observation
abilities (RO), abstract conceptualization abilities (AC), and active
experimentation (AE) abilities. That is, they must be able to involve
themselves fully, openly, and without bias in new experiences (CE).
They must be able to reflect on and observe their experiences from
many perspectives (RO). They must be able to create concepts that
integrate their observations into logically sound theories (AC), and
they must be able to use these theories to make decisions and solve
problems (AE).19
In this way, Kolb’s holistic approach unified learning as a “conceptual
bridge across life situations such as school and work, portraying learning
as a continuous, lifelong process.” Kolb believed that the learning process
must involve the person and the person’s environment whereby the shared
experience between the two is a transaction that leaves both person and
environment changed.
Reflective practice describes the thought processes that professionals
experience when they encounter a new or unexpected situation. Reflection
in action, which occurs immediately, is the ability to learn and develop
continually by creatively applying current and past experiences and
reasoning to unexpected events while they are occurring. Reflection on
action occurs later, after the event has occurred. It is the process of
thinking back on what happened, what may have contributed to the
unexpected event, whether the actions taken were correct or appropriate,
what could have been done better, what should be done in the future to
prevent a recurrence. The ability to understand how past experiences
affect future practice is necessary for individuals to effectively improve
their performance.17
Development of Expertise (Ericsson)
K. Anders Ericsson has revolutionized how we think about the way that
individuals develop expertise. Before Ericsson’s investigations, the def-
initions of medical expertise included possessing superior knowledge (ie,
academic achievement), displaying the ability to teach (ie, lecturing), and
accumulating many years of clinical experience. Age was felt to be
correlated with wisdom.8 Before Ericsson, physician and nursing exper-
tise was often identified through peer-nomination processes among
experienced professionals.20
He was one of the first to scientifically study the acquisition expert
performance and determined that expertise required a period of 10 years
to attain.8 Moreover, he determined that mere practice was not enough.
Expertise was only reliably attained with application of deliberate
practice over these years. DP is defined as “a regimen of effortful
activities designed to optimize improvement”21 and involves “training
(often designed and arranged by their teachers and coaches) focused on
improving particular tasks.”8
Based on a review of research on skill acquisition, Ericsson and
colleagues identified a set of conditions where practice has been uni-
formly associated with improved performance: (1) the individual must be
provided tasks with well-defined goals; (2) the individual must be
internally motivated to improve; (3) the individual must be provided with
contemporaneous (immediately after the experience) and diagnostic
(describing specific items to work on to improve) feedback; and (4) the
individual must be provided with ample opportunities of repetition and
gradual refinements of their performance.8 Individuals must be pushed
beyond their current comfort level and the effort requires full concentra-
tion to achieve effect.
He correlated the skill acquisition learning curve with DP across
multiple domains (ie, athletes, musicians, typists, chess masters) of
elite international performance, noting that “expert performers have
trained to be able to reproduce their superior performance under
representative conditions in everyday life whenever it is required
during competition and training,” resulting from 10,000 hours of
accumulated experience.7,8
He further observed that, “the age-related decreases in performance
appear to result primarily from reductions of regular deliberate practice,
rather than as a direct consequence of aging per se.”7 This finding is
particularly relevant to clinical practitioners and implies that with regular
deliberate practice, they can improve and maintain expertise even if they
have been out in practice for years to decades.
Similar patterns for medical skill acquisition and decay based on
practitioner level of training have been reported since the 1960s. One of
the first medical investigations in clinical expertise, Butterworth and
Reppert’s investigation observed that cardiac auscultatory acumen was
“highest by those physicians who had been certified in the subspecialty of
cardiovascular disease while the lowest scores were made by physicians
without specialized training who had been in practice for more than 20
years.”22 The next most accurate participants were those who were
cardiology fellows. Medical students performed better than general
practicing physicians who had 10 or more years of experience. The scores
for the individual groups are summarized in Fig 2. The authors concluded
that increased specialty training correlated with increased diagnostic
ability and that there was a need for postgraduate training to maintain
proficiency.
Dr. Ericsson’s work defining the expert-performance approach is
leading a cultural shift in medicine where the current practice of socially
designated expertise is being replaced by recognizing expertise based on
consistently demonstrable superior performance. We are now just learn-
ing how to best provide the necessary experiences to assist trainees using
FIG 2. Cardiac auscultatory acumen by level of training. (Adapted from Butterworth JS, Reppert
EH. Auscultatory acumen in the general medical population. JAMA 1960;174(1):32-4.) (Color
simulation-based techniques to achieve superior performance in their

medical specialties.
Creating an Effective Learning Environment for

Adult Learning Utilizing Simulation
Dewey wrote, “Experience and education cannot be directly related to
each other. . . A primary responsibility of educators is that they not only
be aware of the general principle of the shaping of actual experience by
environing conditions, but that they also recognize in the concrete, what
surroundings are conducive to having experiences that lead to growth.”18
An educator has to be attentive to ensuring that the quality of the learner’s
experience is robust and facilitates the learning outcome desired. More-
over, Dewey believed that integrated educational experience is based on
that educational experience occurring in a context of interaction between
people and prior experiences to provide continuity of learning—“What he
has learned in the way of knowledge and skill in one situation becomes
an instrument of understanding and dealing with the situations which
follow. The process goes on as long as life and learning continue.”18
The most important goal for instructors is to create an atmosphere that is
learner-centered.23 There should be a strong sense of a “safe environment”
where the participants do not feel threatened to make mistakes and where
mistakes are used as opportunities for teachable moments rather than
embarrassing the learners. This must be established during the welcoming
and introduction to the patient simulator and simulation environment.
The introduction to the simulator is important for clarification on how
the participants should expect to interact with the simulator, family
members, and confederate health care workers involved in the scenario.23
The students are given an opportunity to listen to normal and abnormal
heart and lung sounds, palpate the pulses, and locate the necessary
medical equipment in the room to be able to manage the patient. This
significantly decreases the ambiguity that arises from the limitations of
the simulator and surroundings and goes a long way toward promoting
participant suspension of disbelief.24
The most effective scenarios for participants allow trainees to experi-
ence complex situations and to see cues and consequences very much like
those in the real environment. This allows trainees to act as they would in
the real environment.24 Attention to this concept helps them remain
engaged in the scenario and invests them emotionally, especially when
the patient is decompensating (“crashing”). After the case, care is taken to
effectively debrief the experience with the participants. The debriefing
session is just as important as running the scenario and is arguably more
important for developing transference of the learning points to clinical
behavior. During this period of self-appraisal and reflection, effective
facilitators provide guided feedback and help trainees determine how to
take responsibility for their own growth and learning after the session is
completed. As Fanning and Gaba have concluded, “Adults learn best
when they are actively engaged in the process, participate, play a role, and
experience not only concrete events, in a cognitive fashion, but also
transactional events in an emotional fashion.”25
Several frameworks for evaluating the effectiveness of simulation
training have been proposed. Kneebone has delineated four criteria for
how simulationists should critically evaluate the quality of their simula-
tions. These are: “(1) Simulations should allow for sustained, deliberate
practice within a safe environment ensuring that recently acquired skills
are consolidated within a defined curriculum which assures regular
reinforcement; (2) simulations should provide access to expert tutors
when appropriate, ensuring that such support fades when no longer
needed; (3) simulations should map onto real-life clinical experience,
ensuring that learning supports the experience gained within communities
of actual practice; and (4) simulation-based learning environments should
provide a supportive, motivational, and learner-centered milieu which is
conducive to learning.”26 Another framework, used widely by industry,
government, and academia, was created by Donald Kirkpatrick in 1959
and consists of four levels: Level 1—reaction; Level 2—learning; Level
3— behavior; Level 4 —results.27 Each level has an impact on the next
level and each level is subsequently harder to measure. Level 1 (reaction)
measures participant satisfaction. Level 2 (learning) measures the extent
to which learners change attitudes, improve knowledge and skills because
of the training. Level 3 (behavior) measures the extent to which the
training led to a change in behavior. Level 4 (results) measures the bottom
line impact of the training in the real world.27
Conclusions
Experiential learning is particularly suited for adult learners and
practicing medical professionals because the integration of theory and
simulated experience into clinical practice is pertinent and ongoing.24-26
Immersive high-fidelity medical simulation provides a platform whereby
participants learn by doing, thinking about, assimilating lessons learned,
and incorporating them into everyday behaviors.25,26 By incorporating
principles of adult learning into curriculum development and debriefing,
simulationists can improve the simulation experience for their trainees.
Conducted well, these experiences can be practice-changing and signifi-
cantly enhance clinical care.
REFERENCES
1. Gaba DM. The future vision of simulation in health care. Qual Saf Health Care
2004;13(suppl 1):i2-i10.
2. Kyle RR, Murray WB. Introduction. In: Kyle RR, Murray WB, editors. Clinical
Simulation: Operations, Engineering and Management. London: Elsevier/Aca-
demic Press, 2008. p. xxiv.
3. Gaba DM, DeAnda A. A comprehensive anesthesia simulation environment:
re-creating the operating room for research and training. Anesthesiology 1988;
69(3):387-94.
4. White PT. Behold the computer revolution. National Geographic 1970;138(5):
596-7.
5. Eyerman JR. For student doctors, it’s Sim the deathproof patient. Life 1967;63(23):
87, 90.
6. Society for Simulation in Healthcare. Our Society, undated. Accessed 2011.
Retrieved from: http://www.ssih.org/SSIH/ssih/Home/AboutSSH/Default.aspx.
7. Ericsson KA. Deliberate practice and the acquisition and maintenance of expert
performance in medicine and related domains. Acad Med 2004;79(suppl 10):
S70-81.
8. Ericsson KA. Deliberate practice and acquisition of expert performance: a general
overview. Acad Emerg Med 2008;15(11):988-94.
9. Ericsson KA. An expert-performance perspective of research on medical expertise:
the study of clinical performance. Med Educ 2007;41(12):1124-30.
10. Kohn LT, Corrigan JM, Donaldson MS, editors. To Err Is Human: Building a Safer
Health System. Washington, DC: National Academies Press, 2000. p. 78-9.
11. Andreatta P, Saxton E, Thompson M, et al. Simulation-based mock codes
significantly correlate with improved pediatric patient cardiopulmonary arrest
survival rates. Pediatr Crit Care Med 2011;12(1):33-8.
12. Barsuk JH, McGaghie WC, Cohen ER, et al. Simulation-based mastery learning
reduces complications during central venous catheter insertion in a medical
intensive care unit. Crit Care Med 2009;37(10):2697-701.
13. Cohen ER, Feinglass J, Barsuk JH, et al. Cost savings from reduced catheter-related
bloodstream infection after simulation-based education for residents in a medical
intensive care unit. Simul Healthc 2010;5(2):98-102.
14. Doerr H, Murray WB. Chapter 80. How to build a successful simulation strategy: the
simulation learning pyramid. In: Kyle RR, Murray WB, editors. Clinical Simulation:
Operations, Engineering and Management. London: Elsevier/Academic Press, 2008, p.
771-85.
15. Alinier G. Chapter 76. Learning through play: simulation scenario ! obstacle
course " treasure hunt. In: Kyle RR, Murray WB, editors. Clinical Simulation:
Operations, Engineering and Management. London: Elsevier/Academic Press,
2008. p. 745-9.
16. Knowles M, Holton III, EF Swanson RA. The Adult Learner: the Definitive Classic
in Adult Education and Human Resource Development, 6th edn. Boston, MA:
Elsevier, 2005.
17. Kaufman DM. Applying educational theory in practice. BMJ 2003;326(7382):
213-6.
18. Dewey J. Experience and Education. New York, NY: Simon and Schuster, 1938.
19. Kolb DA. Experiental Learning: Experience as the Source of Learning and
Development. Englewood Cliffs (NJ): Prentice-Hall, 1984.
20. Ericsson KA, Whyte 4th, J Ward P. Expert performance in nursing: reviewing
research on expertise in nursing within the framework of the expert-performance
approach. ANS Adv Nurs Sci 2007;30(1):E58-71.
21. Ericsson KA, Krampe RT, Tesch-Römer C. The role of deliberate practice in the
acquisition of expert performance. Psychol Rev 1993;100(3):363-406.
22. Butterworth JS, Reppert EH. Auscultatory acumen in the general medical popula-
tion. JAMA 1960;174(1):32-4.
23. Gordon J. ABC of learning and teaching in medicine: one to one teaching and
feedback. BMJ 2003;326(7388):543-5.
24. Issenberg SB, McGaghie WC, Petrusa ER, et al. Features and uses of high-fidelity
medical simulations that lead to effective learning: a BEME systematic review.
Med Teach 2005;27:10-28.
25. Fanning RM, Gaba DM. The role of debriefing in simulation-based learning. Simul
Healthc 2007;2(2):115-25.
26. Kneebone R. Evaluating clinical simulations for learning procedural skills: a
theory-based approach. Acad Med 2005;80(6):549-53.
27. Kirkpatrick DL. Evaluating Training Programs: the Four Levels, 2nd edn. San
Francisco (CA): Berrett-Koehler, 1998.

Growth of a Simulation Lab:
Engaging the Learner Is Key to
Success
Morris Kharasch, MD, FACEP, Pamela Aitchison, RN,
Peggy Ochoa, RNC-OB, MS, Shekhar Menon, MD,
Noah DeGarmo, MD, Sarah Donlan, MD,
John Flaherty, MD, FACEP, and
Introduction
High-fidelity simulation (HFS) is an important adjunct to clinical training for
teaching health care workers. Currently, the American College of Surgeons
has created a multilevel certification for surgical simulation centers.1 The
American Society of Anesthesiologists Workgroup on Simulation Education
has begun to characterize simulation centers for the purposes of “approval”
as a site to provide continuing medical education credits.2 The Accreditation
Council for Graduate Medical Education Residency Review Committee for
Emergency Medicine has determined that simulation may serve as an adjunct
for the documentation of competencies.3 The Society for Academic Emer-
gency Medicine’s Simulation Academy has recently made recommendations
for accreditation and programmatic benchmarks for emergency medicine
simulation.4 Since 2006, HFS has become increasingly integrated into
undergraduate and graduate medical educational curricula.5
The primary benefit of using HFS is that learners can practice medical
decision-making and procedures skills on simulated patients in an environ-
ment where the risk of error will not harm an actual patient.6 These
technologies were developed to practice skills without incurring risk: in the
military for war games exercises, in the aerospace industry for flight training
of pilots and astronauts, and in the nuclear power industry to train personnel.7
Bridging the gap between other industries and medicine, Gaba and DeAnda
pioneered the use of simulation in anesthesia to train anesthesiologists.8
Simulation has also received favorable reviews as an effective model for
teaching medicine because of its ability to allow learners of all levels to
Dis Mon 2011;57:679-690

0011-5029/2011 $36.00 ! 0
doi:10.1016/j.disamonth.2011.08.019

“practice” medicine in an environment without risk to actual patients,9,10 and,
in addition, to provide an environment that bridges basic science and clinical
medicine.6,11 Gordon et al. write, “Consider the issue of patient safety, and
imagine a practitioner who makes a clinical mistake; immediately after
realizing the error, he or she will experience an emotional reaction that is
powerfully instructive— but only for the next patient. What if educators
could . . . [allow] trainees to ‘live through’ a compendium of important cases
in a fraction of real-time?” Emotional involvement allows students to
integrate and understand information at a deeper cognitive level.12 As
“learning by doing” becomes less acceptable to the public, simulation
exercises, done well, provide learners with meaningful repetition, reinforce-
ment of concepts in the debriefing session, and self-reflection that is critical
to improved learning. In doing so, residents may, “. . . see one, simulate
many, do one competently, and teach everyone.”13
There is a growing body of emergency medicine literature describing
the use of HFS in the educational curriculum. Its adaptability to a wide
array of educational situations makes it a particularly useful tool for
enhancing educational objectives.
Educators are documenting their applications of HFS to address general
competencies,14,15 low incidence but high stakes procedures,16 crisis
resource management,17 team training,18-20 IV access,21 resident profes-
sionalism in ethical dilemmas,22 cognitive forcing strategies,23 bioterror-
ism,24 disaster training,25,26 flight crew airway management,27 multiple
patient encounters for error reduction,28 comparative evaluation of
resident performance,29,30 systems-based modular residency curricu-
lum,31 and medical student education.32-35 The significant body of
literature and successful implementation around the country is a driving
demand for HFS training and proliferation of training facilities has
subsequently followed.
Analysis and Discussion of Contributing Factors
As our center enters its 9-year mark, we reflect on the key areas that
fostered our growth. We started our simulation education program
training a small group of internal medicine residents and fourth-year
medical students during their emergency medicine clerkship in 2002-03.
In 2011, we now operate a vibrant multidisciplinary simulation program,
the Center for Simulation Technology and Academic Research (CSTAR),
at NorthShore University HealthSystem in Evanston, IL with over 3000
learners per year from specialties including anesthesia, critical care,
emergency medicine, internal medicine, obstetrics/gynecology, and pedi-
atrics. We partnered with our surgical colleagues, the Minimally Invasive
Surgical Training Institute (MISTI), in 2011 to form the NorthShore
Center for Simulation and Innovation (NCSI). A brief review of the
growth of our center is presented along with key elements for expansion.
The HFS center at our community-based academic center was con-
ceived with the following goals: (1) to provide medical education using
HFS technology; (2) to provide a safe learning environment; and (3) to
discover just what HFS could achieve with an open-minded approach.
Like many centers around the country, ours started out rather modestly. An
internal grant from our medical group provided seed money for an adult HFS
device, but we did not have a dedicated space to begin this training. We chose
a small 10 ! 15 foot conference room to use as the simulation laboratory,
with the caveat that after we were done “playing” we had to “put away our
toys” and return the conference room to its original state.
Some of the first cases we conducted were mock cardiac arrests,
emphasizing advanced cardiac life support skills. Our control room was
separated from our simulation area by an accordion screen. The debriefing
room was physically in the same room as the control area and separated
with a temporary partition.
Our debriefing style, although personal and supportive, was not stan-
dardized. We stood around the mannequin while talking about the case
performance and how we could improve our management of the simu-
lated cases. We did not use video debriefing consistently.
At the 4-year point our laboratory had grown tremendously, not just in
physical size and technical sophistication, but also in the variety of
applications using HFS. We were serving over 2000 participants per year,
with a second 1500 square-foot laboratory at our affiliate hospital,
Highland Park Hospital in Highland Park, IL. Our faculty has developed
approximately 100 well-described and reproducible cases for a variety of
learners, including emergency medicine residents, medical students,
nurses, internal medicine residents, obstetrics and gynecology residents,
paramedics, emergency medical technicians, and community programs
for mass casualty events. We offer a broad variety of courses (Table 1)
with numerous participants from multiple disciplines.
Multiple research projects with grant funding were started in the third
year of operation. Since then, we have maintained an active research
program emphasizing educational applications of simulation. Projects we
have contributed to or have led include resident education using simula-
tion,15,31,36 pediatric educational curriculum design,37,38 competency
evaluation in medical student dysrhythmia education,39 procedures com-
petency training in emergency medicine and for transvenous pacemaker
insertion,40,41 facilitative debriefing technique,42 description of creation
TABLE 1. Courses and Participants 2010-11
Courses Physicians (T) Nurses (T) Prehospital (T)
Pediatric advanced life support 14 70 140
Advanced cardiac life support 14 70 140
Stroke training 4 8 32
Brain death diagnosis 1 20
Nursing first 5 minutes 12 100
Nursing skills 6 130
Nursing interns 8 100
Anesthesia 14 98
Code blue pediatrics 12 240
EMT school 32 640
Paramedic training 32 640
Medical student training 36 360
Introduction to career in 2 40
medicine
Pediatrics 12 70
Internal medicine 40 320
New intern training 12 70
OB training 40 240
ICU training 20 160
Global health emergency 2 7 7 8
Medicine training 18 190
Neonatal training 12 70
Procedures training 3 90
Dialysis
Nurse training 4 20
CRNA training 40 240
T, total unique participants; OB, obstetric; EMT, emergency medical technician; ICU, intensive
care unit; CRNA, certified registered nurse anesthetist.
of simulation cases,43,44 simulation center development policy,3 physio-

logical response during simulation management, and innovation in
simulator design.45-48
Beginning in 2008, we developed the Emergent Procedures Instruc-
tional Collaboration to produce a series of educational procedure videos.
These videos illustrated diagnostic techniques for emergent conditions
and demonstrated techniques required for performing a variety of emer-
gent procedures ranging from emergent airway and cardiovascular pro-
cedures to joint dislocation reduction techniques (Table 2).49-63
In 2010, we expanded our simulation personnel through the develop-
ment of a simulation fellowship. This nonaccredited fellowship is a 1-year
program designed to allow the trainee to practice clinical emergency
medicine while spending significant protected time learning simulation-
based training techniques and developing both a teaching and a research
focus using simulation.
TABLE 2. EPIC Videos
Anterior shoulder dislocation: scapular manipulation technique
Arthrocentesis
Central venous catheter insertion
Cricothyrotomy
Diagnosis of acute aortic dissection
Epistaxis management—anterior
Epistaxis management—posterior
Intraosseous access
Patellar dislocation reduction
Percutaneous transtracheal jet ventilation
Posterior ankle dislocation reduction
Rapid sequence intubation for acute intracranial hemorrhage
Tracheal tube introducer
Transvenous pacemaker insertion
Tube thoracostomy
EPIC, Emergent Procedures Instructional Collaboration.
In May 2011, NorthShore University HealthSystem expanded its HFS

