The previous blog post covered a recent session that I ran for some Australian Rally Championship competitors which covered First On Scene Response training. The aim of the session was to give the competitors some basic skills so that should they be the first to arrive at a rally accident where someone has been seriously injured they have a framework to get help and provide some potentially life or limb saving assistance, buying time for the medical team. The session was deliberately practical with hands-on activities, practicing the different components on eachother or on a mannequin.

This post got me thinking about the work on education, training and skill maintenance that has been going on in critical care circles. We all need to learn our trade and once learnt, we need to maintain those skills, especially skills that are infrequently called upon but may be critical when they are. These may be technical, cognitive, communication or integrative skills.

Simulation training has been around for a while and is used in a variety of industries. Commercial pilots use simulators to learn how to fly a passenger jet and have to regularly attend simulator sessions to revalidate core skills. The military uses simulation to train techniques and prepare for mission scenarios. Simulation training has grown popular in medicine and surgery too and it has led to the development of large and often expensive simulation centre with individuals carving niche careers as simulation educationalists. Simulation is used to train ATLS, APLS, EMST and a bunch of other acronymed acute care courses.

Motorsport is no stranger to simulation either. Drivers attend high-end simulator sessions to practice track layouts and technique to find hundredths of seconds of advantage. Teams use simulators to develop and test design concepts.

High fidelity sim centres are expensive to set up and run and an effect of this is that the courses that they host are often pricey as well, to cover the cost. An emerging simulation model over the past number of years is in-situ simulation, the concept being that most of us do not work in ideal environments with resus teams so big that each task can be assigned to a different individual, so we should train the way we intend to work, in the environment that we work in and with the people and equipment that we work with.

"You can only fight the way you practice"
Miyamoto Musashi

"Under pressure, you do not rise to the occassion, you sink to the level of your training"
Unnamed Navy Seal (allegedly)

In-situ simulation usually makes use of relatively inexpensive equipment with tricks to modulate the training pressure as required. The sessions are designed to be rapidly set up to make use of quiet or protected periods in the department and disbanded just as quickly should there be a sudden surge in department workload that overrides a training priority.

For more on in-situ simulation, read these sites and articles:

Emergency departments, ICUs, prehospital groups and others have taken up this model of simulation for its relative ease of application to their environments. Groups like Sydney HEMS have incorporated in-situ sim to their highly regarded induction weeks and run sessions regularly throughout the year to keep their crews' skills fresh and shiney. Emergency and critical care conferences have adopted the in-situ sim model and in the run up to this year's SMACC conference, the EMS Gathering ran a whole series of in-situ training sessions.

This is a model that should work well for motorsport response teams as well. I'm sure there are teams out there that already run regular simulated response scenarios and it is something that is being worked on for a number of different Australian events and race categories. Both the FIA Institute and the ICMS run medical conferences which often incorporate a demonstration of a race track rescue procedure. These could be ideal opportunities to integrate some delegate sim training, whether as individual workshops or using a model similar to SimWars and SonoGames.

If your team is not already doing in-situ sim, here are some pointers and resources to get you going.

Why run in-situ simulation training?
  • The best time to learn a new skill is not when there is a dying patient in front of you.
  • Simulation sessions allow individuals to explore the limits of their technical skills and decision making in a fairly safe context
  • Regular simulation sessions assist with skill maintenance, including infrequently performed but critical skills; e.g. performing a surgical airway, managing a trapped competitior with a partial limb amputation.
  • Running a mission-specific simulation allows process problems to be identified and solutions trialled and refined; e.g. open cockpit racecar with a halo device inverted against a tyre wall.
  • Facilitates training in the environment and with the people and equipment that you usually work with which in turn frees up cognitive bandwidth to deal with the issues at hand and develops individual and team resilience.

In-situ sim components
  • You can use high-fidelity equipment if you want and can afford it, but it is not necessary.
  • While most people see the clever training models and skill stations, the majority of the work is in developing the scenarios so that they are realistic and have clear training goals.
  • Debriefing is a critical element of any form of simulation training. A poor debrief can undo a lot of the benefit of sim training. Good debriefing is aided by the prepatory work done in developing the scenario goals.
In-situ sim resources
  • mobilesim - Jon Gatward's go-to site for all your in-situ sim needs, from set up to scenarios and debriefing
  • Top ten tips for In Situ Sim at St.Emlyns by Iain Beardsell and Simon Carley - A podcast that highlights key points when setting up and running in-situ sim.
  • Top 10 (+1) tips to get started with in situ simulation in emergency and critical care departments. Jesse Spurr, Jonathan Gatward, Nikita Joshi, Simon D Carley. Emerg Med J, 2015.
  • The NHET-Sim Program - An Australian Commonwealth Department of Health program developed to provide training for those who deliver sim training in healthcare. It used to be free but now I believe there is a fee charged.
  • Simulation Apps – Review by Tim Leeuwenburg and Jonathon Hurley on KI Docs - Another In-situ sim overview that also includes some EBM articles and a review of some of the common real time monitor apps so that you can pile on the pressure by making the BP sink, the heart rate rise and the ECG rythmn go all funky.
  • Simulcast - Jesse Spurr and Victorial Brazil's podcast that discusses all things simulation in healthcare, from evidence to how-to. This is a new start-up podcast, so the content is still being built and at the time of publishing this blog post there are only two episodes available.

Initially sim sessions can be run in a classroom set up and subsequently move out to a trackside, pit lane or rally route location. The aim is to be able to quickly set up a realistic scenario, targeting either 2 or 3 learning points or practicing a whole process in a representative environment. As the skill and experience of the group increases, elements such as pressure can be modulated by adding auditory cues such as beeping alarms and recordings of racecars zipping by. To further add pressure, confederates can be used to simulate interfering spectators, media personnel trying to get "the shot" or race control bellowing through the radio to "clear the scene". All of this should help to build team skill, cohesion and resilience leading to a robust and adaptable team and thereby achieve better outcomes.

One additional element that has arisen lately is the role of 3D printing. When you run simulation sessions that involve procedures you need models that you can do things to. This allows some technical practice and also gives a more realistic tone to the timeline. The intraosseus nail doesn't just go in, you have to actually carry out the procedure. The models available are of variable quality, they often don't feel right, they don't bleed and they are usually isolated. For example, cricothyroidotomy trainers are often dry plastic and foam and are not attached to a head and neck so that there is a lesser need to get into the right position. They are often based on the ideal specimen rather than the anatomical variants that can cause us problems. And with repeated use, these task trainer models need to be replaced which can add up.

So a few of us, including people like Andy Buck (ED physician in Victoria) and Ciaran McKenna (Intensivist in Northern Ireland) are exploring the potential uses of 3D printing to produce low cost, improved tactile and more representative anatomy models for various tasks such as difficult airways, lateral canthotomy and thoracostomy amongst others. It is an exciting area and something I hope to write more about in time. To hear more about this area, listen to this podcast:

If you or your team has a sim training program, please leave your comments below. It could be how you went about setting up your sim program, scenarios that you have developed, task trainer models that you have built or resources that you have found useful.