In Disaster Medicine Training Charles Stewart MD EMDM

Simulation has a long history...

Photos LTC(ret) M. Synovitz

Current “Sims” at Altus Air Force Base Oklahoma Photos LTC(ret) M. Synovitz

The military has also been a major developer of medical simulation technology

My first introduction to medical simulation was the EFMB continuous days of simulation, testing, and performance...

The Combat Casualty Care Course is a military introduction to simulation for RN’s and MD’s on active duty

Military Health Systems Digital SimulationTraining Currently Available MC4/SA (Medical Communications for Combat Casualty Care/Situational Awareness) CHCS (Composite Health Care System) CHCSII-T (Composite Health Care System II-Theater) TRAC2ES (TRANSCOM Regulating and Command & Control Evacuation System) DMLSS (Defense Medical Logistics Standard Support) DMLSSAM (Defense Medical Logistics Standard Support-Assemblage Management) TCAM (TAMMIS Customer Assistance Module)

Oklahoma We are particularly ‘blessed’ with disasters… Tornadoes Heavy weather Ice Storms Floods Wildfires

So... How do we teach readiness for this! We have chosen several methods... Picher tornado, 2008

Simulations Are Ideal For Disaster Training

HSEEP The Homeland Security Exercise and Evaluation Program (HSEEP) is a capabilities and performance-based exercise program which provides a standardized policy, methodology, and terminology for exercise design, development, conduct, evaluation, and improvement planning. It is ONE way of looking at disaster simulations... It is loosely based on the ARTEP.

HSEEP Describes two major types of exercise Discussion based Discussion-based exercises familiarize participants with current plans, policies, agreements and procedures, or may be used to develop new plans, policies, agreements, and procedures. Operations based Operations-based Exercises validate plans, policies, agreements and procedures, clarify roles and responsibilities, and identify resource gaps in an operational environment.

HSEEP ‘Exercises’ Discussion Seminars Not really a simulation or exercise Workshop Also not really simulation or exercise

Simulations Table top exercises Very good for identification of potential problems in the emergency operations plans Useful for training key leadership and management to plan and work together.

Tabletop Simulations Duncan OK, 2009

Tabletop Simulations Duncan, OK, Jan (and they were better prepared, we think!)

Games A game is a simulation of operations that often involves two or more teams, usually in a competitive environment, using rules, data, and procedure designed to depict an actual or assumed real-life situation.

ACLS Games...

Ground Truth Video Game

Text EMDM Disaster Preparedness Game

Operational Simulations Individual (small groups) simulations Teach procedures that you can’t usually do - and may not be able to find the opportunity to see/do. Example - organophosphate poisoning treatment. Often used in training responders to disasters

Simulations Drills Small team simulations: Very good for unit cohesiveness, training for scenarios that are not often seen.

Operational Simulations Functional Exercise A functional exercise examines the coordination, command, and control between various multi-agency coordination centers A functional exercise does not involve any "boots on the ground." (Often difficult to differentiate from table- top exercises)

Operational Simulations Full scale exercises: A full-scale exercise is a multi-agency, multi-jurisdictional, multi-discipline exercise involving functional (e.g., joint field office, emergency operation centers, etc.) and "boots on the ground" response (e.g., firefighters decontaminating mock victims).

Operational Simulations Full scale exercises: Useful for ensuring that agencies work/play well together. Useful for identification of command structure problems VERY expensive!

Tulsa Airport 2010 Lots of people, lots of volunteers, and lots of vehicles.

Tulsa Airport 2010 Plane crashes are especially tough to simulate because most don't actually happen on runways. Instead, they usually occur in remote areas, and that makes it difficult for so many emergency vehicles to respond so quickly.

Tulsa Airport Agencies, 304 casualties, and an airplane Photos, Channel 6, KOTV

We also use medical simulations...

Simulation is a technique, not technology, to replace or amplify real experiences with guided experiences……. in an interactive fashion Gaba Qual Saf Health Care 2004; 13

It may be used for both individuals and teams

Medical Simulation in Emergency Medicine ABEM was the first medical specialization board to adopt simulation within their oral board examinations... from the first ABEM board in These oral examinations are a far cry from the high fidelity simulations now available.

Doctors Trained On Patient Simulators exhibit Superior Skills Beth Israel Medical Centre New Virtual Reality Surgery Simulator hones Surgeons' Skills, Improves Patient Safety Oregon Health & Science University School of Medicine Clinical Simulation Technology Used To Improve Communication Of Medical Teams Washington University School of Medicine Science Daily Medical Simulation In Disaster Medicine... Works

Role Playing Like ABEM oral examinations Task trainers Computer patient Manniquin simulators Medical Simulation

Benefit of Simulators Student can practice key skills in a safe environment Teacher can break down the task into components Student can receive immediate feedback Teacher can create the same situation to assess performance repeatedly

Benefits of Simulators Simulators are great for teaching and assessing: Procedural skills Treatment/interventions Invasive monitoring Allowing mistakes….

Simulations in DM Focus on medical management Crisis resource management skills are reinforced Increased complexity Can be videotaped for review and reflection “What will you do differently next time?

