"I saw it once on TV..."

[Veneficus]

It seems not a week goes by that somebody isn't asking for a youtube link as a place to learn clinical medicine.

My favorites are how to deal with children and how a live birth works.

But there have been others like how to perform everything from IV starts, to patient assessment, to surgical skills.

Permit me to let you in on a little secret?

You cannot learn people skills, clinical skills, or any other "hands on" thing in which you need to participate on youtube and then actually be able to do it.

You must actually put your hands on or be a part of the event.

This is one of the reasons I am also against simulation labs. Anyone can perform any procedure on an overpriced doll expertly. Especially after a few times because that doll never changes.

Would you let somebody operate on you who only ever saw a procedure on TV?

Would you let somebody do something to you unsupervised they only ever did on a doll?

Now I will submit the general public might because they probably believe or trust it is not your first time and you learned it by watching a fictional medical TV show like House.

I realize this is the information age and digital information is easily and readily available.

But medicine is still one of those things that you have to do with your own hand.

Please? If you have want or need to learn something, seek out an expert to teach you.

Hiding in your room watching youtube is not the way to do it.

 

[ThadeusJ]

Interesting topic as the rise of simulation labs has been significant in the last few years. The problem isn't simulation per se, but the use of the available tools (and many places do not use the available tools for what they were designed for). One of the biggest users of simulation as a training tool has been Israel, which only allows surgery on live patients after they have completed extensive simulation training. Their medic training follows the same practice.

You may also find it interesting to learn that most if not all of the airline pilots out there learned through simulation and their safety record is far higher than what we see in the healthcare industry-one of the reasons being a more standardized global practice for even the simplest of tasks. There is very little of that "We don't do it that way here" attitude. Many pilots have learned solely through simulation in that they can graduate without having flown a real airliner.

Paramedic training through simulation has its merits, but the approach has to be done properly using computer based simulation as an entry level, then onto manikins and standardized patients (actors). The net result is that you don't waste time and resources figuring out the small stuff in situations that can be used to practice what's important (i.e. you can learn aseptic technique, organizing the procedure, patient consent, and diffusing volatile situations all through simulation to great effect. I am confident that you (with your years of experience) could act as an excellent "patient" in training newbies the art of diffusing bad situations instead of waiting until they are on their own and experience it down the road (the school of hard knocks model).

 

[Handsome Robb]

What if you stayed at a Holiday Inn the night before? :lol:

Any particular event that motivated this? Edit: disregard, I figured it out

I definitely agree with you, with one caveat: While simulation labs with high fidelity mannequins definitely have their limitations, I see no reason why they cannot be used, effectively, to supplement patient contact time during school. Unfortunately many facilities or the staff of those facilities are not "student friendly" when it comes to the more advanced, invasive, "high risk" skills. I ran into situations where staff would not allow me to preform a skill or assessment, even with supervision, time and time again as an EMT student and a few times as a medic student.

There are some high acuity, low frequency skills that are just so few and far between that there is no way to practice them except on cadavers or mannequins. Surgical and needle cricothyrotomies are the first two that come to mind.

Maybe it's just me, but I would never allow a medic intern to perform one on a live, or freshly deceased patient even under my direct supervision. They will definitely be the one assisting but I'll be the one doing the cutting. Some might say that's unfair to the student but when it comes down to it I'm the one ultimately responsible for that patient and even if I really trusted the student I would still be doing the procedure. Also, I've never done one except on a cadaver and multiple times on a mannequin. After I get one then I might consider allowing an intern who had REALLY proven themselves competent but even then, it's a one shot deal, not something you can make multiple attempts at if they butcher the landmarks. Can't just move down a little bit and try again, you know? Well technically you could but I highly doubt QA/I and my MD, and the ERP would be very happy with me.

 

[ThadeusJ]

I agree with you completely. I once had the great opportunity to work for an aviation simulation company who built a huge sim centre in an allied health school. We were to bring advanced (compressed) education tools and techniques and they were to supply the educators and students. While they were muckin' about, I contacted my paramedic colleagues and solicited ideas for this advanced sandbox. The possibilities were endless. Learn the landmarks on video, then an arm, and then we'll bring in a car chassis and suspend a manikin upside down...in the dark...

Unfortunately the business model failed and now its just standard classroom space following the same education model as before (except in a very advanced recording studio). We actually hosted a cardioperfusion (heart/lung bypass) conference where the response was overwhelming in the sense that experienced practitioners commented that it was a very realistic scenario. It was all recorded and the individual sessions were given back to the practitioners as part of the their self learning.

