Tag Archives: simulation

Reports from the Top End – The TriClinicians Cup

Recently the Aeromedical Society of Australia had their annual conference up in Darwin. This is the first of a few posts arising from people who got there – Dr Sam Bendall with a report from sim land. 

I love the way simulation brings people together. All aeromedical services use simulation as a training tool and that familiarity allows fun to be had and challenges to be set in the form of the 3rd annual ASA & FNA Simulation Cup.

The Getting Ready

It’s quite tricky putting together scenarios that will work for different team configurations and will be fun but enough of a challenge. We also had to be super careful to keep everything under wraps to keep it fair, so only 4 of us from NSW knew anything about it. I have enormous respect for my predecessor in organizing the Simulation Cup – Ben Meadley from Ambulance Victoria. He was unfortunately unable to make it this year but he was always on hand to provide guidance and advice in putting together this challenge. Thanks a million Ben! Kate Smith, the conference organiser, and her team were incredibly flexible and happy to work around the simulation craziness…. you want to what…. where ….. and with THAT??? allllrrriiight 🙂

Our logistics team was once again truly awesome – they are completely unflappable. Despite doing 3 training events in 2 weeks in different states, they not only transported several tonnes of gear to and from Darwin, but also helped in the scenarios and sorted out transporting it all back! Legends (and a double 🙂 for that).

We do a great deal of simulation at CareFlight and we are lucky enough to have some pretty cool toys, dreamed up and provided by our amazing Logistic and Events team. The newest addition to the stable is the NT crash car simulator. We have had version 1 and 2 in NSW for some time, but this one is new to the NT team so it had to have an outing.

It's cool and all but the engine could use some work.
It’s cool and all but the engine could use some work.

The Teams

Three teams competed in the heats – Cheah and his team from Malaysia (who did their scenario in English AND their native tongue), MedSTAR and CareFlight NT. The CareFlight NT and MedSTAR teams went through to the finals that were held at the end of the conference on Friday. Spectators grabbed a cold beverage and most of the delegates came down to support the two teams – a fantastic audience turnout.

Four members of the Northern Territory Emergency Service came to help out and add fidelity to the final scenarios. Gary and his team were happy to help out and be the rescue service in both scenarios. Many of the NTES folks have done the CareFlight Trauma Care Workshops so it was great to have another opportunity to train together.

Game Time

The first scenario saw the CareFlight NT team managing two patients in a Motor Vehicle crash. Their CRM was awesome and they were so calm it was amazing. They even found Chelsea, the puppy!

The second scenario saw the MedSTAR team managing a patient who was impaled on a construction site and bleeding heavily, and another injured construction worker. They too had great communication skills and did a good job of managing their patients. At the end of the day, the scores were close but the MedSTAR team was the winner on the day – NICE WORK TEAM 🙂

It takes an enormous amount of courage to get up in front of your peers and compete in a simulation challenge. It tests your CRM skills, your ability to function under pressure and your ability to treat patients as a team. Thank you to all three teams to stepped up to the plate. You are all incredible and it was a privilege to see you all in action.

Till next time …… bring on Queenstown (which btw, is my FAVOURITE place on earth!)…

QT copy

It Takes a Team

This entry could not pass without a big thanks to the following people who helped us out enormously with the Simulation Cup:

