Simulation-based Training in Emergency Preparedness

1. Simulation-based Training in Emergency Preparedness

2. Rhode Island Hospital Medical Simulation Center (Sim Center) • RIDI Phase II Focused and Full-Scale Exercises in the Sim Center • Scene entry, video and sim • Search • Triage • Skills in PPE

3. Sim Center Features • High-fidelity facility for hands-on medical simulation • Over 2,000 square feet • Multiple manikin/multiple encounter environment – one of few civilian sites • Multichannel digital audio and video recording for debriefing

4. Sim Center Layout

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6. RIH Medical Simulation Center

7. 2000 square feet of flexible Sim space

8. Phase II: Focused Studies Focused studies to test specific processes/ technologies and finalize full-scale exercise design • Involved written pre-tests and post-tests • Tested EMTs, nurses, paramedics, and physicians in individual EMS tasks with and without various PPE • Included tasks such as location, triage, injection (MK-1), auscultation, palpation, communication, and intubation • Performed at: RIH Medical Simulation Center Used high-fidelity adult manikin (SimMan, MPL/Laerdal) • Prepared three abstracts for presentation at the Society for Academic Emergency Medicine (SAEM) conference in April 2004 Phase II – Focused Studies

9. Sim Center Control Room –Phase II Focused Studies 9

10. Phase II Focused Studies –Task Evolution

11. Phase II Focused Study Summary • Helpers rush in – they need PPE and training • Triage by EMTs is professional and high-level. Simple algorithms don’t apply to WMD issues • EMTs can operate in Level C PPE for about 1 hour, but need radio communication and adaptive equipment

12. Phase II Full-Scale Exercise Design • Training – brief, focused, urged to use daily practice. Level C PAPR PPE • 12 evolutions (2 hours each), 60 EMTs, 9 victims • Dirty bomb (Lewisite) in a pediatric clinic. Mix of manikins and professional actors, alarm strobes, smoke, screaming, odors • 4 EMTs respond, 1 “dispatcher” • Level C PPE and medical equipment available • Measured time, action, and quality • 8000 data points

13. Sim Center – Phase II Full-Scale Exercises 13

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22. Phase II Full-Scale Exercise Preliminary Results • RIDI training delays overall patient care very slightly • RIDI training improves entry decision, PPE use, focus of care, teamwork, coordination, WMD recognition, antidote use, and transport priority • All non-trained teams entered the contaminated space without PPE, none decontaminated patients, much care focused on non-viable victims

24. Summary Points • High-fidelity simulation center disaster research is possible • Most current civilian first responder disaster plans are wrong in many ways • First responders act under stress like they do in daily operations • Therefore, daily operations must be standardized but adaptive, scalable, and flexible to meet disaster surges and circumstances • Brief training in WMD recognition, PPE, decontamination, and WMD treatment can alter practice and outcome • Longer training justified for the trainers/leaders

25. Laerdal

26. Laerdal SimMan

27. SimMan Features • Airway features: Realistic life-size intubation head. Bronchial tree is anatomically accurate in size, color and texture and features the accurate anatomical landmarks necessary to facilitate realistic fiberoptic bronchoscopy. Standard ALS airway skills:- Bag/Valve Mask ventilation - Oropharyngeal and nasopharyngeal airway placement- Endotracheal tube intubation. Fiberoptic, light wand and retrograde intubation- Combitube, LMA placement- Trans-tracheal jet ventilation- Needle and surgical cricothyrotomy Spontaneous respiration with variable respiratory rate, auscultation of breath sounds and CO2 detection. Airway complications:  Pharyngeal obstruction, tongue edema, trismus, laryngospasm, decreased cervical range of motion, decreased lung compliance, stomach distension, pneumothorax decompression. Cannot-Intubate-Can-Ventilate or Cannot-Intubate-Cannot-Ventilate conditions. • Cardiac functions: ECG library of over 2,500 cardiac rhythm variants. Defibrillation by Automated External Defibrillators (AED) or manual defibrillators 3 or 4 lead ECG monitoring. External pacing - with variable pacing threshold • CPR:Ventilation.Chest compression. ECG and heart rate can be displayed on the simulated monitor. • Pulses: Synchronized with ECG or compressions. Pulse strength dependent on BP selected and anatomical position. Bilateral carotid pulse, brachial, radial and femoral pulses • Blood Pressure:Can be taken automatically, palpated or auscultated. Blood pressure arm (left) with Korotkoff sounds synchronized with pulse. • Circulatory skills and IV drug administration: Articulating right IV training arm with replaceable skin and veins IV insertion into peripheral veins of forearm, antecubital fossa and the dorsum of the hand. Sites for subcutaneous and intramuscular injections.

28. SimMan Features, continued • Sounds: Heart sounds synchronized with ECG Left and right lung sounds, bowel sounds Cough, vomiting, moaning and vocal sounds and simulation of patient voice Volume adjustment • Genitalia for urinary catheterization: Genitalia can be added to the simulator for urinary catheterization procedures. • Software control: Mouse and/or remote control. Software controls all airway management, cardiac functions, CPR, pulse, blood pressure and sounds. Each of the airway management functions may be controlled individually from remote or set as a group. • Event log: Automatic log system with stopwatch function. Event Log can be saved or printed. • Easy to use scenario and trend tools:Standard validated scenarios includedDesign and save your own scenarios. • Simulated patient monitor: Displays ECG, BP, SpO2, ETCO2, arterial waveform,respiratory rate, heart rate and temperature readings SpO2 sound, variable pitch according to saturation • Air supply available by two alternatives: 1) Air compressor (catalogue No. 38 12 00 for 230 Volt or 38 12 10 for 110 Volt) or 2) regulator unit (catalogue No. 38 12 20) allowing connection to wall air supply or pressurized air canister. • Easy to use:Does not require a technician and acting participant • Portable: Easy storage and transportation. • OPTIONAL FEATURES AVAILABLE FOR MANIKIN: • Trauma modules - A set of trauma modules designed to interchange with the non-traumatic modules on the Laerdal SimMan for added realism in emergency trauma management. Portability kit, allowing for use in field Hard-shell carrying cases

29. SimMan v METI • Less sophisticated, but simpler interface • Portable • “Kit” format for trauma, procedures • Fairly easy to modify • Cheaper (~ 25-40K )

30. Advantages of the Sim Environment for Research • Patient confidentiality not an issue (yet) • Minimal patient risk • Highly controlled environment • Highly instrumented environment • Ability to repeat scenarios

31. Patient Confidentiality • SimMan’s family isn’t upset if you talk about your case…. • He / she doesn’t have to sign a HIPPA form • Maybe some day there will be concerns if scenarios reproduce actual events….

32. Minimal Patient Risk • The SimMan plays the risky role -- the sickest patient. • IRBs like this. • Minimal risk to other participants – needles, falls, etc.

33. Highly Controlled Environment • The center and SimMan can reproduce fairly exact behaviors, vital signs, disease course, sounds etc. • Very useful for “clinical” research related to teamwork, behaviors, etc. • Very useful for mockups of ED space, EMS space?

34. Highly Instrumented Environment • Video and audio recording, multi channel • One-way glass observation • Event recording in software • Bar code meds • Defib, etc • Ability to operator-mark events • Data is easy to obtain!

35. Repetitive Capability • A well-developed scenario can be performed almost exactly again and again. • Very useful for certain types of research into behaviors, ergonomics, etc.