tag:blogger.com,1999:blog-91809789864264378842024-03-19T23:51:18.233-07:00The Simulated ManPete Dickenshttp://www.blogger.com/profile/12970193129355208476noreply@blogger.comBlogger9125tag:blogger.com,1999:blog-9180978986426437884.post-50040543163585827472018-06-18T00:56:00.000-07:002018-06-18T00:56:40.762-07:00RPG - A Random Patient Generator<span id="docs-internal-guid-add75866-11dd-27e3-2587-13897643dfbf"><div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
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<span style="font-family: Arial; font-size: 11pt; font-variant-east-asian: normal; font-variant-numeric: normal; font-weight: 700; vertical-align: baseline; white-space: pre-wrap;">RPG - A Random Patient Generator</span></div>
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<span style="font-family: Arial; font-size: 11pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">Welcome back! A manic few weeks of creativity here at Simulated Towers which I’m keen to share before the inevitable backlash of fear, emptiness and despair (or Monday, as it’s known)</span></div>
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<span style="font-family: Arial; font-size: 11pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">Disclaimer: This is my own work, created in my own time using my own materials.</span></div>
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<span style="font-family: Arial; font-size: 11pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">Among the explosion of projects I’d started previously but will likely never finish I found my Random Patient Generator.</span></div>
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<span style="font-family: Arial; font-size: 11pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">I’m aware that the excellent Doctor Simon McCormick @DrSimonMC has produced such a device and it was for that reason that I made sure to read absolutely nothing about his version until I was finished with mine. I thought it would be interesting to compare them with respect to how we form teaching methods based on our learning goals and the resources available to us.</span></div>
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<span style="font-family: Arial; font-size: 11pt; font-variant-east-asian: normal; font-variant-numeric: normal; font-weight: 700; vertical-align: baseline; white-space: pre-wrap;">Background</span></div>
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<span style="font-family: Arial; font-size: 11pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">We’d been trying to introduce some variation into our interprofessional simulations for the university medic and nursing programmes as we had become aware that we were in danger of falling into a rut. The same patients every week with the same conditions all sat in their hospital beds patiently waiting for care. We felt we were expecting and even predicting patterns of behaviour and that preconception was potentially making it difficult for us to maintain neutral and curious during the cases (and debriefs)</span></div>
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<span style="font-family: Arial; font-size: 11pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">So we rewrote the background to our cases, and now one of our patients is found in the road and is on their way in via ambulance. The participants receive a phone call from the ambo crew and have 3-5 minutes to prepare themselves in the emergency room before one of us instructors, having stretched an ambulance uniform over us, crash the simulator through the doors, hand over and dash out again citing a plausible excuse for leaving (having to write it up in the electronic journal, left something on the stove, saw a squirrel with a *really* fluffy tail, that sort of thing)</span></div>
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<span style="font-family: Arial; font-size: 11pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">Nothing revolutionary there, fairly standard iteration, apart from the squirrel (it’s tail was *very* fluffy)</span></div>
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<span style="font-family: Arial; font-size: 11pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">The way in which the participants used the limited time before the patient arrived was illuminating. They started asking themselves questions. What physical resources are we going to need? Who do we need to ring? What treatments do we need to prepare? Basically, how do we prepare and organise our thoughts and our work?</span></div>
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<span style="font-family: Arial; font-size: 11pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">So I wondered if there was a way in which to recreate this period of activity without going through the process of creating a full scale simulation PLUS without us as instructors pre-judging the cases due to prior knowledge gained in a parallel time stream.</span></div>
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<span style="font-family: Arial; font-size: 11pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">So I finished developing my Random Patient Generator, and then I redeveloped it, because I just can’t leave things alone.</span></div>
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<span style="font-family: Arial; font-size: 11pt; font-variant-east-asian: normal; font-variant-numeric: normal; font-weight: 700; vertical-align: baseline; white-space: pre-wrap;">Method One.</span></div>
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<span style="font-family: Arial; font-size: 11pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">And the first one looks like this…</span></div>
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<span style="font-family: Arial; font-size: 11pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;"><img height="452" src="https://lh6.googleusercontent.com/HoRsWzGtUMNk7Coc5qaifFaPgLNsxvYeoq5lN-G8qcvwg8kLwamNHkuS6YusnXebB1J0ADbQzP6TYT4QXSUbAVdbe7xNxpPcVBIsM-p0ymAyTR6f8VZz_6bB6Mpbcdd_28NMGYR1" style="-webkit-transform: rotate(0.00rad); border: none; transform: rotate(0.00rad);" width="602" /></span></div>
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<span style="font-family: Arial; font-size: 11pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">It’s just an excel spreadsheet, printed on card and laminated. The colours are the colours of the rainbow, ROYGBIV, Richard Of York Gave Battle In Vain, FOA’s (fans of acronyms)</span></div>
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<span style="font-family: Arial; font-size: 11pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">Why those colours? Well, it represents the inclusive rainbow of patients that are welcome to request care from us, naturally. It’s also aesthetically very pleasing...</span></div>
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<span style="font-family: Arial; font-size: 11pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">With a notable exception...</span></div>
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<span style="font-family: Arial; font-size: 11pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">An important point to note is that people who don’t identify themselves binarily as men or women are not represented in this model. This *isn’t* done with any malice. I felt that with only 6 rollable results to the gender variable, including “identifies as non-binary” would have been verging on tokenism and possibly patronising. I am aware I am out on the thinnest of thin ice with this, but that’s the decision that was taken. Non-binary gendered people were considered, but not included (there’s a metaphor for life for you!) What’s obvious is that I need to be better at this sort of thing, and I will, it is after all 2018</span></div>
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<span style="font-family: Arial; font-size: 11pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">Feel absolutely free to adapt the titles of the columns in order to make the tool relevant for your own work. This model works for us. I chose a selection of data that can be relevant in a verbal report, plus a selection of ailments/symptoms that members of the public often present themselves at hospital for. </span></div>
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<span style="font-family: Arial; font-size: 11pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">Another notable exception is the absence of trauma patients, I think they need their very own model given the potential complexity of their cases. This model is cheap and cheerful, trauma is often neither of these things.</span></div>
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<span style="font-family: Arial; font-size: 11pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">Why only 6 results in the outcomes column? For simplicity's sake, we can generate the outcomes using standard dice.</span></div>
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<span style="font-family: Arial; font-size: 11pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">Serendipitously, it so happens that purveyors of pocket-money grabbing tat and whimsy Flying Tiger of Copenhagen sell a set of rainbow coloured dice, so there goes my pocket money for this week.</span></div>
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<span style="font-family: Arial; font-size: 11pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">Let’s roll the dice and see what happens! Won’t we?</span></div>
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<span style="font-family: Arial; font-size: 11pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">R = Currently under fridge, the perils of homebrewing, so we roll an extra Orange = 2</span><span style="font-family: Arial; font-size: 11pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;"><br class="kix-line-break" /></span><span style="font-family: Arial; font-size: 11pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">O =5</span></div>
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<span style="font-family: Arial; font-size: 11pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">Y =5</span></div>
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<span style="font-family: Arial; font-size: 11pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">G =2</span></div>
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<span style="font-family: Arial; font-size: 11pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">B =3</span></div>
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<span style="font-family: Arial; font-size: 11pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">I =2</span></div>
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<span style="font-family: Arial; font-size: 11pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">V =4</span></div>
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<span style="font-family: Arial; font-size: 11pt; font-variant-east-asian: normal; font-variant-numeric: normal; font-weight: 700; vertical-align: baseline; white-space: pre-wrap;">Results</span></div>
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<span style="font-family: Arial; font-size: 11pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">You are at A&E (or the ER for our colonial friends)</span></div>
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<span style="font-family: Arial; font-size: 11pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">Your patient is a woman in her 60’s having had chest pains for the previous 60 minutes. She describes herself as having historically good health despite her diabetes *ahem* (glances nervously to camera)</span></div>
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<span style="font-family: Arial; font-size: 11pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">In 5 minutes this patient is coming crashing through the door! Boom!</span></div>
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<span style="font-family: Arial; font-size: 11pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">Does everyone know what is happening?</span></div>
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<span style="font-family: Arial; font-size: 11pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">Does everyone know what they are doing?</span></div>
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<span style="font-family: Arial; font-size: 11pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">Are we clear in our communication?</span></div>
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<span style="font-family: Arial; font-size: 11pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">What can we anticipate? What do we need to observe? Who do we need to ring? What equipment do we need to prepare? Drugs to draw up? Quick! Quick! Hurry up and slow down!</span></div>
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<span style="font-family: Arial; font-size: 11pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">In another life, I will be developing and extending the results column to allow for the rolling of 8, 10 and 12 sided dice, introducing a difficulty level which one can choose based on the represented work categories, for now, I’m happy with what I’ve done. </span></div>
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<span style="font-family: Arial; font-size: 11pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">We allow the participants to replace and reroll 1 or 2 of the dice should they wish a more clinically relevant or challenging patient. Otherwise, we accept the results and the instructor helps to put some flesh on the bones of the patient. </span></div>
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<span style="font-family: Arial; font-size: 11pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">So, we have a patient to play with in whatever way we like. A discussion on treatment, on patient welfare, a full scale simulation, a test of alarm routines. The world is our lobster.</span></div>
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<span style="font-family: Arial; font-size: 11pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">Alternative method</span></div>
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<span style="font-family: Arial; font-size: 11pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">And the second looks like this!</span></div>
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<span style="font-family: Arial; font-size: 11pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;"><img height="680" src="https://lh6.googleusercontent.com/JlkXFyiYwrdvkWcm-yUb2Lln7pxrGKaRUi-loVsRBONqmr5XpvuJnTFAfOyjmrC0nubonX5HVLM__xnvgsC4nrRxG1zTbhkle77QsDobnrFbo_ebIdEHCIerudX0RD_orz_4tR09" style="-webkit-transform: rotate(0.00rad); border: none; transform: rotate(0.00rad);" width="510" /></span></div>
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<span style="font-family: Arial; font-size: 11pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">The same categories, and pretty much the same results, but instead of a table, the participants take a random card of each colour and place them in the corresponding space on the “gameboard” (I’ve only shown the Age cards as I haven’t translated the others) </span></div>
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<span style="font-family: Arial; font-size: 11pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">The group can decide to change 1-2 cards if they like, or *even* draw an extra “symptom” card if they like a challenge.</span></div>
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<span style="font-family: Arial; font-size: 11pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">Using cards allows the instructor to prepare, expand and customise the decks to suit the learning group.</span></div>
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<span style="font-family: Arial; font-size: 11pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">2 minutes for the group to create a case and flesh it out with the instructor. 3 minutes preparation time before the patient "arrives" 2-12 minutes before the *next* random patient arrives, how do we prioritise then?</span></div>
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<span style="font-family: Arial; font-size: 11pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">Many, many, many permutations, enough to keep us on our toes at least.</span></div>
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<span style="font-family: Arial; font-size: 11pt; font-variant-east-asian: normal; font-variant-numeric: normal; font-weight: 700; vertical-align: baseline; white-space: pre-wrap;">Conclusion</span></div>
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<span style="font-family: Arial; font-size: 11pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">There are many people that might say this is best presented as a Mobile App. I disagree. As a nerdy man of a certain age I still remember how many hit dice a Dire Wolf has, or how to subdue a Gold Dragon thanks to many lost evenings playing Dungeons and Dragons (and similar) I think there is something very pleasing about boards, dice, cards and pens that an App takes away. There’s something abstract about using an App that is disengaging, whereas using your hands and investing your imagination into something physical is more than the sum of its parts.</span></div>
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<span style="font-family: Arial; font-size: 11pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">I’ve tentatively presented both methods at my place of work and had many people immediately declare enthusiasm and try to claim it for their own sphere of responsibility.</span></div>
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<span style="font-family: Arial; font-size: 11pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">However...</span></div>
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<span style="font-family: Arial; font-size: 11pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">I think I’d be a lot happier workshopping it with my work colleagues before unleashing it, and I’d be even happier hearing what my loyal, clever and devastatingly physically attractive readers have to say</span></div>
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<span style="font-family: Arial; font-size: 11pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">Over to you!</span></div>
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<span style="font-family: Arial; font-size: 11pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">Stay Simulated</span></div>
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<span style="font-family: Arial; font-size: 11pt; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">thesimulatedman</span></div>
<br /><br /><br /><br /><br /><br /></span>Pete Dickenshttp://www.blogger.com/profile/12970193129355208476noreply@blogger.com0Uppsala, Sverige59.858563800000013 17.63892669999995659.73089430000001 17.316203199999958 59.986233300000016 17.961650199999955tag:blogger.com,1999:blog-9180978986426437884.post-73902975337429908222018-05-23T13:37:00.000-07:002018-05-23T13:49:52.332-07:00SMARTZones<div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
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<span style="background-color: transparent; font-family: "arial"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Welcome back! No excuses for being away, I just have. So bite me.</span></div>
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<span style="background-color: transparent; font-family: "arial"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Here’s a thing! (of course, you can say that about anything!) But here’s an actual thing that I</span></div>
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<span style="font-family: "arial"; font-size: 12pt; white-space: pre-wrap;">dreamt up in my spare time, and blogged about in my spare time, using my own resources</span></div>
