Should medical simulation be regulated?

In short reply to the title of this post: No, not unless we plan to deprive learners of valuable educational opportunities.

At a recent simulation course that I attended, one session ended with a discussion about the need to regulate simulation. One of the instructors for the day was suggesting that simulation be conducted only by individuals well trained and experienced in medical simulation. He advocated for a need to implement regulation and accreditation for simulation activities. Furthermore he voiced about low fidelity simulation and just anybody out there thinking they can conduct a simulation scenario.

Do we need approval from a governing body to run a simulation scenario? In thinking we do may lead to unintended harms such as clinical errors that may have been prevented by simulation (while we wait for the appropriate regulation)

I approached him afterwards and listened a bit more to his perspective. He described concern about some technology that would facilitate a “lower” fidelity simulation scenario. In his opinion training in an environment  that isn’t identical to the actual work environment might lead to the participant acting inappropriately or being unable to manage in the real world since they may only become proficient using the machines available during simulation. In other words, if you teach people on one machine this may result in error if they’re faced with another machine in their actual work environment. He cited the Tenerife airport disaster as an example whereby simulation could be harmful. This devastating incident occurred when two jumbo jets collided on a runway in the Canary islands.

Despite the pilot being extremely experienced, he had just recently returned from a prolonged period where he had been instructing in the flight simulator. There’s some speculation that this may have contributed. Whether “too long” in the flight simulator and not enough real flight time played a role is difficult to determine. Is it possible that he picked up bad habits in the simulator and subsequently brought these back to his real work environment?

I agree that there is potential for harm in simulation. A recent report from Toronto described a critical event of an anaesthetic canister overheating (unintended) during a simulation scenario. There’s also reports of in-situ simulation equipment being accidentally brought into live use. Such events mandate safety for participants as paramount and that processes are in place to prevent mixing simulation-grade equipment into real life. However, to suggest that eager, enthusiastic clinicians who want to initiate simulation must pass tests or wait until policies are implemented or even receive some type of accreditation risks stifling valuable education. Holding the key to the simulation door in an ivory tower, available only to those who are pass the “test” is irresponsible and impractical.

We have implemented simulation into medicine as a means to improve care, practice critical events and work as a team. If we are to wait for accreditation and have only select individuals conduct simulation, then we are doing a disservice to our trainees and our patients. We should encourage teachers who wish to run scenarios to do so, even if they can’t use the latest most expensive high-fidelity manikin. To suggest that there’s considerable risk by training in a non-identical training environment is crazy. If you can’t train using high-fidelity, would it be better to just read about the procedure and practice on a real patient? Oh wait, this is what we’ve done for years and simulation was implemented to help reduce the harms of such an approach.

If accreditation or regulation will become part of simulation, the process should not inhibit the creativity of clinicians who have generated amazing learning opportunities (often with very little). Waiting for the “most appropriate” policy or procedure to be implemented will only expose our trainees and patients to further threats, errors and harms.

Helicopter Underwater Escape Training (HUET) course

It’s been a busy week so I’ve been a bit delayed getting up this post.

Our choppers at the base are extremely well maintained by a whole crew of super experienced staff, but regardless, there remains the possibility that we’ll “ditch” into the water during a flight. Ideally this occurs in a “controlled” manner but it’s possible that it happens suddenly. This unlikely occurrence has been the impetus for the HUET course that’s occurred at the base for the past 20 years. This course really highlights lots of stuff we can be doing in medicine – practicing rarely performed, high-stakes procedures in a simulated setting. The concept is fantastic and what’s great is that not only do we discuss what to do, we actually go out and practice.

We just finished up a really solid day at the base where we completed our Helicopter Underwater Escape Training (HUET) course. There was a combination of flight crewman, pilots, physicians, paramedics and surf rescue guards who all came together for an excellent day of training.

We started off the day with a full review of our lifejackets, seat belts and exit from the chopper.

Letting off flares over the bay

Then we headed out to the pier where we channelled our inner caveman, got to play with fire and let off  a bunch flares (ones usually kept in our life vests). I think there’s a genetic element (left over from the prehsitoric era) that provides us with great satisfaction from setting off fire into the air and watching fireworks launch into the air. Nothing quite like challenging your manhood with “my flare went further than yours”.

