Air medical. simulation training. Achieving optimum results. Femke van Iperen asks how air medical crews can make the most of simulation training
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2 Air medical ADAC simulation training Achieving optimum results Femke van Iperen asks how air medical crews can make the most of simulation training Medical simulation training can involve an actor with fake wounds (moulage) or high-tech patient simulators; patients can be treated in a replica or actual aircraft interior, or at a mock crash scene such as an overturned or crushed car. For debriefing, course leaders may film the medical crew s actions. Without putting a patient at risk, both inexperienced and experienced medical teams can train complex, rarely occurring and dangerous procedures with simulated patients in lifelike environments. Types of training Fixed-wing and helicopter air medical operators around the world utilise medical simulation training for its many benefits. Germany s DRF Luftrettung, for example, has been offering its medical-emergency teams the opportunity to train emergency missions by use of high-tech mobile patient simulations since Most of the operator s medical simulation training takes place at different HEMS bases in realistic working conditions such as inside actual aircraft, as well as in ground ambulances and in domestic environments, making use of adult and infant models. The training incorporates error management, human factor research, safety aspects in medicine, and the principles of crew resource management (CRM). During training at a facility in Tornado, Mexico, crews from USMX Air Link exercise yearly in a pool, aircraft and on land, with actors as patients who are assigned a variety of complications. USMX Air Link teams also practice medical simulation as part of the operator s standard continuous education courses, for which both actors and mannequins are used. We make active use of simulation training, mostly with human-patient ADAC ADAC Sponsor s message Simulation training is common nowadays in the medical world. In the ADAC HEMS Academy, physicians, rescue assistants and pilots train together under one roof. While pilots make use of the full-flight simulators, the medical crew works with one of the two full-scale EC135 or BK117 mock-ups, called Christoph Sim, a shock room and several manikins. Modern lecture rooms offer the perfect infrastructure for realistic training. In complex scenarios, which reach from the initial treatment of a patient, simulated helicopter transport to the delivery at the hospital. Challenges at the interfaces can be identified and trained specifically. Experienced coaches support the participants to grow together as a team and act as such. The training sessions will normally be performed in German language; for foreign-language groups, the training will be supported by simultaneous translation into the native language. 38 WAYPOINT AIRMED & RESCUE
3 USMX simulators, simulated clinical or emergency environments, or virtual procedure stations, which we use to train invasive processes such as endotracheal intubation or cardiac arrhythmia, said Dr Blanca Garcia, USMX Air Link s director of medical operations. Over in the UK, Exeter-based Capital Air Charter provides a wide assortment of clinical and aviation scenarios to test the mettle of new flight nurses and doctors, said the operator s medical director Dr Terry Martin. He explained that an ex-service, fully equipped aircraft functions as a clinical-scenario simulator, with modern adult male and female, child and baby patient mannequins. CEGA s simulation training, meanwhile, encompasses both air ambulance and scheduled flight missions. Stuart Cox, senior flight nurse and trainer for CEGA Air Ambulance, said: [Training] takes place within the operator s plane in the hangar and in bespoke training rooms, with a high-fidelity, computerised mannequin controlled via remote control. CEGA uses this training during staff inductions and every quarter as a mandatory process, and it s also available to external clients. Optimum training package There are key elements that make up a medical simulation training package and each part can contribute to an optimum result. Simulation training is only an effective tool if the right components are used, said Cox. The optimum mix is the combination of a realistic environment (the plane) and a likely scenario. This should include the actual staff (doctors, nurses, and pilots), all the medical and aviation equipment that they would use and, importantly, the post-training debrief and further learning session. For example, the trainees form an important training element and air medical providers can choose to include other staff and agencies to join Ventilator (in roof rail system) USMX Vacuum pump Syringe pumps the air medical crew they normally work with. This can help create a more realistic experience and improve the effectiveness of the group as a whole. It is important that the complete team trains together to enable appropriate crew resource management, clear communication in both pressured and non-pressured situations and a just culture of fairness, said Cox, explaining that at CEGA, trainees are a collection of intensive care doctors and nurses, pilots and ground crew (operations). Being able to work in realistic mixed teams is key for Martin, and at Capital Air Ambulance, pilots, operations staff, and ground ambulance teams train alongside the core flight medical crew, each representing their own role. We call this logistic simulation, and trainees who are not actively taking part in the scenario are able to observe and critique each other in a constructive way, he said. Exercising this way allows trainees to develop their non-technical human-factor skills, explained Martin, adding: Humanfactor skills are generic and can be applied to most team situations. They include situational awareness, communication, decision making, leadership, the origins and evolution of errors and mishaps, the ability to self-reflect ( learning through debrief ), and conflict resolution. DRF Luftrettung also uses a form of mixed training. In the last 10 years, we have trained about 1,200 emergency physicians and paramedics who are on duty at our HEMS bases, and around 800 external medical crews, said Dr Jörg Braun, DRF Luftrettung s medical director. Since these teams have to work together closely in daily work, joint training is very useful. At the Tornado training facility, USMX Air Link staff are joined by personnel from other aviation companies, as well as universities. This way we also learn how to react when we are outside of a zone where we know everyone, said Garcia, adding that during the operator s in-house training, other flight personnel join medical crew members. It is very important that pilots and doctors on an air ambulance mission are a team, and understand each other s profession. Teamwork training can help enhance performance and possibly reduce errors in real life, she said. >> WAYPOINT AIRMED & RESCUE 39