The key to adult education is that most people don't recognize their actions and errors unless presented to them in a constructive manner. And its all about learning, not criticism.

 

[mycrofft]

I'm reading good stuff mixed with not so good stuff.

Airline pilots use simulators but spend much time working up to an airliner sim actually flying and then will spend much time after the sim on an actual craft before being the primary pilot, right? But I like the overall parallel.

However, it does not parallel medical practice taught in a school with sim then turn the student loose with a certif because the responsibility is too great to teach them on real live patients.

The business model failure note is a good point. Very good point.

Last year I looked into the impact of simulations on medical teaching and the studies showed that while not actually bad, they were not very effective. It is also my experience that simulators become easier to use after being used a few dozen times, (stains show placement points, sim skin not replced so needle marks show, functions get abandoned because they break and are not fixed, so they are glossed over later). Refurbishment and replacement have to be priced in to realize the continued elementary benefit.

Here's a stray one. Some skill sets are best taught in a certain mode (listening, watching, hands-on, rewriting/presenting, etc) above others; people haved a personally predominant learning mode. If their mode mismatches the modes being used, they will not learn that skill well until they happen into their mode somewhere in their professional journey. Some are just not good fits because their modes are not compatible with medical education as it is.

 

[AtlasFlyer]

Airline pilots use simulators but spend much time working up to an airliner sim actually flying and then will spend much time after the sim on an actual craft before being the primary pilot, right? But I like the overall parallel.

Before a pilot is hired by an airline, they have a commercial pilot's license and [at a minimum] several hundred hours flying experience already. So they KNOW how to fly a plane long before ever stepping in the doors of an airline's training center.

The airline puts them through their own training on the specific type airplane they've been hired to fly. This includes ground school and simulator training, this is about 4-6 weeks worth. They then pass a check ride, then go on to IOE (Initial Operating Experience), which is flying with a line check airman. They fly with the check airman on his trips. Actual, revenue, passenger flights. So, it is not only possible, but HIGHLY probable, that the first time that pilot flies that actual, real airplane.. it is a revenue flight, with pax onboard. Aircraft simulators are incredibly realistic, and you can do things in that sim you could/should not do in a real plane except in emergencies. Things like practicing V1 cuts (which is losing one of your engines on takeoff) and windshear recovery are hard on engines and airframes, to practice them in the real airplane would require lots of maintenance. Also, to use a real airplane for training purposes takes an airplane out of revenue service, that's an airplane that's not generating income for the airline. Simulators are an essential, valuable part of pilot training.

First Officers (in the right seat) and Captains (in the left seat) are both qualified pilots, and take turns acting as pilot-flying and pilot-non-flying. They both takeoff, they both fly, they both land. The Captain has been with that airline longer, and "probably" has more overall flight hours. There are some extremely experienced F/Os out there who choose not to upgrade for schedule/quality of life reasons. The Captain is the final authority as to the operation of the flight, though both pilots are fully qualified pilots to fly the plane.

So, in short, yes, the first time an airline pilot flies that specific plane, it IS a revenue flight with passengers onboard. Though they are fully qualified and experienced, thanks to simulators.

(I was a flight attendant for 7 years, am married to an airline pilot, am a private pilot myself and have been in/around the airline industry since 1995.)

 

[Veneficus]

Interesting topic as the rise of simulation labs has been significant in the last few years. The problem isn't simulation per se, but the use of the available tools (and many places do not use the available tools for what they were designed for). One of the biggest users of simulation as a training tool has been Israel, which only allows surgery on live patients after they have completed extensive simulation training. Their medic training follows the same practice.

successful marketing...

I have played with advanced surgical simulators. Even ones with simulated tissue layers. I am not impressed by them.

I have even helped develop simulation training. I am of the opinion that the more complex and expensive "simulators" really don't do anything that the low end ones don't with comparable effect.

I also know that there has been a politcal lobby to try and make regular simulated testing required to demonstrate ongoing skill proficency.

But it comes down to the same thing. Somebody trying to make a dollar selling something that on a good day is nice but not really needed.

You may also find it interesting to learn that most if not all of the airline pilots out there learned through simulation and their safety record is far higher than what we see in the healthcare industry-one of the reasons being a more standardized global practice for even the simplest of tasks. There is very little of that "We don't do it that way here" attitude. Many pilots have learned solely through simulation in that they can graduate without having flown a real airliner.