capabilities by working with CSTAR to develop a 12,000 square-foot
simulation laboratory consisting of a 5000 square-foot immersive simu-
lation laboratory and a 7000 square-foot surgical simulation laboratory
under the direction of the MISTI. Together CSTAR and MISTI were
merged to form NCSI to provide a true multidisciplinary simulation
center for community and academic practitioners.
The new immersive simulation space houses seven fully equipped
rooms: two emergency department immersive resuscitation rooms, two
complete immersive operating rooms based on the standard at our
hospital, a general patient room, a neonatal room, and an obstetrics room.
Staff
To accommodate the growth of the laboratory, the increasing trainee
load, and our emerging academic endeavors, allocated protected time for
physicians was created. Initially the center’s director (and the main
provider of simulation training) was provided with time out of the clinical
schedule for training events only.
As the number and variety of course offerings increased, and clinical
research developed, several physicians’ clinical responsibilities were
reduced to allow time to devote to these responsibilities. This educational
and academic endeavor could only take place with the commitment of the
administration in the Emergency Medicine Division. In addition to
physician time, critical support staff was required.
Based on the success of our crisis communication course for nurses at
NorthShore, our hospital became vested in this type of training for our
professional physician and nursing staff, and as a result, provided
significant funding that supported a full-time emergency medicine nurse
and a simulation technician to run the simulators and set up the sessions.
We anticipate that with our facility expansion, we will require 2-3
full-time nurses, 2 full-time simulation specialists, and 1 full-time
physician equivalent, along with a significant resource team, to handle
increasing number of trainees.
Equipment
Funding for our simulation equipment came from multiple sources.
State and federal grants for disaster planning and prehospital education
drove the acquisition of several devices. The need for filling educational
gaps in emergency medicine residency programs with critically ill
pediatric patients led to our partnering with Children’s Memorial Hospital
in Chicago, IL, to develop a pediatric curriculum using simulation. A
pediatric simulator was purchased to meet this national need. The “trauma
man” simulator was acquired through our level 1 trauma program and the
hospital’s commitment to nursing and resident education.
In reviewing our growth, our core group of educators reviewed each
step of the expansion to identify the key components that fostered the
successful development of our center. The areas we examined were the
physical plant, the simulation equipment, the curriculum, and our teach-
ing methodology.
We looked at each of these factors, but could not attribute our expansion
solely to the physical plant, the equipment, or even a robust curriculum.
Clearly, each of these factors added to our armamentarium for teaching,
but did not contribute to the true expansion of the program. Identifying
the driving force behind this expansion required a reflective analysis of
the events that emerged from the 10 ! 15 foot room where all of this
started.
The initial instruction provided to our residents 9 years ago, using this
new technology, was met with interest, at least with respect to the
computerized patient simulator. However, the first series of classes were,
in retrospect, limited successes. The technology was great; the physiology
of the simulator provided a realistic response to the learner’s input, and it
seemed that all the critical components were in place during the initial
phase to provide a tremendous experience for the participants. Instead,
our initial attempts elicited minimal learner interest. They perceived the
simulator as a novelty, rather than a robust instructional tool.
After this initial foray into resident education, the task of “engaging the
learner” became the priority for our center. We relegated the technology
of the simulator—the blinking of the eyes, the respiratory sounds, and the
heart sounds—in other words, the “bells and whistles,” to a secondary
role. We focused on developing what we felt was the key missing
ingredient— connecting the teacher and the learner.
Two objectives became the primary goals in the remodeling of the
educational component. First, we spent extra time formally identifying
specific learning needs for each trainee group. We paid particular
attention to the postcourse evaluations and written suggestions, incorpo-
rating those elements that were widely requested. By doing this, we
became much more learner-focused in our goals and objectives. We spent
significant presession time ensuring that each learning objective of each
simulation scenario was designed to meet the students’ needs, rather than
generic knowledge items or skills. Second was making it an absolute
priority to conduct the debriefing review sessions and critique perfor-
mances in a nonthreatening, supportive fashion with emphasis on gearing
the discussion to match the level of the audience.
Because of implementing these factors, we discovered that these
strategies generated an almost universal response from our learners:
“When can I come back for more cases?” By creating a learning
environment that was engaging and nonthreatening and by providing
3-4 critical teaching points per case that the learners felt were relevant
for them, we found that it created a powerful experience that was
preferred by students, nurses, paramedics, and residents alike. It also
became evident that it was critical to identify clinical educators with
the ability to conduct this type of session because these teachers were
the most effective at creating the environment we desired for the
learners. We now mandate that all teachers go through a debriefing
course to practice teaching with this new modality, and to debrief the
instructors to ensure they understand the strategies and the art of
keeping the students engaged.
Within our institution, positive feedback spread widely. We suc-
ceeded in providing our participants with constructive diagnostic
performance analysis in a way that was never demeaning or conde-
scending. The simple formula of “critical teaching points geared
toward the level of the learner and appropriate critiques in a positive
non-threatening fashion” was used for every participant. Without this
formula, we could not have cultivated the learners’ desire to partici-
pate again, and the interest and volume could never have been
realized.36 The direct by-product of this tremendous increase in
activity was financial support from the institution, as well as from a
variety of groups that participated in the laboratory.
In the end, we discovered that the software was as important as, if not
more important than, the hardware. The “human factor”—the teaching–is
what really drives the success of the programs we conduct.
Conclusions
The startup costs associated with developing a simulation program are
substantial. The cost of the machines and software approach $250,000 for
a high-end manikin, with space to accommodate these participants often
requiring significant hospital and/or medical school commitment. The
additional costs of nurses, technicians, and a physician can be over-
whelming. Unless a large grant or donation drives the initial startup and
personnel required, we recommend a strategy that focuses on generating
significant interest through positive experience.
This process will likely result in increased student volume and institu-
tion financial support. In our case, support from nursing, medical schools,
and prehospital care providers only came after we had developed a track
record with each group. As we increased the volume of teaching sessions
for these groups of learners, financial support for teachers and equipment
was justified. As the volume grew and more appropriate teachers were
identified, we began data collection for our various research projects and
actively sought outside funding and grants. Key personnel at our
institution with expertise in obtaining financial support focused on this
aspect, which allowed the teachers to focus on the laboratory, the
research, and the students.
There are other important factors that contribute to a successful center,
including a clear statement of purpose or vision, thoughtful consideration
of logistics (location, space, equipment, and personnel support), continu-
ing quality assurance (assessment and reassessment of the training’s
effectiveness), a network of like-minded and capable individuals com-
prising coinvestigators and colleague-educators, significant clinical expe-
rience in the simulation environment to develop expertise and leadership
in the field, and foremost, institutional support.
Our success was accomplished by engaging the learners with relevant
clinical “Pearls” geared toward their training level in a supportive
environment. This fostered a desire to return and gave our laboratory the
ability to improve and expand this unique educational experience. We
have discovered that the success of a simulation center depends more on
the thought and effort put into case development and on the individual
interactions between the educators and the learners than on the physical
plant or the hardware with all the “bells and whistles.” Had we relied on
a “technology-driven” educational model, it is unlikely that our programs
would have grown as they have. Our main lesson learned is that when you
engage the learner, growth will follow.
REFERENCES
1. American College of Surgeons. Accreditation of Education Institutes. Retrieved
6/24/11 from http://www.facs.org/education/accreditationprogram/index.html.
2. American Society of Anesthesiologists. Endorsed Simulation Centers. Retrieved
6/24/11 from http://www.asahq.org/For-Members/Education-and-Events/Simulation-
Education/Endorsed-Simulation-Centers.aspx.
3. Fernandez R, Wang E, Vozenilek JA, et al. Simulation center accreditation and
programmatic benchmarks: a review for emergency medicinee. Acad Emerg Med
2010;17(10):1093-103.
4. Accreditation Council for Graduate Medical Education. Emergency Medicine
Guidelines. Retrieved 6/24/11 from http://www.acgme.org/acWebsite/RRC_110/
110_guidelines.asp.
5. McLaughlin SA, Bond W, Promes S, et al. The status of human simulation training
in emergency medicine residency programs. Simul Healthc 2006;1 Spec no.:18-21.
6. Gordon JA, Oriol NE, Cooper JB. Bringing good teaching cases “to life”: a
simulator-based medical education service. Acad Med 2004;79(1):23-7.
7. Issenberg SB, McGaghie WC, Hart IR, et al. Simulation technology for health care
professional skills training and assessment. JAMA 1999;282(9):861-6.
re-creating the operating room for research and training. Anesthesiology 1988;
69(3):387-94.
9. Weller JM. Simulation in undergraduate medical education: bridging the gap
between theory and practice. Med Educ 2004;38(1):32-8.
10. Steadman RH, Coates WC, Huang YM, et al. Simulation-based training is superior
to problem-based learning for the acquisition of critical assessment and manage-
ment skills. Crit Care Med 2006;34(1):151-7.
11. Bond WF, Spillane L. The use of simulation for emergency medicine resident
assessment. Acad Emerg Med 2002;9(11):1295-9.
12. Gordon JA, Wilkerson WM, Shaffer DW, et al. “Practicing” medicine without risk:
students’ and educators’ responses to high-fidelity patient simulation. Acad Med
2001;76(5):469-72.
13. Vozenilek J, Huff JS, Reznek M, et al. See one, do one, teach one: advanced
technology in medical education. Acad Emerg Med 2004;11(11):1149-54.
14. Okuda Y, Bond W, Bonfante G, et al. National growth in simulation training within
emergency medicine residency programs, 2003-2008. Acad Emerg Med 2008;
15(11):1113-6.
15. Wang EE, Vozenilek JA. Addressing the systems-based practice core competency:
A simulation-based curriculum. Acad Emerg Med 2005;12(12):1191-4.
16. Schaefer JJ. Simulators and difficult airway management skills. Paediatr Anaesth
2004;14(1):28-37.
17. Reznek M, Smith-Coggins R, Howard S, et al. Emergency Medicine Crisis
Resource Management (EMCRM): Pilot study of a simulation-based crisis man-
agement course for emergency medicine. Acad Emerg Med 2003;10(4):386-9.
18. Small SD, Wuerz RC, Simon R, et al. Demonstration of high-fidelity simulation
team training for emergency medicine. Acad Emerg Med 1999;6(4):312-23.
19. Jay GD, Small SD, Langford V, et al. Teamwork training supported by high fidelity
simulation training improves emergency department team behaviors. Acad Emerg
Med 2000;7(5):519 [Abstract].
20. Shapiro MJ, Morey JC, Small SD, et al. Simulation based teamwork training for
emergency department staff: does it improve clinical team performance when
added to an existing didactic teamwork curriculum? Qual Saf Health Care
2004;13(6):417-21.
21. Reznek MA, Rawn CL, Krummel TM. Evaluation of the educational effectiveness
of a virtual reality intravenous insertion simulator. Acad Emerg Med 2002;
9(11):1319-25.
22. Gisondi MA, Smith-Coggins R, Harter PM, et al. Assessment of resident profes-
sionalism using high-fidelity simulation of ethical dilemmas. Acad Emerg Med
2004;11(9):931-7.
23. Bond WF, Deitrick LM, Arnold DC, et al. Using simulation to instruct emergency
medicine residents in cognitive forcing strategies. Acad Med 2004;79(5):438-46.
24. Subbarao I, Johnson C, Bond WF, et al. Symptom-based, algorithmic approach for
handling the initial encounter with victims of a potential terrorist attack. Prehosp
Disaster Med 2005;20(5):301-8.
25. Kobayashi L, Shapiro MJ, Suner S, et al. Disaster medicine: the potential role of
high fidelity medical simulation for mass casualty incident training. Med Health RI
2003;86(7):196-200.
26. Freeman KM, Thompson SF, Allely EB, et al. A virtual reality patient simulation
system for teaching emergency response skills to U.S. Navy medical providers.
Prehosp Disaster Med 2001;16(1):3-8.
27. Godwin SA, Caro DA, Wears RL, et al. The validation of simulation to evaluate
flight crew members’ airway management skills [Abstract]. Acad Emerg Med
2003;10(5):488-a.
28. Kobayashi L, Shapiro M, Hill A, et al. Creating a MESS (Multiple Encounter
Simulation Scenario) for medical error reduction and enhanced medical education
[Abstract]. Acad Emerg Med 2004;11(8):896-b.
29. Clyne B, Gutman DC, Sutton E, et al. Oral board vs. high-fidelity simulation for
competency assessment: senior emergency medicine resident management of an
acute coronary syndrome. Acad Emerg Med 2004;11(5):500.
30. Gordon JA, Tancredi D, Binder W, et al. Assessing global performance in
emergency medicine using a high-fidelity patient simulator: a pilot study [Abstract].
Acad Emerg Med 2003;10(5):472.
31. Vozenilek J, Wang E, Kharasch M, et al. Simulation-based Morbidity and Mortality
Conference: new technologies augmenting traditional case-based presentations.
Acad Emerg Med 2006;13:48-53.
32. Takayesu JK, Gordon JA, Farrell SE, et al. Learning emergency and critical care
medicine: what does high-fidelity patient simulation teach? [Abstract] Acad Emerg
Med 2002;9(5):476-7.
33. Shapiro M, Morchi R. High-fidelity medical simulation and teamwork training to
enhance medical student performance in cardiac resuscitation [Abstract]. Acad
Emerg Med 2002;9(10):1055-6.
34. Vozenilek J, Handler J, Kontrick A. Augmentation of the medical student rotation
with high fidelity simulation: learning by the numbers [Abstract]. Acad Emerg Med
2004;11(8):898.
35. Coates WC, Steadman RH, Huang YM, et al. Full-scale high fidelity human patient
simulation vs problem based learning: comparing two interactive educational
modalities [Abstract]. Acad Emerg Med 2003;10(5):489.
36. Wang EE, Beaumont J, Kharasch M, et al. Resident response to integration of
simulation-based education into emergency medicine conference. Acad Emerg Med
2008;15(11):1207-10.
37. Adler MD, Vozenilek JA, Trainor JL, et al. Development and evaluation of a
simulation-based pediatric emergency medicine curriculum. Acad Med 2009;
84(7):935-41.
38. Adler MD, Vozenilek JA, Trainor JL, et al. Comparison of checklist and anchored
global rating instruments for performance rating of simulated pediatric emergen-
cies. Simul Healthc 2011;6(1):18-24.
39. Wang EE, Aronwald R, Kharasch MS, et al. The Response to Emergent Scenarios
Utilizing Simulation (RESUS) Training Program: the effect of multimodal simu-
lation on dysrhythmia recognition and treatment proficiency in fourth-year medical
students. Society for Academic Emergency Medicine (SAEM) Annual Meeting
Abstracts. Acad Emerg Med 2010;17(5):S124.
40. Wang EE, Quinones J, Fitch MT, et al. Developing technical expertise in
emergency medicine—the role of simulation in procedural skill acquisition. Acad
Emerg Med 2008;15(11):1046-57.
41. Ahn J, Kharasch M, Aronwald R, et al. Assessing the ACGME Requirement for
Transvenous Pacer Procedural Competency Through Simulation. 11th Annual
International Meeting of Simulation in Healthcare. New Orleans, LA: 2011.
42. Wang EE, Kharasch M, Kuruna D. Facilitative debriefing techniques for simula-
tion-based learning. Acad Emerg Med 2011;18(2):e5.
43. Wang EE, Kharasch M, Vozenilek JA. My mouth hurts. In: MedEdPORTAL, 2008.
Available from: http://services.aamc.org/jsp/mededportal/retrieveSubmissionDetail
Byld.do?subld!721 or http://services.aamc.org/jsp/mededportal/browseDetails.
do?discipline!12.
44. Wang EE, Vozenilek JA. A pain in the neck. In: MedEdPORTAL, 2009. Available
from: http://services.aamc.org/jsp/mededportal/retrieveSubmissionDetailById.do?
subId!717.
45. Pettineo CM, Vozenilek JA, Wang E, et al. Simulated emergency department
procedures with minimal monetary investment: cricothyrotomy simulator. Simul
Healthc 2009;4(1):60-4.
46. Pettineo CM, Vozenilek JA, Kharasch M, et al. Epistaxis simulator: an innovative
design. Simul Healthc 2008;3(4):239-41.
47. Pettineo CM, Vozenilek JA, Kharasch M, et al. Inconspicuous portable audio/visual
recording: transforming an IV pole into a mobile video capture stand. Simul
Healthc 2008;3(3):180-2.
48. Wang EE, Vozenilek J, Flaherty J, et al. An innovative and inexpensive model for
teaching cricothyrotomy. J Soc Simul Healthc 2007;2(1):25-9.
49. Beck EH, Kharasch M, Menon S, et al. Percutaneous transtracheal jet ventilation.
Acad Emerg Med 2011;18(5):e38.
50. Wang EE. Posterior ankle dislocation reduction. Acad Emerg Med 2010;17:e152.
51. Tudor BC, Wang EE, Norris R. Anterior shoulder dislocation: the scapular
manipulation technique. Acad Emerg Med 2010;17(6):e40.
52. Griffith JD, Coleman P, Kharasch M, et al. Aortic dissection: an emergent clinical
presentation. Acad Emerg Med 2010;17(4):466.
53. Costello H, Wang EE, Temple B, et al. Rapid sequence intubation for acute
intracranial hemorrhage. Acad Emerg Med 2010;17(3):341.
54. Lu DW, Wang EE, Self WH, et al. Patellar dislocation reduction. Acad Emerg Med
2010;17(2):226.
55. Doelger E, Kharasch M, Pettineo C, et al. Emergent management of anterior
epistaxis. Acad Emerg Med 2009;16(4):365.
56. Asaravala M, Kharasch M, Pettineo C, et al. Emergent intraosseous access. Acad
Emerg Med 2008;12:1324.
57. Insua JA, Griffith J, Wang EE, et al. Emergent airway adjuncts: the tracheal tube
introducer. Acad Emerg Med 2008;15(8):793.
58. Reaven D, Kharasch M, Pettineo C, et al. Management of posterior epistaxis. Acad
Emerg Med 2008;15(6):585.
59. Wang EE, Baran E, Kharasch M, et al. The emergent transvenous pacemaker. Acad
Emerg Med 2008;15(5):487.
60. Van Roo J, Wang EE, Vozenilek JA, et al. Central venous catheterization–right
internal jugular vein approach. Acad Emerg Med 2008;15(4):397.
61. Self WH, Wang EE, Vozenilek JA, et al. Dynamic emergency medicine. Arthro-
centesis. Acad Emerg Med 2008;15(3):298.
62. Levine M, Wang E, Salzman D, et al. The emergent tube thoracostomy. Acad
Emerg Med 2008;15(2):207.
63. Wang E, Vozenilek J, Pettineo C. The emergent cricothrytomy. Acad Emerg Med
2008;15(2):206.

Procedural Simulation
James Ahn, MD, and Shekhar Menon, MD
Development of Procedural Simulation
The philosophy behind procedural simulation lies in the concept of
deliberate practice. The primary goal of deliberate practice is to improve
a specific aspect of performance, and practice is focused on modifying a
well-defined area. Deliberate practice was described by the psychologist
K. Anders Ericsson in the early 1990s as a process necessary to develop
expertise. It is the process of taking a learner’s intrinsic motivation to
work at improving performance and providing the following:
1. Focused instruction geared appropriately to the learner’s level of
training,
2. Immediate informative feedback and knowledge of results of their
performance, and
3. The opportunity to repeatedly perform the same or similar tasks to
solidify their newly acquired skills.1
Simulation provides these essential components. Scheduled sessions
provide predictable exposure. The learners can come prepared to practice.
The task trainers used provide each student with a greater number of
repetitions than they might otherwise receive on actual patients. An entire
class can be given consistent training so that their educational opportu-
nities are not left to chance encounter in the clinical arena.
Procedural simulators are ideal for the application of practice as the
learner can rehearse, record, and correct steps in unfamiliar and rare
procedures. The aviation industry has long used procedural simulation
toward improving the industry safety standards. Patel and coworkers cite
the 1999 Institute of Medicine (IOM) publication, “To Err is Human:
Building a Safer Healthcare System” as the sentinel event that popular-
ized simulation in the medical field.2,3 The IOM’s report stated that
98,000 patient deaths occur from medical errors—a finding that paved the
way for increasing use of procedural simulators.2 Simulation as an
educational modality is ideal because trainees can trial and error in a
Dis Mon 2011;57:691-699