  • Kate Smith and her team – for everything!
  • Ben Meadley – for all his support and advice
  • Melinda Riall from Limbs and Things – provided the Suture Tutor prize for the Simulation Cup Final
  • Anthony Lewis – for providing an iSimulate unit for use in the scenarios
  • Stacey Williams from Zoll – for providing a defibrillator for use in the scenarios
  • NTES – Mark Fishlock, Gary and their team
  • The judges (some of whom were co-opted at very short notice – thank you J:
    • Mary Morgan – Hunter & New England Retrieval Service
    • Anthony De Wit – Ambulance Victoria
    • Paul Gallagher – NET
    • Andrew Pearce – MedSTAR
    • Emmeline Finn – CareFlight QLD
    • Andrew Duma – RFDS Sydney
    • Lachlan Beattie – NSW Ambulance
    • Lindsay Court – NSW Ambulance
  • Martin Dal Santo – CareFlight Logistics Team – he made EVERYTHING work!
  • Don Kemble – Manager Facilities and Logistics CareFlight – Enormously helpful with planning and logistics.
  • Ken Harrison – outstanding confederate performances – thank you
  • Richard Potts – AV guru from Kate’s team
  • Kellie Robertson, Danny Hickey and the AV team from the Darwin Convention Centre
  • Sarah and Ursula – fabulous coordinators from the DCC
  • Justin Treble, Elwyn Poynter and the rest of our fabulous education team – for all your help at the last minute making technology work and packing up!

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 wired.com]
Actually these are just this guy’s sunglasses. [via wired.com]
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.



Why? How? What? Big Questions for Prehospital Simulation

At CareFlight another round of training many people is about to come up so it seemed like a good chance to ask Dr Sam Bendall for her first contribution. 

Sam is an Emergency Physician who is passionate about education, particularly all things simulation. She works half-time at Royal Prince Alfred Hospital in Sydney in the Emergency Department where she helped develop and teaches the RPA Trauma Team Training program, teaches on the CIN nurses programs and helped develop the ED Essentials program. 

At CareFlight she is a retrieval doc (the other half-time) and the Deputy Director of Education. The CareFlight Education Team are always up to interesting things – from training the Australian Defence Force medical on how to look after all things ballistic, medical, surgical and paediatric, to running the Pre-Hospital Trauma Course both in Sydney and other locations (Malaysia, anyone?), to running Trauma Care Workshops all over the country. Oh, and of course all those working with CareFlight too. 

Anyway, here’s Sam …


As a passionate advocate for simulation I look around and see this amazing tool appear in many guises, all under the same blanket term. It certainly seems to mean many things to many people depending on their previous experiences. In some ways it is the SWISS ARMY KNIFE   of kinesthetic education. The coolest knife has pliers and scissors. However, just like a Swiss army knife, it can be a harmful weapon (hence the name!), just plain useless (like when you want the one with pliers but you only have the single blade), or a bit uninspiring and encourage automatic behaviours – e.g. all Swiss army knives are red and you should have one.

This clearly rubbish version doesn't even have the magnifying glass.
This clearly rubbish version doesn’t even have the magnifying glass.

Simulation has almost become the learning apparatus du jour – everyone has to do it but some are not sure why or how to really make it work. A bit like having a Swiss army knife so you can be part of the Swiss army, but it lives in the drawer.

I will put a disclaimer in at this point. The following are my own opinions – the musings of a dedicated simulation-phile after several years of training in simulation and doing simulation exercises for anywhere from 2 – 150 people.

So what’s the point?

WHW copy                                            

I’m going to put a slightly different spin on it, with an emphasis on simulation for the pre-hospital environment. Simon Sinek, in his TED talk in 2009 titled “Start with Why” made a very powerful case for asking yourself WHY you want to do something… in this case, simulation, at the outset. The HOW and the WHAT will follow if you drill down onto the why and firmly establish WHY you want your participants to do simulation.

Simulation is a journey, for both the instructors and participants. Hopefully a journey towards some constructive learning, but one that will have many interesting twists and turns along the way. Being sure of WHY you are undertaking this part of the journey, gives you the freedom to explore the twists and turns of the journey without losing sight of the original intent. So my step 1 in building a simulation, is to ask yourself why? WHY are you doing this?

In our organisation, our WHY? is to create a mission-ready workforce.

Pre-hospital medicine throws out so many variables – communication, teamwork, environmental, situational awareness, medical challenges, geographical challenges and the list goes on.

In order to make our workforce mission ready, we need them to be critical thinkers, able to choose the right skill, equipment and approach for the right case at the right time.

Though if we had one of those shapeshifting Terminator ones could we program it to be friendlier?
Though if we had one of those shapeshifting Terminator ones could we program it to be friendlier?