Others have covered this. It is a sales pitch.

Paramedic training through simulation has its merits, but the approach has to be done properly using computer based simulation as an entry level, then onto manikins and standardized patients (actors). The net result is that you don't waste time and resources figuring out the small stuff in situations that can be used to practice what's important (i.e. you can learn aseptic technique, organizing the procedure, patient consent, and diffusing volatile situations all through simulation to great effect. I am confident that you (with your years of experience) could act as an excellent "patient" in training newbies the art of diffusing bad situations instead of waiting until they are on their own and experience it down the road (the school of hard knocks model).

All of this stuff can be done just as effectively, if not more so, with guided practice. Again, sales pitch.

I think it stems mostly from the idea that simulation has to be technology based. The use of live actor is not the same thing.

I agree with you completely. I once had the great opportunity to work for an aviation simulation company who built a huge sim centre in an allied health school. We were to bring advanced (compressed) education tools and techniques and they were to supply the educators and students. While they were muckin' about, I contacted my paramedic colleagues and solicited ideas for this advanced sandbox. The possibilities were endless. Learn the landmarks on video, then an arm, and then we'll bring in a car chassis and suspend a manikin upside down...in the dark...

Sounds great, but...

Unfortunately the business model failed and now its just standard classroom space following the same education model as before (except in a very advanced recording studio).

It didn't work.

The key to adult education is that most people don't recognize their actions and errors unless presented to them in a constructive manner. And its all about learning, not criticism.

Maybe I am just too old, but I see a trend where this is basically an excuse to justify low performance.

I am all for and about constructive critissm in learning, but I still think there has to be a minimum level of knowledge and ability.

That minimum level seems to keep getting lower and lower with technology as a crutch and everyone who has trouble even meeting the minimum feeling butt- hurt that they were not told what superstars they are.

 

[Carlos Danger]

I think Youtube is great. Obviously it doesn't replace clinical instruction and experience, but it makes a good adjunct to didactic instruction. Especially for visual learners. I find it quite helpful to watch blocks and lines and other procedures done different ways, before practicing them on manikins and then finally in clinical.

Simulation is helpful, too. Not for fine procedural training, of course, and certainly not in lieu of actual clinical training. But for scenario and basic skills practice I think it can be quite helpful. Early in my career as a flight paramedic we used Sim-man heavily for scenario-based practice. I think it was helpful.

Simulators and other technology can be used as a crutch, but that doesn't mean they always are or that they don't have their place.

 

[Rialaigh]

I think Simulation Manikins have advanced so much that they are a very valuable tool in the learning process. Can they simulate surgical conditions, no they cannot. But the hospital I work at recently purchased Sim Mans who you can place arterial lines and in monitor arterial pressures. Is the arterial placement simulation great, probably not. But every concept learned, the "putting it all together" is priceless. You can simulate patient conditions that you would only see once in a blue moon in busy ICU's.

I hate to say it but any skill for an intervention that a paramedic learns can be learned relatively easily...Not to say your a master after a few tries but placing an EJ, once you have placed 10 EJ's you can look at the patient and decide whether you want to attempt and if you will hit it or not. From what experienced nurses and paramedics have told me it does not take hundreds of hours of practice to place an EJ or do a surgical airway.

However the learning from Sim-Mans on the "know how" portion of your skills (in other words, the decision on what interventions to use) is invaluable. The Sim-Mans are so complex these days that you can simulate any number of patient conditions including responses when pushing meds, pacing, shocking, many gauge effective CPR now. You can titrate a dopamine drip to the appropriate blood pressure or evaluate EKG's, hang cardizem and evaluate rhythm changes and patient appearance changes. You can place lines, needle decompress to change lung sounds, simulation of puncturing a lung on a botched decompress. The new ones can have airways placed, OG and NG tubes placed, simulate bowel sounds...hell you can even place foleys on a lot of them now.


In short - For hands on skills there is no replacement for patient contact. For know how, the "putting it all together" I think there is now no replacement for sim-mans.