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<span style="font-family: "arial"; font-size: 12pt; white-space: pre-wrap;">independently from work…(turns to camera, puts on sunglasses)...that should cover it...</span></div>
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<span style="background-color: transparent; font-family: "arial"; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;"><span style="color: blue; font-size: x-large;">SMARTZones</span></span></div>
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<span style="background-color: transparent; font-family: "arial"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">SMARTZones is a thesimulatedman original graphical debriefing tool which borrows and builds on both Karl Rohnkes Comfort/Stretch/Panic model and Stephen Coveys Circles of Concern and Influence. And more on that later!</span></div>
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<span style="background-color: transparent; font-family: "arial"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Previously, on thesimulatedman...I’ve described the unholy amount of simulation we deliver. Today, for example, we are delivering CRM based simulation in 5 different rooms, with a different case in each room, and the participants circulating round from room to room. So that’s 25 cases today, and more tomorrow. Brief/case/debrief x 25. Ambitious.</span></div>
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<span style="background-color: transparent; font-family: "arial"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">The patient cases themselves are by necessity short and simple, and the corresponding debriefs equally so. We use our own models/algorithms for debrief, with SMART (see previous posts) doing the lion's share of the work (it’s CRM broken down into a form of card game)</span></div>
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<span style="background-color: transparent; font-family: "arial"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Rather than the participants experiencing the otherwise wonderful and flawless SMART debrief (***coughcoughcocreatorofSMARTcoughcough***) 5 times and running the risk of it becoming stale, we’ve developed a variety of debrief models and exercises designed to stimulate self-assessment in the participants.</span></div>
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<span style="background-color: transparent; font-family: "arial"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">If we had time to do so, we would prefer to construct a “proper” debrief, but we don’t, so we have a structured and stripped down debrief that is tailored to the fast food simulations that we deliver on days like today. </span></div>
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<span style="background-color: transparent; font-family: "arial"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">One sunny summers day, we shall all sit over a beer/wine/wheatgrass and discuss the positives and negatives of structured versus unstructured debriefings of various lengths and complexities whilst weaving daisies into each others hair. However, in the words of trained CRM instructor Aragorn son of Arathorn, heir to the throne of Gondor “But it is not this day! This day we fight!”</span></div>
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<span style="background-color: transparent; font-family: "arial"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">And by fight, I’m sure he meant introduce a new debrief model what I wrote, in the words of Ernie Wise (a reference for the teenagers there)</span></div>
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<span style="background-color: transparent; font-family: "arial"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">I’d noticed that the debrief models that we (and many others) currently use for both small and full scale simulations focus on the ideal that effective communication is by and large the absolute Holy Grail when it comes to delivering relevant and rapid patient care. Get that right, and the rest will follow, is roughly the mantra. I’m oversimplifying of course, but you get the gist, the focus is on effective communication regardless of clinical or practical relevance.</span></div>
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<span style="background-color: transparent; font-family: "arial"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Clinicians, however, tell us that no amount of effective communication in an acute situation will magic up resources that are not available, or produce know-how in a team where it is missing. It may be so that these factors are illuminated during the patient case, and can even be addressed during the debrief, but often it’s a byproduct of the discussion and doesn’t immediately come to the fore.</span></div>
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<span style="background-color: transparent; font-family: "arial"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">In our model, we’ve only got 10-15 minutes for the debrief, so I wanted a shortcut to a discussion of the relevant components surrounding the case.</span></div>
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<span style="background-color: transparent; font-family: "arial"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Well, what are these components?, you may ask, and I shall tell you, but first, as promised, a little background.</span></div>
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<span style="background-color: transparent; font-family: "arial"; font-size: 14pt; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;"><span style="color: blue;">A little background</span></span></div>
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<span style="background-color: transparent; font-family: "arial"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Karl Rohnke’s model for Comfort/Stretch/Panic is reasonably well known, so I’m going to go ahead and paraphrase it wildly and probably inaccurately. It describes a system where accepting a greater challenge is rewarded with a potentially greater learning experience up to the point where the participant is no longer able to process the experience effectively. Hey, that’s pretty good for a first go, I’ll keep it (note to self, delete the self congratulations)</span></div>
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<span style="background-color: transparent; font-family: "arial"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;"><img height="262" src="https://lh5.googleusercontent.com/l-RsGuzPEOqnnW5p-y_VQq6EiUqXBCRKTkTeWGOrpwNARRXYl9LzV-PjNXVyNXMsDOb63zlan6UO5aqCKfQa2RLEtUTRJvjr_ub2wVc0bMr_jFQsLBKBN-ojQ56Xgh6Ody-scdkn" style="-webkit-transform: rotate(0.00rad); border: none; transform: rotate(0.00rad);" width="265" /></span><span style="background-color: transparent; font-family: "arial"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;"><img height="245" src="https://lh3.googleusercontent.com/gNVpFaLLlWVZqT61pr_aF6qDU-gLN2Rif_oUZbOQf5M2B77UuZyyVxf7U5M3DOKhu43GKLQ0h-jIAtULl_RMPksAVza7FGjUaPRqDCtA6FPLP7OlZwW1tc8ZHGJncunKdazO83o0" style="-webkit-transform: rotate(0.00rad); border: none; transform: rotate(0.00rad);" width="306" /></span></div>
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<span style="background-color: transparent; font-family: "arial"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">It looks like this, graphically, with the superimposed line supposedly representing some form of nebulous “learning”. I’m not overly convinced that being at the edge of panic represents the very best opportunity to learn, otherwise the parents of small children would be all towering intellects and captains of industry rather than the shambling zombies I’ve encountered.</span></div>
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<span style="background-color: transparent; font-family: "arial"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Despite my churlish reservations, however, the model works! Well done Kalle!</span></div>
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<span style="background-color: transparent; font-family: "arial"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Stephen Covey’s circles of influence and concern look like this...</span></div>
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<span style="background-color: transparent; font-family: "arial"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;"><img height="224" src="https://lh6.googleusercontent.com/GwHi41IbtDDHZMyH_B5ZiOdgXsm9zYJDnrq8jLnHU15j41yBssEDtJxN3eNlBQGuwY6j8A0o-bRdqMs0jjpePdpzfJBUGTpqczhmk-6BIx2hGJ3nmIvGtcOJU2fQpmopfjmZnD1L" style="-webkit-transform: rotate(0.00rad); border: none; transform: rotate(0.00rad);" width="432" /></span></div>
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<span style="background-color: transparent; font-family: "arial"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Important to note that on some representations within the circle of influence lies an additional circle of control.</span></div>
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<span style="background-color: transparent; font-family: "arial"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">With a bit of imagination and redefinition, it’s possible to overlay Coveys circles over Rohnkes model, and when we do we see the following...if we squint</span></div>
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<span style="background-color: transparent; font-family: "arial"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">In terms of the treatment of acutely sick simulated patients....</span></div>
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<span style="background-color: transparent; font-family: "arial"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">We are </span><span style="background-color: transparent; font-family: "arial"; font-size: 12pt; font-style: italic; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">comfortable </span><span style="background-color: transparent; font-family: "arial"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">dealing with what we can </span><span style="background-color: transparent; font-family: "arial"; font-size: 12pt; font-style: italic; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">control </span><span style="background-color: transparent; font-family: "arial"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">(our own behaviour, simple practical tasks etc)</span></div>
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<span style="background-color: transparent; font-family: "arial"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">We need to be </span><span style="background-color: transparent; font-family: "arial"; font-size: 12pt; font-style: italic; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">proactive </span><span style="background-color: transparent; font-family: "arial"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">(Stretch) to deal with things that we need to </span><span style="background-color: transparent; font-family: "arial"; font-size: 12pt; font-style: italic; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">influence </span><span style="background-color: transparent; font-family: "arial"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">(the behaviour of other members of the team, more nuanced patient interventions etc)</span></div>
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<span style="background-color: transparent; font-family: "arial"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">We are </span><span style="background-color: transparent; font-family: "arial"; font-size: 12pt; font-style: italic; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">concerned </span><span style="background-color: transparent; font-family: "arial"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">(but not panicked) about things that we can neither control nor influence (missing resources, lack of know-how, unstable patient parameters, zombie apocalypse etc)</span></div>
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<span style="background-color: transparent; font-family: "arial"; font-size: 14pt; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;"><span style="color: blue;">What it looks like.</span></span></div>
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<span style="background-color: transparent; font-family: "arial"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">NB: This is a homebrewed BETA model knocked together in my virtual shed, no apologies for the somewhat vanilla presentation</span></div>
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<span style="background-color: transparent; font-family: "arial"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">My model looks like this, and plays somewhat like a board game (rules to follow)</span></div>
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<span style="background-color: transparent; font-family: "arial"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;"><img height="452" src="https://lh6.googleusercontent.com/Qs-UHaOaLPRV9LEJtddZfJuaCQAZxBo5SDay-FmN25qzBDl3BqTcy3n-0anyjdvgbeeaNsgO4zfjrqor5uzMq2wD4kyRvP0nyve-rjcjkGrHMwXE-oXjTLGQ1rThiUQiGve4HCt5" style="-webkit-transform: rotate(0.00rad); border: none; transform: rotate(0.00rad);" width="602" /></span></div>
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<span style="background-color: transparent; font-family: "arial"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">The counters look like this, that’s the patient at the top in the centre (right on ethics fans!)</span></div>
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<span style="background-color: transparent; font-family: "arial"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;"><img height="411" src="https://lh5.googleusercontent.com/lmpn5JRUr18AMQ1ft9nTbvq3w7LYyoXqw1aMYXwKTf-BCDXFzaABfsuJwUl1D_0B1_akQqWRDO6J2tmolFOO7Qr9PGL4qW7Ls3L1NKYOxShwYPwNfqv_Zgr-Gz_VvtOKvmn2WCwy" style="-webkit-transform: rotate(0.00rad); border: none; transform: rotate(0.00rad);" width="548" /></span></div>
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<span style="background-color: transparent; font-family: "arial"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">The other counters represent some of the components that go into creating the system surrounding the delivery of patient care. A couple of these might not have survived translation from the original Swedish without some clumsiness being baked in. Feel free to suggest others. I’ve made a point of leaving out elements of Crew Resource Management as they are well catered for elsewhere. Similarly, the feelings and emotions of the participants and patient are the focus of other debrief techniques. So, the above components are those we are working with today.</span></div>
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<span style="background-color: transparent; font-family: "arial"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Level of care - Is the patient in the right place to receive the most effective care?</span></div>
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<span style="background-color: transparent; font-family: "arial"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Information - How was the flow of information managed? </span></div>
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<span style="background-color: transparent; font-family: "arial"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Knowledge - Did we have the practical skills in place to deliver effective care?</span></div>
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<span style="background-color: transparent; font-family: "arial"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Alarm Routines - Did we know who to ring? What to say? Which button to push?</span></div>
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<span style="background-color: transparent; font-family: "arial"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">ABCDE - Did we structure the work?</span></div>
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<span style="background-color: transparent; font-family: "arial"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Resources - Did we have the equipment and manpower available?</span></div>
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<span style="background-color: transparent; font-family: "arial"; font-size: 14pt; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;"><span style="color: blue;">How it works</span></span></div>
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<span style="background-color: transparent; font-family: "arial"; font-size: 12pt; font-style: italic; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;"><span style="color: blue;">Intro/Briefing</span></span></div>
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<span style="background-color: transparent; font-family: "arial"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">We begin the session by discussing with the participants what they understand by each of the case component counters, and the relevance of each component to their work. In this way the participants help define their learning goals. I’ve toyed with the ideal of introducing blank counters for participants to write their own goals on but as a dyed-in-the-wool control freak I’m hesitant to introduce (literal) wild cards to a new concept.</span></div>
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<span style="background-color: transparent; font-family: "arial"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">We also introduce the “board” at this point, to let them know that the debrief will be structured in a certain way. </span></div>
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<span style="background-color: transparent; font-family: "arial"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">The participants then choose between 3 and 6 of the components that they feel are most relevant to them.</span></div>
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<span style="background-color: transparent; font-family: "arial"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Then it’s off to the Simulation Room for the most exciting 15 minutes of their lives! Wooooo!!!</span></div>
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<span style="background-color: transparent; font-family: "arial"; font-style: italic; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;"><span style="color: blue; font-size: large;">Debrief</span></span></div>
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<span style="background-color: transparent; font-family: "arial"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">The debrief consists of two simple questions, with two simple corresponding actions</span></div>
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<span style="background-color: transparent; font-family: "arial"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">How challenging did you find the patient's condition? </span></div>
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<span style="background-color: transparent; font-family: "arial"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Take the Patient counter and have the group start moving it upwards on the Challenge Thermometer (to the left in the picture) until the group are in agreement that that is the level of challenge they experienced.</span></div>
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<span style="background-color: transparent; font-family: "arial"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">I introduced the Challenge Thermometer so we could run the same case in different environments with different skill constellations, and the answer would always be relevant to those taking part.</span></div>
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<span style="background-color: transparent; font-family: "arial"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">2. How easy was it to manage the case components?</span></div>