We then headed up to the local dive pool to practice our underwater escape plans. The Trust has a great training apparatus – a mini chopper known as the “dunker”! This thing functions as a practice model for escaping as the chopper is flipped upside down. As it was described in our course, we have to wait at least 7 seconds once we hit before we escape. By then all the chopper blades will have stopped and it will be safer to exit. This simulation process helps you gain appreciate for the complete clusterf*#)@ that it would be if the helicopter crashed into the water. While we couldn’t recreate the likely injuries you’d suffer, the gasoline in the water, the inability to see, the hectic ocean swells, we were at least able to go through the motions of our exit plans. When my wife asked, “how was your day?”, I started explaining what we were up to.  Judging by her reaction on my training for a possible helicopter crash, it appears that such things are best left on the list “things not to tell your wife”.

We had 4 divers in the water watching us as we got dunked under and to help us escape if we ended up down too long.

Two crewman getting the dunker back to “right side up” for another simulation

Imagine being in a set of rapids, hanging upside down without an idea of which way is up and completely disoriented while not being able to breath. This is exactly what we went through today…except in real life we’d then probably have to get to the surface (some 30-50m away). There’s little around to help you navigate except the simple technique of opening the door first then seat belt (otherwise you can float away and have no idea of your bearings).

This was a fascinating experience that helped emphasize the importance of in-situ training. When experiences are vastly different than what we’re used to, we must engage this environment and practice in a foreign situation.

A nice side-profile of the dunker! What a sweet ride!

I’ve included a video of the dunker, so that it can be observed in action! You’ll see the two that were belted in, pop up right at the end of the clip! Another successful escape!

Is there value in scientific meetings?

This short editorial published recently in JAMA raises the question of the utility and value of scientific meetings. Dr. John Ioannidis writes an interesting and provocative editorial about whether these meetings serve any valuable purpose. He describes some of the negative aspects

  • carbon footprint associated with international travel to these meetings
  • lack of stringent review of abstracts and subsequent low percentage that are published as full articles (researchers can easily get accepted partially completed articles that don’t tell the whole story…especially since most abstracts are less than 300words)
  • lack of evidence-base required by keynote speakers; instead they often speak based on opinion yet because they’re considered “experts” – of concern is that their influence can alter practice substantially and this may be despite lacking evidence
  • infiltration of drug/device companies and the potential for conflicts of interest within the conference

pretty sure this could be done online at a fraction of the cost…??

Instead the author argues that given our technological advancements, money used for conference planning that has little educational impact (e.g renting the venue, food, etc) could be better used to design high-yield educational materials. The author also suggests that conferences become subject of study and trials.

He raises excellent points and ones that deserve consideration. As we move to more accessible technology that connects us virtually instantaneously, there is reduced utility traveling 2 days of simply to hear a few poorly peer-reviewed lectures. Though if the parties are good, might be hard to turn down a good conference!

Crew (or crisis) resource management…a must for medicine

While CRM (or crew resource management) is well described in the aviation literature, it’s not nearly as well known within medicine. Interestingly, it applies extremely well since we (medical professionals) work in teams and often in high-stress situations where decisions involve life and death.

Graphic illustrating that pilot responsibilities increase near landing and subsequent reduction in the safety margin. Similar patterns occur in medicine when we approach critical events…though without CRM training, these high risk periods may not be managed as effectively as possible

This past week I completed a CRM course with fellow physicians, paramedics and pilots through the ARHT. I wanted to share with you a recent publication by one of my supervisors here in Auckland, and a staff physician I work with back home in Toronto.

Chris Hicks and Chris Denny recently published their findings from a study of CRM instruction implementation among emergency medicine residents. It’s difficult to believe that we continue to train and do simulation without some emphasis on CRM. It’s well documented (as I’ve mentioned in a previous post) that stress affects decision making (often negatively) and also adversely affects team communication. So why don’t we train to improve this?

This study examined EM residents in their clinical & team leadership performance before and after a CRM training day. Findings suggest that participant attitudes were positive towards the impact of CRM on team work and error reduction. In addition, while it didn’t reach statistical significance, post course nontechnical skills (leadership, communication, problem solving, etc.) improved after well designed CRM instruction.  Further study is required to assess what impact such training has on trainee performance but the findings are important. As trainees/staff become more experienced, the likelihood that they’ll make one serious error is less likely, but serious errors still occur. Most often, these errors occur as a result of multiple smaller (“less significant”) errors that compound and subsequently affected by poor communication, leadership and team work. As educators, we need to work help trainees understand where teams break down under stress and plan to correct this.