 

[Handsome Robb]

However the learning from Sim-Mans on the "know how" portion of your skills (in other words, the decision on what interventions to use) is invaluable. The Sim-Mans are so complex these days that you can simulate any number of patient conditions including responses when pushing meds, pacing, shocking, many gauge effective CPR now. You can titrate a dopamine drip to the appropriate blood pressure or evaluate EKG's, hang cardizem and evaluate rhythm changes and patient appearance changes. You can place lines, needle decompress to change lung sounds, simulation of puncturing a lung on a botched decompress. The new ones can have airways placed, OG and NG tubes placed, simulate bowel sounds...hell you can even place foleys on a lot of them now.

You should meet our OB Meti-woman. I'm pretty sure they named her Claire. All sorts of delivery presentations, complications, and a meti-baby that pops out of her that is just as "smart" as she is.

 

[ExpatMedic0]

I'm reading good stuff mixed with not so good stuff.

Airline pilots use simulators but spend much time working up to an airliner sim actually flying and then will spend much time after the sim on an actual craft before being the primary pilot, right? But I like the overall parallel.

haha yes, and CECBEMS who accredits all our(EMS) continuing education recently recognized F5 learning (online with a live instructor on webcam) the same as being in a classroom in person. In addition to this most well respected universities offer distant learning which relies on media to supplement text.

I think its just a part of our post/late modern society now and it will only continue to increase.

 

[MrJones]

Give me a shout when someone cites a reputable, peer-reviewed study or two which demonstrate that simulation, videos, distance learning, etc are ineffective educational tools for learning "...people skills, clinical skills, or any other "hands on" thing".

Until then,

 

[Veneficus]

A quick pubmed search shows studies both for and against simulators as being effective, with no preponderance either way.

I can find nothing in a literature search that is not produced by a simulation company that shows high fidelity sims are more effective than basic ones.

All ofthe studies I looked through end with "more studies are needed."

Looks like a damn fine marketing campaign.

Is that how evidence based medicine works now? If there is not evidence against it it must be good?

In that case I have a couple of new and awesome treatment modalities I think should be standard. I could probably even write up a "study" on how well they work. In the absence of evidence in contra, since I like the ideas they must be great right?

 

[MrJones]

A quick pubmed search shows studies both for and against simulators as being effective, with no preponderance either way....

Exactly.

 

[Veneficus]

Exactly.

An aweful lot of money to spend on an industry that works "sometimes."

 

[systemet]

Is that how evidence based medicine works now? If there is not evidence against it it must be good?

I've taken to making myself unpopular recently by asking two questions every time someone says "There's no evidence that intervention X improves outcomes". They are, "Is there evidence that intervention X is harmful", and "Which outcomes?". Occasionally I like to throw in "Which journal was this published in ?". This is probably career-limiting, and definitely building up some bad karma if I should ever become a training officer.

 

[mycrofft]

Give me a shout when someone cites a reputable, peer-reviewed study or two which demonstrate that simulation, videos, distance learning, etc are ineffective educational tools for learning "...people skills, clinical skills, or any other "hands on" thing".

Until then,

See earlier thread:
http://www.emtlife.com/showthread.php?t=26155&highlight=simulators

 

[MrJones]

See earlier thread:
http://www.emtlife.com/showthread.php?t=26155&highlight=simulators

Thanks. Didn't see anything definitive one way or the other when it comes to the efficacy of simulation etc, but based on what I read there it appears that the balance of study results cited leaned somewhat to the pro-simulation POV.

 

[mycrofft]

Good thread.

About Youtube, I have to admit I have used it as an adjunct to learn a small specific non-critical technique (e.g., athletic taping, exam of distal extremities in re. minor athletic injuries). I watch more than one for each skill because Youtube material is sometimes an ad, and none is checked for quality before posting but after leaving the originator.

I found it very useful for learning about crosscultural nursing/medicine as an intro.

I am just really stuck upon the aspect of integration of simulators into training programs as long-term invesatments. My FD had three ALS simulators, now they are used just for IV's because everything else has worn out or took expensive parts they wopn't buy (and the IV sites are riddled with holes and finger stains).

The Pareto Principle applies. Weighted/jointed rescue manikins; great. Flat Masonitge search outlines: great. CPR manikins: start getting inaccuracies, tailor teaching to manikin. The first 20% effort gets the first 80% results.

Do they have manikins which present with the distractors, false leads and subtle clues live patients present? Do they scream, defecate, vomit, get handsy with/on you?

 

[Veneficus]

Do they have manikins which present with the distractors, false leads and subtle clues live patients present? Do they scream, defecate, vomit, get handsy with/on you?

Of course they do.

But the dolls at Toys R Us are cheaper.