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<span style="background-color: transparent; font-family: "arial"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">For *each* case component, have the group take the appropriate counter and, beginning in the comfort (control) zone, start to radiate outwards through the stretch (influence) zone and finally the panic (concern) zone, stopping when the group are in agreement that that is how manageable each of the components felt.</span></div>
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<span style="background-color: transparent; font-family: "arial"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">At this point your SMARTZones could look like this…</span></div>
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<span style="background-color: transparent; font-family: "arial"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;"><img height="452" src="https://lh5.googleusercontent.com/pnp7wxBDXLTUJ_f_fCBGGXW5agEB0oJ2lpy8nNm5ayMK9ACJccpHFlDoj70s5KTax6eGegWlHYJjy8_LurTTxiS9nv6Rdv8SKzuWArRYU5Oc8rlor9_B9gExHGdnN5ugI-CI7u_R" style="-webkit-transform: rotate(0.00rad); border: none; transform: rotate(0.00rad);" width="602" /></span></div>
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<span style="background-color: transparent; font-family: "arial"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Neato! In the immortal words of Princess Daisy</span></div>
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<span style="background-color: transparent; font-family: "arial"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">If we were comparing this to a classic debrief then we might say that this represents both the descriptive phase and the analytical phase in one lovely colourful picture (bit of a stretch I know but that’s the ambition)</span></div>
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<span style="background-color: transparent; font-family: "arial"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">However the counters land, we have at the very least an honest picture of the case that the participants experienced and that can only be a good thing.</span></div>
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<span style="background-color: transparent; font-family: "arial"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">This particular case is describing a suspected opioid overdose landing at a doctors surgery/general practice. The group appears comfortable with the situation and their part in it, but are aware that they don’t have the resources to cope, and are concerned that the patient is not going to receive the care that they need if they stay where they are.</span></div>
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<span style="background-color: transparent; font-family: "arial"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">It is possible to wilfully break the model, it could work out that all the counters fall in the comfort zone or even the panic zone. At that point you’ll have to go META on the participants and ask them to think, “How would the picture look if…”</span></div>
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<span style="background-color: transparent; font-family: "arial"; font-size: 14pt; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;"><span style="color: blue;">Results</span> </span></div>
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<span style="background-color: transparent; font-family: "arial"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">We’ve run this a few times now and it’s yet to fail as a debrief support tool (Am currently too busy counting my chickens to listen to negative feedback) </span></div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgULcXxcggTm4GauTaWdkLia893eQVLQUsacJCW5cwBJavsfdkeFXuJHDTWNjDViLgWtA4zuH_b4KMZ0vukJCyCzp0L4g3kktCilLcJUKVTVAE1NQZmQ7aJDoS6ZJj9ItyxT7y3x8Bf_Vbj/s1600/FoghornLeghorn2.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="300" data-original-width="300" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgULcXxcggTm4GauTaWdkLia893eQVLQUsacJCW5cwBJavsfdkeFXuJHDTWNjDViLgWtA4zuH_b4KMZ0vukJCyCzp0L4g3kktCilLcJUKVTVAE1NQZmQ7aJDoS6ZJj9ItyxT7y3x8Bf_Vbj/s200/FoghornLeghorn2.png" width="200" /></a></div>
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<span style="background-color: transparent; font-family: "arial"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">It works best as a way in to the “Development Phase” of the debrief, so you still need to be able to facilitate this phase, lead the discussion that arises and steer it to a logical conclusion. It performs the heavy lifting, as it were, leaving you to tune the piano.</span></div>
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<span style="background-color: transparent; font-family: "arial"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Importantly, the participants have been positive about using it. We talk often about creating a “common picture” of the participants experience and more often than not we do this through description. Here we are creating a literal, actual “common picture” that they say is recognizable and relatable.</span></div>
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<span style="background-color: transparent; font-family: "arial"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">It works as a way of illuminating factors and problems surrounding the delivery of patient care that may not classically receive enough attention. These factors have been chosen and defined by the participants themselves, so they are hopefully invested in them.</span></div>
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<span style="background-color: transparent; font-family: "arial"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Quite often the patient's condition is experienced to be more challenging than the placing of the components would suggest. When asked why that was, the participants began to talk about stress and empathy, which is an interesting by-product of a debrief focussed on something else entirely.</span></div>
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<span style="background-color: transparent; font-family: "arial"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Similarly, when asked how they might move a counter from one zone to another, the discussion turned to effective communication, human factors and Crew Resource Management.</span></div>
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<span style="background-color: transparent; font-family: "arial"; font-size: 14pt; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;"><span style="color: blue;">Conclusion</span></span></div>
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<span style="background-color: transparent; font-family: "arial"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">I’m tired now so I’m going to sum it up in one sentence</span></div>
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<span style="background-color: transparent; font-family: "arial"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">An intuitive graphical debrief tool with customizable learning objectives, based on established educational principles, delivering a platform for nuanced observations?</span></div>
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<span style="background-color: transparent; font-family: "arial"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">I give it the Simulated Man seal of approval. </span></div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiN_xCUCh03F0qE8uIvP0dEmrm6cSRUOuSJQRRv7fc7fJByn6AI829V4TEUQg5lriBLhS-8ajiszLqLlVTFKkZ8Xvf-HzPLepVe-Lfw0w8Su6tahhfCn7AqizcyKEXGaZfR3DixmYFadnj2/s1600/Fallout_PIP-Boy.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" data-original-height="1024" data-original-width="1024" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiN_xCUCh03F0qE8uIvP0dEmrm6cSRUOuSJQRRv7fc7fJByn6AI829V4TEUQg5lriBLhS-8ajiszLqLlVTFKkZ8Xvf-HzPLepVe-Lfw0w8Su6tahhfCn7AqizcyKEXGaZfR3DixmYFadnj2/s200/Fallout_PIP-Boy.jpg" width="200" /></a></div>
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<span style="background-color: transparent; font-family: "arial"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">I’m still not entirely happy with sections of it, and I’d be more than happy to revisit certain elements.</span></div>
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<span style="background-color: transparent; font-family: "arial"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Please let me know what you think @thesimulatedman on Twitter, or in the Blog Comments or by yelling at me in the street</span></div>
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<span style="background-color: transparent; font-family: "arial"; font-size: 14pt; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;"><span style="color: blue;">Coming Soon!</span></span></div>
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<span style="background-color: transparent; font-family: "arial"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">A random patient/case generator. No, not the most original ideal in the world, but I’m still going to write up my interpretation.</span></div>
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<span style="background-color: transparent; font-family: "arial"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Soon, he said</span></div>
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<span style="background-color: transparent; font-family: "arial"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Stay Simulated, your friend</span></div>
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<span style="background-color: transparent; font-family: "arial"; font-size: 12pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">thesimulatedman</span></div>
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Pete Dickenshttp://www.blogger.com/profile/12970193129355208476noreply@blogger.com2tag:blogger.com,1999:blog-9180978986426437884.post-20964543461929746052017-08-28T02:52:00.000-07:002017-08-28T02:53:06.236-07:00Programming People 2 - This time it's personal<div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
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<span style="background-color: transparent; color: black; font-family: "arial"; font-style: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;"><b>Programming People 2 - This time it's personal</b></span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-style: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Greetings, fans of simulation old and new. Welcome to The Simulated Man, an introductory article can be found elsewhere on these pages so I’ll just crack on. I know who I am.</span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-style: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">I like to start these blarticles with an apology, usually for lateness and broken promises. However, I find as an Englishman I can start literally any conversation with an apology. I’m sorry for colonialism. I’m sorry for football hooliganism. I’m sorry for the ubiquitous nature of poorly prepared fish’n’chips and so on and so forth. I can’t affect these things, but I can affect the frequency with which I prepare these articles, so I’ll crawl out from under my guilt and get on with it.</span></div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiS7uMO15JzJ242eQ8UAqr3T0V3AllaYpC6wmQEPWqauA_r8McIHqIxBFpXZ-0NorDOOB798FILXXOWTa1Li2JqtJ5xN7GSsPDMrf2sLVUqJJ-AATPu2xrsfcu_ijHTRAl4P0tG374u8Fdu/s1600/poll2.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" data-original-height="249" data-original-width="335" height="237" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiS7uMO15JzJ242eQ8UAqr3T0V3AllaYpC6wmQEPWqauA_r8McIHqIxBFpXZ-0NorDOOB798FILXXOWTa1Li2JqtJ5xN7GSsPDMrf2sLVUqJJ-AATPu2xrsfcu_ijHTRAl4P0tG374u8Fdu/s320/poll2.jpg" width="320" /></a></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-style: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">It’s become a fairly recent tradition in the western world to ignore the will of the people, so, despite the results of the Twitter poll pointing fairly heavily towards today's subject being either Graphical Debrief Tools or Bigfoot, I’m going to finish off the long promised article on Simulator Programming, and save at least one of the other subjects for another time (*turns to camera*...probably not bigfoot…)</span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-style: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">In part 1 of Programming People, I caricatured two largely familiar ways of driving the patient simulator.</span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-style: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Kim the experienced health care provider driving simulation “on-the-fly” from instinct and anecdote, generating an uneven and hard to replicate simulation.</span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-style: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Charlie the tech-savvy IT wonk pre-programming “hard-wired”, “story-boarded” patient states from textbooks, generating an inflexible simulation lacking in nuance and finesse.</span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-style: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">If only, if *only*, I hear you cry, there was a 3rd way combining both nuance and standardisation…I hear your cries, my fellow humans, suffer no more!</span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-style: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Given the “ambitious” amount of simulation we are committed to here at Simulated Towers (Akademiska University Hospital), it is quite the challenge to deliver a teaching experience that is consistent from university cohort to university cohort and from ward to ward and from session to session. We feel that consistency of experience is important.</span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-style: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">We have a large team of trained instructors, with but a few who boast more than a few hundred hours of simulation experience. In our simulation delivery, we generally work as a team with 3 clearly defined roles. The clear definition of these roles means we can support and rely on each other with no grey areas in terms of duties and responsibilities. Individual instructors are more than welcome to bring their own style and interpretation to a simulation session and even simulation debrief, an experienced instructor can of course adapt their style to fit the group in front of them.</span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-style: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">However, once you have landed in the role as simulator driver/operator, there is a *lot* of personal interpretation taking place in translating what’s written down in the patient case document into some sort of believable living responding patient. Not least of which is translating a medical intervention by the participants into something equally believable and medically relevant in terms of physiological response.</span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-style: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">And if you manage that, who’s to know if the operator in the other room has the same idea as you what should or shouldn’t be happening, or if you can manage the same thing in the afternoon, or next month? </span></div>
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<span style="font-family: "arial"; white-space: pre-wrap;">There’s more grey on display than at a nudist colony for elephants. *pauses for laughter and </span><span style="font-family: "arial"; white-space: pre-wrap;">applause...not a sausage*</span><br />
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<span style="background-color: transparent; color: black; font-family: "arial"; font-style: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Why, when we have clearly defined roles and clearly defined learning outcomes and hundreds of years of medical knowledge as backup are we baking *in* inconsistencies to our simulations?</span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-style: normal; font-weight: 700; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Why is inconsistency a problem? Why is standardisation a positive thing?</span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-style: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">The vast majority of the simulations we deliver have, as a goal, learning outcomes associated with teamwork and communication. We deliver multiple parallel sessions over several days to a large number of participants in such small groups as is manageable. </span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-style: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">We control and standardise the patient's mental and physical state and physiological and mental responses from session to session. We control and standardise the resources available to the participants. We control the routines for raising alarms in line with hospital procedure etc etc etc</span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-style: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">What we don’t control, and what we absolutely do not want to control, is the way in which the participants communicate with each other. Given that the entire session's goal is analysis of communication tools and styles. That is the one variable we don’t want to control.</span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-style: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">So when participants from different groups discuss their cases (as we know they do) in the tea room or corridor they are not confused as to why things worked out differently for each other. In these cases, with these patients, we have manufactured a simulated controlled environment where effective teamwork results in effective care, and ineffective teamwork results in ineffective care, and that’s it, no other variables impinge on this principle.</span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-style: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">And what’s more, from session to session, regardless of who is operating the simulator, whether it’s Kim, Charlie, me or even you, yes you, this underlying principle holds true.</span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-style: normal; font-weight: 700; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">What do we know? What don’t we know?</span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-style: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">In simulation, we often live in denial of the ideal that we know what the participants are going to do, it’s hugely unpopular to second guess them, but if we want consistent results we can at least give them the benefit of the doubt and trust their skills. Let’s be arrogant enough to imagine they are semi-competent shall we?</span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-style: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">So, we don’t know that they absolutely 100% are going to administer oxygen to a de-saturated patient in respiratory distress.</span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-style: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">So, we don’t know that they absolutely 100% are not going to release a number of flaming tigers into the treatment room.</span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-style: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Now, one of these interventions is highly likely, and it’s highly likely to be repeated from session to session on this patient (*turns to camera*...it’s not the tigers…). What is more, we *know*, how much effect 2 litres of oxygen is going to have on this patient's oxygen saturation because these effects are documented, recorded, scientific facts. </span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-style: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">By the same token, we do know how much effect a litre of fluid has on the same patient, and we do know how the patient responds to different drug interventions.</span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-style: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">We know more than we think we know, aphoristically speaking (I like aphorisms, I have the whole Swedish winter to think them up)</span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-style: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">So what if, instead of driving on the fly, and instead of having hard wired patient states, we “floated” a simulated patient out on some clinically relevant start parameters but on a raft of small scripted responses ? </span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-style: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Would that result in a degree of standardisation without losing nuance? </span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-style: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">I’ve borrowed heavily from the approach we’ve taken with our SMART Simulations, wherein buttons appear on the instrument for driving the simulator which are named after the clinical interventions performed by the participants.</span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-style: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">There are *not* buttons for every imaginable intervention, so if you *want* to simulate the introduction of x number of flaming tigers *that* is up to you to interpret and I’d be fascinated to read your paper on that. However, there *are* buttons for administering oxygen, buttons for administering fluids and buttons for administering medicines/drugs specific to that patient case.</span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-style: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">What’s more, these buttons are linked to physiological and mental patient responses, so the administration of 2 litres of oxygen results, in this particular case of a patient with respiratory distress, to a 2 point increase in SpO2 and a 2 point decrease in breathing rate over the course of 2 minutes. A pop up message on the instructor's screen tells the driver that patient can respond in a slightly calmer manner from now on.</span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-style: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">So far, so good, so what?</span></div>
