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....
3 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 27-28 2010
(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 tabletop 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 2010
Photos, Channel 6, KOTV
23 Agencies,
304 casualties,
and an airplane
• 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 1980.
• These oral examinations are a far cry
from the high fidelity simulations now
available.
Medical Simulation
In Disaster Medicine... Works
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
• Role Playing
• Like ABEM oral examinations
• Task trainers
• Computer patient
•
Manniquin simulators
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
Medical Simulation
Hardware & Infrastructure
Are NOT inexpensive….
We have over $1x106
invested
in our equipment
Medical Simulation
Manpower and Training
Are also NOT inexpensive….
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 2nd year resident is
frequently teaching the 1st 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
Medical Simulation
In Disaster Medicine
• 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”
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 =
Medical Simulation
In Disaster Medicine
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
Verification of Competency
• Reliability
• Validity
• Predictive validity
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. Crit
Care Med 1999;27:821-824.
• AND MANY MORE....
We’ve done this a few times......
• Since the inception of OIDEM in 2006...
• 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
Medical Simulation...In Disaster
Medicine
• 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.
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
• charles-e-stewart@ouhsc.edu