Friday, 27 February 2015

A view from the ivory tower (by M Moneypenny)


On the 21st of February 2015 there was a brief Twitter exchange between Mark Forrest (@Obidoc) and others regarding the benefits of in situ "applied" simulation versus simulation centres. Although the 140 character limit on Twitter ensures thoughts are distilled, at times this can be difficult to lay out an argument. (The benefits and drawbacks listed below are by no means exhaustive.)

The benefits of in situ

The positives of in situ are manifold. By definition, the participants are in the actual environment (in the resus department, on the ward, at the roadside, under a train) which increases environmental fidelity. They are using their own equipment, guided by their own protocols. One can carry out systems testing and, if the simulation is realistic enough, performance approaches actual performance in real life.

The drawbacks of in situ

If the exercise is taking place in the actual environment there is disruption to the rest of the workplace. This can be minimised by good preparation and planning. Because of this disruption, the number of in-hospital in situ exercises is limited.

For those who extol the realism of in situ, running a simulation in a field or country lane is very different from running a simulation on a busy (and aren't they all nowadays?) hospital ward. The pre-hospital in situ equivalent would be running a simulation alongside a major motorway with a lane closed off.

When is in situ not in situ?

The Uaill Scottish Fire & Rescue Service Training Centre in Glasgow, has its own section of motorway and train track. The fire service runs multi-agency mass casualty simulations here. But the centre, and others like it across the UK, cost millions to build. Is this in situ sim?

Our home, but darn it! Why does it have to be a white tower?

The benefits of sim centres

The sim centre's sole function is as a place where simulation exercises take place. Sim centre personnel are dedicated to certain roles e.g. administrative, technical. Because the sim centre's focus is simulation the faculty are often involved in research and the development of other simulation-based medical educators.

The sim centre can be modified to replicate a "generic" ICU, ward, theatre or resus. The sim centre can accommodate hundreds of undergraduates and other trainees every year which would not be possible on a hospital ward.

The drawbacks of sim centres

Building a sim centre is expensive, although if it is built as part of a new hospital this lessens the expense. If a sim centre solely uses mannequins it is limited by what it can replicate and the "generic" ward or ICU means that it is not actually any ward or ICU. Sim centres may become silos if they don't make and sustain links with other stakeholders such as patient representatives, pre-hospital organisations and higher education institutions.

Final thoughts

A straw man(ikin)
The ivory-towered sim temple which sucks up millions of pounds and doesn't do "real simulation, which takes planning and hard work" is a straw man, which no-one would support. The reality is very different, no-one is throwing millions of pounds at us, with every penny justified and accounted for. Sim centres carry out exercises in the centre and in situ, the SCSCHF has been in the back of ambulances, in hospital wards, in ICU and paediatric resus. We haven't (yet) been out in a field or at the side of the road, primarily because we feel that colleagues (in the fire service, ambulance service, BASICS) already occupy this niche and do a fantastic job. We use the appropriate technique based on the learning objectives of the learners, this may be high technical fidelity mannequins, part-task trainers, iPad-based sim "monitors" or a cardboard box with a 2-litre reservoir bag inside. 

In conclusion, rather than adopting an "us versus them" attitude, the poor in situ practitioners in the trenches throwing mud at the rich, work-shy inhabitants of the ivory towered temples of simulation, I would suggest an approach which involves communication and cooperation.