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doi:10.1016/j.disamonth.2011.08.015

consequence-free environment. Using procedural simulators, trainees can
acquire skills through deliberate practice in a safe and measured manner
before performing procedures on patients.
Further, the dogmatic approach of “see one, do one, teach one” may no
longer be acceptable or ethical. There are ethical ramifications of trainees
practicing unfamiliar or high-risk procedures on patients—a situation that
certainly exposes patients to increased propensity toward adverse events.
This concept is less palatable when other modalities of training, such as
procedural simulation, are readily available.4 An increased scrutiny on
medical errors combined with the potential ethical issues have rendered
the philosophy of “learning by doing” far less tenable or acceptable. For
the aforementioned reasons, multiple specialties have advocated using
procedural simulation to teach and evaluate the Accreditation Council for
Graduate Medical Education (ACGME) general competencies.5
The current approach to teaching procedural skills in medicine has been
called “unsystematic and unstructured.”6 Moreover, due to ACGME work
duty hour restrictions, medical trainees are restricted to fewer training
hours, thereby decreasing their exposure to and limiting their ability to
practice procedures. All these factors have reinforced the momentum for
adopting procedural simulation as a training tool.
Even though the 1999 IOM publication “To Err is Human: Building a
Safer Healthcare System” is thought to have spurred the evolution of
procedural simulation, the roots of this teaching modality reach back to
the 1960s. The beginnings of procedural simulation within the medical
specialty can be traced back to the Resuci-Anne doll.7 This mannequin
simulator was used to train mouth-to-mouth ventilation as well as other
resuscitation techniques. The simulator became valuable in instructing the
chin-thrust to open the airway, hyperextension of the neck, and, eventu-
ally, cardiopulmonary resuscitation. Conventional task trainers were
introduced in 1987 and used for fiber-endoscopic training.8 After this
training device was unveiled, multiple simulators for surgical procedures
followed suit. Current simulators range from partial-task mannequins to
virtual reality software with haptic feedback. The range and depth of
simulation are rapidly growing and most conceivable procedures will
soon be able to be practiced in the simulation arena.
Current Uses of Procedural Simulation
The scope of procedural simulation is vast and varied. Partial-task
mannequins can be used to practice central venous catheter (CVC)
insertions, lumbar punctures, IV insertions, epistaxis management, intu-
bations, and laparoscopic techniques. Rapidly increasing technology has
introduced the advent of virtual reality simulators with haptic technol
ogy—these simulators that can allow the trainee to practice procedures
with the benefit of tactile feedback. For example, the trainee will be able
to “feel” the liver while performing a virtual cholecystectomy. Further,
procedural simulation has been used to teach noninvasive procedures
such as cardiopulmonary resuscitation.
Castanelli had summarized numerous frameworks in procedural simu-
lation— useful lenses to analyze the different uses and justifications for
this teaching tool.9 In the Systematic Training and Assessment of
Technical Skills, the framework is deconstructed into 5 portions: (1)
knowledge-based learning, (2) task deconstruction, (3) training in a
laboratory environment, (4) transfer of skills to a real environment, and
(5) granting privileges for independent practice.10 For the purposes of this
discussion, components 2, 3, and 4 will be highlighted, as the first and
fifth components are self-explanatory.
Task deconstruction, or task analysis, is the process where individual
steps of the desired procedure are delineated and repeated. More specif-
ically, key tasks are separated from the entire procedure and focused on
as points of instruction. For example, during laparoscopic training, key
tasks, such as “clip application” and “lifting and grasping,” were
highlighted and focused during procedural training.11 With this training,
the specific procedure is deconstructed to its core elements—the trainees
are assured of mastering basic skills before attempting the entire proce-
dure. Evidence supports the use of the framework of task analysis, since
when using this methodology, trainees showed improved surgical deci-
sion-making, as CVC insertion compared to traditional teaching method-
ologies.12,13
The third component, “training in a laboratory environment,” occurs
after the trainee has been deemed proficient in specific steps highlighted
during task analysis. This aspect of training is the most commonly
thought of aspect of procedural training— using a partial-task trainer or
virtual reality device to practice the entire procedure of interest. The
challenge is this component is finding an appropriate training device for
the procedure, eg, a virtual reality simulator may be inappropriate or
unnecessary for lumbar puncture training. Finally, the most interest in
procedural training lies with the fourth component: “transfer of skills to
a real environment.” More specifically, the question becomes: Does
simulation training improve the trainees’ performance in the hospital?
In the surgical literature, numerous randomized controlled trials have
demonstrated improved performance in colonoscopies and laparoscopic
procedures.14-16 Simulation training for laparoscopic cholecystectomies
showed that trainees had decreased observed errors, better economy of
movement, and decreased operative time. Trainees who underwent
procedural simulation training for endoscopy required less supervisor
assistance and were able to perform endoscopies independently after
simulation training.17 Also, medical students training with the lap
suturing trainer were found to have their technical skills rated as similar
to senior level residents.18 Surgical residents felt that incorporating such
simulator training as essential to their graduate medical education.19
Obstetrics have also been using partial-task trainers to practice common
and uncommon procedures, such as determining cervical dilation or fetal
station, amniocentesis, basic deliveries, and obstetrical emergencies.
When using procedural simulation training with shoulder dystocia,
Draycott et al. were able to demonstrate a reduction in neonatal injuries.20
Internal medicine residents, using procedural simulators, were able to
obtain mastery level learning of thoracentesis skills.21
Task trainer simulation models have been especially useful in teaching
many low-incidence/high-stakes airway management procedures that are
needed in the emergent setting—specifically, with fiberoptic intubations,
pediatric intubations, and cricothyrotomies. One study using airway task
trainers in emergency medicine training used an advanced airway course
that identified 4 important lessons through repeated errors made by
trainees: application of advanced cardiac life support to all emergency
situations, identifying a team leader, familiarity with pharmacokinetics
and dynamics of drugs, and an rapid sequence intubation (RSI) knowl-
edge-base.22 A 2008 study using a virtual-reality-based simulator to teach
emergency medicine residents how to perform pediatric fiberoptic intu-
bation allowed residents to first attempt an intubation, then watch a
tutorial, practice for 10 minutes, and then repeat the attempt.23 In 2 of 3
simulated cases, there was a significant decrease in median procedure
times and number of scope collisions and an increase in median efficiency
scores. When pediatric residents were being taught pediatric intubation
techniques and practices, simulation was used to identify mistakes not just
in technique, but also in the entire sequence of properly intubating
patients, including preoxygenation, rapid sequence induction techniques,
cricoid pressure, end-tidal carbon dioxide detection, nasogastric tube
placement postintubation, correct equipment, and correct use of equip-
ment.24 This study emphasized that simulation can highlight critical
aspects of a procedure that are often overlooked. Although there have
been no studies pertaining specifically to emergency medicine based
cricothyrotomy simulation training, multiple studies within the specialty
of anesthesia have used simulators to practice this rare, but necessary
procedural skill, including one that demonstrated a significant decrease in
time to successful completion of the procedure over 10 attempts as well
as showing that after 3 attempts, a higher level of expertise was
gained.25,26
A 2010 study demonstrated that intubation success in novices (12
critical care transport nurses) improved with procedural training and
assisted in identifying key factors that lead to unsuccessful intubation.27
The Laerdal Airman Difficult Airway Simulator (Laerdal, Norway) was
used as the subjects were initially put through 1 of 64 different scenarios
(such as tongue edema), 1 month later were formally trained under normal
airway conditions, and then 1 month later were retested with one of the
scenarios. First-pass intubation rates improved from 19% to 36% after
training on the simulator. Straight blade use, laryngeal spasm, and tongue
edema were all identified as factors that reduce success rates.
Lee et al. evaluated 16 emergency medicine residents in CVC insertion
by videotaping ultrasound-guided CVC insertion in the right internal
jugular vein in a partial task-trainer model, reviewing a web-based
module with them along with practicing on the task trainer; finally, they
were videotaped again inserting the CVC into the model.28 Pre- and
posttraining videotapes were assessed using a preperformance checklist.
Performance scores and global ratings assessments improved signifi-
cantly, as well as the residents’ self-evaluated confidence and technical
skills. In addition, vessel cannulation time improved from 91 to 60
seconds. Another study measured first-attempt success rate of ultrasound-
guided CVC insertion by residents rotating through the emergency
department, medical intensive care unit, and surgical intensive care unit.29
Four hundred ninety-five insertions were observed in total, and residents
were placed in either an intervention group (didactics and training on a
partial-task trainer) or a control group (traditional, bedside, apprentice-
ship). Successful first cannulation (51% vs 37%) as well as overall
successful CVC insertion (78% vs 67%) was higher in the intervention
group vs the control group. Subsequent studies have demonstrated a
reduction in catheter-related bloodstream infections because of simula-
tion-based training. A 2010 study determined that by training residents on
CVC insertion (at a cost of $112.00/year), reduction in catheter-related
bloodstream infections saved a hospital greater than $700,000 when
taking into account additional treatment and hospital days.30
Emergency medicine and critical care studies demonstrate that CVC
taught via simulation shows an improved in-hospital performance and
reduced complications vs traditional training among trainees. Simulation-
trained residents demonstrated an increased success at first cannulation
and successful CVC insertion coupled with decreased needle passes,
arterial punctures, and catheter adjustments.29,31
Again most importantly, practicing low-frequency life-saving skills via
simulation, such as intubation, cricothyrotomy, and tube thoracostomy,
has demonstrated increased proficiency among the trainees.32-35 The most
effective simulation-based learning offers learning within a clinical
context—successful procedural simulation is predicated on the ability to
“map” onto real-life scenarios to ensure learning supports the experience
gained from actual practice.36 In addition to improving performance,
procedural simulation improves the confidence and comfort level of the
trainees. Medical students showed increased confidence in cricothyroto-
mies, CVCs, and tube thoracostomies when trained with simulators.37
Also, patients showed an increasing willingness to have the student
perform procedures after simulation training.38 There is a bevy of
literature supporting the usage of procedural simulation as a training
modality. As a teaching tool, procedural simulation provides superior
results over traditional methods, as well as improving trainee and patient
comfort levels.
Future Directions
Although simulation is not required by the ACGME as part of the
graduate medical education, procedural simulation has steadily been
incorporated into medical education—a phenomenon that will only
accelerate. However, this teaching instrument will eventually have
applications beyond teaching medical trainees. A call for using simulation
for competency testing already exists—procedural simulation can be used
to assess trainee skill levels before advancement.5 Emergency medicine
curriculums are already beginning to incorporate simulation to assess core
competencies.39 Procedural simulation as an adjunct to board examina-
tions is of particular interest, especially to procedure-heavy specialties,
such as surgery, anesthesia, emergency medicine, and various internal
medicine subspecialties. Traditional oral examinations will be replaced by
simulation-based tests where applicants will need to demonstrate rather
than verbalize how to perform a procedure. Similarly, hospital privileges
may be based on the physician’s ability to demonstrate the desired
procedure on a simulator to sponsoring departments.3 Finally, simulation
technology has entered the medical-legal field as insurance companies
offer incentives for anesthesiologists who have practiced crisis resource
management with high-fidelity simulations. A similar approach toward
procedures may not be unreasonable—premiums for procedure-heavy
specialties may be decreased based on participation and practice with
procedural simulators.40
REFERENCES
1. Ericsson KA. Deliberate practice and acquisition of expert performance: a general
overview. Acad Emerg Med 2008;15(11):988-94.
2. Patel AA, Glaiberman C, Gould DA. Procedural simulation. Anesthesiol Clin
2007;25(2):349-59.
3. Kohn JT, Corrigan JM, Donaldson MS, editors. To Err Is Human: Building a Safer
Healthcare System. Washington, DC: National Academies Press, 1999.
4. Ziv A, Wolpe PR, Small SD, et al. Simulation-based medical education: an ethical
imperative. Acad Med 2003;78(8):783-8.
6. Grantcharov TP, Reznick RK. Teaching procedural skills. BMJ 2008;
336(7653):1129-31.
7. Cooper JB, Taqueti VR. A brief history of the development of mannequin
simulators for clinical education and training. Postgrad Med J 2008;
84(997):563-70.
8. Gillies DF, Williams CB. An interactive graphic simulator for the teaching of
fibrendoscopic techniques. In: Marechal G, editor. EUROGRAPHICS 1987.
Amsterdam: North-Holland, 1987. p. 127-38.
9. Castanelli DJ. The rise of simulation in technical skills teaching and the implica-
tions for training novices in anaesthesia. Anaesthesiol Intensive Care 2009;
37(6):903-10.
10. Aggarwal R, Grantcharov TP, Darzi A. Framework for systematic training and
assessment of technical skills. J Am Coll Surg 2007;204(4):697-705.
11. Aggarwal R, Grantcharov TP, Eriksen JR, et al. An evidence-based virtual reality
training program for novice laparoscopic surgeons. Ann Surg 2006;244(2):310-4.
12. Velmahos GC, Toutouzas KG, Sillin LF, et al. Cognitive task analysis for teaching
technical skills in an inanimate surgical skills laboratory. Am J Surg 2004;
187(1):114-9.
13. Luker KR, Sullivan ME, Peyre SE, et al. The use of a cognitive task analysis-based
multimedia program to teach surgical decision making in flexor tendon repair. Am J
Surg 2008;195(1):11-5.
14. Ahlberg G, Hultcrantz R, Jaramillo E, et al. Virtual reality colonoscopy simulation:
a compulsory practice for the future colonoscopist? Endoscopy 2005;37(12):
1198-204.
15. Seymour NE, Gallagher AG, Roman SA, et al. Virtual reality training improves
operating room performance: results of a randomized, double-blinded study. Ann
Surg 2002;236(4):458-63.
16. Grantcharov TP, Kristiansen VB, Bendix J, et al. Randomized clinical trial of
virtual reality simulation for laparoscopic skills training. Br J Surg 2004;91(2):
146-50.
17. Di Giulio E, Fregonese D, Casetti T, et al. Training with a computer-based
simulator achieves basic manual skills required for upper endoscopy: a randomized
controlled trial. Gastrointest Endosc 2004;60(2):196-200.
18. Van Sickle KR, Ritter EM, Smith CD. The pretrained novice: using simulation-
based training to improve learning in the operating room. Surg Innov 2006;
13(3):198-204.
19. Boyd KB, Olivier J, Salameh JR. Surgical residents’ perception of simulation
training. Am Surg 2006;72(6):521-4.
20. Draycott TJ, Crofts JF, Ash JP, et al. Improving neonatal outcome through practical
shoulder dystocia training. Obstet Gynecol 2008;112(1):14-20.
21. Wayne DB, Barsuk JH, O’Leary KJ, et al. Mastery learning of thoracentesis skills
by internal medicine residents using simulation technology and deliberate practice.
J Hosp Med 2008;3(1):48-54.
22. Ellis C, Hughes G. Use of human patient simulator to teach emergency medicine
trainees advanced airway skills. Acad Emerg Med 1999;16(6):395-9.
23. Binstadt E, Donner S, Nelson J, et al. Simulator training improves fiber-optic
intubation proficiency among emergency medicine residents. Acad Emerg Med
2008;15(11):1211-4.
24. Overly FL, Sudikoff SN, Shapiro MJ. High-fidelity medical simulation as an
assessment tool for pediatric residents’ airway management skills. Pediatr Emerg
Care 2007;23(1):11-5.
25. Wong DT, Prabhu AJ, Coloma M, et al. What is the minimum training required for
successful cricothyroidotomy?: a study in mannequins. Anesthesiology 2003;
98(2):349-53.
26. Vadodaria BS, Gandhi SD, McIndoe AK. Comparison of four different emergency
airway access equipment sets on a human patient simulator. J Anesth 2004;
59(1):73-9.
27. Thomas F, Carpenter J, Rhoades C, et al. The usefulness of design of experimen-
tation in defining the effect difficult airway factors and training have on simulator
oral-tracheal intubation success rates in novice intubators. Acad Emerg Med
2010;17(4):460-3.
28. Lee AC, Thompson C, Frank J, et al. Effectiveness of a novel training program for
emergency medicine residents in ultrasound-guided insertion of central venous
catheters. CJEM 2009;11(9):343-8.
29. Evans LV, Dodge KL, Shah TD, et al. Simulation training in central venous catheter
insertion: improved performance in clinical practice. Acad Med 2010;85(9):1462-69.
intensive care unit. Simul Healthc 2010;5(2):98-102.
32. Naik VN, Matsumoto ED, Houston PL, et al. Fiberoptic orotracheal intubation on
anesthetized patients: do manipulation skills learned on a simple model transfer into
the operating room? Anesthesiology 2001;95(2):343-8.
33. Ti LK, Tan GM, Khoo SG, et al. The impact of experiential learning on NUS
medical students: our experience with task trainers and human-patient simulation.
Ann Acad Med Singapore 2006;35(9):619-23.
34. Friedman Z, You-Ten KE, Bould MD, et al. Teaching lifesaving procedures: the
impact of model fidelity on acquisition and transfer of cricothyrotomy skills to
performance on cadavers. Anesth Analg 2008;107(5):1663-9.
35. Homan CS, Viccellio P, Thode Jr HC, et al. Evaluation of an emergency-procedure
teaching laboratory for the development of proficiency in tube thoracostomy. Acad
Emerg Med 1994;1(4):382-7.
36. Kneebone R. Evaluating clinical simulations for learning procedural skills: a
theory-based approach. Acad Med 2005;80(6):549-53.
37. Sanchez LD, Delapena J, Kelly SP, et al. Procedure lab used to improve confidence
in the performance of rarely performed procedures. Eur J Emerg Med 2006;
13(1):29-31.
38. Graber MA, Wyatt C, Kasparek L, et al. Does simulator training for medical
students change patient opinions and attitudes toward medical student procedures in
the emergency department? Acad Emerg Med 2005;12(7):635-9.
39. Gordon JA, Tancredi DN, Binder WD, et al. Assessment of a clinical performance
evaluation tool for use in a simulator-based testing environment: a pilot study. Acad
Med 2008;78(suppl 10):S45-7.
40. Hanscom R. Medical simulation from an insurer’s perspective. Acad Emerg Med
2008;15(11):984-7.

Physiological Stress Responses of
Emergency Medicine Residents
During an Immersive Medical
Simulation Scenario
Morris Kharasch, MD, FACEP, Pam Aitchison, RN,
Christopher Pettineo, BA, Laura Pettineo, MA, and
Introduction
High-fidelity simulation is now considered a standard educational tool in
many residency training programs. The Accreditation Council for Grad-
uate Medical Education Residency Review Committee for Emergency
Medicine now allows procedural skills completed in a simulated envi-
ronment to count toward their overall procedural exposure during
residency training.1 The rationale is that these simulated experiences
provide a level of training realistic enough to allow the patient to perform
better in an actual patient experience. Research has also shown that
proficiency demonstrated in simulated settings can translate accurately
into patient care and improve patient safety.2
Measuring the learner’s subjective experience, as compared to the real
clinical environment, is a challenge in the simulation environment.
Proponents of immersive medical simulation claim that participating in a
scenario provides an emotional response that causes the trainees to
respond to the situation as if it were real. This emotional response is
considered an important factor contributing to the simulation’s effective-
ness in embedding the experience in the learner’s memory. We attempted
to objectively measure the learner’s physiological heart rate and blood
pressure response to stress encountered in an immersive medical simu-
lation involving a critically ill patient.
Methods
Twelve resident physicians from a 4-year Emergency Medicine Pro-
gram, representing all levels of training, consented for this Institutional
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FIG 1. 100 millimeters visual analog bar scale.
Review Board approved study. A convenience sample of volunteers was