I don't have a problem with simulation per say. I guess I should be more specific.

1. The "advanced" simulators cost way more than their value. As you discovered, it is an ongoing investment. There are things to be learned from simulation, but the lessons and benefits do not seem to match what the mannequins are marketed for. (which is usually skills practice)

I will use a personal example. I was in a surgical skills class, they had these mannequins that had "realistic" tissue, just like cutting into somebody.

The cost was $1500 for each replacable module according to the surgeon instructing. (no need to doubt it because he authorized payment for it.) It has different "layers" but was nowhere near realistic. You couldn't seperate the layers. so while it did bleed when you cut it, you couldn't lift up on the skin to begin. (everyone knows that is the easiest way to cut skin, plus it helps stop cutting deeper tissue like veins)

We somehow were able to "modify" the techniques we were using to get 2 uses per module. WHich means we weren't practicing what we would do, we were operating around the limits of the mannequin.

But whether it is super sim man or fred the head, that is how they all work. Most of the "bells and whistles" are actually computer software. Just like on those little rhythm generator boxes, the "proctor" can change them. But the investment in the audio visual equiment is significant, and most require a computer of some sort too. (many places like laptops)

It is the latest money draining fad. But despite universities investing millions in dedicated buildings, equipment, training, teachers, etc, the benefits in my experience seem to be reproducable at a much cheaper price. Nobody seems to be examining these cost/benefit ratios in the effort to keep up with the Joneses who are also investing in this.

It is really just over-priced toys to play make believe. Undoubtably there is benefit to playing make believe, but at what price? How much should we spend to "teach" or "immerse" people in the moment of make believe?

In my opinion, far less than we are. I am sure the people who get wealthy off of this don't think so.

Let's face it, money is a big problem no matter where you practice medicine. Far too much money has been wasted on this.

2. I was not born yesterday. I know that many of these "simulations" are used to make up for the lack of real training opportunities. On the surface, that may seem like a good thing. But then when the "EMS providers can't intubate" study comes out, everyone gets up in arms. They have been intubating Fred the head since the first day of medic class.

How many paramedics reading this intubated a ped during their training? An infant? How about an infant intubation head? How many of them defend the "need" of intubating infants in the field "just in case?"

But it comes back to opportunity. From my EMT Basic clinicals (all 16 hours of them, at a time they were not required to my medical education has been in an academic medical facility, though not at the same one) These institutions are by definition "teaching" hospitals. They have large patient populations, many specialty departments, and are used to teaching students. I actually learned how to perform an escharotomy in medic school because that was what was going on that day in the burn unit. Not to be confused with something I was permitted to do, but no knowledge is useless.

Many smaller institutions, and ems schools who partner with them, use these simulators to try and make up for experts teaching in the clinical environment. Podunk hospital, just can't do it.

Again to price, simulation training is "better than nothing" but how much better? At what price?

At what point does it make more sense to pay another larger facility for what they offer?

Physician medical providers are required to do their "clinical" rotations and residency at designated and accredited facilities. What is the accredidation for a paramedic class? "We have a hospital."

Why are EMS providers permitted to do clinicals in these "local" facilities?

Because if you follow the money...

and "convenience" of the student.

It was mentioned here that low frequency high acuity procedures, like surgical cric, are not going to be done by students. That is directly a reflection of the quality of the teaching facility.

I learned how to do them in a hospital, under the watchful eye and direct guidance of a surgeon. I am not special, if that is how I was taught, that is how it should be taught. If not, then those who practiced on sim man should not be doing them at all. The same for intubation, etc.

IVs. How many people come here seeking IV advice? Clearly IV arms are missing something. Otherwise everyone should be near perfect.

The evidence speaks for itself.

3. Ineffective simulation. Using mass causualty as a great example. How many sim mans do you have? enough to run a disaster drill? How much would that run you? How much benefit is to be had starting an IV on that puking, peeing, blinking baby doll?

It is much easier to black tag Fred the head than it is to a person talking to you, or their family demanding care. There isn't even randomness to it.

4. Repairs, upgrades, andall of the logistics. How many centers can dedicate funds and people to this? I have seen some extremel wealthy high prestige hospitals struggle with the costs. Stuggle not for having the money, but getting a large enough slice of the budget every year.

I'll bet the sales guy didn't tell you about the total ongoing costs, including personell costs required. Must have slipped his mind.

Have to go, more on this later.