Limitations Not great for: 2-way communication skills Treating the patient as a person Students tend to treat the sim as a “dummy.” Representing family/staff/other team members

Hardware & Infrastructure Are NOT inexpensive…. We have over $1x106 invested in our equipment Medical Simulation

Manpower and Training Are also NOT inexpensive…. Medical Simulation

The “Usual” Training Model “S1D1T1” See One Do One Teach One

S1D1T1 “S1D1T1” Often used in surgical training Frequently used for procedures in other specialties. The 2 nd year resident is frequently teaching the 1 st year resident…

In Disaster Medicine If you’ve seen three disasters of the same kind, you are either in the wrong part of the world… very unlucky… Or both…. S1D1T1 doesn’t work well in this situation.

We also have invested in the AMA sponsored NDLS as a training method to help introduce responders at multiple levels to disaster medicine

ADLS – At the conclusion of this ADLS course the student will be able: Identify the Critical Need to Be Prepared for Natural Disasters and Events involving: chemical, biological, nuclear, radiological, and explosive incidents. Define “all-hazards: and list possible etiologies

ADLS Identify the components of the DISASTER paradigm and apply the paradigm using both the M.A.S.S. and the ID-me BDLS triage model Meet the Acute Care needs of patients involved in either a public health emergency or a natural disaster Rapidly and effectively become part of the public health system

ADLS Demonstrate the ability to participate in a coordinated, multidisciplinary, mass casualty incident using personal protective equipment Demonstrate the use of elements of decontamination site selection and the operation of basic chemical and radiological detection.

ADLS Demonstrate the ability to operate within the Incident Command System and exercise leadership competencies related to emergency preparedness and response. So... How do we teach this?

ADLS ADLS™ makes use of interactive scenarios and drills in which the participants treat simulated patients in a disaster. Through the use of high fidelity mannequins the student can gain experience in treating conditions that they would normally not treat even with years of experience.

Our friends.... help us Teach ADLS

Management of Mass Casualty from Explosion

Hemorrhagic fever Contaminated patient

Provides the opportunity to train on unusual medical problems…. Problems… that you won’t (hopefully) see Problems… that require unusual resources Problems… that require unusual equipment or personal protective gear. Medical Simulation In Disaster Medicine

Also provides a balance between the emotional load associated with the crisis experience and the professional lessons that can be learned. We can ‘stress’ the provider… without the risk of overload. Medical Simulation In Disaster Medicine

Also…. Provides professionals with the skills to cope competently with those mistakes that could not be prevented Reduces occurrences of errors in real life The military has clearly shown that we ‘play’ just like we train Medical Simulation In Disaster Medicine

In order for this to work.... Trainees must have some ability to invoke a “Suspension of Disbelief” Medical Simulation In Disaster Medicine

This is a ‘disaster’.... And we invoke the“Suspension of Disbelief”

During training, we need to avoid MONITOR Focus Looking at the monitor to prompt the next clinical decision!

And then we talk....

Feedback Students are asked how they thought the scenario went Leading questions probe the students’ thought processes

A hidden benefit of feedback The immediacy of the post simulation reflective learning process may provide trainees with snapshot of their abilities in certain clinical areas For some = impetus for further self assessment/new learning in those areas that are perceived as being less than optimal or below expectation  For some this =

Is Resource Intensive and Time Consuming for both Trainers & Trainees Medical Simulation In Disaster Medicine

Initial exposure raises awareness Repeated exposure to simulation improves performance High Impact But does will it translate into improved clinical outcomes? Medical Simulation In Disaster Medicine

Reliability Validity Predictive validity Medical Simulation Verification of Competency

2008 Academic Emergency Medicine Consensus Conference on the Science of Simulation Objective methods and measures to demonstrate simulator training actually improves patient safety Effective feedback of information from error reporting systems into simulation training to improve patient safety Methods and outcome measures to demonstrate teamwork improves disaster response ……………..

Other’s experiences... Abrahamson SD, Canzian S, Brunet F. Using simulation for training and to change protocol during the outbreak of severe acute respiratory syndrome. Critical Care 2006;10(R3): Schwid HA, Rooke GA, Ross BK, Sivarajan M. Use of a computerized advanced cardiac life support simulator improves retention of advanced cardiac life support guidelines better than a textbook review. C rit Care Med 1999;27: AND MANY MORE....

We’ve done this a few times Since the inception of OIDEM in We’ve trained 211 students in Advanced Disaster Life Support in 4 classes per year. But... we don’t just do ADLS for disaster training We have bi-monthly simulation training sessions for our residents

... We’ve doing team training with nursing students in Emergency Procedures. We help the Urban Search and Rescue Teams with their disaster exercises and drills. We help with Advanced Trauma Life Support procedure training. We work with both rural EMS agencies, EMSA, and Tulsa Fire Department Medical Simulation In Disaster Medicine

We’ve been active in all of the disaster training shown in this slide set... Including HSEEP training. We BELIEVE in using training simulations in disaster medicine. Medical Simulation In Disaster Medicine

Our ‘friends’ help us teach in ways that living people just can’t... in places or situations we can’t put living people... and react to agents that we can’t use on living people...

Thank you....

Charles Stewart MD EMDM, MPH (candidate) Professor of Emergency Medicine Department of Emergency Medicine Director, Oklahoma Institute for Disaster and Emergency Medicine