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<span style="font-family: "arial"; white-space: pre-wrap;">Does that mean that we have a library of standard responses that we can use again and again for all the patient cases? Float the start parameters and pick and mix the responses?</span><br />
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<span style="background-color: transparent; color: black; font-family: "arial"; font-style: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Well, no, and here is where it starts to get a bit obsessive and granular (*turns to camera, rolls eyes* “starts to”)</span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-style: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">A litre of fluid administered to a hypovolemic patient will have different effects based on the cause of the hypovolemia. Using the analogy that the cardiovascular system is like your central heating system, fixing a bleeding is as simple as refilling the radiator. Trying to refill the same radiator under sepsis is like trying to refill the sea, as the vasculature has dilated so much. </span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-style: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">The analogy is a *little* broad, but works for my purposes, so I’m keeping it. Better analogies are available...</span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-style: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">So we need different physiological responses to the pressing of buttons for administration of fluids for both trauma and for sepsis-based patient cases. Fair enough.</span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-style: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">But wait! Won’t then those individual responses themselves be affected by whether or not other interventions have taken place, and indeed when those interventions took place. Won’t we need separate buttons for that too? Won't, for example, administering a vasoconstrictor influence the effect of fluids? Doesn’t the vasoconstrictor itself need something to “work” with? Is the patient state stable or dynamic? Won’t we need even more buttons? </span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-style: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Well yes, and no. And yes again, but then again...no</span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-style: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Let’s just have the one button called Administer 1l fluid. It can be called that across all the cases in which it's going to be used. Whoever is driving sees the same colour button in the same place regardless of patient case. Simple, repeatable, intuitive.</span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-style: normal; font-weight: 700; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Variables within variables</span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-style: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Depending on patient case/sickness, the button is programmed to have an incremental effect on the physiology of the patient.</span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-style: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">When the button is pressed is going to be a factor (How sick has the patient become?)</span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-style: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;"><span class="Apple-tab-span" style="white-space: pre;"> </span></span><span style="background-color: transparent; color: black; font-family: "arial"; font-style: italic; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">We can program a timer for this and factor the responses accordingly.</span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-style: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">The anxiety of the patient is going to be a factor.</span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-style: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;"><span class="Apple-tab-span" style="white-space: pre;"> </span></span><span style="background-color: transparent; color: black; font-family: "arial"; font-style: italic; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">We can program responses based on the patient's psychology.</span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-style: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Previous interventions are going to be a factor</span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-style: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;"><span class="Apple-tab-span" style="white-space: pre;"> </span></span><span style="background-color: transparent; color: black; font-family: "arial"; font-style: italic; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">We construct a series of IF>THEN>ELSE loops to handle this and hang our physiological responses from them.</span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-style: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">And so on, and so forth.</span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-style: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">We do this for every intervention we believe is going to be repeated and create a button for this intervention. We control the variables. We control the vertical and the horizontal Twilight Zone fans...</span></div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjhq6tyfPHSB_trjJO9DhG7pwg_w0V4r18Hi0KaFv6irdDbXQjRzJwT20KXVXV-cyHgwzpwGyoXMnH8V6I3LY9u26-ssH7Zvom6fcBqmY3EdQpR8DNC2D6e5BXXZtBDSy1kwynZwQii8e5u/s1600/top.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="421" data-original-width="842" height="100" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjhq6tyfPHSB_trjJO9DhG7pwg_w0V4r18Hi0KaFv6irdDbXQjRzJwT20KXVXV-cyHgwzpwGyoXMnH8V6I3LY9u26-ssH7Zvom6fcBqmY3EdQpR8DNC2D6e5BXXZtBDSy1kwynZwQii8e5u/s200/top.png" width="200" /></a></div>
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<span style="font-family: "arial"; white-space: pre-wrap;">How far do we go with this? This is all going a bit Inception now isn’t it? What is the point in this obsessive granularity? When does the spinning top fall? </span><br />
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<span style="background-color: transparent; color: black; font-family: "arial"; font-style: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">The broad point of having physiologically correct patient cases is that we then don’t need to discuss the medicine/physiology of the case at the expense of the true learning objective, communication and teamwork.</span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-style: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">The point of having buttons labelled after which interventions the team perform is that the instructor/operator isn't looking at numbers when the intended focus of the debrief is the team and the interventions they performed.</span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-style: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">The more we control, the more we are able to influence the learning environment, effectively laser-targeting our goals by turning unwanted variables into tools that allow us to shape a clearly defined debriefing session.</span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-style: normal; font-weight: 700; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">In conclusion</span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-style: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">We’ve alloyed our experience in delivering clinically relevant simulations to our experience debriefing these simulations. What we wanted to avoid is discussing medicine under the debrief when it’s more relevant to discuss teamwork, so we have focused on the medicine in the patient case. What we want to avoid is discussing variables under the debrief, so we have focused on the variables in the patient case.</span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-style: normal; font-weight: 700; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Give me a lever and a place to stand and I shall move the earth</span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-style: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">What I’ve outlined across Programming People and Split Simulated Personality is the beginning of my simulation concept based on the resources available to me. There are many puzzle pieces to consider, when building a simulation, and depending on your perspective, you are picking and choosing the pieces you want based on the picture you want to build or even just the picture you are able to see. Excitingly, we are moving to new premises in the new year, where I’m hoping that increased access to resources means that I’m able to have a broader perspective and deliver more varied and interesting simulations. I shall keep you posted. </span></div>
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<span style="font-family: "arial"; white-space: pre-wrap;">Next, and in not too long on The Simulated Man, Bigfoot! </span><br />
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<span style="background-color: transparent; color: black; font-family: "arial"; font-style: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Or not, I’m in the middle of designing a graphical tool for structuring and steering simulation debriefings and I’m looking forward to sharing it with you all.</span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-style: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;"><b>Stay Simulated!</b></span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-style: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;"><b>The Simulated Man</b></span></div>
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<br />Pete Dickenshttp://www.blogger.com/profile/12970193129355208476noreply@blogger.com0tag:blogger.com,1999:blog-9180978986426437884.post-52028869743446292052016-09-01T04:01:00.005-07:002016-09-01T05:17:53.651-07:00SMART Simulation<div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: "arial"; font-style: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;"><span style="font-size: large;"><br /></span></span>
<span style="background-color: transparent; color: black; font-family: "arial"; font-style: normal; font-weight: 400; vertical-align: baseline; white-space: pre-wrap;"><span style="font-size: large;"><u>SMART Simulation</u></span></span><br />
<span style="background-color: transparent; color: black; font-family: "arial"; font-style: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;"><span style="font-size: medium;">Welcome back!</span></span><br />
<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">In the immortal words of, among others, </span><span style="background-color: transparent; color: black; font-family: "arial"; font-style: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;"><span style="font-size: medium;">Slayer</span></span><span style="background-color: transparent; color: black; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">.</span></div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjIGHrY8PNhtVDYlz8U6OnXtqnJp-DXG0sFsqQVLIXljM3k7lm2vyNQ1JNnINOLtj_pfkfeUF1R1olJsk2FJ9f2eXf1drVXk3NnsIt5Xk1fygSfNKK3jOIqrETxS6kSTVM4-JVeNfUtJ_yH/s1600/SMART.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" height="86" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjIGHrY8PNhtVDYlz8U6OnXtqnJp-DXG0sFsqQVLIXljM3k7lm2vyNQ1JNnINOLtj_pfkfeUF1R1olJsk2FJ9f2eXf1drVXk3NnsIt5Xk1fygSfNKK3jOIqrETxS6kSTVM4-JVeNfUtJ_yH/s320/SMART.jpg" width="320" /></a></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Apologies for the delay (as usual), there’s always a delay, and I’m always sorry. Mae culpa, mae culpa, mae maxima culpa</span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">That being said, I’ve received enough positive feedback, comments, mentions, likes, retweets, pokes, shrugs, swipes right, whatever one does on LinkedIn, and even a good old fashioned e-mail to allow myself to consider the ideal that there is more to this blog than me simply howling into the void.</span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Many, many, many heartfelt thanks for the motivation and encouragement. Let’s get on with it, shall we? (Yes!) I promise to stop blogging when y’all eventually carry me around shoulder high singing hosannas and chanting my name as the saviour of modern simulation, or when I get bored, either feels like a natural end.</span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">In this blarticle (blog/article) I’m going to be presenting a simulation concept I have been instrumental in co-creating with my excellent work colleague and future rock star John Karlsson of Akademiska University Hospitals Clinical Training Centre. </span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">It’s called SMART simulation.</span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">The mechanics and content of SMART are currently undergoing some form of copyright protection process, so I can’t share the material or programming but I can describe the concept.</span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">S.M.A.R.T simulation - Full Metal Packet</span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">“This is our SMART concept, there are many like it but this one is ours…” </span></div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg7cYjcmwWfBKjfkCCFPMBaKx7DkT3_39H3jtfM30S4GAtl0_JbO8mS5BdomtPaFrYMA3qlRMOshlYhy-fAPFrlTaffvbpH6nHGrge5uZbIJJ9i-GrdMl9GbR_vfZqJQZal_kgWCk2o0fkL/s1600/FMJ.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg7cYjcmwWfBKjfkCCFPMBaKx7DkT3_39H3jtfM30S4GAtl0_JbO8mS5BdomtPaFrYMA3qlRMOshlYhy-fAPFrlTaffvbpH6nHGrge5uZbIJJ9i-GrdMl9GbR_vfZqJQZal_kgWCk2o0fkL/s200/FMJ.jpg" width="180" /></a></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">SMART is an acronym for Simulation Made Accessible via Resource-Saving Training in-situ.</span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">I’m aware that we’re not the first people to use SMART as an acronym, and that there even exists at least one another SMARTSim.</span></div>
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<div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">The great thing with acronyms is that you can change them, let’s refer back to popular heavy metal combo SLAYER, who were so kind as to welcome us back at the beginning of this article. Slayers name *CAN* be an acronym for Satan Laughs As You Eternally Rot *OR* it *CAN* be an acronym for Sings Lovely And Yes, Even Rhymes. You can adapt the acronym to fit the content (or the recipients of the content)</span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Originally SMART stood for Simpad, Manikin And Relevant Training, which sounds maybe a little more elegant and easier to understand but is then constrained to the use of Laerdals SimPad (more of which later). We found, however, that one of SMARTS strongest features was its modular nature, that we could use the SMART concept as a framework for any event that would benefit from a briefing and a debriefing.</span></div>
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<div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">As expressed in a previous blarticle, we run a lot of simulation, meaningless figures abound that I am unwilling to pluck out of the air but it’s a *loooooooooot* We run so much simulation that the resources of our centre are stretched trying to keep up with demand. Running in situ (point of care) simulations in the relevant hospital departments helps take the weight off of the physical resources of the centre and conveys with it the intrinsic benefits that in situ simulation delivers (more on this here, and everywhere else, another time) However, in situ simulation also demands human resources in the form of trained simulator instructors and operators, of whom we have a finite number.</span></div>
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<div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">So, saturation point for simulation? No more resources to commit without a drop in quality and for some we go back to being that place in the cellar that ward staff visit once a year (at best!) and play with scary dolls?</span></div>
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<div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Well we could loan out a simulator to the staff responsible for teaching on the ward. But then we have *no* control over what is delivered during the teaching session. This isn’t something that is attractive for us as a centre charged with delivering learning that has the raising of patient safety as its core value.</span></div>
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<div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">In short, we don’t want to say no to people who want to engage with simulation, so we need to find a way to make simulation accessible without it losing its meaning.</span></div>
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<div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">As we see it, the barriers to simulation include the following preconceptions</span></div>
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<li dir="ltr" style="background-color: transparent; color: black; font-family: Arial; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; list-style-type: decimal; text-decoration: none; vertical-align: baseline;"><div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">A technologically advanced simulator is not something one can just pick up and use as a teaching resource without prior experience</span></div>