recruited. Residents needed to report overall general good health. Exclu-
sion criteria included active use of antihypertensive medication or any
potential medical condition that would adversely affect the participant’s
heart rate and blood pressure during the simulated stress. To mitigate any
perception of evaluation as adding to stress level during the simulation,
the residents were clearly told that this was not in any way an evaluative
assessment of their clinical competency and that their performance would
remain confidential. Noninvasive baseline blood pressures and heart rates
of the participants were obtained before participation in the case.
Residents recorded pre-encounter self-assessment of stress level scores on
a 100-mm visual analogue bar scale (Fig 1).
A standardized case of a critically ill patient was presented as a “man
found down.” The METI Emergency Care Simulator adult manikin was
used to during this evaluation. The scenario was standardized such that
the patient’s condition would deteriorate at fixed 2-minute intervals with
the patient transitioning through a variety of lethal arrhythmias and
requiring emergent airway intervention (Table 1). Measurements of blood
pressure and heart rate were taken at fixed intervals during the critical care
scenario, to track the physiological response of participants (Fig 2).
Pre-encounter and postencounter self-assessment stress levels were
recorded on the same 100-mm visual analogue scale for each question.
Residents were asked to identify their stress level by placing a mark on
the 100-mm horizontal bar scale (0 mm ! no distress and 100 mm !
unbearable distress). Subjective stress questions on the prescenario data
form attempted to capture a baseline stress level of the residents’ current
role in general patient care, perceived stress level when caring for a
critically ill patient, and their perceived stress level at this time.
Postscenario questions included the residents’ perceived stress level
immediately after the simulation, their estimated stress level if this were
an actual patient encounter, and a stress estimation if this case was an
assessment of their abilities needed to pass a professional licensing
examination.
TABLE 1. Simulation—“Man down” scenario
Time (min) Event BP HR Pox RR
Start Nurse confederate provides history as follows: 110/75 100 90% 28
this is a 30-year-old male brought in by
paramedics, found in his home by a
concerned neighbor. The paramedics
indicate this is an apparent overdose of an
unknown substance. Patient scripted to
provide unintelligible moans (no further
history available).
2 100/50 110 88% 40
4 70/P 150 86% 40
BP, blood pressure; HR, heart rate; RR, respiratory rate.
FIG 2. Participant’s monitor reading during simulation scenario. (Color version of figure is
available online.)
Results
All the residents’ heart rate and systolic blood pressure increased during
the management of the case. The mean increase in heart rate was 42 bpm
over baseline with a range of 21 bpm to 72 bpm; the mean systolic blood
pressure increase was 23 mm Hg. One of the cases was stopped before
completion when there was concern for a resident whose pulse reached
170 (Table 2).
Residents recorded mean pre-encounter self-assessment of stress levels
of 39.2 mm on a 100-mm visual analogue score and postencounter stress
levels of 49 mm, 59 mm if the case were a real patient, and 72.1 mm if
the case were hypothetically to be used as criteria for passing a
certification examination. Despite the physiological stress response trig-
TABLE 2. Participants’ physiological data during the simulation
Mean heart rate increase 42 beats per minute
Range of heart increase 21-72 beats per minute
Mean systolic blood pressure increase 23 mm Hg
Willingness to participate in future sessions 12 of 12 participants
gered by the study, 100% of the study participants (n ! 12) indicated they
are willing to participate in future sessions.
Discussion
One of the major goals of high-fidelity simulation is to create a realistic
environment that reproduces the actual patient experience as closely as
possible to generate a required emotional response. Quantifying the
perceived reality of a high-fidelity experience is often a subjective
measure. Ideally the learner interacts with the manikin in the immers-
ive environment as they would with an actual patient. Comments by the
learner over the years have said they almost all uniformly feel as if they
are taking care of a real patient, especially as the case progresses. These
are important subjective evaluations, but do not quantify how much they
felt the simulation was “real.”
We hypothesized that the physiological response of the participants’
heart rates and blood pressures could act as a surrogate marker for their
subjective evaluations of the reality to simulation. We did not determine
the effect of individual factors’ contributions to the stress level. We told
the residents that we were not evaluating their performance in the case,
but we did not assess whether this may have decreased their perceived
stress level. The simulation scenarios involved several observers (the
ancillary personnel, nurses, and technicians) and being physically con-
nected to the monitors. The fact that they were being observed may have
increased their stress level. However, these participants had been working
in the Emergency Department (ED) already and had been accustomed to
being observed by nurses and technicians, as well as by their attending
physicians. Furthermore, participants’ perceived stress may have in-
creased just by having noninvasive monitoring on their body during the
case.
Simulations are demonstrably both physically and psychologically
stressful for residents.3 These findings suggest that treating a patient
simulator can indeed be similar to treating a real critically ill patient.
Physiological arousal suggests that the residents developed a sense of
urgency and responsibility for managing the simulated patient. Because
stress and chaos is common in the ED, staff must learn to function
competently within such an environment. Triggering genuine internal
stress is likely a significant factor in creating authenticity in a simulation
laboratory for an ED staff member.
Although it is not possible from our data to delineate the specific factors
responsible for creating a realistically stressful laboratory experience in a
“man down” scenario, one can reasonably assume that the situation
closely parallels a genuine life-threatening case. Similar to emergency
medical cases, this particular case requires participants to respond to the
simulator’s rapidly deteriorating state, to make quick decisions, and to
demonstrate good technical skills. A future area of study would be to
compare how a resident copes with elevated stress levels and high
emotional acuity during a medical simulation with their performance in
an actual clinical setting.
Psychological stress can be enormously beneficial in terms of decision-
making, memory retrieval, and focus. It can also significantly interfere
with cognitive processes and performance. Studies have shown that the
relationship between stress and performance is most accurately reflected
by a bell curve. In general, an optimal amount of stress tends to improve
performance.4 Although an optimized level of stress can enhance clinical
ability, too much stress may lead to poorer performance and possibly
place a patient’s life at increased risk. It is imperative that physicians in
training have opportunities to practice coping with highly stressful
external situations that trigger an internal stress response. Increased
self-awareness of stress triggers and coping mechanisms may help a
clinician take textbook and conceptual knowledge and transfer it more
successfully into clinical and procedural performance. A clinician who is
unable to determine when their stress level is interfering with perfor-
mance is more likely to become overwhelmed and make mistakes that are
potentially lethal for the patient.5
Because we have demonstrated that residents can experience physio-
logical arousal from treating simulated patients using an immersive
environment, the next steps would be to determine whether these levels
accurately represent their response to real clinical situations, whether the
degree of response correlates with difficulty of a case, and whether the
responses correlate with the realism of specific patient simulations. Data
involving the arousal levels during various simulated scenarios may be
useful predictors of anticipated difficulty with those cases. Furthermore,
would failure to elicit a stress response during a contrived emergency case
indicate lack of viability or usefulness of that specific case? Are certain
simulation scenarios more able to trigger a stress response than others?
This investigation was limited to emergency medicine trainees. How-
ever, stress response variables using high-fidelity patient simulators may
be generalizable to training in many other medical specialties, such as
anesthesiology, critical care, internal medicine, obstetrics, pediatrics, and
surgery. Anecdotally, there are different “personality types” in different
fields of medicine. Surgery, anesthesia, critical care, obstetrics, and
emergency medicine are commonly thought of as fields where clear and
decisive thinking under pressure is a valued skill. Other fields are more
“cerebral” and rarely involve high-pressure situations. There may come a
day when stress levels during a standardized set of cases may help
medical students with their specialty choices. By helping them discover
and become self-aware of their own stress response coping mechanisms,
it could allow them to decide the field of medicine that may best suit
them.
Conclusions
Although patient simulators currently do not fully re-create the demands
placed on a physician during a life-threatening case, this investigation
suggests that simulations can trigger a very “real” stressful experience.
We were able to demonstrate that residents adequately “suspended
disbelief” and performed “as if” it were real. All participants indicated
interest in future participation in medical simulation, despite the stress
provoked. The opportunity to practice clinical skills in a realistic
environment has previously been limited to actual clinical settings in
which death was always a possibility. Simulations provide invaluable
opportunities for medical trainees to practice their critical care and
thinking skills under very real stress. The obvious difference is also a
critical one: a trainee can learn to harness their own stress response
without placing patients’ lives at risk.
REFERENCES
1. Accreditation Council for Graduate Medical Education. Emergency Medicine
Guidelines—Procedures and Resuscitations. Retrieved from: http://www.acgme.
org/acWebsite/RRC_110/110_guidelines.asp. Accessed 2011.
3. Shapiro SL, Shapiro DE, Schwartz GE. Stress management in medical education:
a review of the literature. Acad Med 2000;75:748-59.
4. Medin D, Ross B, Markman A. Cognitive Psychology. New York: John Wily and
Sons, 2002.
5. Huebner LA, Royer JA, Moore J. The assessment and remediation of dysfunctional
stress in medical school. J Med Educ 1981;56:547-58.
Use of Mannequin-Based Simulators
in Anesthesiology
Arthur J. Tokarczyk, MD, and
Steven B. Greenberg, MD
Introduction
The field of anesthesiology is one of the first medical specialties to use
high-fidelity simulation in a quest to improve patient safety and reduce
human errors. Medical mistakes have been shown to result in significant
morbidity and mortality,1 including preventable adverse anesthetic
events.2 “See one, do one, teach one” may be inadequate to educate
trainees on complex procedures and skills, let alone communication and
leadership required during critical situations. Traditionally, long hours of
the working day and on-call shifts provided the crude exposure to these
experiences, but restrictions and streamlining of the time spent in the
hospital reduce the exposure to various situations. Simulators may
provide training on less common, but critical, events, while standardizing
the residents’ approach to these situations. Furthermore, simulations
require the ability to physically put into practice knowledge, and solidify
learning by creating an emotional attachment through the juxtaposition of
making a decision and realizing the consequences.
The limitations of adequately preparing for uncommon or dangerous
events can limit the ability to adequately manage such events. Throughout
history, humankind has been confronted with numerous situations for
which he has been unable to anticipate or master. Historically, the ability
to fully prepare for battle was restricted because of safety concerns for
both the trainee and the trainer. The Roman soldiers developed fighting
simulators, or “quintains,” to replicate the actions that would be danger-
ous to practice.3 This ability to practice individual skills is similar to
modern task trainers, while more advanced computerized simulators now
allow for replication of an entire environment, from flight simulators to
full multinational war games. The military, aircraft, medical, and nuclear
power industries are just a few notable employers of modern simulators.
By training and evaluating personnel through simulators, a variety of
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situations can be replicated reliably. This permits an environment of
learning with minimal risk to the people being tested or subjects involved
in the scenario.
History of Anesthesia Simulators
The history of mannequin-based anesthesia simulators follows two
distinct phases. The first such electromechanical simulator was Sim One,
developed by Sierra Engineering Company in the late 1960s. This was
developed for the University of Southern California and was able to
replicate an impressive number of signs, including heart sounds and
peripheral pulses, and had the ability to sense a mask placement and
endotracheal intubation. It had the ability to identify four commonly used
medications (succinylcholine, thiopental, methoxamine, and ephedrine)
and used dose-time-effect curves for drug responses. Despite the apparent
need for this type of simulator, its inability to keep up with the current
progression of anesthetic practice eventually led to its demise.
Over the next twenty years, several factors supported a resurgence of
interest in anesthesia simulators. Public attention to aviation, space, and
nuclear power industries underscored the need for hands-on preparations
and crisis management. Advancements in technology, namely the avail-
ability and power of modern computer processing, allowed for the
operation necessary in a high-fidelity simulator. Improved medical
monitoring allowed for replication of electrocardiogram and pressure
transducer waveforms and thus allowed replication of the operating room
environment. This culminated in the next iteration of a mannequin-based
simulator, Comprehensive Anesthesia Simulation Environment in 1986.
Using a modified mannequin, endotracheal intubation and breath sounds
were available, along with placement of intravenous catheters. The
operating system followed a script-based logic, rather than modeling of
physiological or pharmacologic systems. CAE-Link, a manufacturer of
military and space flight simulators, licensed the Comprehensive Anes-
thesia Simulation Environment system and sold it to MedSim Eagle
Simulation. Although it stopped production in 2000, many of these
systems continued operation for years.
In the late 1980s, a team led by Good and Gravenstein at the University
of Florida, Gainesville, developed a simulator with accurate physical
replication of gas exchange involving oxygen, nitric oxide, nitrogen, and
a volatile anesthetic. Instead of scripted or operator-driven controls, the
values were based on mathematical models of gas uptake and exchange.
This was initially sold by Loral Data Systems (Sarasota, FL) and then
expanded by Medical Education Technologies, Inc (METI) (Sarasota,
FL). At that point, it became the Human Patient Simulator, with a more
economical, mobile version named Emergency Care Simulator in 2003.
Current advancements in the Human Patient Simulator permit respiratory
gas exchange, papillary responses, thenar twitch for monitoring of
peripheral nerve stimulation, automated responses to administered drugs,
variations in lung compliance, and measurement of urine output.
The SimMan mannequin simulator was introduced in 2000 by
Laerdal (Stavanger, Norway), with a background of already producing
mannequins for Basic and Advanced Cardiac Life Support training
devices. Unlike the METI simulators, the SimMan uses a script-based
system with operator-driven controls of vital signs and settings. It
allows for intubation with changes in lung compliance, intravenous
line placement, papillary responses, Foley catheter placement, and
gastric tube placement. A more recent 3G version of this simulator
adds wireless operation, allowance for the insertion of intraosseous
lines, drug recognition, release of secretions (sweat, cerebrospinal
fluid, froth), and more detailed ocular and cardiopulmonary resusci-
tation feedback.
Current iterations of a mannequin-based simulator often include a
completely immersive environment designed to replicate a location, such
as an operating room, with multiple personnel, equipment, stimuli, and a
“patient.” These are typically used to stimulate behavioral responses, such
as communication and leadership qualities, in addition to assessment
and management skills. Unfortunately, these have typically been
immobile and expensive and require significant operator training and
preparation. In contrast, a training device or task trainer focuses on a
specific set of skills or procedure, such as a central venous catheter
placement or lumbar puncture. These devices are portable and do not
require an operator.
For specific procedures or skills, task trainers or devices are able to
provide the necessary elements for practice. This can be considered a
flight simulation for landing an aircraft or a mannequin for placement of
a central venous catheter. It does not allow for the complete management
of a situation, but it allows the trainee to focus on a core skill set. During
a crisis situation, either simulated or real, the needs of patient care
supersede the needs of the trainee. This has been demonstrated in airway
management training, in which proficiency in a simple task, such as
endotracheal intubation, is more rapidly achieved with focused training
and simulation.4 A full discussion of this type of training device is beyond
the scope or focus of this section.
Current Anesthesia Practice
Most current high-fidelity mannequin-based simulators are used for the
education of trainees. Although it has been used to train a variety of
medical personnel, these simulators have been predominantly located
within academic departments and used for anesthesiology residents. With
the ability to imitate an entire environment with multiple personnel, these
simulators are used to provide advanced training in crisis resource
management with a multidisciplinary team of hospital personnel. This
would require integration of the specific individual skills of each member,
such as Anesthesiology, Nursing, Surgery, etc, with general behavioral
skills, such as communication, leadership, delegation of duties, and
teamwork. A typical scenario would include a common or uncommon
life-threatening event and would require the trainee to properly assess the
situation to derive the proper diagnosis. Anesthesiologists often need to
reliably “manage unusual but lethal events.”5 Oftentimes the initial stages
of stabilization and management follow similar pathways, but the resident
anesthesiologist must learn to perform these actions while going through
and updating a differential diagnosis. The paucity of formally training the
behavioral skills is very real, and measures of progression and learning
these skills are poorly defined. Assessment scales often fall back on
checklists, which often fail to capture the trainee’s behavioral aspects, or
global rating scales, which may be subject to significant interrater
variability.
As the benefits and availability of the simulators become more avail-
able, so do the applications. Simulator programs can be devised to meet
almost any situation, from complex events to remedial topics. Intuitively,
clinical performance is typically believed to be improved with simulator
training.6 Realistic evaluations of physician performance are becoming
valued over simple factual knowledge, evidenced by the recent addition
of a simulation requirement for anesthesiology certification. Evaluations
and comparisons of simulator training often include comparisons to a
control group without the benefit of simulator training. If the chosen
measurement of knowledge or improvement is via a simulator, the benefit
of simulator training may be simply owing to “teaching to the test.”7
More recently, high-fidelity simulators have been shown to improve the
novice residents’ management of core topics in the operating room.8,9 An
additional uncommon, but necessary, subject of anesthesiology residency
is the process of weaning from cardiopulmonary bypass. Senior anesthe-
siology residents who participate in simulations of cardiopulmonary
bypass have demonstrated improvements in their performance.10 In
addition to resident training, high-fidelity simulators certainly have
applications in training medical students11 for core topics in pathophys-
iology and management, although exposure of specific anesthesiology
topics for medical students has been limited to date.
High-fidelity simulation training is used not only for partial tasks,
procedures, and material at the trainee level, but also for multidisciplinary
and behavioral skills. Although knowledge and judgment have been
tested at all stages of an anesthesiologist’s career, crisis management,
leadership, and teamwork have not. It was recognized with the resurgent
interest in simulators that anesthesiologists were not specifically trained
in crisis management,5 which is similar to the concomitant needs of the
aviation industry. Similar to the traditional training of airline pilots,
anesthesiologists were expected to develop or absorb the necessary
critical skills simply by experience and repeated exposure to more
experienced personnel. Learning does not end with formal training and
skills, such as crisis resource management and postcrisis resident debrief-
ing, can be practiced.12 In fact, the growing support that simulator-based
training translates into real-world performance can yield more concrete
benefits (i.e. malpractice insurance premium reductions for simulator-
trained anesthesiologists).12
With the ability to more closely approximate a realistic practice
environment, a high-fidelity simulator would theoretically be able to
assess performance during a real event. Written examinations test
memory, knowledge, and simple judgment. By involving a live examiner,
oral examinations are able to test problem solving skills and more
in-depth judgment, without concentrating on simple knowledge of the
material. With simulators, the examinee will need to use problem-solving
and judgment while physically performing actions in real-time. No longer
able to ponder a corrective measure or simply explain a sequence of
decisions, the examinee must be able to assess a situation and provide the
diagnosis while performing supportive and corrective measures.
At the trainee level, simulators have been used to evaluate senior
residents.13,14 Adding simulations of essential topics, such as resuscita-
tion and trauma scenarios, to an oral examination, Savoldelli and
coworkers were able to demonstrate moderate correlations with the
traditional oral examination. With this in mind, they rightly stress that the
residents that “know how” may not be able to “show how” in realistic
situations.14 This use of performance assessment for residents is still a
type of training to correct deficiencies and inappropriate decision-making.
Simulator-based performance assessments are being integrated into the
assessment and certification of anesthesiologists. Evaluations of perfor-
mance are still uncommon,15 but simulator-based examinations have been
recently incorporated into the Israeli National Board Examination in
anesthesiology.16 The American Society of Anesthesiologists (ASA) has
emphasized the value of the simulator as an assessment tool for practicing
anesthesiologists by adding a simulator component to the Maintenance of
Certification in Anesthesiology. Although still in its infancy, the optimal
frequency of simulator assessments is yet to be determined and the
breadth of topics may be limited because of the time invested in each
simulator session. If the focus lies heavily with routine, albeit critical,
events, more uncommon and equally threatening processes may go
untested. The ASA Committee on Simulation Education believes that
anesthesiology training should focus on hemodynamic events, hypoxemic
events, and teamwork. As a result, this may foreshadow the focus of
certification testing by the ASA.
This hesitation to using the simulator as an assessment measure lies in
additional assessments of validity beyond the choice of subject material.
Although simulators often receive very high satisfaction scores11 and are
often desired as an addition to the medical student and resident training
curriculum, quantitative measures of the simulator as an assessment tool
have been more elusive. The examinee’s performance on the simulator
has been shown to correlate with written or clinical assessments of
performance,13 although this has not been entirely consistent.17,18 Part of
the discrepancy could be due to the choice of performance measures:
what is a critical step for one operator or examiner may only be optional
for another one. Whether to use checklists for assessment or global
performance measures depends on the task at hand. Furthermore, famil-
iarity and comfort with the simulator process will not be universal, as not
all anesthesiologists have the ability to practice with state-of-the-art
simulators. Variations in simulator conduct, assessment measures, and
debriefing techniques may affect the benefits and reliability of simulator
training. The type of simulator could have a significant effect on the
participant’s ability to understand and collect information. The ability to
suspend disbelief and act in a realistic manner is a potential concern with
less realistic simulators, although little information supports this theory
with simpler tasks19,20 as opposed to the benefit in more complex
events.21 The process of reflecting on one’s own performance is believed
to be one of the more significant sources of learning with simulators.
Participants are able to objectively assess their own performance without
the distraction of recall bias. The ability to reflect on one’s own
performance appears to be significant in solidifying the experience.22
Last, knowing what to do and actually doing it are not necessarily one in
the same.
Future Course of Anesthesia Simulation
The current progression of simulator training is consistent with the more
universal availability of high-fidelity and mannequin-based simulators.
Initially restricted to well-funded academic centers, simulators within the
United States are slowly becoming more common and accepted. The
reason for growing acceptance and use are due to the expanding objective
benefits in training and assessment of performance. With advances in
technology come improvements in fidelity. Resistance to use of simula-
tors because of financial and time limitations23 can be obviated with
demonstration of cost savings12 and improvements in efficiency of
training. Further public appreciation of simulator-based training benefits
and association with other high-reliability fields will allow for further
allocation of resources for purchasing simulators.
With greater availability of simulator facilities, the potential benefits of
simulators may be realized. Not only can clinical expertise, and, theoret-
ically, safety be improved with simulator-training, but equipment and
procedural expertise can be enhanced with simulator training. No longer
restricted to testing anesthesiologists, simulators can be a medium to
evaluate hospital processes and performance measures of ancillary
support staff in more critical situations.24 Trials of new equipment and
techniques no longer require real patient risk, and clinical processes, such
as intelligent monitors, can be evaluated for efficacy.25 An added depth of
understanding can be added to retrospective evaluations of adverse
events, as in the traditional morbidity and mortality presentation. With the
ability to replicate events, personnel and processes can be evaluated to
determine if similar errors are simply happenstance or unavoidable.
The evolution of computer processing allowed for modern high-fidelity
simulators, and so the future of anesthesia simulators will also be driven
by technologic advancements. A potential next step after mannequin-
based simulators would be virtual reality-based simulators. These simu-
lators may have the ability to replicate the complete operating room
experience, including the patient and additional support personnel. Haptic
feedback and artificial intelligence can reduce the needs for additional
personnel and customize the experience for the subject using the
simulator.26 Virtual reality would allow the simulator to re-create not only
the environment, but also personnel, patients, and staff within the
simulation. Artificial intelligence could improve the ability to mimic a
realistic environment while reducing the number of simulator operators.
It may also allow for customization of the responses and situations based
on the trainee’s needs and abilities.
REFERENCES
1. Kohn L, Corrigan J, Donaldson M. To Err Is Human: Building a Safer Health
System. Washington, DC: National Academies Press, 1999.
2. Chopra V, Gesink BJ, De Jong J, et al. Does training on an anaesthesia simulator
lead to improvement in performance? Br J Anaesth 1994;73:293-7.
3. Good ML, Gravenstein JS. Anesthesia simulators and training devices. Int
Anesthesiol Clin 1989;27:161-66.
4. Tatiyanupunwong S. Optimum cases for predicting the success rate of endotracheal
intubation in Thammasat University’s medical students. Thamassat Med J
2008;8:436-44.
5. Gaba DM. A brief history of mannequin-based simulation and applications. In:
Dunn WF, editor. Simulators in Critical Care and Beyond. Mount Prospect, IL:
Society of Critical Care Medicine, 2004. p. 7-14.
6. Kuduvalli PM, Parker CJ, Leuwer M, et al. Retention and transferability of team
resource management skills in anaesthetic emergencies: the long-term impact of a
high-fidelity simulation-based course. Eur J Anaesthesiol 2009;26:17-22.
7. Steadman RH. Improving on reality: can simulation facilitate practice change?
Anesthesiology 2010;112:775-6.
8. Park CS, Rochlen LR, Yaghmour E, et al. Acquisition of critical intraoperative
event management skills in novice anesthesiology residents by using high-fidelity
simulation-based training. Anesthesiology 2010;112:202-11.
9. Scavone BM, Toledo P, Higgins N, et al. A randomized controlled trial of the
impact of simulation-based training on resident performance during a simulated
obstetric anesthesia emergency. Simul Healthc 2010;5:320-4.
10. Bruppacher HR, Alam SK, LeBlanc VR, et al. Simulation-based training improves
physicians. Anesthesiology 2010;112:985-92.
students. Acad Med 2001;76:469-72.
12. Blum RH, Raemer DB, Carroll JS, et al. Crisis resource management training for
an anaesthesia faculty: a new approach to continuing education. Med Educ
2004;38:45-55.
13. Schwid HA, Rooke GA, Carline J, et al. Evaluation of anesthesia residents using
mannequin-based simulation: a multiinstitutional study. Anesthesiology 2002;97:
1434-44.
14. Savoldelli GL, Naik VN, Joo HS, et al. Evaluation of patient simulator performance
as an adjunct to the oral examination for senior anesthesia residents. Anesthesiol-
ogy 2006;104:475-81.
15. Morgan PJ, Cleave-Hogg D. A worldwide survey of the use of simulation in
anesthesia. Can J Anaesth 2002;49:659-62.
16. Berkenstadt H, Ziv A, Gafni N, et al. Incorporating simulation-based objective
structured clinical examination into the Israeli National Board Examination in
Anesthesiology. Anesth Analg 2006;102:853-8.
17. Morgan PJ, Cleave-Hogg D. Evaluation of medical students’ performance using the
anaesthesia simulator. Med Educ 2000;34:42-5.
18. Morgan PJ, Cleave-Hogg DM, Guest CB, et al. Validity and reliability of
undergraduate performance assessments in an anesthesia simulator. Can J Anaesth
2001;48:225-33.
19. Nyssen AS, Larbuisson R, Janssens M, et al. A comparison of the training value of
two types of anesthesia simulators: computer screen-based and mannequin-based
simulators. Anesth Analg 2002;94:1560-5.
20. Friedman Z, You-Ten KE, Bould MD, et al. Teaching lifesaving procedures: the
impact of model fidelity on acquisition and transfer of cricothyrotomy skills to
performance on cadavers. Anesth Analg 2008;107:1663-9.
ment skills. Crit Care Med 2006;34:151-7.
22. Morgan PJ, Tarshis J, LeBlanc V, et al. Efficacy of high-fidelity simulation
debriefing on the performance of practicing anaesthetists in simulated scenarios.
Br J Anaesth 2009;103:531-7.
23. Savoldelli GL, Naik VN, Hamstra SJ, et al. Barriers to use of simulation-based
education. Can J Anaesth 2005;52:944-50.
24. Weller JM, Merry AF, Robinson BJ, et al. The impact of trained assistance on error
rates in anaesthesia: a simulation-based randomized controlled trial. J Anesth
2009;64:126-30.
25. Larsson JE, Hayes-Roth B, Gaba DM, et al. Evaluation of a medical diagnosis
system using simulator test scenarios. Artif Intell Med 1997;11:119-40.
26. Cumin D, Merry AF. Simulators for use in anaesthesia. J Anesth 2007;62:151-62.