Another day at the office…

We just got back from a beautiful day working at ARHT. Not a super busy day but we did get out flying for a few jobs. We enjoyed amazing weather, great crew and got the patients safely to the hospital. Weather was about 20 degrees, sunny without much wind. We had a stunning trip out to Great Barrier Island…I’ve just posted a few pics from the day.

View during the flight home with Waiheke Island in the background.

Great Barrier Island

Doing my best Topgun look…maybe I should have a more serious face

Me and Leon (crewman). Probably the best guy to have on your team. Keeps us all under control and has tons of experience! Plus fairly certain he can bench 300lbs…not bad to have on your side

Here’s a new article about the impact of stress among clinicians.

Auckland HEMS

In a recent study from Toronto, researchers studied paramedics in two similar scenarios. Both scenarios involved a 50 year old patient suffering from chest pain. The patient develops pulmonary edema, hypotension and an ECG reveals a STEMI. All study participants (paramedics) performed interventions based on their established local protocols.

In the “high stress” scenario, there was an actor playing the patient’s partner who was visibly distressed and challenging the paramedic’s actions. Also, all alarms were turned up to full volume and there was constant 2-way radio communication going on in the background. None of this occurred in the “low stress”  scenario.

Paramedics were assessed using a global rating scale, a checklist scale and their salivary cortisol levels were measured before and after each scenario (as a response to stress).

The authors noted that “When faced with clinically relevant stressors, paramedics demonstrated significant increases in subjective (anxiety) and physiological
(salivary cortisol) measures…

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Podcasts in Emergency Medicine and Medical Education

Podcasts have become increasingly popular in medicine over the past 5 years and I would argue that emergency medicine has really been influential in pushing the boundaries of what’s possible. Some of the most well known EM educators have become internationally renowned based on their podcasts. The concept is easy, sit down and record interviews/thoughts/critiques and then disseminate it. However, the practical reality is that the amount of work required is considerable to have a well designed, thoughtful and carefully edited podcast. For me, podcasts add an additional learning method, that allows me to be free from flipping through pages or sitting in front of a screen and over the past 3-4 years I’ve spent a good deal of time listening to EM podcasts. As a result, I wanted to share some of the better podcasts out there with those of you looking to incorporating podcasts into your continuing medical education. This list was compiled with a resident colleague of mine, Max Ben-Yakov. So thanks to Max for putting this together.

Most of these podcasts are by EM physicians around the world who have a passion for education. They go to great lengths to interview leaders in the medical field, read new articles and share their knowledge. However, there’s a growing trend among medical journals to incorporate a monthly podcast which I think is fantastic! These podcasts come in a variety of forms and I’ll include mention of two here in this list. Annals of Emergency Medicine has an excellent monthly summary of all it’s journal articles – this is done by Drs. David Newman & Ashley Shreves (both from NY, USA). They provide an outstanding summary of each article and best of all, its FREE!!! I strongly support any methods to disseminate free medical education and I think the Journal should be commended.

Another journal, Medical Education, has taken an interesting approach which also should be commended. The editor (Dr. Kevin Eva) conducts a conversation with a selected author(s) from a paper published each month. It’s fascinating to listen to the authors take on their own research, why they did the research and what were some of the issues. We learn more about the research then can be conveyed in any published article. This is similar to what you might get at a conference but in a more question and answer format. These podcasts provide an easily accessible (and free) method of disseminating important medical research. As technology becomes increasingly integrated into our lives and culture, we should look for ways to embrace it and make it work for us. I think these journal podcasts do just that.

Just for transparency, I have no conflicts of interest to declare with any of these podcasts. I’m certainly not paid by any of these podcasts (though willing to take money if they want to give me some!) I have published an article in Medical Education but have also been rejected from them too!

Now here’s a list of some of my favorites and ones that I’ve come across. The list isn’t comprehensive and I welcome any feedback or necessary additions.

EM:RAP: Emergency Medicine: Reviews And Perspectives. A monthly audio series for emergency medical practitioners. Born in September 2001, it now is heard by up to 8000 subscribers every month and it is the fastest growing audio publication in Emergency Medicine.

EM:RAP presents the best speakers from across North America, brining lectures from many prestigious Emergency Medicine meetings, all in a tightly edited audio format. Emphasis is added through the lectures by our internationally acclaimed hosts Mel Herbert and Stuart Swadron. It is available with an EMRA subscription.  It is THE most popular podcasts out there – highly recommended.  Some listeners complain that the jokes are immature and there’s occasionally too much banter… I think it just emphasizes why we’re not internists and we know how to have fun. Duration: 1-2 hours. Cost: $50/year for residents or FREE with EMRA subscription.