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<li dir="ltr" style="background-color: transparent; color: black; font-family: Arial; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; list-style-type: decimal; text-decoration: none; vertical-align: baseline;"><div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Debriefing a group of potential strangers according to Crew Resource Management (CRM) guidelines is not a job for the faint hearted and if mishandled can lead to as much harm as good.</span></div>
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<li dir="ltr" style="background-color: transparent; color: black; font-family: Arial; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; list-style-type: decimal; text-decoration: none; vertical-align: baseline;"><div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Simulation is HEAVY on resources, sending 10 members of staff down to the clinical training centre for a half day has the potential effect of removing a weeks worth of ward work</span></div>
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</ol>
<b style="font-weight: normal;"><br /></b>
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<div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Being a successful simulation instructor or simulator operator could be said to require a set of skills that are if not unique, then *highly* specialised and reliant on experience. So how to translate that?</span></div>
<b style="font-weight: normal;"><br /></b>
<br />
<div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">The vast majority of requests we have to deliver simulation are with specific CRM based goals as the preferred learning points (rather than practical/psychomotor skills) Starting with the preferred learning goals of the target group sounds pedagogically healthy and worthwhile, so let’s do that.</span></div>
<b style="font-weight: normal;"><br /></b>
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<div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">For entry level instructors, there exists a preconception that CRM as a concept can be clumsy and hard to get to grips with. One of the reasons for this is that the central principles of CRM can mean different things to different people, and another is that there are so damn many. Cognitive theory suggests we as humans can only effectively think about seven things at once, so how are we considering the impact of a dozen or more CRM principles on an active group of people with a view to debriefing them? Is it even possible?</span></div>
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<div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">The Ace of Spades</span></div>
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<div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">We have broken down the introduction of CRM principles and the corresponding debriefing into a card game *gasps from the audience, someone in Denmark just fainted, cries of “No!, you can’t DO that!”</span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 14.6667px; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;"><i>“Oh but,” puts on sunglasses, turns to camera, “we did…” </i></span></div>
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<span style="font-family: "arial";"><span style="font-size: 14.6667px; line-height: 20.24px; white-space: pre-wrap;"><br /></span></span><span style="background-color: transparent; color: black; font-family: "arial"; font-size: 14.6667px; font-style: normal; font-weight: 400; line-height: 1.38; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;"></span></div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgVeFwbQww2GqSZg1cOVEZE0sZ4780vDwPQbznYejJkDvK3Ouv_UvZ5lh3b95CNVgSUsJGDFHBQMXecH_hZOHDF9x9z9IS3fJSmhhnrvNVR6gPPRp7pvH9e5pUvY4jBEEfWvtLOcxijcyc5/s1600/AOS.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgVeFwbQww2GqSZg1cOVEZE0sZ4780vDwPQbznYejJkDvK3Ouv_UvZ5lh3b95CNVgSUsJGDFHBQMXecH_hZOHDF9x9z9IS3fJSmhhnrvNVR6gPPRp7pvH9e5pUvY4jBEEfWvtLOcxijcyc5/s1600/AOS.png" /></a></div>
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<div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Each card set has a theme (Communication, Effective Teamwork etc), and there are maybe 4-6 cards in each set. Upon each card is the title of one of the CRM principles (Closed loop communication for example), and on the back of each card is a description of that principle and how it might translate into actual work duties.</span></div>
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<div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">The card set forms the basis of an introduction to the simulation session. Once the principles and descriptions have been discussed and agreed upon, it’s time to meet our patient.</span></div>
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<div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">All our S:M:A:R:T patients are gender neutral, there’s even a word for a gender neutral person in the swedish language, hooray for a progressive society.</span></div>
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<div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">(Nearly) all our S:MA:R:T patient cases can happen whenever, to whomever and wherever. It’s up to the educator delivering SMART to add some finesse to the case if it needs to be made more relevant to a specialist ward or unusual healthcare environment.</span></div>
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<div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">The cases are medically straightforward, with the ideal that time spent in the debrief discussing the medical aspects of the case is time spent NOT discussing or reaching the CRM based learning goals.</span></div>
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<div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Drive, she said</span></div>
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<span style="font-family: "arial";"><span style="font-size: 14.6667px; line-height: 20.24px; white-space: pre-wrap;"><b><br /></b></span></span><span style="background-color: transparent; color: black; font-family: "arial"; font-size: 14.6667px; font-style: normal; font-weight: 700; line-height: 1.38; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;"></span></div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhI0J7Ca3MDbaJ0Ki-zRYfNePTVLsE2wYLCFIbub73eF3ZFT2dkt5TJ5ysEw6N2CuMJxOtUNDfqqFZhpO2xndhgZSsUmDdqwu52TOMd7dXMeGS4PdR_c8jikwfJkzhVmtr-BZ_Es7bwOh3m/s1600/DSS.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="169" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhI0J7Ca3MDbaJ0Ki-zRYfNePTVLsE2wYLCFIbub73eF3ZFT2dkt5TJ5ysEw6N2CuMJxOtUNDfqqFZhpO2xndhgZSsUmDdqwu52TOMd7dXMeGS4PdR_c8jikwfJkzhVmtr-BZ_Es7bwOh3m/s320/DSS.jpg" width="320" /></a></div>
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<div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Driving a simulator is </span><span style="background-color: transparent; color: black; font-family: "arial"; font-size: 14.6667px; font-weight: 700; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;"><i>easy</i></span><span style="background-color: transparent; color: black; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">, it’s simply a matter of having 100% focus on the patient's vital statistics (SpO2, Heart rate, Blood Pressure etc) with respect to both the patient's underlying sickness (which you have expert knowledge of) and the actions and interventions carried out by the team of participants, and translating these actions and interventions into realistic physiological responses as displayed on the patient monitor and via the simulator. Simultaneously you are voice acting the patient's symptoms and emotions.</span></div>
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<div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Did I say it was easy, well it is easy to do a bad job, far too easy. So how do we make it easy to do a better job?</span></div>
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<div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">As outlined in the previous blarticle “Programming People - Part 1” there are broadly speaking two approaches to driving a patient case on the simulator. “On the fly”, making things up as you go along, an approach that does not suit an inexperienced simulator operator, and Hard Wiring, an approach whose rigidity doesn’t suit a flexible simulation package like SMART</span></div>
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<div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">With SMART, we have programmed physiological responses linked to on screen button presses on a mobile device, with the buttons marked according to known likely medical interventions.</span></div>
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<div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">It works like this, the participants administer oxygen, the operator presses a button named “Administer Oxygen” or something similar and the physiological response to oxygen administration happens in the background over time. The participants raise the rate of oxygen delivery, there is a button for that with the physiology programmed in. Fluids? Drugs? Tipping the bed? For each likely intervention there is an appropriate button linked to a physiological response.</span></div>
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<div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">The patient's condition is preprogrammed to deteriorate over time, with choosable levels of severity of disease state.</span></div>
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<div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">For each case, one of the “Participant Action” buttons is red, and is considered the key treatment to allow the case to progress positively and the patient to begin to normalise. For example, the programmed allergic shock case requires the intervention of an EpiPen or similar. Once this intervention has taken place, the red button is pressed and the patient normalises over time. </span></div>
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<div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Simple, elegant, SMART. A physiologically correct patient case that is easy to drive and focuses on the actions of the participants.</span></div>
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<div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">“But how does the patient feel?” I hear you ask</span></div>
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<div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">As outlined in another previous blarticle (see how its all coming together, long term readers?), patients are, surprisingly, people, as well as fleshy objects, and how they feel has an affect on how they react to treatment.</span></div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhhvUOrkSMqr_G4otREOHYMcMyCUHe4avuMVgUfbZRrWPx38stYDkkHNRwmMu8puPEpHjRrUV8W6surq6PGU51G4sp4yjgjwZRcUQjT5O26GWBbPMieQI0AxqkRcKEh4RN6V3EY0eZdkSuJ/s1600/feelings.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="150" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhhvUOrkSMqr_G4otREOHYMcMyCUHe4avuMVgUfbZRrWPx38stYDkkHNRwmMu8puPEpHjRrUV8W6surq6PGU51G4sp4yjgjwZRcUQjT5O26GWBbPMieQI0AxqkRcKEh4RN6V3EY0eZdkSuJ/s200/feelings.jpg" width="200" /></a></div>
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<span style="font-family: "arial"; font-size: 14.6667px; line-height: 1.38; white-space: pre-wrap;">Scroll a little right on the SMART programmed mobile device to the Symptoms button to find the answers. Pressing this button will display different things according to which phase of treatment/sickness the patient is in. The information is provided in a pop up on the mobile device and includes key phrases the patient might say at this point, and the answers to questions the simulator itself can’t deliver (capillary refill, patient temperature, how warm does the skin feel etc etc)</span><br />
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<div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">After running the scenario, the participants are invited to take part in a debriefing. The debrief itself is based on the previously discussed CRM card set and introduces a specially prepared “board game” in order to define, structure and focus the debriefing towards the discussion of the chosen goals, rather than a general roundtable agreement that “good things are better than bad things”</span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Participants later receive a web based survey in which they may submit further reflections and feedback.</span></div>
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<div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">How is this solving the resource problem? </span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">The ward personnel in charge of education come to us for a half days “Smart-Instructors education” course, after which they receive a crown and sceptre and are allowed to book the SMART package (Course material, card game, SMART-programmed simulator)</span></div>
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<div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">We have enjoyed huge success delivering SMART using Laerdals Resusci Anne Simulator (RA Sim) and Laerdals SimPad mobile device. The RA Sim is a medium fidelity simulator, that is to say it has pulses, it breathes, you can take its blood pressure. Its ability to be driven by the SimPAd mobile device also makes it very attractive as part of a physical, collectable/deliverable simulation package.</span></div>
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<div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">The (newly crowned) SMART instructor collects the package themselves and then delivers the session (often it needs two instructors) back at their own department in the hour long gap between two work shifts. Scheduling education under this hour means that NO patient hours are lost and as a SMART simulation session lasts 30 minutes (10 min intro, 10 min medical case, 10 minute SMART debrief) we can deliver two sessions. </span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">This is the end, beautiful friend</span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Simplified CRM structured and focussed to deliver specific teaching goals.</span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Absurdly easy to drive simulation.</span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Flexible and light on resources.</span></div>
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<br />
<div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Sure, it’s simulation LITE, in a way, but it punches way above its weight by directly addressing preconceptions about simulation.</span></div>
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<br />
<div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">We don’t see SMART as a way out of full scale simulation rather than a way into full scale simulation. We see it as one of the ways in which we don’t have to say no anymore.</span></div>
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<div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">After a successful pilot scheme, we launched our own SMART instructors course and are delighted to say we have now more than 40 SMART instructors across our local authority. Which, in context, is 40 plus more people engaged in delivering simulation in Uppsala Län than there was 6 months ago, boom!</span></div>
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<div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Feedback has been overwhelmingly positive, both first hand and via the web survey. One overheard comment at the last course was how this was potentially going to make a MAJOR difference to patient safety, and how EVERYONE should become a SMART instructor. </span></div>
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<div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">I was struck by a certain feeling at that point which I can only describe like this...</span></div>
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<div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Remember the film JAWS, when Roy Schneiders character is tossing rubbydubby/chum/fishheads off the back of their vessel and The Shark appears for the first time, revealing its true size? </span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">The look on his face, and the phrase “I think we are going to need a bigger boat”</span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">That.</span></div>
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Exciting times at Simulated Towers!</div>
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<div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Till next time, whenever that is, and whatever that is about, stay simulated! </span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;"><br /></span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">TSM</span></div>
Pete Dickenshttp://www.blogger.com/profile/12970193129355208476noreply@blogger.com1tag:blogger.com,1999:blog-9180978986426437884.post-66757863231878746232016-05-05T23:15:00.001-07:002016-05-05T23:36:52.333-07:00Programming People<div dir="ltr" style="line-height: 1.295; margin-bottom: 8pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: Calibri; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;"><br /></span></div>
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<span style="background-color: transparent; color: black; font-family: Calibri; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;"><span style="font-size: large;"><b>PROGRAMMING PEOPLE: PART 1</b></span></span></div>
<b id="docs-internal-guid-31f31e80-84ad-cdbd-73c9-8d59523a9f09" style="font-weight: normal;"><br /></b>
<div dir="ltr" style="line-height: 1.295; margin-bottom: 8pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: Calibri; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Apologies for the delay in the (planned) fortnightly article, pesky minor inconveniences such as parenthood, and holding down a job in a foreign land have been tickling my procrastination bone.</span></div>
<b style="font-weight: normal;"><br /></b>
<div dir="ltr" style="line-height: 1.295; margin-bottom: 8pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: Calibri; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">And apologies in advance to all Charlies and Kims out there…</span></div>
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<div dir="ltr" style="line-height: 1.295; margin-bottom: 8pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: Calibri; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">In this article we are going to begin to look at ways that simulators can be programmed.</span></div>
<div dir="ltr" style="line-height: 1.295; margin-bottom: 8pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: Calibri; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Programmed you say? Well yes, I’m going to be using the word programming a *lot* in this article, and I make no apologies for doing so. </span></div>
<div dir="ltr" style="line-height: 1.295; margin-bottom: 8pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: Calibri; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">I am NOT a programmer. Real programmers use real programming languages, I’m just using the software as provided by the simulator manufacturer.</span></div>
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<span style="background-color: transparent; color: black; font-family: Calibri; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">However, I’m using the software to generate a nested series of IF>THEN>ELSE loops and triggers in order to change the simulated patient’s condition.</span></div>
<div dir="ltr" style="line-height: 1.295; margin-bottom: 8pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: Calibri; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">The simplest example I can give is this, in the case of a patient struggling with an unspecified breathing problem</span></div>
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<span style="background-color: transparent; color: black; font-family: Calibri; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">IF (Oxygen is applied) THEN (Raise Saturation) ELSE (Do nothing)</span></div>