Critical Care Simulation
Steven B. Greenberg, MD, Arthur Tokarczyk, MD,
and Stephen Small, MD
Introduction
Health care providers continue to look for ways to prevent devastating
medical errors that the Institute of Medicine has estimated contributes to
approximately 98,000 deaths per year in the USA.1 The incidence of
intensive care unit (ICU) medication errors ranges from 3% to 27%
depending on the definition and study design.2 Conventional didactic
teaching alone has not been shown to reduce fatal medical mistakes.
Leaders in critical care have begun to adopt innovative ways such as
simulation to educate providers in an attempt to further reduce ICU-
related medical errors.3
Simulation is defined as “the imitative representation of the functioning
of one system or process by means of the functioning of another.”4 Often
times, critical care staff must make timely, effective decisions during
emergency situations. However, real-life emergency events may not
occur with the required frequency for appropriate training. Simulation is
a vehicle by which a variety of clinical situations and uncommon
phenomenon can be presented to a large group of providers to enhance the
individual and group experience. This style of training may transform the
“see one, do one, teach one” dogma into a process that focuses on
“rehearsal, repetition, and reaction within a master-apprentice atmo-
sphere.”5 Simulation (life-size mannequins and equipment used to ap-
proximate reality as 1 example) can foster a multidisciplinary approach to
critical learning without risking harm to patients. This essay discusses the
ongoing development of simulation training in critical care, the early
research supporting its role in education and outcomes, and the future
tasks of simulation in the ICU.3
The recent reduction in resident work hours mandated by the Accred-
itation Council of Graduate Medical Education coupled with the Institute
of Medicine’s recommendation to establish multidisciplinary training via
simulation has paved the way for an increase in the development of
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nationwide state-of-the-art simulator centers. Historically, simulation was
a cost-conscious, expedient method to train pilots for war. Modern day
medical training first used mannequins to train health care staff how to
perform cardiopulmonary resuscitation or auscultate breath and heart
sounds. Beginning in the 1990s, full-size computer-driven human-like
medical simulators were developed to provide a more real life experience
for health care providers. In 2004, it was projected that greater than 1000
simulator centers were created worldwide for medical training.3,6
Presently, there are 3 major simulator systems used for critical care
training. The Medical Education Technologies (METI, Sarasota, FL) is
the most inclusive device, but it carried the highest price tag.3 Newer
models from METI have brought the cost down to approximately
$50,000-$80,0000. Gaumard Simulators (Miami, FL) for Education has
recently focused on advancing the newborn and maternal parturient
models for simulation. This simulator company markets their simulators
for approximately $25,000-$35,000. Several institutions use the Laerdal
Medical SimMan (Wappingers Falls, NY) for critical care simulation,
which is an affordable multipurpose simulator that allows for training of
large groups because of the ability for centers to purchase several
simulators.3 This simulator usually costs between $35,000 and $80,000.
Laerdal Medical SimMan allows for instructors to talk through a
microphone, which projects through the simulator or allows for prere-
corded sounds to be used. Both Gaumard and Laerdal simulators drive
their own monitoring systems. The advantage of this style of simulator is
that the system is more simplistic. However, these systems are not fully
capable of connecting to hospital monitors in alternative locations. The
METI system can drive monitors of any kind, but it is very complex to run
and setup.
There are a variety of critical care simulated physiological parameters
that are achieved through these simulators: pulses are palpable; breath
sounds are auscultated; and carbon dioxide can quantitatively be mea-
sured. Trainees can also learn how to intubate the airway, perform
cricothyroidotomies, and perform needle decompression for pneumotho-
races. The accurate replica of the bronchial tree allows for fiberoptic
bronchoscopy training. These systems also support the ability to perform
external defibrillation and pacing. Operation of the simulator is via a
computer that records all data and updates the operator regarding the
trainees’ progress during the simulation. Numerous clinical scenarios can
be easily programmed. Physiological responses are manually controlled
or preprogrammed to recognize certain responses from the trainees. All of
these components attempt to reproduce reality for the training group.3,7
Recently, the previously mentioned simulator systems have been
incorporated into the actual ICU environment with specialized critical
care technologies (ie, infusion pumps, central venous catheters, arterial
lines, etc) to truly mimic real-life experiences.8 In situ simulation is a
team-oriented strategy that takes place in the ICU and involves ICU team
members and organizational platforms. This type of simulation practice
reproduces stressful critical scenarios that require effective team interac-
tions and group decision-making. By engaging in simulation training in a
real ICU setting where patient care is provided, in situ simulation hopes
to achieve high fidelity.9 A recent study reported using in situ simulation
to identify and resolve latent environmental threats to patient safety.10
Another study used in situ simulation to recreate 14 unannounced cardiac
arrests for health care providers to respond to in diverse locations in a
tertiary care hospital.11 Twenty-four hazardous errors were identified
during these exercises that could have been a significant threat to the
safety of patients.11 Identification of these errors through in situ simula-
tion lead to the development of policies and procedures that may prevent
recurrences. Therefore, in situ simulation of critical events may be a tool
used to improve the quality of critical care services delivered to patients.
Through the above technologies, human patient simulation (HPS) can
re-create the real-life environment of critical care, where trainees must
use higher analytical skills to complete the presented task. HPS may result
in an improvement in long-term performance, a reduced response time,
and an increased adherence to standard of care practices.12 It can also
provide an environment for testing, evaluation, and feedback. The
multidisciplinary critical care team may also engage in hands-on experi-
ence practicing team communication and interaction under patient-
simulated life-threatening circumstances. During these events, providers
may learn and enhance skills in leadership, followership, conflict resolu-
tion, and delegation.12
The Peter M. Winter Institute for Simulation Education and Research
Center at the University of Pittsburgh Medical Center is one of the earliest
and most advanced centers that offers critical care medicine simulation
courses for a multitude of health care providers.3 Since its inception in
1994, this center has grown to nearly 11,000 sq ft with 16 simulators.3 It
has been responsible for training over 8000 health care providers during
8500 simulations.3 This simulation center trains a variety of providers,
including: medical students, residents, fellows, attending physicians,
student nurses, nurses, pharmacists, respiratory therapists, and paramed-
ics. Some of the highlighted critical care courses include crisis team
training, difficult airway management, fiber-optic bronchoscopy training,
and cardiopulmonary resuscitation.3
Because simulator centers like the one mentioned at the University of
Pittsburgh Medical Center do cost a substantial amount of human and
financial resources, several efforts worldwide are attempting to prove that
simulation can enhance provider satisfaction with learning, improve
provider skill, and improve patient outcomes.13 A recent study by Healey
et al demonstrated that simulation courses for internal medicine residents
resulted in an improved self-reported confidence in resuscitation knowl-
edge and skills.14 Similarly, Cooke et al demonstrated that residents were
more confident in performing critical care skills after engaging in clinical
simulation.15 Another study observed that medical students preferred ICU
simulation training over the experience of direct patient care.16 Still, it is
unclear to whether increased trainee confidence will lead to improved
trainee skill.
Technical Skills
Emerging evidence supports the notion that simulation may improve
trainee clinical skill. Studies demonstrate that simulation training can
improve residents’ performance in critical care technical skills, such as
central line placement, endotracheal intubation, and bronchoscopy.13
Other studies have shown that simulation may improve efficiency in
mastering the above technical skills.13 A recent randomized controlled
trial compared traditional methods of teaching central venous catheter
(CVC) insertion with simulation training.16 This study demonstrated that
simulation training of CVC placement was associated with immediate
significant improvement in trainee performance.16 However, these skills
declined over time and simulation did not show a significant benefit over
traditional methods at 3 months after the exercise.16 Further studies will
be needed to investigate the long-term benefits of simulation on improv-
ing trainee technical skills.
Nontechnical Skills
Nontechnical skills, such as team leadership, communication, and
delegation, may be more important to the effectiveness of a multidisci-
plinary ICU than technical skills.13 Simulation training combined with
postsimulation debriefing has been shown to improve team performance
by increasing collaboration and teamwork.13 Simulation has also been
associated with improving physicians’ ability to lead and communicate in
a multidisciplinary environment.12,13 The use of videotaping can facilitate
group and individual review without putting patients at risk. Human
simulation may also improve teamwork by allowing for activities to be
repeated, thereby enhancing experiential learning.7 Integrated training
programs, such as the SAINT (Simulation Applied to Intensive Care
medicine and Nursing Training) program, may help facilitate improved
multidisciplinary provider decision-making in critical patient care situa-
tions.7 This training program focuses on the nontechnical skills of critical
care (ie, leadership, followership, effective communication, and team-
work).
Critical care provider practices can also be evaluated during simulation
exercises. A recent pilot study demonstrated that simulation may be used
to investigate physician varying beliefs and practices regarding end-of-
life decisions.17 Fuhrmann et al developed a multidisciplinary simulator
course in Denmark to help improve provider early recognition of
deteriorating patients.18 Other small observational studies have used
simulation to detect compliance of sepsis bundle practices.19,20 Further
studies should validate the effectiveness of these simulation training
exercises.7
Scoring Systems
To further validate simulation for critical care training, performance
measuring systems continue to be devised. Group and individual check-
lists, scorecards, and verbal reviews have been used to improve trainee
ability to reflect on personal simulation experiences without added direct
patient care stress.12,13 One of the proposed objectives for improved
learning is to couple checklists with debriefing sessions to help promote
both individual and group self-discovery. This way, the learners may be
able to recognize their own deficiencies and come up with solutions on
how to correct them. Researchers have recently demonstrated that with a
combination of the appropriate examination stations and raters, accurate
and reliable measurements of trainee clinical skills can be performed.13
Ottestad et al devised scoring systems for evaluating a multidisciplinary
group of residents managing simulated patients with septic shock.21 Both
technical and nontechnical skills were evaluated. Participants’ scores
demonstrated both acceptable and poor levels of performance.21 Musac-
chio et al used a 3-way scoring method (ie, pre/postexercise testing,
survey feedback, and videotaped replay) to assess trainee learning in
neurocritical care.22 Using simulation and the scoring method mentioned,
the authors observed an average 25% improvement in trainee understand-
ing of neurocritical care topics, such as spinal shock, cerebral vasospasm,
and closed head injury.22 Still, limitations, such as the validity of the
simulated atmosphere, the inflexibility of the scoring methods, and the
lack of consistency of incorporating external clinical cues into simulation,
must be addressed before universal adoption of HPS into professional
evaluation and credentialing.13
Patient-Related Outcomes
Studies supporting ICU simulation exercises in improving patient
outcomes are limited. Barsuk et al demonstrated that with the initiation of
a CVC insertion simulation program, catheter-related bloodstream infec-
tions were reduced.23 Wayne et al observed through a case-controlled
study that simulation-based Advanced Cardiac Life Support (ACLS)
training resulted in improved resident performance during real-life
resuscitations.24 Another study used simulation to improve the incidence
of critical care nurses providing crucial communication during hand-
offs.25 Although these studies and others do not directly indicate
improved patient outcomes with simulation, it would appear that with
increased provider experience and confidence that future studies may
show a clearer correlation.
Future Goals of Critical Care Simulation
There continues to be several opportunities for further examination of
the utility of simulation for critical care. First, further data are required to
determine whether increased knowledge, experience, and confidence
developed through simulation will translate into improved delivered
patient care and outcomes in the critical care setting.13 Second, further
studies will need to focus on validating evaluation tools for assessment of
provider performance. Only then can simulation be used on a widespread
basis for professional certification and recertification. Third, further
investigation is required to develop strategies that sustain initial improve-
ments in performance seen with simulation training. Last, cost– benefit
ratio studies are required to further justify the extraordinary financial
resources required to create simulator centers nationwide.13
Conclusions
Simulation appears to be an ideal form of training for critical care
providers. It can provide practitioners with enhanced learning in critical
care physiological principles, technical skills, and nontechnical skills. It
may be able to improve the effectiveness of the multidisciplinary
approach by providing repetitive, experiential learning. Improved perfor-
mance may occur without the direct risk to patients. Re-creating an
environment where health care providers can engage in rare and more
common critical events may be the closest style of training to real-life
situations. Further growth in simulation technology will continue to aid
this effort. Although simulation will not likely replace traditional teaching
methods, it can serve as an appropriate complement to allow for trainees
to gain the best experience for preparing to take care of the critically ill.
This article reviews the past, present, and potential future applications of
critical care simulation. With its rising popularity among trainees, health
care providers, and government, ICU simulation will continue to help
shape the future educational platform for critical care education.
REFERENCES
1. Kohn KT, Corrigan JM, Donaldson MS. Institute of Medicine: To Err Is Human:
Building a Safer Health System. Washington, DC: National Academies Press,
1999.
2. Moyen E, Camiré E, Stelfox HT. Clinical review: medication errors in critical care.
Crit Care 2008;12:208-15.
3. Grenvik A, Schaefer JJ, DeVita MA, et al. New aspects on critical care medicine
training. Curr Opin Crit Care 2004;10:233-7.
4. Simulation. Retrieved 2010 http://www.merriam-webster.com/dictionary/simulation.
Accessed; 2011.
5. Croley WC, Rothenberg DM. Education of trainees in the intensive care unit. Crit
Care Med 2007;35:S117-21.
6. Hammond J. Simulation in critical care and trauma education and training. Curr
Opin Crit Care 2004;10:325-9.
7. Fox-Robichaud AE, Nimmo GR. Education and simulation techniques for improv-
ing reliability of care. Curr Opin Crit Care 2007;13:737-41.
8. Miller KK, Riley W, Davis S, et al. In situ simulation a method of experiential
learning to promote safety and team behavior. J Perinat Neonat Nurs 2008;22:
105-13.
9. Allan CK, Thiagarajan RR, Beke D, et al. Simulation-based training delivered
directly to the pediatric cardiac intensive care unit engenders preparedness,
comfort, and decreased anxiety among multidisciplinary resuscitation teams.
J Thorac Cardiovasc Surg 2010;140:646-52.
10. Hamman WR, Beaudin-Seiler BM, Beaubien JM, et al. Using in situ simulation to
identify and resolve latent environmental threats to patient safety: case study
involving a labor and delivery ward. J Patient Saf 2009;5:184-7.
11. Lighthall GK, Poon T, Harrison TK. Using in situ simulation to improve in-hospital
cardiopulmonary resuscitation. Joint Comm J Qual Patient Saf 2010;36:209-16.
12. Lighthall GK, Barr J. The use of clinical simulation systems to train critical care
physicians. J Intensive Care Med 2007;22:257-69.
13. Lam G, Ayas NT, Griesdale DE, et al. Medical simulation in respiratory and critical
care medicine. Lung 2010;188:445-57.
14. Healey A, Sherbino J, Fan J, et al. A low-fidelity simulation curriculum addresses
needs identified by faculty and improves the comfort level of senior internal
medicine resident physicians with inhospital resuscitation. Crit Care Med
2010;38:1899-903.
15. Cooke JM, Larsen J, Hamstra SJ, et al. Simulation enhances resident confidence in
critical care and procedural skills. Fam Med 2008;40:165-7.
16. Smith CC, Huang GC, Newman LR, et al. Simulation training and its effect on
long-term resident performance in central venous catheterization. Sim Health Care
2010;5:146-51.
17. Barnato AE, Hsu HE, Bryce CL, et al. Using simulation to isolate physician
variation in intensive care unit admission decision making for critically ill elders
with end-stage cancer: A pilot feasibility study. Crit Care Med 2008;36:3156-63.
18. Fuhrmann L, Østergaard D, Lippert A, et al. A multi-professional full-scale
simulation course in the recognition and management of deteriorating hospital
patients. Resuscitation 2009;80:669-73.
19. Mah JW, Bingham K, Dobkin ED, et al. Mannequin simulation identifies common
surgical intensive care unit teamwork errors long after introduction of sepsis
guidelines. Sim Health Care 2009;4:193-9.
20. Nguyen HB, Daniel-Underwood L, Van Ginkel C, et al. An educational course
including medical simulation for early goal-directed therapy and the severe sepsis
resuscitation bundle: an evaluation for medical student training. Resuscitation
2009;80:674-9.
21. Ottestad E, Boulet JR, Lighthall GK. Evaluating the management of septic shock
using patient simulation. Crit Care Med 2007;36:769-75.
22. Musacchio MJ, Smith AP, McNeal CA, et al. Neuro-critical care skills training
using a human patient simulator. Neurocrit Care 2010;13:169-75.
intensive care unit. Crit Care Med 2009;37:2697-701.
24. Wayne DB, Didwania A, Feinglass J, et al. Simulation-based education improves
quality of care during cardiac arrest team responses at an academic teaching
hospital: a case-control study. Chest 2008;133:56-61.
25. Berkenstadt H, Haviv Y, Tuval A, et al. Improving handoff communications in
critical care: utilizing simulation-based training toward process improvement in
managing patient risk. Chest 2008;134:158-62.

Simulation Applications in
Emergency Medical Services
Scott Leikin, BA, Pam Aitchison, RN,
Martha Pettineo, RN, Morris Kharasch, MD, FACEP,
and Ernest E. Wang, MD, FACEP
Introduction
Prehospital emergency medical services (EMS) play an important role
in the initial stabilization and transport of critically ill patients daily
around the world. In the USA, there are an estimated 840,000!
certified first responders and, of these, there are greater than 192,000
EMS providers.1 These individuals work for a variety of governmental
and private organizations such as fire departments, private companies,
volunteers, hospitals, and third-party providers. All states require a
trained and certified EMS responder to provide emergency medical
care in the event of a weapons of mass destruction (WMD) incident
and the administration of antidotes as dictated by region.1 As a
response to September 11, comprehensive competency-based curricula
for terrorism preparedness have been created.2
The hallmark of an expertly trained EMS provider is the ability to
recognize rapidly and treat immediate life threats, initiate timely
communication with receiving facilities to prepare them for patient
arrival, and execute proper protocols in the event of a disaster or mass
casualty. EMS providers require a unique skill set to deal effectively
with the complexities of the scope of their practice. They are under
significant time pressure to triage and initiate treatment for unstable
patients. This requires clear thinking and poise. They must be able to
think flexibly and cope with an array of environmental factors
particular to the scene. Additionally, they need to be able to work
effectively while maintaining situational awareness of dangers to their
personal safety. Finally, they need to maintain vigilance and be
prepared to react to the possibility that their scene response is
potentially related to a mass casualty or disaster that they have never
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experienced. Simulation-based training assists EMS systems and
providers prepare for these contingencies.
EMS Training
Simulation-based training for EMS professionals has broad applica-
tions. Procedural skills required include cardiopulmonary resuscitation,
basic and advanced airway skills, intravenous and intraosseous access
techniques, electrocardiogram and telemetry interpretation, and adminis-
tration of pharmacologic agents. Broader skills include proficiency with
standard operating procedures and regional protocols, as well as effective
teamwork behaviors.
With the use of airway task trainers, procedures that can be taught
include airway assessment, oxygen administration, oral and nasal airway
application, noninvasive positive pressure ventilation, endotracheal intu-
bation, laryngeal mask airways and other airway bridge devices, and
surgical airways. Cardiopulmonary skills amenable to task training
include effective bag-valve-mask ventilation, performance of chest com-
pressions, and intravenous/intraosseous access.
Simulation-based investigation on airway management with prehospital
providers has been an area of significant research. Simulation has been
used to investigate which difficult airway abnormalities affect success
rate of orotracheal intubation in novice intubators.3 The King LT
Supralaryngeal Airway device (Noblesville, IN) may be advantageous in
prehospital airway management situations involving multiple patients or
hazardous environments and was shown to be performed faster than
endotracheal intubation when performed by community EMS providers.4
Simulation has been used to demonstrate that a paramedic’s success in
securing a difficult airway may depend on the type of airway device they
use.5 Additionally, in a 2011 usability study of 7 different types of
supraglottic airway devices in 41 previously inexperienced paramedics
following training on a manikin model, the investigators found that
endotracheal intubation success rates by paramedics 3 months after
simulation training was significantly less than 5 different supraglottic
airway devices (Laryngeal mask unique [LMA] [LMA Company North
America, San Diego, CA], Laryngeal tube disposable [King-LT-D, VBM,
Sulz, Germany], I-Gel [Intersurgical Ltd, Wokingham, England], Com-
bitube [Covidien, Mansfield, MA], and EasyTube [Teleflexmedical
Ruesch, Research Triangle Park, NC]), indicating that simulation may
have a role in identifying methods that are more preferable for newer
paramedics in the prehospital setting.6 A just-in-time educational inter-
vention was able to demonstrate retention of skill with LMA placement at
6 months. Fifty-five first-year paramedic students watched a manufactur-
er’s LMA instruction video and practiced insertion in 3 different task
trainers. Six months later, subjects were randomized to an intervention
(reviewing the video and 10 minutes unsupervised practice) or control
group before participating in a high-fidelity simulated clinical scenario.
Those in the intervention group displayed significantly shorter insertion
times (P ! 0.029), displayed fewer attempts to achieve success (P !
0.033), and had significantly higher LMA skill performance levels (P !
0.019) at 6 months.7
Because EMS providers infrequently encounter seriously ill and injured
pediatric patients, simulation can be useful for training and assessing the skill
level of prehospital providers in the area. Lammers et al. conducted
manikin-based pediatric simulations on 3 core topics---infant cardiopulmo-
nary arrest, sepsis/seizure, and child asthma/respiratory arrest. Two hundred
twelve paramedics from 5 EMS agencies in Michigan participated in this
prospective, observational study. Performance deficiencies included lack of
airway support or protection; lack of support of ventilations or cardiac
function; inappropriate use of length-based treatment tapes; and inaccurate
calculation and administration of medications and fluids.8
Another area of research with prehospital providers is patient safety.
High-fidelity manikin scenarios have been used to identify gaps in patient
safety9 and to improve providers’ communication skills.10 Zimmer et al. used
several prehospital scenarios involving advanced life support, asthma, pul-
monary embolus, and multiple trauma to identify and quantify specific
communication breakdowns or errors that led to unsafe acts. They noted that
the paramedics committed an average of 7.4 unsafe acts per scenario and
transmitted only 53.7% of their interventions to the emergency physicians.
The most common unsafe acts were observed in the areas of respiratory
management, physical examination, and circulatory management.9
Developing immersive EMS simulation environments often requires
more creativity than in any other field of medical simulation. For EMS
providers, their mobile intensive care units are usually ambulance or
helicopters. Immersive simulation environments can be designed to
replicate the space, equipment, and functionalities of these vehicles (Fig
1). This allows for the providers to use familiar equipment and practice
providing care within the confines of their spaces. For novices, it helps
develop awareness of the limitations and capabilities of the vehicle. It can
help them practice to look for the clues of an impending problem (monitor
or physical examination findings that are associated with pneumothorax),
prevent complications, improve assessment in a noisy environment,
improve anticipatory skills, and increase situational awareness. A study
FIG 1. EMS Ambulance simulation environment. (Tober-Pollack Emergency Simulation Center at
the Michael S. Gordon Center for Research in Medical Education, Miami, FL. Photo courtesy of
S. Barry Issenberg, MD, FACP.) (Color version of figure is available online.)
involving emergency medicine residents participating in a high-fidelity