EMCrit Scott Weingart is an EM physician in NY City who has a serious interest in critical care medicine. He puts together an outstanding podcast that is a must listen for anyone that ever takes care of sick patients. The podcasts are usually 20-30 minutes and he’ll focus on one topic. These range from recent literature, new approaches to old problems or pretty much anything else that’s relevant to critical care in the ED. He has a great website with lots of additional info and often summaries of podcast. Best of all, his podcast is FREE!!!

ERCast Rob Orman is an EM physician on the west coast of the US. He focuses on a different topic each week or month. This is aimed at the everyday EM doctor, and he provides practical insight and advice about how you can be a better clinician.  There are tons of commonsense nuggets of wisdom along with interesting interviews of EM physicians or specialists (e.g. a month ago he interviewed an orthopod about distal radius fractures…). Also FREE!! Check it out.

Emergency Medicine Cases. From my hometown, Toronto, Canada, big shout out to fellow Canadian, Dr. Anton Helman who put together this one. He interviews some of the EM physicians from our neck of the woods about a range of different topics. From his website…“Emergency Medicine Cases (EMC) is Canada’s premier educational website dedicated to keeping staff physicians and emergency medicine residents up to date on the most current topics in emergency medicine. In ten episodes each year we present cases to two of Canada’s leading experts in emergency medicine, and discuss clinical pearls, important management issues and current clinical literature around the cases. We highlight key practical learning points that you can use in your every day practice.

SMART EM. A highly polished podcast from NYC – brought to you by Drs. David Newman and Ashley Shreves. This is the podcast for those who feel that everything you’ve been taught is a lie… and probably isn’t supported by evidence. The authors take “deep dives” into the literature and discuss controversial topics faced by Emergency Medicine while doing an amazing job of doing an exhaustive review. It is a bit on the longer side, but holy shit, if you want a comprehensive review of the literature, then this is what you should listen to. I probably don’t listen to enough peds EM stuff, but I really should. This is a great one from south of the equator (Australia), not too far from where I’m currently sitting as I right this in NZ. Definitely worthwhile checking out.

Free Emergency Medicine Talks: A collection of over 500,000 talks on everything that is emergency medicine from conferences and lectures around the world. This is an excellent resource if you’re looking for a particular topic (e.g. resource for upcoming rounds). It’s put together by a world class educator and emergency physician, Dr. Joe Lex from Temple University, Philadelphia.

Peds Emerg Podcast: This one is relatively new, haven’t listened to it enough, but seems quite good and its peds! And sick kids can be scary – so more knowledge is better!

Traumacast. For those of us who are passionate about trauma and taking care of these patients. This is a collection of interviews addressing upcoming research and how it can be applied to the injured patient. This is brought to by EAST (a very influential group of trauma surgeons in the US) who publish many guidelines that we implement in trauma care.

Toxtalk. I think this is a relatively new one and I actually have only heard one episode but its a well done podcast from the tox program at UMass.

Finally, from a medical education perspective, ICRE (International Conference for Residency Education) now disseminates podcasts from their conferences which is a great idea. Some fascinating discussions about all that is medical education! I think this a great way to distribute learning to all those who weren’t able to make it!

Low cost SimMan having a seizure!!!

Part of the great thing about simulation is the creativity that can be had while organizing and planning scenarios. Often we’re restricted only by our imaginations (though a small stash of cash is generally quite helpful!).

So this past week as I was designing an out-of-hospital scenario that involved a seizing patient (status epilepticus) I spent some time looking into how I could recreate a seizure in a low-fidelity SimMan. For anyone that has spent time doing simulation, the importance of recreating realism can’t be overstated. It doesn’t necessarily need to be high-fidelity but it should allow the learner to feel like they’re actually in the situation.

I did some research and found one place ( that sells a device called SimSeize that recreates seizures. While it looks great, it was going to run me about $5000 which is slightly outside of my annual operating budget (approximately $50 NZD…or $40 CDN). For anyone is interested, check out their site.  So borrowing from the idea of having the shaking occur under the patient, I developed a slightly lower tech version which I’ve included in the video below. My apologies that the audio is a little distant, but just turn it up full. I’m thinking about patenting it and feel because it’s for medical simulation, it’s probably worth upwards of $300…maybe more!