<div dir="ltr" style="line-height: 1.295; margin-bottom: 8pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: Calibri; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">We can make this more sophisticated by asking how much oxygen is applied. By which method? And when in the scenario? But the principle remains the same.</span></div>
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<span style="background-color: transparent; color: black; font-family: Calibri; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">IF (Intervention=True)</span></div>
<div dir="ltr" style="line-height: 1.295; margin-bottom: 8pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: Calibri; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">THEN (Alter the patient’s condition),</span></div>
<div dir="ltr" style="line-height: 1.295; margin-bottom: 8pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: Calibri; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">ELSE (Do nothing, or further deteriorate the patient)</span></div>
<div dir="ltr" style="line-height: 1.295; margin-bottom: 8pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: Calibri; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Well, it </span><span style="background-color: transparent; color: black; font-family: Calibri; font-size: 14.666666666666666px; font-style: italic; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">looks</span><span style="background-color: transparent; color: black; font-family: Calibri; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;"> like programming and </span><span style="background-color: transparent; color: black; font-family: Calibri; font-size: 14.666666666666666px; font-style: italic; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">smells</span><span style="background-color: transparent; color: black; font-family: Calibri; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;"> like programming and…oh, delicious, this programming is beautifully cooked! It also works like programming, which is a bonus. </span></div>
<div dir="ltr" style="line-height: 1.295; margin-bottom: 8pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: Calibri; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">In my own simulation environment, where we don’t have the time, space or resources available to moulage or make up the patients and rooms, we need to try and introduce quality into our simulations in other ways. Programming the physiological responses of the simulator is one of these ways.</span></div>
<div dir="ltr" style="line-height: 1.295; margin-bottom: 8pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: Calibri; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Much more on this later. Woo!</span></div>
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<span style="font-family: Calibri; font-size: 14.6667px; line-height: 18.9933px; white-space: pre-wrap;"><b>PROGRAMMING IS A DIRTY WORD</b></span></div>
<a href="https://lh6.googleusercontent.com/lvfr9kyjM-J0RNQjHhiiTS5vw77Mi1rr4fL-dPxyEg_Tc3xcbthbYDJVpB8J34c2j7m9MHvWw1ko745TsQ8T-7bh6OK_x4cID_OrN4duy_OyGpw5e0JH62SqTwcut9rBzvWQjrBB70T8oNEwMw" imageanchor="1" style="clear: left; display: inline !important; float: left; line-height: 1.295; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="216" src="https://lh6.googleusercontent.com/lvfr9kyjM-J0RNQjHhiiTS5vw77Mi1rr4fL-dPxyEg_Tc3xcbthbYDJVpB8J34c2j7m9MHvWw1ko745TsQ8T-7bh6OK_x4cID_OrN4duy_OyGpw5e0JH62SqTwcut9rBzvWQjrBB70T8oNEwMw" style="border: none; transform: rotate(0rad);" width="324" /></a><br />
<div dir="ltr" style="line-height: 1.295; margin-bottom: 8pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: Calibri; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Traditionally and sadly currently, programming is seen as a substitute for medical knowledge and experience. I believe that when used effectively it can only augment and strengthen the delivery of medical simulation.</span></div>
<div dir="ltr" style="line-height: 1.295; margin-bottom: 8pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: Calibri; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Operators; those that “drive” the simulators, respond verbally as the patient, and manage the physiological parameters of the patient via the software, fall veeeery broadly into two distinct camps.</span></div>
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<span style="background-color: transparent; color: black; font-family: Calibri; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;"><br /></span></div>
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<span style="background-color: transparent; color: black; font-family: Calibri; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;"><br /></span></div>
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<li dir="ltr" style="background-color: transparent; color: black; font-family: Calibri; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; list-style-type: decimal; text-decoration: none; vertical-align: baseline;"><div dir="ltr" style="line-height: 1.295; margin-bottom: 0pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: Calibri; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Experienced healthcare practitioners (HCP) that have “seen everything”</span></div>
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<li dir="ltr" style="background-color: transparent; color: black; font-family: Calibri; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; list-style-type: decimal; text-decoration: none; vertical-align: baseline;"><div dir="ltr" style="line-height: 1.295; margin-bottom: 8pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: Calibri; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Non medically qualified technicians/engineers/IT nerds/weirdos</span></div>
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<div dir="ltr" style="line-height: 1.295; margin-bottom: 8pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: Calibri; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">And programming the simulator has itself traditionally taken one of the following forms</span></div>
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<li dir="ltr" style="background-color: transparent; color: black; font-family: Calibri; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; list-style-type: decimal; text-decoration: none; vertical-align: baseline;"><div dir="ltr" style="line-height: 1.295; margin-bottom: 0pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: Calibri; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Start parameters, lung and heart sounds etc. are set up for the beginning of the scenario and any changes or interventions are handled live “On the Fly”</span></div>
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<li dir="ltr" style="background-color: transparent; color: black; font-family: Calibri; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; list-style-type: decimal; text-decoration: none; vertical-align: baseline;"><div dir="ltr" style="line-height: 1.295; margin-bottom: 8pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: Calibri; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">The patient moves from one hard wired state/set of parameters to another after a specific time, specific intervention or at the direction of the session leader. We’ll call this “Storyboarding”</span></div>
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<span style="background-color: transparent; color: black; font-family: Calibri; font-size: 14.6667px; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;"><b>“THERE IS NO SUBSTITUTE FOR EXPERIENCE”</b></span></div>
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<a href="https://lh4.googleusercontent.com/VyHVHUyPmQL5ompkmBwWoLuw0kLCPmwyi_u-u26wL8OxHfG658EsOFxOm0ETiQK1Z4MrHQFBZkJboGUvk_eZpxCnRW3dyZp7XB0XPAXyWjOHXgXRrVZ_OHDVWLq4XlTGWNBzVcNAVEuD70W4HQ" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img alt="\\lul-net\dfsLUL\Users\d\dip001\My Pictures\nurse-leather-strap-anesthesia.jpg" border="0" height="312" src="https://lh4.googleusercontent.com/VyHVHUyPmQL5ompkmBwWoLuw0kLCPmwyi_u-u26wL8OxHfG658EsOFxOm0ETiQK1Z4MrHQFBZkJboGUvk_eZpxCnRW3dyZp7XB0XPAXyWjOHXgXRrVZ_OHDVWLq4XlTGWNBzVcNAVEuD70W4HQ" style="border: none; transform: rotate(0rad);" width="249" /></a><span style="background-color: transparent; color: black; font-family: Calibri; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Let’s call our experienced HCP Kim, for gender neutralities sake, and because I don’t know anyone called Kim. Kim has worked in emergency medicine and on the intensive care wards for many years, they have seen just about every simulatable situation there is. Kim trusts in their knowledge and experience, we trust in Kims knowledge and experience and many patients have trusted in Kims knowledge and experience. Kim prefers to drive the simulator “On the Fly”, because of the wealth of anecdotal knowledge available to them. Kim doesn’t like to Storyboard their simulations, they know what a Septic Shock looks like, and they have seen Septic Shock many times and are happy to trust themselves to manage the numbers and patient responses without relying on programming. After all, it’s received knowledge that we don’t know which interventions the participants are going to perform, or in which order.</span></div>
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<span style="background-color: transparent; color: black; font-family: Calibri; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">However, from day to day, and from session to session, Kim remembers a different Septic Shock on a different patient, in a different place with a different level of care, with different vocal responses and demeanor on behalf of the patient. These inconsistencies play a part in making the rest of the team unsure as to how the session is going to go, especially when it is a session that is likely to be repeated or even run in parallel, or when the other instructors aren’t familiar with Kim. It’s pretty much all down to Kim (but Kim likes this!) They may even feel threatened or slighted by the idea that their expertise isn’t being called upon if the simulation relies on programming (but they shouldn’t) </span></div>
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<span style="background-color: transparent; color: black; font-family: Calibri; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">When the goal of the simulation part of the teaching session is to illicit some sort of Crew Resource Management based teamwork that can be discussed during a structured debrief, it can be an advantage to have some idea of how sick the patient is going to be that’s not based on the whim of the operator. Additionally, despite Kim’s wealth of experience, they are likely at some point to make a mistake. CRM debriefing a group of participants is challenging enough without then folding their arms and thinking, “Well, medically, that was bullshit, so why are we taking it seriously?”</span></div>
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<span style="background-color: transparent; color: black; font-family: Calibri; font-size: 14.6667px; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;"><b>A TEXTBOOK EXAMPLE</b></span></div>
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<span style="background-color: transparent; color: black; font-family: Calibri; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Let’s introduce our Technical Wonk, and let’s call them something gender neutral and non-familiar like Charlie.</span></div>
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<span style="background-color: transparent; color: black; font-family: Calibri; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Charlie doesn’t trust in their medical knowledge and feels sure they are going to miss something if they drive “On the Fly”, Charlie, however has consulted patient cases and textbooks and has constructed a Storyboard in the programming that matches exactly that patient on that day in that textbook as treated at that time by that team.</span></div>
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<span style="background-color: transparent; color: black; font-family: Calibri; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Patient presents as sick, patient gets worse, the team works, patient gets better. That’s the plan and generally speaking it’s a sound one. The physiological parameters fit the disease state, the simulator can be programmed to have a deteriorating condition over time and at the click of a button, the patient improves to a point where we are satisfied that the learning goals of the session are met and nothing is missed. After all, it is documented medical fact which interventions should take place for a particular disease state, and in which order.</span></div>
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<span style="background-color: transparent; color: black; font-family: Calibri; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">This case can be repeated with the same results across multiple dates, across parallel sessions with predictable consequences.</span></div>
<a href="https://lh5.googleusercontent.com/Z5YCC-IDHbtxbC23_hpBfksDyXtNIOfqLLX-6FkmrFHKmSVwUJeOCVao75xrzDLOaJzfs6i_EjTzhlIA9kgKHsMuCfZfmjQaPPHLyMePTcuzBbPR-3vUGBgESwiNt0aR_0FZQq5JP4XrsmpxUA" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img alt="\\lul-net\dfsLUL\Users\d\dip001\My Pictures\Medical-Sim-Lab-Control-room-800x400.jpg" border="0" height="100" src="https://lh5.googleusercontent.com/Z5YCC-IDHbtxbC23_hpBfksDyXtNIOfqLLX-6FkmrFHKmSVwUJeOCVao75xrzDLOaJzfs6i_EjTzhlIA9kgKHsMuCfZfmjQaPPHLyMePTcuzBbPR-3vUGBgESwiNt0aR_0FZQq5JP4XrsmpxUA" style="border: none; transform: rotate(0rad);" width="200" /></a><br />
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<span style="font-family: Calibri; font-size: 14.6667px; line-height: 1.295; white-space: pre-wrap;">However, this approach assumes a lot, not least of which is that the participants come to a specific diagnosis and the correct treatment plan. As the physiology is “hard-wired” in obvious stages (Sick, deteriorating, recovering) it can leave participants feeling that they didn’t really participate in a way that affected the patients’ recovery directly, rather than the patient became better in some semi arbitrary manner after an amount of time had passed, or enough treatment boxes where ticked. Challenging enough to CRM debrief a team without participants crossing their arms and saying “That may as well have been numbers on a screen, and I don’t feel part of a team”</span></div>
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<span style="background-color: transparent; color: black; font-family: Calibri; font-size: 14.6667px; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;"><b>STRAW MEN</b></span></div>
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<span style="background-color: transparent; color: black; font-family: Calibri; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Clearly, I’m oversimplifying things to emphasize my own point of view (It’s my blog and I’m allowed to!) But we’ve all worked with individuals that remind us of Charlie or Kim and recognize and appreciate the strengths and weaknesses of their own approach to simulation even if they don’t.</span></div>
<div dir="ltr" style="line-height: 1.295; margin-bottom: 8pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: Calibri; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">And again, there are many more ways to program simulators and simulation, I’ve just taken two of the most recognizable examples which, handily, happen to be polar opposites of each other.</span></div>
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<span style="background-color: transparent; color: black; font-family: Calibri; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">But they don’t need to be.</span></div>
<div dir="ltr" style="line-height: 1.295; margin-bottom: 8pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: Calibri; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">As outlined in a previous article, we run an absurd amount of simulation, across multiple and parallel sessions with huge cohorts of students. What we know is that the participants crave consistency, they talk to each other before and after and compare their experiences, even when we ask them not to, y’know?</span></div>
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<span style="background-color: transparent; color: black; font-family: Calibri; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">It is UNFAIR for one group of participants to suffer a poorly executed simulation session when the poor execution is entirely avoidable and down to inbuilt inconsistencies or inflexible programming.</span></div>
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<span style="background-color: transparent; color: black; font-family: Calibri; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Our simulated patients can’t be based on Kims anecdotes, as there is only one Kim.</span></div>
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<span style="background-color: transparent; color: black; font-family: Calibri; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Our simulated patients can’t be That patient in That case study treated by That team as it’s not That team.</span></div>
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<span style="background-color: transparent; color: black; font-family: Calibri; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">In each of our sessions it is always This patient in This room treated by This team (But also, This patient in That room treated by That team)</span></div>
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<span style="background-color: transparent; color: black; font-family: Calibri; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">So how do we do that?</span></div>
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<span style="background-color: transparent; color: black; font-family: Calibri; font-size: 14.6667px; font-variant: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;"><i><b>COMING SOON!</b></i></span></div>
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<span style="background-color: transparent; color: black; font-family: Calibri; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">I’m splitting this article in two, it is long enough already.</span></div>
<div dir="ltr" style="line-height: 1.295; margin-bottom: 8pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: Calibri; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">So, in the next exciting installment of The Simulated Man I’ll be introducing the approach to programming that I’ve developed here at Akademiska University Hospital</span></div>
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<span style="background-color: transparent; color: black; font-family: Calibri; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">In the meantime, </span></div>
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<span style="background-color: transparent; color: black; font-family: Calibri; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Stay simulated!</span></div>
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<span style="background-color: transparent; color: black; font-family: Calibri; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">PETE</span></div>
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<span style="background-color: transparent; color: black; font-family: Calibri; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Thesimulatedman.blogspot.se</span></div>
<br />Pete Dickenshttp://www.blogger.com/profile/12970193129355208476noreply@blogger.com4tag:blogger.com,1999:blog-9180978986426437884.post-17824112905620514112016-04-15T01:57:00.000-07:002016-04-15T01:59:23.945-07:00Split simulated personality: Parallell simulations<div dir="ltr" id="docs-internal-guid-5e9d86c8-191b-6f5d-533d-325cf5e26e58" style="line-height: 1.295; margin-bottom: 8pt; margin-top: 0pt;">