We also need them to be aware of the variables they will need to deal with on real jobs so that they can manage them consciously. In order to do this we need to replicate as many of these variables as possible so they can address them in a training environment. We aim to send our participants out on jobs that feel just like the scenarios they have done in training. No pressure!

HOW? – choose your weapon

Weapon copy

The simulation menu is fairly extensive and limited only by your creativity and ability to structure it in a way that is true to the learning objectives and easy to follow for your participants. The key elements of creating a scenario, whether it be for 2 or 50 participants, is that they need to know the rules, boundaries, and premises for the scenario….. hmm sounds like parenthood!

So first decide on your structure. Is it an audience that is learning a concept for the first time and you need to do it for real, but slow it down? Well “pause and discuss” is your man. Do you need to see where your participants’ critical decision making is at and where the deficits lie? Immersive, relatively high fidelity simulation, with key variables built in, is the tool of choice.

Do you need to occupy 30 participants in a large scale simulation? – Create foci so the participants will need to form their own teams within the simulation. This will bring out all of the teamwork, communication and leadership points from the start.

Whatever weapon you choose, it needs to be appropriate to the audience, their experience and what you are trying to teach by doing the simulation exercise.

WHAT …the final frontier

Well this depends on what you are trying to deliver in your simulation. If, for example, your aim is to test and consolidate a new protocol, then the scale of your simulation can be quite limited. You may not need to bring in as many variables, or much fidelity. As long as the key prompts are there for the participants and they have the knowledge, skills and equipment to fulfill the protocol, then a limited scenario is fine.

BUT…. and there is a BIG but in this one. Be realistic in developing your scenario. If you are testing an ALS protocol, doing a bog standard ALS protocol with a patient in a bed may tick your box. BUT ….. in 20 years of medicine I think I have been to less than 10 arrests in ward beds and way more than 30 in other places – the toilet, the CT scanner, theatre, the foyer of the hospital, the waiting room, the beach etc. etc. You get the picture. So I would argue here that a bog standard ALS type scripted scenario has its place, but should be followed up by the application of the protocol where it is likely to happen and bring in the teamwork and communication aspects that we know actually make ALS protocols work in real life.

At CareFlight we educate using a “crawl, walk, run” paradigm.

  • First you crawl – i.e. you learn the skill or concept in isolation.
  • Then you walk – using relatively low fidelity simulation with limited learning outcomes, you learn to apply that skill appropriately.
  • Then you RUN. In our “RUN” scenarios, we introduce many more variables that replicate the environment they will have to operate in. We increase the fidelity and prompt the participants to evaluate the situation, decide whether that skill or concept is appropriate, apply it if it is or find an alternative if it is not. This layering approach helps to consolidate skills and knowledge and develops critical decision-making processes in a way that is directly applicable to the job we do.

When you get to the RUN scenario you are trying to bring out multiple learning points across many categories, for example:

  • Teamwork and communication (CRM)
  • Leadership skills (CRM)
  • Graded assertiveness and conflict resolution (CRM)
  • Scene safety and situational awareness (CRM, environmental and logistics)
  • Management of a multitrauma patient in an isolated environment (medical)
  • Packaging and preparation for transport (logistics, medical)
  • How to carry a patient out of the bush safely (logistics, medical)
  • Planning for contingencies e.g. weather etc. (logistics)

Then the scenario has to be much higher fidelity and be crafted in a way that replicates those key learning objectives – CRM, medical, environmental and logistic. You need to recreate the key environmental elements that will impact on the participants’ decision-making, bring in the key teamwork elements, replicate the equipment or types of equipment they will use and think about the team structures they will be given. Even simple tweaks to the scenario such as limiting access to the patient’s head, can improve the problem solving and CRM elements of the scenario so the devil is very much in the detail here. AND SO IS THE FUN …

Why yes that is a mobile rollover simulator that some clever people built ...
Why yes that is a mobile rollover simulator that some clever people built …