Fidelity – can you have too much of a good thing?

Finally Dr Sam Bendall returns with another post on things educational. This time around it’s about how to focus on fidelity. You can read Sam’s earlier post right about here

The human mind is a complex machine. I am constantly amazed at its ability to “fill in the gaps” or create a reality. Like …. I was SURE I saw my keys on the bench this morning.

This is not a post about drug-altered states. (By Rob Gonsalves.)
This is not a post about drug-altered states. (By Rob Gonsalves.)

Fortunately for those of us who love simulation as a teaching tool, this amazing ability can be exploited to create realism in our scenarios.

So this then begs the question, if the most powerful simulator in the world is on top of your neck, capable of filling in many environmental deficits, how much external fidelity do we really need? I love Dr. Cliff Reid’s line: “Run resuscitation scenarios in the highest fidelity simulator in the known universe.. your human brain.” (you can check out the related talk here). So how do you get other people’s brains working for you in your simulation?

Searching High and Low

In doing a little research for this post, I was curious to see what others felt constituted high fidelity vs low fidelity simulation. In many sources it was simply to do with how technologically fabulous the manikin was. No mention of recreating key environmental stimuli. No mention of inserting the human factors elements that play out repeatedly in any microcosm. No mention of recreating other sensory or physical cues that affect the way we behave in any given situation and affect our decision making.

The über end of the spectrum is virtual reality – full recreation of the all the visual stimuli you would ever encounter in any situation, sometimes involving goggles. Maybe something like this Virtual reality “cave” simulator.

Now some folks may thing that is amazing, and in my humble opinion the graphics are amazing. But how often do you treat patients with goggles on and by waving a wand thing at a wall? If you do…. well there is olanzapine for that. Last time I looked we also don’t work in a three-sided 3m x 3m box.

Actually these are just this guy's sunglasses. [via]
Actually these are just this guy’s sunglasses. [via]
The Experiences Where You Gain Experience

So lets take a step back. Think about your most memorable experiences – positive or negative. What are the details of those experiences that caused them to be so strongly imprinted in your mind? Was it the smell? The fact that you were freezing cold? Was it to do with touch? Chances are, it was not just the view in front of you.

Now think back on the medical cases you remember. What is now stuck in your mind about them? Was it the sound of the pulse oximeter descending into the basement where hypoxia hides? Was it the conflict going on in the resus bay? Was it the difficulty you had getting a piece of equipment to work?

I put it to you that THIS is the stuff we remember. If we are using simulation as a teaching tool, we want our participants to remember what they learnt so that they can apply it when it counts. So we have to make it memorable. Perhaps we need to rethink exactly what fidelity means in simulation…

I am fortunate to work with someone I consider to be a master of simulation, Dr Ken Harrison. By making the smallest tweaks, he can add a whole new aspect to the scenario and increase the fidelity for the participants that little bit more. Usually the cost involved in making the scenarios highly memorable is about $0.

I did his scenarios many years ago as a participant in the CareFlight Pre-Hospital Trauma Course, the first of which ran as a trial in 2001 (not with me attending) after years before that of employing simulation in education.

I can still remember being cold. I can still remember making a cluster of our environment. I have never forgotten the lessons I learned from those as the necessary fidelity was there, even though the manikin was a Resusci Annie simulator, the monitor was a billion year old defibrillator and the Thomas packs we were using were generic. No lights, no camera, no creepy goggles. Just the cold of the ground reminding me to wear warm stuff on jobs, the difficulty in getting unfamiliar equipment to work (know your equipment) and the difficulty in getting to the head of the patient because of the tree we had centred quite nicely in our workspace.

These are lessons I have not forgotten and things I will not repeat. All this by simply setting up a scenario on the side of a moderate embankment that our minds turned into  a 100 ft cliff, on a chilly July day. Job done I reckon!

The Bits You Need to Stick

So in considering where to invest your money, time and energy in creating fidelity in your simulation ask yourself this:

What is it about this scenario that I want my trainees to remember vividly in six months time when they will really need it?

For example I want my trainees first and foremost to stay safe on the job. There are a variety of hazards in the pre-hospital environment, some of which will kill you. Like this one.

This is not a recommended way to remember where your car is. [via Springfield New Sun]
This is not a recommended way to remember where your car is. [via Springfield New Sun]
Do I need to connect the car simulator to a 12V battery to teach them to look out for power lines? No. I can bring that same learning point out with a much more subtle long fat piece of electrical wire across the simulation field (car/ building site etc.).

This means if they notice it – great! The didactic part around scene safety worked. If they didn’t, one of our confederates will draw attention to it and ask for it to be isolated. The realisation that they have all potentially been electrocuted because they didn’t look is pretty powerful. Fidelity for $9 from Bunnings. Awesome!

Similarly if they are working outside in the elements, train outside. There is no point doing a scenario in an air-conditioned classroom if you work in an aircraft that is usually around 40 degrees Celsius. Once you get used to working with sweat dripping in your eyes yours, your patient’s and your teammates temperature you are able to concentrate on the task at hand.

Alarms are another easy one. We are so accustomed to hearing that pulse oximeter beep. Most critical care practitioners have an operant response when that tone starts to decrease or the rate goes up. It makes us look around. It can also be really distracting if the volume is turned up too high and the general anxiety level goes up. Easy way to create a bit of stress in the environment.

Then of course there’s broken things. Not everything goes well on every retrieval job. Equipment malfunctions, patients crash, the aircraft become unserviceable. We need to train our training audience to think laterally and deal with these problems quickly when they come up.

Most retrieval equipment sets have redundancy. Bringing this in is a different example of  fidelity. Give them a scenario and make some key equipment stop working or not work at all and watch their response. If they have a methodical approach to using the “other” equipment then they are more mission ready.

Weapon of Choice

So in essence, choose your weapons wisely. I LOVE cool toys more than most. Give me gadgets any day. BUT if you want me to remember what you taught me 6 or 12 months later or even 7 years later in the aforementioned example, make it real. Make me own it, smell it, feel it, touch it, troubleshoot it, be anxious in it, be hot/cold in it and THAT I will remember. And building that type of fidelity into your simulation usually takes neurons but not too many dollars.



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