<span style="font-family: "calibri"; font-weight: 700; vertical-align: baseline;">Simulated People are People too!</span></div>
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<span style="font-family: "calibri"; vertical-align: baseline;">Here at Akademiska KTC, we deliver upwards of 400 hours of simulation every term, to put that in laymans terms, thats a HELL OF A LOT! IT’s MADNESS!</span></div>
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<span style="font-family: "calibri"; vertical-align: baseline;">We like to keep the group size as small as manageable, and find that maybe 6 or 8 is the maximum we can take and still deliver a debriefing that facilitates an advanced depth of reflection and a focus on Crew Resource Management.</span></div>
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<span style="font-family: "calibri"; vertical-align: baseline;"> “Thanks” to the enormous and increasing demand for Medical Simulation, we find ourselves running often two, sometimes three and on occasion FOUR simulation sessions simultaneously.</span></div>
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<span style="font-family: "calibri"; vertical-align: baseline;">So that’s more repeat sessions, repeated more frequently.</span></div>
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<span style="font-family: "calibri"; vertical-align: baseline;">In an ideal world we would like all our students/customers/stakeholders (insert your own description here) to have had a similar learning experience, and have reached their teaching goals regardless of which session they have attended.</span></div>
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<span style="font-family: "calibri"; vertical-align: baseline;">How do we go about attempting that?</span></div>
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<span style="font-family: "calibri"; vertical-align: baseline;">Well…</span></div>
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<span style="font-family: "calibri"; vertical-align: baseline;">Four simultaneous sessions, in four different rooms. Importantly, it is THE SAME PATIENT experiencing the SAME SCENARIO in EVERY ROOM.</span></div>
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<span style="font-family: "calibri"; vertical-align: baseline;">Much of what the students perceive during a simulation comes from the operator/voice of the patient. Therefore, there is a responsibility for the simulation team to make sure as much as possible that the broadcast information is correct, or at least not misleading.</span></div>
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<span style="font-family: "calibri"; vertical-align: baseline;">Operating the simulator, and interacting with the students as the patient is a criminally underappreciated art form. Yes, I absolutely would say that, and I absolutely believe it to be true. So important that it merits its own article, so stay tuned for some serious soapboxing in the coming weeks.</span></div>
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<span style="font-family: "calibri"; font-style: italic; font-weight: 700; vertical-align: baseline;">NUMB3RS</span></div>
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<span style="font-family: "calibri"; vertical-align: baseline;">Repeating the same case across four sim sessions is simply a matter of programming/storyboarding the process, right? As long as the numbers show the same thing at the same time then the students should be led along the right lines, and everyone kind of stumbles over the finish line together.</span></div>
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<span style="font-family: "calibri"; vertical-align: baseline;">Well, that is assuming that each group of students does the same thing at the same time in every room, and that the patients disease state is non dynamic and everything follows a linear progression.</span></div>
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<span style="font-family: "calibri"; vertical-align: baseline;">In the immortal words of trained simulator instructor ICE-T, “Shit ain’t like dat”</span></div>
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<span style="font-family: "calibri"; vertical-align: baseline;">The students should be free to deliver whichever sort of intervention they feel to be relevant to the patients disease state as they themselves interpret it, however, and this is a BIG however…</span></div>
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<span style="font-family: "calibri"; vertical-align: baseline;">A liter of fluid delivered to the patient in Room A should have roundabout the SAME effect as a liter of fluid delivered to the same patient in Room B and 5l/min of administered oxygen should have the same effect on Patient A as it does on Patient B, C and D and NOT just what the operator *thinks* is right based on their clinical experience. Yes the operator may have seen patients in this disease state, and yes, their experience is in no way to be discounted but to ensure parity of experience for our students, anecdotal evidence is not enough. *Much* more on numbers, trends and science on another occasion.</span></div>
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<span style="font-family: "calibri"; font-style: italic; font-weight: 700; vertical-align: baseline;">Feelings, nothing more than feelings</span></div>
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<span style="font-family: "calibri"; vertical-align: baseline;">Patients are, of course more than a set of standard responses coupled to a set of trends in their physiology.</span></div>
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<span style="font-family: "calibri"; vertical-align: baseline;">When we run standardized patient cases (using real people made up as patients) we often employ professional trained actors to convey the emotion of being a patient in a disease state. So why are we neglecting this important aspect of patient care when we run patient cases using a patient simulator? Patient simulators can be hard to communicate and empathize with due to how they look and their lack of mobility. It is often left to the simulator operator to interpret and convey the patients mental state how they see fit. Had a bad day? Grumpy patient maybe.</span></div>
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<span style="font-family: "calibri"; vertical-align: baseline;">Fine I guess for one off simulations, but let’s remember, THE SAME PATIENT in the SAME SCENARIO in EVERY ROOM should mean the SAME EMOTIONAL STATE for every instance.</span></div>
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<span style="font-family: "calibri"; vertical-align: baseline;">Realism is as important as repeatability, in every sim session we run.</span></div>
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<span style="font-family: "calibri"; vertical-align: baseline;">A recent post from the excellent SimGhosts blog (Hail! My brothers and sisters in arms!) Shared a feature not commonly found on Sim Scenario templates. It’s taken from a journal article regarding integrating actors into a simulation program and is mainly aimed at the SP world.</span></div>
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<span style="font-family: "calibri"; vertical-align: baseline;">The original looks like this</span></div>
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<span style="font-family: "calibri"; vertical-align: baseline;"><img height="506" src="https://lh3.googleusercontent.com/YYlCkDSWUHXnzRxBw41dnmAq4IxUzuXAR51q3yK3RiMsflInWxsww4FMZg4jt9AbPCJq-c8fKPPHF2kGM3c5fajPbzf_xzcb07s9vnFcPb12SSUd52viXhLGsQFW0LEh-4UvVHBQ1uOkvXeRHg" style="-webkit-transform: rotate(0.00rad); border: none; transform: rotate(0.00rad);" width="1087" /></span></div>
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<span style="font-family: "calibri"; vertical-align: baseline;">It can be agreed in advance with the Sim Team what sort of state the patient is in when encountered, and the appropriate numbers ringed, the sim operator then has a better idea of how to deliver their lines and frame their responses.</span></div>
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<span style="font-family: "calibri"; vertical-align: baseline;">So far so good.</span></div>
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<span style="font-family: "calibri"; vertical-align: baseline;">I’ve developed this strategy further and would like to share my suggestions.</span></div>
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<span style="font-family: "calibri"; font-weight: 700; vertical-align: baseline;">Firstly</span><span style="font-family: "calibri"; vertical-align: baseline;">, nine categories of patient feelings are maybe too many when considering all the other info the simulator operator is dealing with. I’ve gone for six.</span></div>
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<span style="font-family: "calibri"; font-weight: 700; vertical-align: baseline;">Secondly</span><span style="font-family: "calibri"; vertical-align: baseline;">, the info is presented in the form of a simple table, I’ve gone for something a little more intuitive</span></div>
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<span style="font-family: "calibri"; font-weight: 700; vertical-align: baseline;">Thirdly</span><span style="font-family: "calibri"; vertical-align: baseline;">, what happens as the scenario develops? Does the patient become calmer? Angrier? </span></div>
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<span style="font-family: "calibri"; vertical-align: baseline;">My version looks like this</span></div>
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<span style="font-family: "calibri"; vertical-align: baseline;"><img height="693" src="https://lh6.googleusercontent.com/E8KU_D9vzi4cAFTTK-imXcKhhwTqt6lstvP3TaBVO4o65a8lyrPM_W5kaGDFxhwLBWWsLz_Rbk-PlYhPapfz-vYAhT2elFYx2EUDlBhwMA6oySFFvFOSCltgl3O4I6u7JP4KjiAK9f97Whz5lQ" style="-webkit-transform: rotate(0.00rad); border: none; transform: rotate(0.00rad);" width="1151" /></span></div>
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<span style="font-family: "calibri"; vertical-align: baseline;">It’s a simple spider diagram easily created using Microsoft Excel (I say easily, we work with Office Online and it’s as *easy* as pushing water uphill with a fork) </span></div>
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<span style="font-family: "calibri"; vertical-align: baseline;">I actually took the ideal from marriage-destroying football management simulation Football Manager where it is used as a way of comparing players attributes. </span></div>
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<span style="font-family: "calibri"; font-weight: 700; vertical-align: baseline;">Firstly</span><span style="font-family: "calibri"; vertical-align: baseline;">, six categories of patient feelings. Simpler, broader, less open to interpretation. </span></div>
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<span style="font-family: "calibri"; font-weight: 700; vertical-align: baseline;">Secondly</span><span style="font-family: "calibri"; vertical-align: baseline;">, a spider diagram allows for an at-a-glance overview of a patients emotional state. More coloured area equals higher emotions, more drama and overacting! (Hopefully not)</span></div>
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<span style="font-family: "calibri"; font-weight: 700; vertical-align: baseline;">Thirdly</span><span style="font-family: "calibri"; vertical-align: baseline;">, two shades of colour. Why? The darker shape represents the patients INITIAL emotional state, and the lighter shape represents the patients potential emotional state as the case develops. Overlapping trends don’t need to be hidden under each other with some clever formatting of lines and transparency.</span></div>
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<span style="font-family: "calibri"; vertical-align: baseline;">In this medical case, the patient exhibits the symptoms of ongoing sepsis/septic shock.</span></div>
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<span style="font-family: "calibri"; vertical-align: baseline;">Emotionally, we can see the patient is mostly stressed and increasingly confused as the scenario develops.</span></div>
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<span style="font-family: "calibri"; vertical-align: baseline;">A patient in a diabetic coma, or heavily intoxicated might present with a 0 or a 1 in all the categories, but become extremely confused or even angry when awake.</span></div>
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<span style="font-family: "calibri"; vertical-align: baseline;">DOES IT WORK?</span></div>
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<span style="font-family: "calibri"; vertical-align: baseline;">We have started using this approach with some success during the running of multiple sessions. The success is purely based on anecdote as I can’t think of a way to measure parity of teaching across multiple scenario sessions without using the time travel machine that I am going to have invented last week tomorrow.</span></div>
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<span style="font-family: "calibri"; vertical-align: baseline;">That being said, using this device could be argued toward contributing towards parity of experience for all our students, and that feels important to us.</span></div>
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<span style="font-family: "calibri"; vertical-align: baseline;">Coupled to this, we are looking to program the parallel patients physiological responses to interventions in a novel way.</span></div>
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<span style="font-family: "calibri"; vertical-align: baseline;">We are not looking to standardize the sessions, but we are looking to ensure that we can standardize our delivery without sacrificing the creativity and spontaneous nature of Medical Simulation.</span></div>
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<span style="font-family: "calibri"; vertical-align: baseline;">Next up on thesimulatedman</span></div>
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<span style="font-family: "calibri"; vertical-align: baseline;">Programming People : Pros, Cons and tricks</span></div>
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<span style="font-family: "calibri"; vertical-align: baseline;">See you then, stay simulated!</span></div>
<span style="font-family: "calibri"; vertical-align: baseline;">PETE</span>Pete Dickenshttp://www.blogger.com/profile/12970193129355208476noreply@blogger.com0tag:blogger.com,1999:blog-9180978986426437884.post-40725739859040739852016-04-01T01:23:00.001-07:002016-04-01T02:10:12.829-07:00*Published* Advances in Physiology Education *In Press*<span style="font-family: "arial" , "helvetica" , sans-serif;"><b>Simulation as Science</b> </span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">In my simulation career, I've been lucky enough to work with some very talented and knowledgeable people, and in work environments where our combined talents and knowledge where given the opportunity to flourish and grow.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">During my time at Bristol University I was part of a team developing a novel approach to medical science based simulation, and we continue to be proud of the steps that we made.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">I'm not going to go too much into the details now, but sure to bang on about it at length in good time.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">However, I'm very proud to say that Dr Richard Helyer and my humble self have had a short communication on the subject accepted for publication in a forthcoming issue of Advances in Physiology Education.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">I am happy to present a draft below...feedback gratefully recieved.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;"><b>Progress in the utilisation of high-fidelity simulation in basic-science education</b></span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">Richard J Helyer* PhD & Peter J Dickens**</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">*School of Physiology, Pharmacology & Neuroscience, University of Bristol. Bristol, BS8 1TD, UK</span><br />
<span style="font-family: "arial" , "helvetica" , sans-serif;">**Akademiska University Hospital, Uppsala, Sweden</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">High-fidelity simulators with responsive, functional physiological models are typically used to teach clinical skills and clinical emergencies. This teaching is usually delivered to cohorts other than those in early years of undergraduate courses or those studying the basic-sciences that underpin medicine such as physiology and pharmacology. It is now some 15 years since seminal papers by Euliano and others (Euliano, 2000, 2001; Zvara et al., 2001) first described the utility of using human patient simulators (HPS) to teach key physiological principles, 10 years since adoption of HPS (CAE, Canada) at the University of Bristol into basic-science teaching to early-years undergraduates, and some 5 years since the Bristol approach was summarised by Harris et al. (2011). </span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">In Bristol over the past 10 years we have continued to develop simulation as a core part of the curriculum embedded alongside traditional lecture, tutorial and practical class teaching (Harris et al., 2011). We currently use HPS to teach seven separate scenarios in physiology and pharmacology across three basic-science and three professional programmes including medicine. Over 1000 students per year receive some form of simulation teaching in their first two undergraduate years. Final year basic-science students are also able to select ‘laboratory’ projects using simulators to explore in-depth aspects of integrated human physiology that would otherwise be impossible eg. altitude and descent to depth as similarly reported by Hyatt & Hurst (2010).</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">Despite these exciting innovations, high-fidelity simulators with a functional physiology are still under-utilised in basic-science teaching, with only few reports in the literature (Hyatt & Hurst, 2010; Gabi et al, 2013). In fact, the converse is probably true in that they are more typically utilised in teaching basic skills that do not require high-fidelity models – the ‘fidelity trap’ (Lampotang, 2008). Further, there may be a misconception as to what is actually being taught with simulation. Teaching that demonstrates changes in heart rate and blood pressure during bleeding to nursing students, although clearly valuable, is far removed from using simulated physiological data to effectively demonstrate the action of Starling’s law during haemorrhage. The latter is an example of high-fidelity teaching aimed at complex principles that students may find difficult. The potential for using simulators in this type of teaching was first shown by Euliano et al. (1997) & Euliano (2000, 2001) and further developed at Bristol (reviewed by Harris et al. 2011) and a small number of locations elsewhere (including Waite et al., 2011; )</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">The question remains as to why high-fidelity simulation still remains under-utilised in teaching basic-sciences despite this potential and the increased adoption among teaching hospitals and university departments. A number of factors may be involved. First, developing physiologically accurate scenarios can be difficult and time consuming. Scenarios should be validated against published human data (Lloyd et al., 2008; Harris et al., 2011), which itself may be scarce, and the model modified in order to improve fidelity. Second, there are few simulators with an effective, integrated physiological model that produces data required for full exploration of physiological principles, and these are expensive in terms of basic cost and servicing. Other less expensive, commonly adopted simulators may fall short in terms of integration of even the most basic cardio-respiratory responses. Third, faculty may be wary of using simulator models versus traditional teaching or non-integrated computer simulations which may produce accurate, but limited data in terms of homeostatic integration with other systems, eg. an isolated heart model. In Bristol, concerns by faculty around the fidelity of pharmacolological models of HPS vs stand-alone computer simulations for calculating dose-responses and drug interactions, have hampered wider adoption. This is despite the attraction of being able to demonstrate effects across systems. Finally the complexity of scenario creation may dissuade even the keenest developer. It is very easy to produce a simple model of say, blood loss that can be demonstrated at a superficial level. It is very hard to develop one where all relevant physiological variables closely match published human data. </span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">Matching data produced with the literature is an example of the highly accurate, validated approach taken in Bristol. To add a further level of fidelity in terms of simulating homeostatic interactions, we adopted a ‘dogma’ that our scenarios should be exclusively ‘model-driven’. In theory, this means that layers of changes and perturbations can be applied over the primary scenario. For example, in demonstrating the response to low inspired O2, rather than simply setting controllable variables to simulate the response, data were entirely based on the actual response of the simulator via its ‘lung’ and in real-time. To do this, the basis must be a reasonably accurate model with responses that can be fine-tuned by applying gains and factors to variables, rather than overrides. And certainly without simply presenting static data to students, for example when blood-gases are requested. This though, produces a further level of complexity.