As I was looking into opportunities for continuing medical education, a coworker informed me of an opportunity to collaborate with faculty at New York-Presbyterian Hospital's emergency medicine residency program. Dr. Fareed Nabiel Fareed, assistant professor of emergency medicine at the hospital, had asked if our department would be interested in participating in a new initiative to improve the teaching of trauma management to residents--specifically, to make it more hands-on by using volunteers to play trauma patients and moulage to simulate injuries.
This new initiative reflects how simulation--initially adopted by healthcare from the airline industry--is becoming an increasingly important part of medical education. Rather than teaching about trauma in a lecture format, the idea is to emphasize the procedural aspects of directing a trauma resuscitation and the teamwork approach necessary to be successful. Paramedics, an integral part of that team, are invited to participate in these mock traumas because, just like in real trauma resuscitations, the interface and handoff between the paramedics bringing a critical trauma patient into the ED and the ED physicians receiving the patient is critical to excellent trauma care.
These mock traumas allow our paramedics to earn CME credit from discussions held both before and after each scenario. In delineating our goals for these sessions, we saw the chance to take part in the debriefing and critique of the EM residents' abilities to perform skills that, as paramedics, we do every day in much less controlled environments--things like spinal immobilization, basic airway management, achieving rapid hemostasis and splinting fracture deformities. Learning how to obtain critical historical and prehospital data from EMS in the often-chaotic environment of a major trauma resuscitation is also emphasized. While the ED physicians learn more about the prehospital aspects of trauma care, EMS providers benefit by gaining insight into the continued care of their patients, from initial ED management and diagnostic testing to disposition and outcome. This insight helps paramedics focus on what prehospital information is most critical to relay to ED personnel.
The majority of trauma cases simulated are actual cases that have presented to the New York-Presbyterian Hospital ED. Residents are given feedback on how their management compares to the actual management in the case, and are told what the outcome of the patient was (e.g., required a massive transfusion, went to the operating room, was managed nonoperatively, expired, etc.).
One of our first mock trauma cases was a young male with abdominal evisceration secondary to a stab wound. The simulation involved a lot of makeup and preparation. To recreate the evisceration, we bought pig intestine skins from a local butcher. We then packed them with cornmeal, rice, beans and stewed tomatoes and bathed them in an emesis container with oil and blood-colored concentrate to mimic blood and clots. The patient (whom I played) was presented to the ED staff via EMS on a long board with cervical collar and a trauma dressing covering the evisceration. The ED staff were then expected to manage the patient as if it were a real scenario--that is, do the primary and secondary surveys, and address all the emergent issues (managing the airway and hypotension from intra-abdominal bleeding, detected via FAST exam; IV fluids; type and cross; blood transfusion; and surgery consultation for immediate transfer to the OR, etc.).
Other cases we have recreated in our mock trauma sessions include multiple gunshot wounds requiring emergent thoracotomy, methamphetamine lab explosion victim, impaled screwdriver to the chest with pneumothorax, severe thermal burns with smoke inhalation and cyanide toxicity, five-story fall with multiple major injuries including an unstable pelvic fracture, and a critically ill pregnant woman in the third trimester in a motor vehicle collision requiring a perimortem cesarean section.
THE SIMULATION PROCESS
To simulate cases, we prepare the volunteer beforehand by briefing him on the case, how to behave (e.g., "you are nonverbal and grimace to sternal rub") and application of the moulage, c-collar and backboard. The designated leader of the trauma resuscitation (usually a third- or fourth-year EM resident) will then get a "notification" call from EMS alerting him that they are on their way with a trauma patient. The leader then needs to pick his team members and assign them specific roles and positions around the patient. For example, one resident is at the head of the bed. Her job is to manage the airway, do an HEENT exam and get an AMPLE history. A critical component of successfully running trauma resuscitations is clearly assigning roles and responsibilities. Our scenarios teach the team leader these skills.
To facilitate and encourage the team approach to trauma management, nursing staff also participate in our sessions. In real traumas, part of the challenge for nurses can be where to actually locate certain items physicians need (e.g., where is the thoracotomy tray in the trauma room?), how to use certain equipment (e.g., set up the rapid infuser or the pleurovac), and how to coordinate efforts with the doctors (e.g., should a nurse or a physician put in the large-bore IV?). Running these sessions helps iron out these kinks.
Team members are of course instructed not to do anything invasive on the live volunteer (we would have trouble getting volunteers otherwise!). So obviously there are no IV insertions, Foley catheters or rectal exams. However, we tell the participants to otherwise go through all the motions. If they want to know the breath sounds, they need to listen to the chest with a stethoscope. If they want a FAST result or to roll the patient, they need to actually perform that procedure. When it comes to invasive procedures like chest tube insertions, they are instructed to actually get the chest tube tray and tube, open it and then describe the procedure, to make it as realistic as possible. Sometimes we will set up an ACLS manikin and IV arm on another stretcher so as the residents decide they need to do procedures, they can do them on the manikin. As the case proceeds, the team is given repeat vital signs as requested and results of tests they have ordered, like x-rays. Dangerous actions and omissions of critical treatments result in patient decompensation.
After the scenario, we have a debriefing session where we seek feedback from participants on how they think it went. Then formal teaching points about the case are discussed and reviewed, with EMS, nursing and physician involvement. Feedback from all staff fosters mutual understanding and collaboration. Specifically, demonstration and input from EMS help dispel misperceptions regarding the level of training and education of the paramedic/EMS professional on the part of ED staff. Furthermore, personal bonds are forged between EMS and ED staff. It builds bridges on both professional and personal levels.
Whenever we as EMS providers can help improve our own service and the continued service for our patients in the hospital, it benefits everyone. This program started as a simple question from the ED doctors to us: "What would you guys do if you saw this in the field?" Now it is a monthly part of EMS CME and the hospital's EM residency program. Having held these mock traumas since October 2006, we have seen great increases in the trauma skills of our ED and EMS staff members, as well as a more collaborative atmosphere. As with anything in EMS, what you don't use, you lose. These educational sessions give everyone the ability to stay sharp and up to date with their skills and knowledge. This reinforcement is especially important in a Level 2 trauma center, where there may not be as much volume as in a Level 1. Despite our Level 2 designation, critically ill polytrauma patients can and do come through our doors more often than you might expect, and we all need to be prepared.
You can build similar bridges between your EMS agency and the hospital staff you work with. Develop educational sessions with input and participation from MDs, nurses and EMS. You will get to know whom you're working with and what their limitations, abilities and perspectives are. It's a win-win situation.
When it comes to doing the makeup and moulage, keep an open mind and be creative. There are many formal moulage kits available on the market, but we have found that some imagination can lead to things that look just as good. For example, for a pneumothorax with chest crepitus, we simulated the crepitus with crumpled paper. For an actively bleeding scalp laceration, we placed red blood concentrate in a three-liter saline IV bag and taped the IV tubing to the area of the laceration. This simulated a heavy bleed very well and helped make the injury more realistic
Peter E. Tostaine III, EMT-P, is an emergency care instructor for New York-Presbyterian Hospital's EMS Division of Training in New York, NY.
Fareed Nabiel Fareed, MD, FACEP, is a physician specializing in emergency medicine. He currently serves as an assistant professor at the Columbia University College of Physicians and Surgeons. He is also a board-certified emergency medicine attending physician at New York-Presbyterian Hospital. Dr. Fareed is a member of Physicians for Peace and has served on multiple humanitarian missions in the Middle East.