Training: "Participants do not have to experience every mistake they make at the simulator with the patient first"

Interview with Dr. Michael Müller, medical director of the clinic and polyclinic for anesthesiology and intensive-care medicine, University Hospital Center Dresden

In an emergency, every flick of the wrist has to be correct - the right treatment is time-critical and usually vital. Mistakes can be fatal, so emergency physicians and paramedics need to be seasoned and experienced. But they will not always know certain problems from their daily work. Using patient simulators, they are able to train for rare situations and learn possible solutions.


Photo: Intubation exercise at a patient simulator; Copyright: Olson

Intubating a patient simulator; © Tyler Olson talked to Dr. Michael Müller, medical director of the clinic and polyclinic for anesthesiology and intensive-care medicine at the University Hospital Center Dresden, about training for rarely occurring scenarios. Being head of the Interdisciplinary Medical Simulation Center Dresden ISIMED, he is an expert for emergency medicine training with patient simulators.

Dr. Müller, in your lecture at the 2014 German Interdisciplinary Emergency Medicine Congress (German: Deutscher Interdisziplinärer Notfallmedizin-Kongress, DINK 2014) you asked whether "simulator training can replace practical experience in medicine?" What is the reason behind this question?

Dr. Michael Müller: There are different procedures in emergency medicine that emergency physicians or paramedics only rarely use in practice. In doing so, they do not obtain enough expertise to safely handle the respective emergency cases. Patient simulation is one way to train these procedures. Of course, we are also asking whether training on a simulator is as effective as practical training with the patient.

For which cases are training simulators best suited?

Müller: Patient simulation as a resource is expensive and requires high personnel costs. This is why you choose scenarios that are particularly useful for participants. Such scenarios are rare, but also essential for survival. One example for this would be the correct diagnosis of a tension pneumothorax. If this condition is not identified and properly treated within minutes, the patient could die. If you experienced a tension pneumothorax at the simulator, you are also very likely to recognize it in an emergency.
Photo: Working at the simulator; Copyright: Olson

Working at the simulator does not only improve the technical skills of physicians, but also communication, teamwork and situational awareness; © Tyler Olson

What is state-of-the-art in simulator training?

Müller: There is no one-size-fits-all answer to this. Different simulators have different degrees of fidelity; depending on the learning objective, you use a different simulator. I think it is very important to choose the right teaching aids for the different course aims. This ranges from simple devices costing several hundred Euros to a very expensive simulator that costs almost 300,000 Euros.

What features does this expensive device have?

Müller: It illustrates many physiological functions such as ECG, blood pressure and blood oxygen saturation level. You can also connect the simulator to real surveillance monitors. In doing so, the users can utilize the same equipment in training as they do in practice. The device independently recognizes 80 drugs and responds to their administration just as a real person would. Its exhaled air is identical to that of a real person, so that you can also measure the concentration of anesthetic gas. It is essentially a classic anesthesia simulator.

What does effective simulator training look like in emergency medicine?

Müller: Effective simulator training depends more on the environment than the actual doll. The scenario should match the real setting. This can be a living room for instance, where we simulate a heart attack at home, complete with actors, who portray family members. When the work environment is very real for the emergency physician, he also gets the feeling that he is in a real situation after a few short minutes. Basically, it is important for the training to be as realistic as possible.

Training participants also experience very realistic stress, which we were able to show in studies on stress response. They perform the same activities and make the same mistakes as they do in an emergency in such a lifelike work environment. During the debriefing, they can see their mistakes and learn from them thanks to video recording.
Photo: Reanimation at the simulator; Copyright:

Scenarios that rarely occur in daily work, like the reanimation of a patient, are preferably practiced with a simulator; © macor

The Interdisciplinary Medical Simulation Center Dresden, ISIMED, is located at the University Medical Center Dresden. What do you learn about the benefits of this training there and what kind of feedback do you get?

Müller: Simulator training is a lot of hard work for instructors and participants. However, all participants are grateful for having experienced it. Here mistakes are very openly discussed and every participant shares his experiences. Instructors can also learn from this when participants explain what they do differently in practice. This is a useful exchange of experiences and many participants visit us frequently.

What does the debriefing look like?

Müller: We usually record the scenario on video and also have a simultaneous video conference. Typically, there are two to three participants in the scenario at the same time; the others watch via conference and receive specific observation tasks. On the one hand, these pertain to technical abilities such as the measures performed at the simulator. On the other hand, they are also asked to pay attention to non-technical skills such as teamwork, task sharing and situational awareness.

During the actual debriefing, we show selected video sequences and specifically discuss what was missed and how we can make sure that an important reading or an important diagnosis will be identified next time. This combination between targeted observation, feedback from colleagues and instructors and video analysis helps us to avoid making this mistake during the next scenario. Participants do not have to experience every mistake they make at the simulator with the patient first.
Photo: Timo Roth; Copyright: B. Frommann

© B. Frommann

The interview was conducted by Timo Roth at the German Interdisciplinary Emergency Medicine Congress 2014 in Wiesbaden and translated from German by Elena O'Meara.