simulated flight medicine experience reported significantly improved
understanding of the obstacles to patient care in a helicopter. The reported
cost for such a session included a monetary cost of $440 and a time cost
of 22 hours of skilled instructor time.11
Unique to prehospital medicine is the infinite variability of the scene
responses to which paramedics must respond. Their ability to provide care
is often dictated by the circumstances they encounter. Simulation envi-
ronments can be created to resemble a home environment, a work
environment, or a crime scene. Motor vehicle collisions can be created
using old cars, and victim extrication exercises can be performed (Fig 2).
These simulations can help with protocol testing or new equipment
testing or help providers develop the ability to think creatively and
develop workarounds for unanticipated contingencies.
Disaster Preparedness
Disaster preparedness for a possible mass casualty incident or bioter-
rorism event is a great concern for EMS and the associated hospitals
FIG 2. Motor vehicle collision victim extrication simulation training exercise. (Northeastern
Illinois Public Safety Training Academy, Glenview, IL. Photo: Ernest E. Wang, MD, FACEP.)
within the catchment area. Disasters can be categorized into several types:
1. natural disasters (eg, fires, floods, droughts, hurricanes, landslides,
tornadoes, earthquakes, heat waves, winter storm events such as bliz-
zards, and cold-related emergencies); 2. human-caused or technological
disasters (eg, dam failures, hazardous material accidents, aviation acci-
dents, accidents involving nuclear reactors); or 3. national security
disasters (terrorism associated with WMD, such as nuclear/biological/
chemical attacks).12 Domestic preparedness for such events relies on
capable and properly trained prehospital personnel as well as effectively
integrated hospitals within the local community. Despite this, it is
estimated that only 4% of the US Homeland Security funding for public
safety terrorism preparedness is allotted to EMS.1
First responders need to be able to identify a mass casualty situation,
recognize the potential causes based on the presentation, and trigger alerts
to initiate containment protocols. Because bioterrorist events will likely
occur without warning and the cause will not be known, symptom-based,
all-hazards, decision-making algorithmic approaches have been proposed
to improve providers’ ability to predict the cause and initiate rapid
treatment. Bond et al. studied the use of this type of algorithm on the
ability of health care providers to correctly choose the proper triage and
management for 26 unknown terrorism scenarios.13 Each required that
one make a triage choice on the “attack” algorithm (the trunk algorithm)
and then proceed to 1 of 4 other branch algorithms (dirty resuscitation,
chemical agents, biological agents, bomb/blast/radiation dispersal device)
to make a final triage choice. The authors found that the 110 physicians
and nurses who participated in the study performed substantially better
than would have been expected by chance alone. The overall total score
was 45% correct for all participants, whereas the conditional probability
of guessing both the attack algorithm and the final card correct ranged
from 4.7% for the biological, chemical, and bomb/blast algorithms to
2.4% for the dirty resuscitation algorithm.13 The algorithms described by
Bond et al. have been implemented in an Advanced Bioterrorism Training
Course at our NorthShore Center for Simulation and Innovation Highland
Park Hospital Simulation Campus in Highland Park, IL to extensively
disseminate this training to EMS providers throughout Lake County, IL
(Fig 3).
Using the Simple Triage and Rapid Treatment (START) triage system,
triage accuracy in one large urban study was documented at 78%.14
During a disaster drill (train collision with blast injury and chemical
release), the accuracy and speed of triage of 130 patient-actors by the Fire
Department of New York City EMS personnel was evaluated using the
START triage system. All EMS personnel had been previously trained in
START, but refresher training was not administered before the drill.
Overall triage accuracy was 78%. In patients who had additional changes
in their status during the triage process (injects), 62% were retriaged
appropriately.14 Triage/treatment began 40 minutes after the drill began;
the average time from start of triage to transport was 1 hour and 2
minutes, and the scene was completely cleared in 2 hours and 38
minutes.14
Likewise, natural disasters pose similar potential for injury and death
while exposing first responders to environmental hazards as well. In the
Asia-Pacific region, where over one-half of the world’s natural disasters
occur, manikin-based simulations have been effectively conducted in
multiple countries to treat traumatic injuries and life threats: (1) leg
wound (hemorrhagic shock/immediate); (2) chest wound (tension pneu-
mothorax/immediate); (3) head wound (traumatic brain injury/expectant);
and (4) limb trauma (leg fracture/delayed).15
Disaster drills differ from manikin-based simulations because these
scenarios test the systems’ response to disaster and have broader scope
FIG 3. Bioterrorism dirty resuscitation simulation. (Advanced Bioterrorism Training Course
conducted at NorthShore Center for Simulation and Innovation CSTAR Highland Park Hospital,
Highland Park, IL. Photo: Ernest E. Wang, MD, FACEP.) (Color version of figure is available
online.)
and costs associated with mobilizing simulated patients, money, re-

sources, time, and number of personnel it takes to correctly coordinate a
proper disaster drill.12 Because of this, they are only performed period-
ically and do not often address the “what if” variables associated with the
uncertainties of a particular scenario. Examples of “what if” variables
were described by Christie and Levary and include the following: How
much time would it take, given the number of ambulances in the city, to
transport the injured to hospital? How long must the injured wait for
ambulances to arrive? What is the longest waiting time for a patient? How
many ambulances are needed to transport the injured? If two patients are
transported in an ambulance instead of one patient, how much does it
reduce the transportation time? What strategy should be followed to
transport the injured, first to nearby hospitals and later to hospitals that are
further away? What would the change in average waiting time be for the
injured or what would the total time be for transporting all patients to
hospitals if variables such as arrival rate, weather, type of disaster,
availability of beds, availability of trauma centers, and ambulances were
changed?12
Computer simulation has been suggested to assist with these. Advan-
tages of computer simulation include the ability to repetitively test
scenarios while changing variables, lowering operational costs, and
providing a risk-free environment for medical personnel to develop
critical thinking and medical decision-making skills quickly.12 Transient
modeling approaches using programming simulation and exponential
functions have been devised. The model can represent transient, patient
waiting times during a disaster and allows real-time capacity estimation
of hospitals of various sizes and capabilities.16 Web-based training
models have been studied to teach EMS providers to recognize and treat
ocular injuries associated with WMD attacks.17
Disaster simulations can expose system weaknesses and identify
targets for improvement. A study performed to assess EMS systems’
effectiveness in response to possible chemical, biological, radiologi-
cal, nuclear, explosive (CBRNE) units examined the “after-action”
reports from the Office of Domestic Preparedness, Chemical Weapons
Improved Response.1 They discovered that only 6 of 70 after-action
reports reported the use of level C or higher personal protective
equipment (PPE). Forty-four (63%) reported no additional PPE other
than their regular work uniform. Twenty (28.6%) of the 70 after-action
reports made no comment regarding the use of the PPE gear used by
EMS providers at all.1
Hospital preparedness has been assessed with simulated exercises and
training has been shown to improve topical knowledge.18 These types of
exercises usually involve alerting the hospital with a hypothetical sce-
nario and delivering moulaged patients of varying degrees of severity to
the emergency department (ED). Each patient undergoes real-time triage
and registration followed by compressed time treatment and disposition.
Patient disposition and management is beyond the ED and is often
conducted as a tabletop exercise.18
Subbarao et al. report the use of a combination of high-fidelity manikin
simulations and video clinical vignettes to create a curriculum to train first
responders and receivers (attending emergency physicians, emergency
medicine residents, nurses, physician assistants, medical students, para-
medics, and ED technicians) in the acute management of victims of an
unknown CBRNE event. Statistically significant improvement was noted
in all learner groups post training.19
Future Roles of Simulation in EMS Training
In addition to manikin-based simulation and full-scale disaster drill
simulation, other potential simulation-based applications show promise.
“Gaming” simulation has been shown to improve students’ knowledge of
a bioterrorism and emergency readiness curriculum.20 Web-based curri-
cula may become more prominent because of improved feasibility of
distance learning and because web-based applications can allow for
real-time virtual networking between regional hospitals. Citywide disaster
drills will likely incorporate Access Grid-like technologies (Chicago, IL)
for real-time coordination of every hospital from a central command
center.
Another promising tool in the future of EMS training is the use of
virtual worlds. A 2008 study used 3D virtual environments to evaluate
and train teamwork behaviors with emergency medical technicians,
emergency physicians, and emergency nurses in two virtual scenarios: a
sarin gas attack and a trauma victim from a radioactive dirty bomb
explosion. Each participant was assigned an online character and inter-
acted with the other members through the virtual world. Evaluation of
these virtual world simulation exercises demonstrated that trainees found
the exercise adequately realistic to “suspend disbelief.” The participants
were able to learn quickly to use Internet voice communication and user
interface to navigate their online character/avatar to work effectively in a
critical care team. Sixty-two percent thought multiplayer game-based
training was as effective as or more effective than traditional methods.
The utility of the game environment was felt to be better suited for initial
training (56%) and for refresher training (75%). Self-efficacy scores were
improved after participation in these exercises as well.21
Andreatta et al. compared disaster triage performance using full-
immersion virtual reality simulation and standardized patient (SP) simu-
lation. Although the results showed an effect in favor of the SP group
performance on the posttest, no significant differences were found with
respect to triage performances. The authors conclude that virtual reality
should be considered as a viable alternative training tool for disaster
triage and has the benefits of increased flexibility, repeatability, and
availability relative to SP exercises.22
Conclusions
The skills required of EMS providers are complex and can be difficult
to master. They need to be skilled with emergent interventions to stabilize
patients with acute conditions in a variety of situations dictated by the
environment, to effectively work in micro- and macrounits as part of a
larger EMS system, and to be situationally aware of CBRNE threats.
Emergent procedures are now being taught using simulation so that
EMS providers can apply superior skills to actual clinical care and
improve outcomes for the patients they encounter.
The key to disaster preparedness is providing first responders with the
best possible training modalities to simulate the experience of a mass
casualty event so that they have a working knowledge of the general
principles for effectively managing the situation.
Effective periodic simulation exposure and contemporaneous debriefing
are necessary to foster teamwork and communication with receiving
facilities and to improve pre-hospital providers’ ability to perform
emergent procedures effectively. Additionally, simulation can help them
perform rapid cognitive processing and act effectively in high-pressure,
highly variable, and possibly dangerous environments. In this way,
simulation can help make poise under pressure a learned behavior.
REFERENCES
1. Phelps S. Mission failure: Emergency medical services response to chemical,
biological, radiological, nuclear, and explosive events. Prehosp Disast Med
2006;22(4):293-6.
2. Markenson D, DiMaggio C, Redlener I. Preparing health professions students for
terrorism, disaster, and public health emergencies: core competencies. Acad Med
2005;80(6):517-26.
3. Thomas F, Carpenter J, Rhoades C, et al. The usefulness of design of experimen-
tation in defining the effect difficult airway factors and training have on simulator
oral-tracheal intubation success rates in novice intubators. Acad Emerg Med
2010;17(4):460-3.
4. Burns Jr, JB Branson R, Barnes SL, et al. Emergency airway placement by EMS
providers: comparison between the King LT supralaryngeal airway and endotra-
cheal intubation. Prehosp Disaster Med 2010;25(1):92-5.
5. Nasim S, Maharaj CH, Butt I, et al. Comparison of the Airtraq and Truview
laryngoscopes to the Macintosh laryngoscope for use by Advanced Paramedics in
easy and simulated difficult intubation in manikins. BMC Emerg Med 2009;9:2.
6. Ruetzler K, Roessler B, Potura L, et al. Performance and skill retention of
intubation by paramedics using seven different airway devices---a manikin study.
Resuscitation 2011;82(5):593-7.
7. Hein C, Owen H, Plummer J. A training program for novice paramedics provides
initial laryngeal mask airway insertion skill and improves skill retention at 6
months. Simul Healthc 2010;5(1):33-9.
8. Lammers RL, Byrwa MJ, Fales WD, et al. Simulation-based assessment of
paramedic pediatric resuscitation skills. Prehosp Emerg Care 2009;13(3):345-56.
9. Zimmer M, Wassmer R, Latasch L, et al. Initiation of risk management: incidence
of failures in simulated Emergency Medical Service scenarios. Resuscitation
2010;81(7):882-6.
10. Batchelder AJ, Steel A, Mackenzie R, et al. Simulation as a tool to improve the
safety of pre-hospital anaesthesia. J Assoc Anesth Gt Br Irel 2009;64:978-83.
11. Wright SW, Lindsell CJ, Hinckley WR, et al. High fidelity medical simulation in
the difficult environment of a helicopter: feasibility, self-efficacy and cost. BMC
Med Educ 2006;6:49.
12. Christie PM, Levary RR. The use of simulation in planning the transportation of
patients to hospitals following a disaster. J Med Syst 1998;22(5):289-300.
13. Bond WF, Subbarao I, Kimmel SR, et al. Testing the use of symptom-based
terrorism triage algorithms with hospital-based providers. Prehosp Disaster Med
2008;23(3):234-41.
14. Schenker JD, Goldstein S, Braun J, et al. Triage accuracy at a multiple casualty
incident disaster drill: the Emergency Medical Service, Fire Department of New
York City experience. J Burn Care Res 2006;27(5):570-5.
15. Vincent DS, Berg BW, Ikegami K. Mass-casualty triage training for international
healthcare workers in the Asia-Pacific Region using manikin-based simulations.
Prehosp Disast Med 2009;24(3):206-13.
16. Paul JA, George SK, Yi P, et al. Transient modeling in simulation of hospital
operations for emergency response. Prehosp Disast Med 2006;21(4):223-36.
17. Gershon RR, Canton AN, Magda LA, et al. Web-based training on weapons of
mass destruction response for emergency medical services personnel. Am J
Disaster Med 2009;4(3):153-61.
18. Bartley BH, Stella JB, Walsh LD. What a disaster?! Assessing utility of simulated
disaster exercise and associated educational process. Prehosp Disast Med
2006;21(4):249-55.
19. Subbarao I, Bond WF, Johnson C, et al. Using innovative simulation modalities for
civilian-based, chemical, biological, radiological, nuclear, and explosive training
for the acute management of terrorist victims: A pilot course study. Prehosp Disast
Med 2006;21(4):272-5.
20. Olson DK, Scheller A, Larson S, et al. Using Gaming simulation to evaluate
bioterrorism and emergency readiness education. Public Health Rep 2010;125:468-
77.
21. LeRoy Heinrichs W, Youngblood P, Harter PM, et al. Simulation for team training
and assessment: case studies of online training with virtual worlds. World J Surg
2008;32:161-70.
22. Andreatta PB, Maslowski E, Petty S, et al. Virtual reality triage training provides
a viable solution for disaster-preparedness. Acad Emerg Med 2010;17(8):870-6.