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">The question remains even for the teaching of basic science in some detail, is this level of model-driven fidelity required? Are even physiologists effectively using simulation caught in the ‘fidelity-trap’. Has the ‘fidelity-trap’ hampered wider utilisation of simulation in basic-science teaching? It is evidently far more practical to produce accurate data by applying overrides and ‘fixes’ to models to produce data at valid values in terms of the literature, and as importantly, what students might expect to see in a textbook. This approach is also repeatable, as data will be identical for each session – in the model-driven HPS equipped with a lung, respiratory data in particular vary from run to run and drift over time. Further, setting variables to fixed values avoids having to work within a complex model with feedback loops where changing one parameter will have knock-on consequences on another. In other words inconvenient homeostatic algorithms can be circumvented . Finally, we could ask why use a simulator at all? This question is beyond the scope of the current discussion!</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">The future for high-fidelity simulation in basic-science education may be in finding a middle-way. Some lower-cost simulators without the ability of the HPS to effectively exchange gases or operate with a ventilator utilise similar physiological models (it should be noted that not all do, eg. presentation of blood gas data, so careful choice of mid-range platform is required) . In fact, a mixed-approach to producing teaching scenarios with some data produced by model-driven aspects of the scenario, and others determined by over-rides, can produce data where a dogmatic, purely model-driven approach fails. An example is demonstration of the classic alveolar gas equation derived by Fenn, Otis and Rahn that shows the relationship between O2 and CO2 (learning opportunities described by Curran-Everett, 2006). An accurate demonstration of this equation is not possible using a CAE HPS with a lung. However, using the HPS software-model alone, or with a manikin that does not have a lung, extremely accurate results can be obtained compared to published human data (Helyer & Lloyd, 2009). </span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">Unfortunately, a final area of consideration remains for even the keenest adopter that remains a prevailing question- does using simulation improve learning outcomes? Here there is no clear evidence in the basic-sciences. There is little doubt that simulation in the broadest sense is an effective tool in improving learning and outcomes in medical education (McGaghie et al., 2011). This is probably most apparent in disciplines assessed via achievement of skills and day-one competencies. In other areas, the relatively scarce evidence centres around improving confidence of students or in preferential learning methods (eg. Harris et al, 2011) rather than in measurable improvements in examination results. This is not limited to simulation as assessing impact on learning in terms of measurable outcomes is notoriously difficult. We may take some solice by consider whether this is really an issue in a climate where student satisfaction and learning-method preference seems to be becoming a prevailing driver.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">We conclude that high-fidelity simulation in basic science education remains an under-developed resource with considerable potential. By careful matching of hardware and software to teaching and learning objectives, it remains a potentially highly-effective tool.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">References</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">McGaghie, WC, Issenberg, SB Cohen, ER, Barsuk, JH & Wayne, DB (2011). Does Simulation-based Medical Education with Deliberate Practice Yield Better Results than Traditional Clinical Education? A Meta-Analytic Comparative Review of the Evidence. Acad Med. 86: 706–711.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">Helyer, R & Lloyd, E (2009). The response to hypoxia: a refined Human Patient Simulator (HPS) model to demonstrate high altitude physiology. Proc Physiol Soc 15</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">Lloyd, E, Helyer, R, Dickens, P & Harris, JR (2008). Use of a high fidelity Human Patient Simulator to demonstrate the control of ventilation</span><br />
<span style="font-family: "arial" , "helvetica" , sans-serif;">Proc Physiol Soc 11</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">Curran-Everett, D (2006). A classic learning opportunity from Fenn, Rahn, and Otis (1946): the alveolar gas equation. Adv Physiol Educ. 30: 58-62.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">Harris, J, Helyer, R & Lloyd, E (2011). Using high-fidelity human patient simulators to</span><br />
<span style="font-family: "arial" , "helvetica" , sans-serif;">teach physiology. Med Educ. 45: 1131–1162.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">Hyatt, JP & Hurst, SA. (2010). Novel undergraduate physiology laboratory using a human patient simulator. Med Educ. 44:523</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">Zvara, DA, Olympio, MA & MacGregor, DA (2001). Teaching cardiovascular physiology using patient simulation. Acad Med. 76:534.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">Waite, GN, Hughes EF, Geig, RW & Duong, T (2013). Human patient simulation to teach medical physiology concepts: A model evolved during eight years.</span><br />
<span style="font-family: "arial" , "helvetica" , sans-serif;">J. Teaching & Learning with Tech 2: 79-89.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">Euliano, TY (2000). Teaching respiratory physiology: clinical correlation with a human patient simulator. J Clin Monit Comput. 16:465-70.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">Euliano, TY, Caton, D, van Meurs, W & Good, ML (1997) Modeling obstetric cardiovascular physiology on a full-scale patient simulator. J Clin Monit. 13(5):293-7. </span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">Euliano, TY (2000). Small group teaching: clinical correlation with a human patient simulator. Adv Physiol Educ. (2001) 25:36-43.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">Lampotang (2008) in Manual of Simulation in Healthcare ed. Riley, R. Oxford University Press.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">Correspondence</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">Richard Helyer, PhD. School of Physiology, Pharmacology & Neuroscience, University of Bristol, Bristol BS8 1TD, UK;</span><br />
<span style="font-family: "arial" , "helvetica" , sans-serif;">E-mail: richard.helyer@bris.ac.uk</span><br />
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Pete Dickenshttp://www.blogger.com/profile/12970193129355208476noreply@blogger.com0tag:blogger.com,1999:blog-9180978986426437884.post-41377555660688361022016-04-01T01:02:00.000-07:002016-04-01T01:02:15.953-07:00What is Simulation? <span style="font-family: "helvetica" , "arial" , sans-serif; line-height: 22.4px;"><b>What is Simulation?</b></span><br />
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<span style="font-family: "helvetica" , "arial" , sans-serif; line-height: 22.4px;">That's a mighty mighty big question, too big for a blog post, or a website, or even a shelf of books to answer concisely. Best if we are a bit more specific to begin with.</span><br />
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<span style="font-family: "helvetica" , "arial" , sans-serif; line-height: 22.4px;">What is Medical Simulation? is possibly a more realistic subject to cover in a blog post. Possibly? I doubt it, but lets keep it simple and we will be okay. Relax, you are amongst friends.</span><br />
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<span style="font-family: "helvetica" , "arial" , sans-serif; line-height: 22.4px;">But even so, there are groups of renowned and learned experts in the field who devote much of their time to defining simulation, what it is, and what it absolutely is not, and the setting the boundaries for the sub categories of simulation, and refining their definitions, and naming and renaming the categories...</span><br />
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<span style="font-family: "helvetica" , "arial" , sans-serif; line-height: 22.4px;">Let's just leave them to it, shall we?</span><br />
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<span style="font-family: "helvetica" , "arial" , sans-serif; line-height: 22.4px;">Here goes...</span><br />
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<span style="font-family: "helvetica" , "arial" , sans-serif; line-height: 22.4px;">Any simulation can be argued to be a model of a situation, whether it is a computer model of the stretching of polymers, or an improvised role play between a group of people, or a life threatening CPR situation, or a model of the economy of a housing association etc etc etc</span><br />
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<span style="font-family: "helvetica" , "arial" , sans-serif; line-height: 22.4px;">As the situation becomes more and more complex, so does the model, and the most important component in a model of a real life situation is not what is contained, but what is left out. What is real or real life identical, and what needs to be simulated?</span><br />
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<span style="font-family: "helvetica" , "arial" , sans-serif; line-height: 22.4px;">Lets take an example from Medical Simulation to explain my ramblings</span><br />
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<span style="font-family: "helvetica" , "arial" , sans-serif; line-height: 22.4px;">At my place of work, we recreate acute emergency medical situations, with effective communication being the learning goal, so what do we need for that practically speaking?</span><br />
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<span style="font-family: "helvetica" , "arial" , sans-serif; line-height: 22.4px;">Hospital ward environment? Yes (we are based in a hospital), so no need to simulate that</span><br />
<span style="font-family: "helvetica" , "arial" , sans-serif; line-height: 22.4px;">Up to date, functional medical equipment? Yes (Insert own joke about state funded hospital here)</span><br />
<span style="font-family: "helvetica" , "arial" , sans-serif; line-height: 22.4px;">An interprofessional group featuring all the work categories? Absolutely yes</span><br />
<span style="font-family: "helvetica" , "arial" , sans-serif; line-height: 22.4px;">A handsome, knowledgeable simulator technician? Not a necessity, but it does help...</span><br />
<span style="font-family: "helvetica" , "arial" , sans-serif; line-height: 22.4px;">Real, relevant case studies? Yes</span><br />
<span style="font-family: "helvetica" , "arial" , sans-serif; line-height: 22.4px;">An endless supply of willing patients just waiting for us to use their illnesses and diseases for teaching purposes?....Well. No. Obviously not.</span><br />
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<span style="font-family: "helvetica" , "arial" , sans-serif; line-height: 22.4px;">So that is the bit we simulate, often using a computer driven manikin for the participants to react to in real time, with a debriefing session afterwards.</span><br />
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<span style="font-family: "helvetica" , "arial" , sans-serif; line-height: 22.4px;">So we are building a model of an emergency medical situation using a mixture of components that are either real, actual and identical to those used and/or using components that are simulated.</span><br />
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<span style="font-family: "helvetica" , "arial" , sans-serif; line-height: 22.4px;">In this case, it is the patient that is simulated, and allowances are made for the fact that they don't move much, and they talk through a speaker, and they find it hard to display physical side effects and symptoms. However, the session is manned by staff skilled in facilitating teaching using simulated patient manikins.</span><br />
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<span style="font-family: "helvetica" , "arial" , sans-serif; line-height: 22.4px;">It is VITALLY important that the simulated part of our model is not the weakest link in the chain.</span><br />
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<span style="font-family: "helvetica" , "arial" , sans-serif; line-height: 22.4px;">Another example would be disaster/evacuation/zombie apocalypse simulation. Real buildings/environment. Real staff. Real emergency procedures to follow. Real cops/fire brigade. The zombies/poison gas/godzilla attack? Thankfully simulated. But real enough for people to feel stressed, and to react professionally.</span><br />
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<span style="font-family: "helvetica" , "arial" , sans-serif; line-height: 22.4px;">And the point of simulation? Because it is certainly NOT a silver bullet when it comes to teaching Well, there goes another bookshelf of books but simply speaking it is this. We can recreate disease conditions, stress conditions, human feelings, triggers for alarms etc etc in such a way that the results speak to the idea that</span><br />
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<span style="font-family: "helvetica" , "arial" , sans-serif; line-height: 22.4px;">Simulation is MORE THAN THE SUM OF ITS PARTS</span><br />
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<span style="font-family: "helvetica" , "arial" , sans-serif; line-height: 22.4px;">And let us leave it at that for now.</span><br />
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<span style="font-family: "helvetica" , "arial" , sans-serif; line-height: 22.4px;">PETE</span>Pete Dickenshttp://www.blogger.com/profile/12970193129355208476noreply@blogger.com0tag:blogger.com,1999:blog-9180978986426437884.post-63924591990965626232015-10-14T13:19:00.000-07:002015-10-14T13:19:16.949-07:00Welcome to The Simulated Man - Introductions<div style="text-align: left;">
<span style="font-family: 'Helvetica Neue', Arial, Helvetica, sans-serif; font-size: x-large;">Welcome to </span><b style="font-family: 'Helvetica Neue', Arial, Helvetica, sans-serif; font-size: xx-large;">The Simulated Man</b><span style="font-family: 'Helvetica Neue', Arial, Helvetica, sans-serif; font-size: x-large;">, a blog about Medical Simulation. </span></div>
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjUwd8M8KpFYN9ETyWqomVUJdN8lYgKHM5gY7sNH4ENjK5A6eYLMw6hsszVe9iZEjFqRHNNO6RO5lt4FQmR9fuUBSkFnvjv0go97X7zBwZjhuwv-kg6qoVdvMKc1wKXR7ob7l6rEb66LVeG/s1600/B10shrlIMAABpbp.jpg" imageanchor="1" style="clear: right; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" height="400" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjUwd8M8KpFYN9ETyWqomVUJdN8lYgKHM5gY7sNH4ENjK5A6eYLMw6hsszVe9iZEjFqRHNNO6RO5lt4FQmR9fuUBSkFnvjv0go97X7zBwZjhuwv-kg6qoVdvMKc1wKXR7ob7l6rEb66LVeG/s400/B10shrlIMAABpbp.jpg" width="300" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">That's me on the left</td></tr>
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<span style="font-family: 'Helvetica Neue', Arial, Helvetica, sans-serif;">In publishing </span><b style="font-family: 'Helvetica Neue', Arial, Helvetica, sans-serif;">The Simulated Man</b><span style="font-family: 'Helvetica Neue', Arial, Helvetica, sans-serif;"> I am hoping to develop a network of like-minded simulation specialists and enthusiasts, provoke debate, explore ideas and raise awareness of what is still quite a specialised educational tool.</span><br />
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<span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;">I'm <a href="mailto:akademiskaktctech@gmail.com">Pete Dickens</a>, that's me in the photo, just putting the finishing touches to a medical simulation in one of the operating theatres at Enköping hospital.</span><br />
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<span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;">I've had a long and interesting journey to get here, both geographically and personally, but more on that in another post.</span><br />
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<span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;">Behind me on the operating table lies Simon Karlsson, our patient. Sometimes Simon becomes Simona and sometimes the more gender neutral Kim. </span><br />
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<span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;">Does it and should it make a difference that our simulated patient has a name? A gender? If so,why? and is it significant? More on that another time...</span><br />
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<span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;">Simon is inhabiting a Laerdal 3G patient simulator, because that's the one we chose to get the best out of the patient case we were running (and more on <i>simulator choice </i>in another post, so stick around!)</span><br />
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<span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;">Okay, introductions over, there's already a lot to discuss.</span><br />
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<span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;">Ambitiously, for our next post, I'm going to be putting an answer to the question...</span><br />
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<span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif; font-size: x-large;">What is simulation?</span></h3>
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<span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;">See you next time, </span></div>
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<span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;">PETE</span></div>
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<span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif; font-size: x-large;"><br /></span>Pete Dickenshttp://www.blogger.com/profile/12970193129355208476noreply@blogger.com0