High-Fidelity Simulation—Emergency
Medicine
Shekhar Menon, MD, Morris Kharasch, MD, FACEP,
and Ernest E. Wang, MD, FACEP
Background
High-fidelity simulation (HFS) has become an essential tool for training
many health care providers in virtually every field of medicine. The
primary benefit of using HFS as an educational and evaluative tool is that
learners can practice medical decision-making and procedural skills on
simulated patients in an environment where the risk of error will not harm
an actual patient.1 These technologies and the educational constructs
designed around their use were developed to practice skills without
incurring risk. Medicine followed precedents set by model high reliability
organizations such the military with its war games exercises, the aero-
space industry with flight training of pilots and astronauts, and the nuclear
power industry to train personnel to deal effectively and resiliently in
crises situations.2 Bridging the gap between other industries and medi-
cine, Gaba and DeAnda pioneered the use of simulation in anesthesia to
train anesthesiologists.3 Their report described the creation of a compre-
hensive anesthesia simulation environment that re-created an operating
room. Appropriate monitoring equipment was included as was a realistic
intubation/thorax mannequin, which allowed for the formulation of
realistic problems within the operating room.
Built on Gaba’s work in the 1980s, the subspecialty of anesthesia was
the first to adopt it as an educational tool within the field of medicine.4
The first study regarding training in emergency medicine occurred in
1999 and emphasized airway training.5 This advanced airway course used
simulation to teach rapid sequence intubation skills as well as how to
manage problems during rapid sequence intubation.
The idea of using HFS to limit human error and improve safety was
initially introduced by the airlines and National Aeronautics and Space
Administration as a Crew Resource Management (CRM) Curriculum.4 It
was then used to create an Anesthesia Crisis Resource Management
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(ACRM) program that emphasized teamwork and responses to medical
crises.6 Based in the ACRM principle, an additional study was published
in 1999 that began to design and establish an HFS course to “improve EM
clinician performance, increase patient safety, and decrease liability.”7
This course used simulators and patient-actors to teach these ideas while
using ACRM as a basis. Finally, a formal CRM course was established
for emergency medicine in 2002, entitled “EMCRM.”8 This course used
didactics, simulation, and debriefing to teach principles on human error
and crisis management, was rated very favorably by the participants, and
helped establish the idea of HFS as an effected teaching tool in
emergency medicine training.
Simulation has also received favorable reviews as an effective model
for teaching medicine.9,10 In addition to its ability to allow learners of all
levels to “practice” medicine in an environment without risk to actual
patients, simulation can bridge basic science and clinical medicine.1,11
Competency training can be effectively performed using simulated
patient encounters.12 The idea is that simulation education acts as a
practical model on which to build real-life skills before using these skills
on real patients.
However, the greatest strength of effective simulation is that partici-
pants experience a heightened emotional response during the event.
Gordon et al writes, “Consider the issue of patient safety, and imagine a
practitioner who makes a clinical mistake; immediately after realizing the
error, he or she will experience an emotional reaction that is powerfully
instructive— but only for the next patient. What if educators could . . .
[allow] trainees to ‘live through’ a compendium of important cases in a
fraction of real-time?”11 Emotional involvement allows students to
integrate and understand information at a deeper cognitive level. As
“learning by doing” becomes less acceptable to the public, simulation
exercises, done well, provide learners with meaningful repetition, rein-
forcement of concepts in the debriefing session, and self-reflection that is
critical to improved learning so that residents may “. . .see one, simulate
many, do one competently, and teach everyone.”13
Currently, the American College of Surgeons has created a multilevel
certification for simulation centers.14 The American Society of Anesthe-
siologists Workgroup on Simulation Education has begun to characterize
simulation centers for the purposes of “approval” as a site to provide
continuing medical education certification.15 The Accreditation Council
for Graduate Medical Education ACGME Residency Review Committee
for Emergency Medicine has determined that simulation can serve as an
adjunct for the documentation of competencies.16 Use of HFS is becom-
ing increasingly integrated into undergraduate and graduate medical
educational curricula.17
As HFS has become more popular within emergency medicine, formal
interest groups within different emergency medicine societies have
formed and fellowship training in medical simulation is being estab-
lished.18 The first Simulation Academy was created by the simulation
interest group of the Society for Academic Emergency Medicine in 2009
and has one of the largest constituencies of simulation-based experts in
emergency medicine.
Current Use of Simulation in Emergency Medicine
There is a growing body of emergency medicine literature describing
the use of HFS in undergraduate and graduate medical education
curricula. Its adaptability to a wide array of educational needs makes it a
particularly useful tool for meeting educational objectives. Educators are
documenting their applications of HFS to address core competencies,12,19
high-stakes—low-frequency procedures,20 crisis resource management,8
team training,7,21,22 venous access,23 resident professionalism in ethical
dilemmas,24 cognitive forcing strategies,25 comparative evaluation of
resident performance,26,27 systems-based modular residency curricu-
lum,19 and medical student education.28-31
The significant literature and successful implementation around the
country are driving the demand for HFS training and proliferation of
training facilities has followed.
Between 2003 and 2008, there was an increase in the use of HFS within
emergency medicine residency programs from 29% to 85%. Additionally,
91% of emergency medicine training programs report using some form of
simulation.32
The use of HFS has been extended to address and evaluate the 6 core
competencies that are emphasized during emergency medicine (EM)
training. Bond et al identified that HFS was most useful for addressing the
following core competencies: patient care (disease management and
procedures), system-based practice (knowing resources available and
structuring the team), and interpersonal skills (communication and acting
as a team leader).12 Wagner et al studied the application of the medical
knowledge competency to EM training, indicating the simulation is an
effective means to assess procedural skills, critical care, and less
common, high-acuity clinical scenarios.33
In 2005, Wang et al described a simulation-based curriculum specifi-
cally designed to address the Systems-Based Practice (SBP) core com-
petency, which focuses on the residents’ abilities to “understand the
relationship of their individual medical practice to the context of the
health care system as a whole. . . [as well as]. . . how to practice
cost-effective health care, how to efficiently allocate resources, and how
to deal with system complexities such that the quality of patient care is
not compromised.”19 The importance of developing a strong SBP skill set
in emergency medicine cannot be overemphasized. The scope of emer-
gency medicine is broad, with respect to the variety of medical conditions
treated, the specialists with which emergency physicians interact, and the
social conditions of patients who present to the emergency department.
An HFS-based curriculum provides a “hands-on” experience that at-
tempts to reproduce not just an emergent case, but also the systems-based
issues unique to that case within an emergency department. A simulation
with properly executed SBP learning objectives forces the resident not
only to manage the medical aspects of the case but also to provoke the
resident to think critically about how to manage the specific circum-
stances of the case to optimize care with the available resources at that
time. A few examples of SBP-related skills that can be incorporated into
the case include requiring the resident to obtain more history from an
Emergency medical services (EMS) provider or family member, problem
solving in situations where a consultant is not available or occupied (a
patient presents with an acute ST-elevation myocardial infarction, but the
cardiologist is in the cath laboratory at another hospital performing a
procedure), and understanding necessary elements of patient transfer.
Other cases could involve end-of-life management in the peri-arrest
period or devising alternative therapy for a patient who does not have
insurance. This article provided a curriculum that incorporated both
attending and peer observation, checklist evaluation of competency
criteria, and videotape-based debriefing to reinforce key principles to both
the participating and the observing residents.
Crisis resource management training was patterned after the aviation
industry based CRM concept and was initially developed by anesthesi-
ologists.4,6 First mentioned in 1998, a course based on ACRM training
was formed that provided the basis for Emergency Crisis Resource
Management (ECRM).7 In 2003, Reznek et al published a pilot study that
established a structured crisis management curriculum for teaching and
assessing the ability of resident emergency physicians to perform the
following behaviors: planning, communication, leadership, resource
awareness and use, workload distribution, re-evaluation of the situation,
and awareness and use of all available information.8 In addition, the
following behaviors were added: appropriate triage, management of
multiple patients, coping with disruptions. The curriculum involved
didactics, simulated crisis scenarios, and debriefing.
In 2008, Hicks et al surveyed attitudes of EM personnel toward CRM
training, recognizing that EM resuscitations often require additional skills
beyond medical knowledge.34 A coordinated effort is often required to
maximize patient care in the setting of crisis. This study emphasized the
participants’ desire for further CRM training, with communication
between team members being identified as an area for improvement. HFS
training has thus been used to improve team building.
Shapiro et al demonstrated that simulation-based teamwork training is
an effective way to enhance didactic teamwork training.22 Two emer-
gency department (ED) groups received didactic training at baseline and
then were observed in the simulation setting or in the ED by blinded,
independent observers. These observers measured the teamwork via a
previously validated scale. There was no difference in the didactic or the
simulation groups at baseline. An experimental group was provided 8
hours of simulator-based training involving 3 HFS scenarios focused on
teamwork training. The groups were then observed again in the ED
clinical setting after the intervention. There was a greater tendency toward
quality of team behavior in the simulator group, while the comparison
group demonstrated no change.22
The use of standardized patients to assess professionalism has been
mentioned in the literature frequently.35 HFS has been used to assess
professionalism in EM residents.24 An ethical dilemma was introduced in
a simulated case that focused on (1) patient confidentiality, (2) informed
consent, (3) withdrawal of care, (4) practicing procedures on the recently
decreased, (5) the use of do-not-attempt resuscitation orders. Each of the
residents who participated was evaluated with a predefined checklist.
Senior residents demonstrated better overall performance, but what the
HFS course revealed was that there was more work necessary in
professionalism education, specifically in areas such as patient confiden-
tiality and informed consent.
HFS has been used to teach the concepts of metacognition and error
avoidance to educate residents.25 Cases were designed so residents would
make a particular error and subsequently learn from the mistake. A renal
failure patient with respiratory distress was simulated and 2 cognitive
traps were created. The first trap was making the resident believe that the
respiratory distress was secondary to a cardiac condition and giving
succinylcholine to the patient erroneously. The second error was created
after the resident witnessed a wide-complex tachycardia (WCT) on the
monitor. Shocking and antiarrhythmics would be the incorrect treatment
options, while recognizing that the WCT was secondary to hyperkalemia
and subsequent treatment. Residents would be led into the second error
regardless of whether they gave succinylcholine, with the WCT being
delayed if succinylcholine is not given. Afterward, a debrief session was
performed that highlighted succinylcholine and cognitive forcing strate-
gies. “Residents ranked this second only to direct patient care for
educational effectiveness.” Residents indicated that they felt more knowl-
edgeable about succinylcholine, treating hyperkalemia, and cognitive
forcing strategies as a teaching tool.
HFS has tremendous potential as a resident evaluation tool. A study by
Gordon et al demonstrated that an oral objective-structured clinical
examination based performance evaluation tool was equally valid in the
simulation setting, thereby making HFS a viable alternative to objective-
structured clinical examination for resident evaluation.27 Girzadas et al
demonstrated that HFS could be used to differentiate junior level from
senior level residents.36 In an anaphylaxis case, novice residents took
longer to establish a surgical airway, to start the surgical airway, to
complete the case, and to use epinephrine as an initial action. HFS proved
to be an effective assessment tool that differentiated between different
levels with respect to the patient care general competency.
With the increased use of HFS in residency, its use has been imple-
mented more and more as a part of the residency curriculum. A study by
Wang et al in 2008 determined that emergency medicine residents rated
simulation-based training sessions higher than traditional lectures.37
Residents scored simulation higher than lectures with respect to address-
ing goals and objectives, increasing knowledge and understanding of the
topic of the session, and following the subject matter presented.
A simulation model has been created to make an effective simulation
training session, involving 5 different stations: a manikin-based HFS
scenario followed by debriefing, a standardized patient encounter with
family members, partial task trainers for procedural proficiency, and
small-group interactive sessions.38 This model has been used at multiple
resident conferences, including ones at our institution.
Simulation education has been used as a novel method for conducting
morbidity and mortality conferences. Patient encounters were re-created
and resident input was obtained with audience response systems that
allowed for evaluation of the case in “real-time.” This method allowed a
more realistic interpretation of the case and understanding of why
mistakes were made.39
Simulation is now being used in residency training programs to promote
resident-as-teachers curricula. Learning effective teaching skills in emer-
gency medicine residency can now be accomplished by having resident
physicians assume educator roles for medical student simulation training
sessions.18 HFS training has even been extended to medical student
teaching and has been shown to be as effective, if not more, than standard
didactics, with 27 of 28 subjects performing better on high-risk/low-
frequency cases with HFS rather than standard didactics.40 In addition,
more critical actions were performed with HFS rather than didactics (93%
vs 71%).
Future Directions in Emergency Medicine
As HFS training has become a more effective and accepted means of
education within emergency medicine, future exciting directions are
forming. As more emergency medicine residencies implement HFS, the
formation of HFS centers is increasing as well, with up to 85% of EM
residency programs use HFS.32,41
Simulation education has extended to postresidency training in the form
of simulation education fellowships.41 As the number of these fellowships
grows, accreditation status may be considered, thereby further solidifying
the status of HFS within emergency medicine education. Fellowship
opportunities could create a larger research base with increased funding.
HFS has proven utility within the domains of medical knowledge
acquisition, procedural competency, and professionalism. Its use has now
been extended to death notification and family conferences.35,42 Although
a simulation setting can never approximate the emotions and gravity of
notifying a family member of the death or complication regarding a loved
one, the SPIKES protocol (Set the stage, Perception, Inform, Knowledge,
Empathy, and Summarize) was implemented using lectures and role-
playing, and a HFS case and the simulation aspect was found to be most
useful by EM residents (43%) vs role play (14%) and lecture (7%).
Finally, HFS-based Continuing Medial Education and maintenance of
certification may not be far off for emergency medicine practitioners, as
it would allow for improved documentation and opportunity to demon-
strate competency with procedures that are not frequently performed.
Opportunities for this type of life-long learning will become increasingly
more feasible as simulation centers within close proximity of the primary
employment site become more widespread.41
The field of simulation in emergency medicine is rapidly changing.
Technological improvement and innovation in simulation instruction will
lead to new applications for simulation, improved realism that will allow
a more powerful experience, and increased transference of the lessons
learned to the clinical setting. It seems certain that HFS will remain an
integral part of how we train and maintain the skills of emergency
practitioners as we head into the 21st century.
REFERENCES
1. Gordon JA, Oriol NE, Cooper JB. Bringing good teaching cases “to life”: a
simulator-based medical education service. Acad Med 2004;79(1):23-7.
2. Issenberg SB, McGaghie WC, Hart IR, et al. Simulation technology for health care
professional skills training and assessment. JAMA 1999;282(9):861-6.
re-creating the operating room for research and training. Anesthesiology
1988;69(3):387-94.
4. Reznek M, Harter P, Krummel T. Virtual reality and simulation: training the future
emergency physician. Acad Emerg Med 2002;9(1):78-87.
5. Ellis C, Hughes G. Use of human patient simulator to teach emergency medicine
trainees advanced airway skills. Acad Emerg Med 1999;16(6):395-9.
6. Howard SK, Gaba DM, Fish KJ, et al. Anesthesia crisis resource management
training: Teaching anesthesiologists to handle critical incidents. Aviat Space
Environ Med 1992;63(9):763-70.
7. Small SD, Wuerz RC, Simon R, et al. Demonstration of high-fidelity simulation
team training for emergency medicine. Acad Emerg Med 1999;6(4):312-23.
8. Reznek M, Smith-Coggins R, Howard S, et al. Emergency Medicine Crisis
Resource Management (EMCRM): pilot study of a simulation-based crisis man-
agement course for emergency medicine. Acad Emerg Med 2003;10(4):386-9.
9. Weller JM. Simulation in undergraduate medical education: bridging the gap
between theory and practice. Med Educ 2004;38(1):32-8.
ment skills. Crit Care Med 2006;34(1):151-7.
students’ and educators’ responses to high-fidelity patient simulation. Acad Med
2001;76(5):469-72.
12. Bond WF, Spillane L. The use of simulation for emergency medicine resident
assessment. Acad Emerg Med 2002;9(11):1295-9.
14. Sachdeva AK, Pellegrini CA, Johnson KA. Support for simulation-based surgical
education through American College of Surgeons—accredited education institutes.
World J Surg 2008;32(2):196-207.
15. ASA. ASA Approval of anesthesiology Simulation Programs, A.B.o.S. Education,
Editor. 2006, American Society of Anesthesiologists. Available at: http://www.
asahq.org/For-Members/Education-and-Events/Simulation-Education/White-
Paper-on-ASA-Approval-of-Anesthesiology-Simulation-Programs.aspx. Accessed
March 14, 2011.
16. Accreditation Council for Graduate Medical Education, American Board of
Medical Specialties. Assessing resident performance: examples from the field.
Available at: http://www.acgme.org/outcome/assess/asses_residentPerf.pdf. Ac-
cessed March 14, 2011.
17. McLaughlin SA, Bond W, Promes S, et al. The status of human simulation training
in emergency medicine residency programs. Simul Healthc 2006;(1 Spec no.):
18-21.
18. McLaughlin S, Fitch MT, Goyal DG, et al. Simulation in graduate medical
education 2008: a review for emergency medicine. Acad Emerg Med 2008;
15(11):1117-29.
19. Wang EE, Vozenilek JA. Addressing the systems-based practice core competency:
a simulation-based curriculum. Acad Emerg Med 2005;12(12):1191-4.
20. Schaefer JJ. Simulators and difficult airway management skills. Paediatr Anaesth
2004;14(1):28-37.
21. Jay GD, Small SD, Langford V, et al. Teamwork training supported by high fidelity
simulation training improves emergency department team behaviors. Acad Emerg
Med 2000;7(5):519 [Abstract].
22. Shapiro MJ, Morey JC, Small SD, et al. Simulation based teamwork training for
emergency department staff: does it improve clinical team performance when
added to an existing didactic teamwork curriculum? Qual Saf Health Care
2004;13(6):417-21.
23. Reznek MA, Rawn CL, Krummel TM. Evaluation of the educational effectiveness
of a virtual reality intravenous insertion simulator. Acad Emerg Med
2002;9(11):1319-25.
24. Gisondi MA, Smith-Coggins R, Harter PM, et al. Assessment of resident profes-
sionalism using high-fidelity simulation of ethical dilemmas. Acad Emerg Med
2004;11(9):931-7.
25. Bond WF, Deitrick LM, Arnold DC, et al. Using simulation to instruct
emergency medicine residents in cognitive forcing strategies. Acad Med
2004;79(5):438-46.
26. Clyne B, Gutman DC, Sutton E, et al. Oral board vs. high-fidelity simulation for
competency assessment: senior emergency medicine resident management of an
acute coronary syndrome. Acad Emerg Med 2004;11(5):500 [Abstract].
27. Gordon JA, Tancredi D, Binder W, et al. Assessing global performance in
emergency medicine using a high-fidelity patient simulator: a pilot study. Acad
Emerg Med 2003;10(5):472.
28. Takayesu JK, Gordon JA, Farrell SE, et al. Learning emergency and critical care
medicine: what does high-fidelity patient simulation teach? Acad Emerg Med
2002;9(5):476-7.
29. Shapiro M, Morchi R. High-fidelity medical simulation and teamwork training to
enhance medical student performance in cardiac resuscitation. Acad Emerg Med
2002;9(10):1055-6.
30. Vozenilek J, Handler J, Kontrick A. Augmentation of the medical student rotation
with high-fidelity simulation: learning by the numbers. Acad Emerg Med
2004;11(8):898.
31. Coates WC, Steadman RH, Huang YM, et al. Full-scale high fidelity human patient
simulation vs problem based learning: comparing two interactive educational
modalities. Acad Emerg Med 2003;10(5):489.
32. Okuda Y, Bond W, Bonfante G, et al. National growth in simulation training within
emergency medicine residency programs, 2003-2008. Acad Emerg Med 2008;
15(11):1113-16.
33. Wagner MJ, Thomas Jr. HA Application of the medical knowledge general
competency to emergency medicine. Acad Emerg Med 2002;9(11):1236-41.
34. Hicks CM, Bandiera GW, Denny CJ. Building a simulation-based crisis resource
management course for emergency medicine, phase 1: Results from an interdisci-
plinary needs assessment survey. Acad Emerg Med 2008;15(11):1136-43.
35. Quest TE, Otsuki JA, Banja J, et al. The use of standardized patients within a
procedural competency model to teach death disclosure. Acad Emerg Med
2002;9(11):1326-33.
36. Girzadas Jr, DV, Clay L, Caris J, et al. High fidelity simulation can discriminate
between novice and experienced residents when assessing competency in patient
care. Med Teach 2007;29(5):472-6.
37. Wang EE, Beaumont J, Kharasch M, et al. Resident response to integration of
simulation-based education into emergency medicine conference. Acad Emerg Med
2008;15(11):1207-10.
38. Noeller TP, Smith MD, Holmes L, et al. A theme-based hybrid simulation model
to train and evaluate emergency medicine residents. Acad Emerg Med
2008;15(11):1199-206.
39. Vozenilek J, Wang E, Kharasch M, et al. Simulation-based morbidity and mortality
conference: new technologies augmenting traditional case-based presentations.
Acad Emerg Med 2006;13:48-53.
40. McCoy CE, Menchine M, Anderson C, et al. Prospective randomized crossover
study of simulation vs. didactics for teaching medical students the assessment and
management of critically ill patients. J Emerg Med 2011;40(4):448-55.
41. Vozenilek JA, Gordon JA. Future directions: a simulation-based continuing
medical education network in emergency medicine. Acad Emerg Med 2008;
15(11):978-81.
42. Park I, Gupta A, Mandani K, et al. Breaking bad news education for emergency
medicine residents: A novel training module using simulation with the SPIKES
protocol. J Emerg Trauma Shock 2010;3(4):385-8.

Simulations in Internal Medicine
Emily C. Singer, MD, and Ernest E. Wang, MD, FACEP
Background
Simulation-based medical education (SBME) has revolutionized training
in both undergraduate and graduate medical education. Over the past 2
decades, SBME has been used and studied by the specialties to provide
clinical training, reduce medical errors, and improve patient safety.
In the 1970s and 1980s, simulation-based training was primarily computer
program screen-based learning or low-fidelity task trainer airway and
cardiopulmonary resuscitation skills practice. The cardiac auscultation man-
ikin “Harvey” and the anesthesia manikin “Sim One,” developed at the
University of Southern California, were the forefathers of modern-day
high-fidelity simulators. In the last 10 years, more sophisticated full-body
manikins have been developed and a wider variety of partial task trainers
have been designed to teach specific procedures requiring high levels of
skill. Simulation-based medical education in its modern form enables
trainees to practice and perfect high-stakes procedures that may only
rarely occur in the clinical setting without any risk to patients. This article
offers an overview of the current uses of SBME in internal medicine (IM)
training for medical students, residents, fellows, and attending physicians
along with future possibilities for the use of SBME in IM.
Advanced Cardiac Life Support
Advanced cardiac life support (ACLS) training using SBME enables
IM trainees to practice these high-stakes skills in a controlled
environment without any risk of patient harm. ACLS situations are
infrequently encountered in the hospital, leading to inadequate train-
ing from clinical experience alone. SBME has been used to augment
clinical training and has been shown to improve ACLS performance as
measured by adherence to American Heart Association (AHA) guide-
lines.1
Studies have shown that traditionally trained residents often fail to meet
a minimum required skill level to run ACLS scenarios because of poor
Dis Mon 2011;57:744-756

0011-5029/2011 $36.00 ! 0
doi:10.1016/j.disamonth.2011.08.016

skills retention.2 Simulation-based ACLS training significantly improves
adherence to AHA standards when compared with traditionally trained
residents on a variety of ACLS scenarios, including asystole, ventricular
fibrillation, ventricular tachycardia, supraventricular tachycardia, symp-
tomatic bradycardia, and pulseless electrical activity. In one study,
simulation-trained residents exhibited a mean correct response rate of
68% compared with 44% of traditionally trained residents (P ! 0.001).1
The improvement in ACLS skills from four 2-hour-long simulation-
based training sessions combined with small-group teaching and deliber-
ate practice was retained when the participants were retested 14 months
later.3 This is in contrast to the typical poor retention using traditional
training. This 14-month retention is notable, because ACLS is renewed on
a 2-year cycle.
The low rate of survival to discharge among patients undergoing ACLS
resuscitation limits the ability to detect significant differences in
mortality when managed by physicians who have undergone simula-
tion-based training vs traditionally trained physicians.1 Despite this
failure to demonstrate improved clinical outcomes, improved compli-
ance with AHA guidelines and enhancement of resident comfort with
the resuscitation protocols are compelling endorsements of simula-
tion-based ACLS training. Mastery of ACLS is required for IM board
certification,4 making it an important application for deliberate prac-
tice using SBME.
Airway Management
Noninvasive and invasive airway management are critical components
of in-hospital cardiac arrest management. Acquisition of these skills is
limited by infrequent exposure and by the high stakes of each event.
Simulation-based training in airway management using a computerized
high-fidelity patient simulator in conjunction with lectures on respiratory
emergencies and initial airway management has been shown to improve
IM residents’ airway management during code situations in comparison
with those who receive instruction alone.5 The study was set up so the
intervention group received simulation-based training immediately after
having their baseline skill level measured, while the control group had
their training delayed by 4 weeks, during which time the differences
between the 2 groups’ skill levels were investigated. During the lag period
when the immediate-training group had received their simulation training
and the delayed-training group had not, 80% of the trained group received
perfect scores on their testing, while none of the trainees in the delayed
training groups did. The participating interns felt inadequately prepared
without the simulation-based training, and those who learned of the delay
in their simulation-based training “expressed strong disappointment and
sometimes anger when informed that their training would be delayed by
4 weeks.”5 The simulation-based training was beneficial for both skill
acquisition and enabling interns to feel comfortable managing an airway.
Another study comparing post-graduate year (PGY3) IM residents who
had received traditional vs simulation-based training on airway manage-
ment echoed the above findings, showing significantly stronger perfor-
mance by simulation-trained residents. The study identified traditional
clinical training as inadequate to achieve proficiency in airway
management, frequently because of improper use of equipment, and
pointed to SBME as a more effective way to teach residents to manage
an airway. Simulation-trained residents performed significantly better
on several steps, including attaching bag-valve mask to high-flow
oxygen (69% vs 17%, P ! 0.001), correctly inserting oral airway
(88% vs 20%, P ! 0.001), and achieving bag-valve-mask seal (97% vs
20%, P ! 0.001).6 Simulation-based training has been shown to improve
IM residents’ ability to secure an airway.
Procedures
Simulation has been used to teach residents a variety of clinical
procedures germane to the practice of IM, including central line place-
ment, thoracentesis, and paracentesis (Fig 1). Simulation-based training
has been shown to improve resident confidence in performing procedures
in addition to improving actual skill level.7 A simulation-based interven-
tion to teach third-year IM residents thoracentesis demonstrated a 71%
improvement in clinical skills following a simulation-based training, with
all residents achieving mastery skill level following the training.8 The
simulation involved two 2-hour-long education sessions involving a
videotaped presentation followed by deliberate practice with a thoracen-
tesis simulator. Another study taught residents to perform knee arthro-
centesis, central venous catheterization, lumbar puncture, paracentesis,
and thoracentesis, all using the model of video instruction with discussion
of key concepts followed by a faculty-led hands-on simulation-based
instruction and individual deliberate practice using simulators. Partici-
pants demonstrated statistically significant improvement in skills follow-
ing the intervention.9
Central line placement is another important procedural skill for IM
house staff. SBME using manikins with deliberate practice and directed
feedback has been used to teach residents proper central venous catheter
FIG 1. Simulator task trainers. Central line simulator (CentralLineMan; Simulab, Seattle, WA;
http://www.simulab.com/product/ultrasound-trainers/centralineman-system); paracentesis ul-
trasound training model (Blue Phantom; Redmond, WA) (http://www.bluephantom.com/
details.aspx?pid!55&cid!430); thoracentesis ultrasound training model (Blue Phantom; Red-
mond, WA) (http://www.bluephantom.com/details.aspx?pid!92&cid!432). (Color version
of figure is available online.)

(CVC) insertion technique. One study showed a 7:1 return on funds used
to provide simulation-based training for IM residents before a medical
intensive care unit (MICU) rotation because of reduced bloodstream
infections after residents received the training.10 A related study demon-
strated fewer overall complications in MICU CVC insertion when
residents were trained using SBME. Improvements were noted in terms of
fewer needle passes, reduced arterial punctures, fewer catheter adjust-
ments, and higher success rates.11 These studies demonstrate the benefit
to both hospitals and patients of deliberate practice of CVC insertion.
Simulation-based training has also been used for instructing fellows and
specialists how to perform more specialized procedures, including endos-
copy, bronchoscopy, angiography, and temporary hemodialysis catheter
insertion. Simulation-based training has demonstrated the ability of the GI
Mentor II (Simbionix in Cleveland, Ohio) virtual reality simulator to
distinguish between the psychomotor skills of novice and intermediate-
level endoscopists with a high level of reliability and has demonstrated
improvement among novice practitioners throughout several training
sessions.12
In a study using a virtual reality bronchoscopy simulator, investigators
found that none of the critical care fellows who had performed fewer than
200 flexible bronchoscopies were able to successfully identify all the
bronchial segments required in the simulation-based testing, whereas 50%
of the trainees who had performed more than 200 bronchoscopies
identified all the segments correctly.13 The ability to distinguish between
novice and expert practitioners demonstrates the potential for simulators
to be used to monitor skill level of practitioners and as a future tool for
endorsing certification.
The efficacy of simulation-based training for cardiology fellows learn-
ing to perform coronary stenting is already well established, with the
Food and Drug Administration requiring completion of virtual reality
simulation training for all physicians learning to perform stenting.14 One
simulation study examined interventional cardiologists who participated
in a series of training sessions using the Vascular Interventional System
Trainer. The study showed improvements in procedure time, fluoroscopy
time, contrast volume, and catheter-handling errors following the Vascu-
lar Interventional System Trainer training.14
Simulation-based training has also been used to train nephrology
fellows in temporary hemodialysis catheter insertion. The intervention
involved a 2-hour education session that included a lecture on catheter
insertion, ultrasound training, deliberate practice using the CentralLine-
Man (Simulab, Seattle, WA) manikin (Fig 1), and directed feedback. The
study showed “poor” performance by traditionally trained graduating
fellows (mean 53.1% with only 17% meeting the minimum passing score)
and demonstrated that simulator-trained fellows showed significantly
higher catheter insertion performance than traditionally trained graduat-
ing fellows (P ! 0.001). Simulator-trained first-year fellows demon-
strated significant improvement with the training (from 29.5% to 88.6%,
P ! 0.002).15
The development of simulation-based educational tools has allowed for
more innovative and reliable training in a variety of technical and
resuscitation skills for IM trainees. Establishing comfort among house
staff with management of these life-threatening scenarios offers a way to
improve resident compliance with AHA and other clinical guidelines
during stressful and high-stakes situations. Simulation-based training has
also been shown to reduce complication rates, decrease infection rates,
and ultimately save money by ensuring trainee compliance with proper
protocols.
Physical Examination Skills
SBME can also be used to teach concrete physical examination skills
that are often inadequately acquired from clinical experience alone.
Cardiopulmonary auscultation is one of the most frequently used skills in
clinical medicine, but trainees often experience insufficient exposure to
patients with abnormal clinical examinations.16 Studies have shown that
clinical experience alone is inadequate to teach cardiac auscultation,17
with the deficit identified in all levels of medical education—from
students to residents and even attending physicians18–suggesting a
significant need for SBME to complement clinical education. Two hours
of cardiorespiratory simulator training for first-year Canadian medical
students was shown to improve accuracy in identification of abnormal
clinical findings (70.0% vs 52.2%, P " 0.0001) and to improve diagnostic
performance (72.1% vs 55.6%, P ! 0.0007).16 The combination of
computer-based tutorial with cardiac patient simulator has been shown
capable of achieving mastery of heart sound identification with both
simulated sounds and real patients.19 Both high-fidelity simulation using
a Harvey-type manikin and low-fidelity simulation via compact disks
have been shown effective in teaching this crucial skill, suggesting that
compact disks of abnormal heart sounds offer an inexpensive means of
improving cardiopulmonary auscultation among students and residents.20
Trainees at all levels can benefit from this training, from first-year
medical students to attending physicians who are looking to improve their
diagnostic expertise.
Future uses of SBME training to improve physical examination skills
among trainees could include simple, inexpensive initiatives, such as
giving out compact discs or MP3s to medical students with examples of
abnormal heart or lung sounds. This intervention, combined with a simple
lecture on abnormal heart and lung sounds, would offer a way to
counteract the declining art of the physical examination and improve the
diagnostic capabilities of our medical students and residents. SBME has
the potential to assist with training in the entire gamut of physical
examination skills, from cardiac auscultation to fundoscopic examina-
tions to orthopedic examinations.
Communication Skills and Clinical Reasoning
Simulation training has been used to teach higher cognitive patient care
domains, including communication skills and clinical reasoning. SBME
can be used to simulate a vast variety of clinical conditions, both
medical and surgical, and can be used to both teach proper clinical
evaluation to inexperienced clinicians and evaluate more advanced
clinicians for competency. One study used simulators to teach medical
students multiple clinical competencies. Lessons included how to distin-
guish urgent from nonurgent clinical presentations using simulation of a
patient in anaphylaxis, which required the student to recognize the symptoms
of anaphylaxis, initiate the proper treatment, and discuss with the standard-
ized patient (SP) ways to avoid anaphylactic reactions in the future. The same
study used alternate scenarios to teach students to communicate during
stressful situations using a SP mother requesting antibiotics for her screaming
toddler’s uncomplicated upper respiratory tract infection. The study also used
simulations to teach students to uncover hidden medical problems when
patients present with unrelated complaints with a SP who presented with
reflux but was found on examination to be suffering from depression. The
student was charged with the task of uncovering the hidden diagnosis and
communicating that diagnosis with the standardized patient.21 SBME offers
the potential to teach and evaluate clinical reasoning and communication-
based competencies using case scenarios with simulated patient examinations
and complications.
Effective communication skills are crucial for physicians to address
sensitive patient care issues, ensure patient understanding of and
compliance with medical advice, and coordinate care teams for
complex medical conditions. Clinical experience alone has been
shown to be inadequate preparation to develop these skills,22 and
malpractice litigation is closely related to poor physician communi-
cation.23 Deliberate communication training is rarely given in the
clinical environment, leaving a gap that can be filled by simulation-
based training. SBME, whether web-based or SP-based, has been
shown effective to improve physician communication skills.
SBME has been used in the Netherlands to train medical students on
proper interphysician communication.24 The training used the Dynamic
Patient Simulator, an educational computer program that simulates virtual
patients with a variety of medical conditions in diverse clinical settings.
Students were presented a patient via the Dynamic Patient Simulator and
were asked to present that patient and their treatment plan via electronic
communication to another student who was designated the consulting
physician. The cases involved multiple episodes of interphysician commu-
nication and the training lasted about 5 days. Students gave each other
feedback on multiple aspects of patient data transfer, including completeness,
validity, and timing. The study showed a statistically significant improvement
in students’ perception of their ability to call referrals. The training has since
been incorporated into medical training in the Netherlands.24
Delivering bad news is another intimidating communication task for
young physicians and, when performed insensitively, can leave patients
feeling upset and alone during an exceptionally difficult time. One study
looked at improvements in communication skills after training IM interns
with both online modules and standardized simulations using videocon-
ferencing technology in which interns were required to inform an SP
about a new diagnosis of lung cancer with a poor prognosis. The focus
was on teaching interns how to deliver bad news with the quality of the
communication determined by a detailed checklist that was taught to the
student during the tutorial. The interns who participated in both the online
module and the videoconferencing-based intervention showed greater
improvement than those who had access to only one or none of the
interventions.25 The use of simulation technology to teach effective
communication enables rich feedback through videotaping of patient
experiences that allows instructors to pinpoint flaws in a participant’s
simulated patient interaction. This sort of detailed feedback is not feasible
in clinical settings where videotaping sensitive patient interactions would
be invasive and disruptive. SBME allows students and residents to
practice this sensitive skill and establish a degree of comfort with the
process before using it with a real patient.
Even experienced oncologists can benefit from simulation-based train-
ing to improve their ability to deliver bad news.26 This study used a
1.5-day-long intensive workshop for oncologists that incorporated pre-
sentations, DVDs showing ideal examples, and role-playing practice
using SPs. The participants had their communication skills evaluated at 6
and 12 months following the training to evaluate for retention. Although
no statistical significance was reached in terms of quantifying communi-
cation skills, the oncologists responded encouragingly toward the train-
ing, and the trends were positive in terms of creating an environment
conducive toward delivering bad news and avoiding “blocking” patient
responses by interrupting or monopolizing discussion. The study also
showed trends toward use of more empathetic skills, including careful
listening and acknowledging the key messages of a patient’s words,
although these trends did not reach statistical significance. This study
could benefit from being repeated with a larger sample size to demon-
strate more clearly if the intervention had a lasting effect on participants.
It clearly demonstrated the need for such an intervention, with poor
baseline abilities, including difficulty both eliciting and responding
appropriately to patients’ emotions even among these experienced prac-
titioners.26
Disclosing medical errors is perhaps the most difficult communication
skill that physicians must master. Simulations have identified the need for
improved communication training to enable young physicians to deliver
the news of a medical error in an honest and empathetic way.22 By
identifying SBME as a potential resource for quantification of provider
ability to disclose medical errors, this study raises the possibility of using
simulators in conjunction with lectures and hands-on instruction as a way
to teach the art of disclosing medical errors. No studies to date have
looked at improvements in resident performance following simulation-
based training for the communication of medical errors. This represents
an exciting future application for SBME research.
Identification of Systemic Problems
The simulation environment can also be used to identify systemic
problems that pose a threat to patient safety by conducting simulations in
either the laboratory setting or the actual clinical environment. In situ
simulation in the hospital setting was used in one study to identify threats
to patient safety with respect to patient handoffs, transportation, and
mobilization of cardiac catheterization resources.27 The study used in situ
simulation at a large Midwestern hospital using a high-fidelity manikin to
simulate a patient with chest pain and hypotension who required cardiac
catheterization. The simulation identified several latent threats to patient
care, including transportation of patients using the main elevator, which
led to unacceptable wait times for a free elevator, delaying patient
catheterization by several crucial minutes. Another threat to patient safety
was the handoff process between the Emergency Department (ED) staff
and the catheterization laboratory staff. No procedure was in place to
identify the person in the catheterization laboratory who should be
receiving the information, leading to an awkward and inadequate handoff
between teams. Finally, the study identified unclear role assignment in the
catheterization laboratory, leading to confusion over who should be
performing various tasks. Solutions to the problems identified in this
study include holding a key for the service elevator at the ED front desk
to enable transporters to use the service elevator in emergent situations,
designating a catheterization laboratory staff member to receive handoff
from the ED nurse, and identifying team roles and prioritized tasks for the
catheterization laboratory staff.27
Another simulation demonstrated that residents make more errors with
longer hours of wakefulness. Resident performance was studied during 26
hours of continuous wakefulness at 4 points throughout the shift using
high-fidelity patient simulation in which residents were asked to manage
1 of 8 dysrhythmia scenarios using ACLS protocols followed by
management of a critically ill patient. The study showed an increase in the
number of errors when taking care of the critically ill patient with
increased hours of wakefulness.28
Laboratory-based simulation training can be used to identify common
errors in house staff procedures before they become a threat to real
patients. One study, using the laboratory-based SimMan (Laerdal Medi-
cal, Wappinger Falls, NY) manikin (Fig 2) to simulate respiratory arrest,
identified a common error in failure to attach bag-valve-mask to oxygen
for patients undergoing ACLS resuscitation. This finding heightened
awareness of this preventable error and inspired changes to avoid similar
mistakes during the care of actual patients.5 The identification of
commons errors through both in situ and simulation-laboratory-based
trainings represents a dynamic way to identify and address risks to patient
safety.
The Future of IM Simulation
Simulation-based medical education has been successfully inte-
grated into IM training programs in a variety of capacities—from
ACLS training to communication skills to complex subspecialty-level
procedures. Medical educators in IM are actively expanding the role of
simulation-based education to reach more residents and to teach a
growing list of skills. SBME can be used for initial training for
students and residents who are learning new diagnostic and procedural
skills and for residents and attending physicians who need additional
practice with clinically rare events or to learn new techniques.
FIG 2. High-fidelity simulation manikin (http://www.laerdal.com/us/doc/86/SimMan). (Color
Simulation training also offers the potential for professional licensing

bodies to require proof of performance competency as a standardized
method of evaluation or as a proxy for maintenance of certification.
The use of SBME to identify latent threats to patient safety has vast
potential for growth and expansion to a greater number of institutions and
specialties. Although commonly used in other careers, such as aviation
and the military, SBME has not yet been integrated into medicine to its
full potential. Future uses promise to improve patient safety through a
variety of laboratory-based, hospital-based, and office-based scenarios.
Future research outcomes of simulation-based education include im-
proved patient outcomes in addition to improved behaviors following
training.
Simulation-based training is one of the most robust methods for
providing a wide variety of experiential training from infrequently
encountered, high-stakes procedures and scenarios to lower acuity skills
for which clinical experience offers inadequate training. SBME will
undoubtedly continue to play a central role in student, resident, fellow-
ship, and attending level education with many exciting possibilities for its
future expansion to other clinical realms.
REFERENCES
1. Wayne DB, Didwania A, Feinglass J, et al. Simulation-based education improves
quality of care during cardiac arrest team responses at an academic teaching
hospital: a case-control study. Chest 2008;133:56-61.
2. Wayne DB, Butler J, McGaghie WC, et al. Simulation-based training of internal
medicine residents in advanced cardiac life support protocols: a randomized trial.
Teach Learn Med 2005;17:202-8.
3. Wayne DB, Siddall VJ, Butter J, et al. A longitudinal study of internal medicine
residents’ retention of advanced cardiac life support skills. Acad Med 2006;81:
S9-S12.
4. American Board of Internal Medicine. Requirements for certification in internal
medicine. http://www.abim.org/certification/policies/imss/im.aspx. Accessed 2010.
5. Mayo PH, Hackney JE, Mueck JT, et al. Achieving house staff competence in
emergency airway management: Results of a teaching program using a computer-
ized patient simulator. Crit Care Med 2004;32:2422-7.
6. Kory PD, Eisen LA, Adachi M, et al. Initial airway management skills of senior
residents: simulation training compared with traditional training. Chest 2007;132
(6):1927-31.
7. Cooke JM, Larsen J, Hamstra SJ, et al. Simulation enhances resident confidence in
critical care and procedural skills. Fam Med 2008;40(3):165-7.
8. Wayne DB, Barsuk JH, O’Leary KJ, et al. Mastery learning of thoracentesis skills
by internal medicine residents using simulation technology and deliberate practice.
J Hosp Med 2008;3:48-54.
9. Lenchus JD. End of the “see one, do one, teach one” era: the next generation of
invasive bedside procedural instruction. J Am Osteopath Assoc 2010;110(6):
340-6.
intensive care unit. Simul Healthc 2010;5:98-102.
12. Ritter EM, McClusky DA, Lederman AB, et al. Objective psychomotor skills
assessment of experienced and novice flexible endoscopists with a virtual reality
simulator. J Gastrointest Surg 2003;7:871-7.
13. Crawford SW, Colt HG. Virtual reality and written assessments are of potential
value to determine knowledge and skill in flexible bronchoscopy. Respiration
2004;71:269-75.
14. Patel AD, Gallagher AG, Nicholson WJ, et al. Learning curves and reliability
measures for virtual reality simulation in the performance assessment of carotid
angiography. J Am Coll Cardiol 2006;47:1796-802.
15. Barsuk JH, Ahya SN, Cohen ER, et al. Mastery learning of temporary hemodialysis
catheter insertion by nephrology fellows using simulation technology and deliber-
ate practice. Am J Kidney Dis 2009;54:70-6.
16. Fraser K, Peets A, Walker I, et al. The effect of simulator training on clinical skills
acquisition, retention and transfer. Med Educ 2009;43:784-9.
17. Mangione S, Nieman LZ. Cardiac auscultatory skills of internal medicine and
family practice trainees. A comparison of diagnostic proficiency. JAMA 1997;
278:717-22.
18. Issenberg SB, Gordon MS, Greber AA. Bedside cardiology skills training for the
osteopathic internist using simulation technology. J Am Osteopath Assoc 2003;
103(12):603-7.
19. Butter J, McGaghie WC, Cohen ER, et al. Simulation-based mastery learning
improves cardiac auscultation skills in medical students. J Gen Intern Med
2010;25(8):780-5.
20. De Giovanni D, Roberts T, Norman G. Relative effectiveness of high- versus
low-fidelity simulation in learning heart sounds. Med Educ 2009;43:661-8.
21. Halaas GW, Zink T, Brooks KD, et al. Clinical skills day: preparing third year
medical students for their rural rotation. Rural Remote Health 2007;7:788.
22. Stroud L, McIlroy J, Levinson W. Skills of internal medicine residents in disclosing
medical errors: a study using standardized patients. Acad Med 2009;84:1803-8.
23. Levinson W, Roter DL, Mullooly JP, et al. Physician-patient communication. The
relationship with malpractice claims among primary care physicians and surgeons.
JAMA 1997;277:553-9.
24. Sijstermans R, Jaspers MW, Bloemendaal PM, et al. Training inter-physician
communication using the Dynamic Patient Simulator. Int J Med Inform 2007;76:
336-43.
25. Daetwyler CJ, Cohen DG, Gracely E, et al. Elearning to enhance physician patient
communication: a pilot test of “doc.com” and “WebEncounter” in teaching bad
news delivery. Med Teach 2010;32:e381-90.
26. Butow P, Cockburn J, Girgis A, et al. Increasing oncologists’ skills in eliciting and
responding to emotional cues: evaluation of a communication skills training
program. Psychooncology 2008;17:209-18
27. Hamman WR, Beaudin-Seiler BM, Beaubien JM, et al. Using simulation to identify
and resolve threats to patient safety. Am J Manag Care 2010;16(6):e145-50.
28. Sharpe R, Koval V, Ronco JJ, et al. The impact of prolonged continuous
wakefulness on resident clinical performance in the intensive care unit: A patient
simulator study. Crit Care Med 2010;38:766-70.

Simulation - Applications - in Adult Learning

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Disease-a-Month!

Volume 57 Number 11 November 2011

Michael I. Greenberg, MD, MPH

Volume 57 Number 11 November 2011

Simulation in Healthcare, Part I: The

Ernest E. Wang, MD, FACEP

Morris Kharasch, MD, FACEP

Peggy Ochoa, RNC-OB, MS

Information for Readers

Simulation in Healthcare, Part I:

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Access to Disease-a-Month Online is reserved for print subscribers!

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Dis Mon 2011;57:664-678

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Adult Learning Theory

1. Adults need to know why they need to learn something before

describe the learning process “whereby knowledge is created through

simulation-based techniques to achieve superior performance in their

Creating an Effective Learning Environment for

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Dis Mon 2011;57:679-690

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of simulation cases,43,44 simulation center development policy,3 physio-

In May 2011, NorthShore University HealthSystem expanded its HFS

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Dis Mon 2011;57:691-699

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Dis Mon 2011;57:700-705

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Review Board approved study. A convenience sample of volunteers was

Dis Mon 2011;57:706-714

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Dis Mon 2011;57:715-722

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involving emergency medicine residents participating in a high-fidelity

and costs associated with mobilizing simulated patients, money, re-

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Dis Mon 2011;57:734-743

734 DM, November 2011

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Dis Mon 2011;57:744-756

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Simulation training also offers the potential for professional licensing

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