4 Training environment Our scenarios are based either on real-life situations with which the crews have been involved, or on best practice or equipment changes, said Cox, highlighting that a realistic working environment (for example with appropriate levels of light and noise) is also considered conducive to the training. At DRF Luftrettung, positive feedback has left no doubt that a high level of realism has been contributing to its training success. Due to the realistic environment, the participants immerse themselves in the scenario and feel as if they have treated a real patient, said Braun. The patient Operators have a number of choices when it comes to what type of patient simulator to use. Today s computerised high-tech patient simulator dummies, for example, can emulate a range of bodily functions. This ensures that cases can be based on real patient experiences, and symptoms and responses can be modified as the training scenario evolves. The adult and infant models that DRF Luftrettung utilises act like real patients, said Braun. They can articulate, such as groan and cry, and instructors can direct clinical symptoms such as heart rhythm disorders. In addition, it is possible to apply all kinds of drainage or apply artificial ventilation. DRF Luftrettung finds further value in matching the simulated medical conditions to what crews come across in their daily work. If a helicopter crew mainly conducts intensive care transports, the focus of the training could be the handover of a patient to an intensive care team at the hospital, said Braun. He added that his organisation has a high number of paediatric call-outs, so scenarios with an infant patient simulator are often included. Cox said that the remote control, computer-driven patient simulator and wireless patient monitor used by CEGA allows the training instructor to operate the simulator from outside the cabin. He explained: You can change the physiological parameters on the simulated mannequin, and carry out more advanced tasks such as collapsing a patient s lung or speaking on behalf of the mannequin. Any simulated relatives that are used are scripted to ensure correct depiction of the scenario. However, the use of airway mannequins, an actor, or trainee playing a role can contribute to an equally successful outcome. This totally depends on the objective of the training, said Garcia. For example, I find mannequins good tools when we need to practise invasive processes, management of airways, or CPR, but a mannequin doesn t have emotions. The patient can scream (at you), be angry, or aggressive due their painful or stressful situations. This reminding us that medical emergencies are complex and that medical teams need to learn to manage a range of human factors as well as clinical or scientific data. Often, those playing the role of patients are medical experts so they can respond appropriately to the trainees actions. However, said Garcia, that depends again on the training objective: Sometimes a non-medical actor is better, so that the reaction can be pure, without knowing what is going to happen. Many situations can be taught with low-fidelity simulation apparatus, commented Martin. A well-informed actor can add a whole new dimension to a scenario that simply can t be achieved with training mannequins, however high tech they may be. Using a variety of simulation methods, he added, allows diversification of learning for individuals who absorb knowledge and skills in different ways. The educator The trainer provides another important element of the simulation training package. Crew members can be trained to operate a system, but all activity should be led by a facilitator to ensure that the benefits of the training scenario are maximised, said Cox, explaining that an educator should run each scenario efficiently and provide briefing and debriefing to make best use of crew knowledge. In addition, an educator must bring all the learning points together to ensure that clinical and aviation practices move forward, he said. Instructors with a thorough understanding of both medicine and the medical teams can train complex, rarely-occurring and dangerous procedures DRF LUFTRETTUNG 40 WAYPOINT AIRMED & RESCUE
5 simulation training is only an effective tool if the right components are used simulation process help to deliver the best results, and at CEGA, the trainer and facilitators are senior air ambulance professionals experienced doctors, nurses and fleet managers. At DRF Luftrettung, experienced emergency physicians and CRM instructors, qualified at the European Resuscitation Council, American Heart Association, Advanced Trauma Life Support and Pre-Hospital Life Support, make up its group of tutors. For Martin, a good instructor is skilled across the board in both the technical aspects and in human factors, which are so often ignored in hospital-based simulation scenarios. An instructor should have a clear understanding of the complexities of flight environments and aircraft operations, he added. The feedback To be able to use video recordings for debriefing allows trainees and the trainer to get a close-up view of the actions, and allows trainees to learn from their performance and potential slip-ups. This is often seen as an essential component of the training. CEGA trainees benefit from audio streams and live video cameras installed in the plane, together with external video links, said Cox, who noted that this enables others to view and be actively involved in the debrief. The video-based debriefings are the central element in teaching professional special care teams, said Braun, explaining that DFR Luftrettung also uses audio-video equipment during the training sessions to transmit live to a screen so that groups can learn from each other. The focuses of the training are optimal reacting and acting under stress, and the improvement of team co-ordination and communication. Cameras film the training from different perspectives, microphones register the communication and in the debriefings tips and tricks are discussed as well as possible pitfalls. Even better Medical simulation training is constantly evolving, and most operators would agree that it has not yet been perfected. The one area which needs to be looked at in detail is the platforms within which the simulation takes place, said Martin. Moving platforms that mimic accelerations, turbulence and vibrations in flight are a less expensive option than using real aircraft, but, he said, perhaps the ultimate goal is to include a DRF LUFTRETTUNG ADAC simulation flight to the initial training and annual accreditation process of flight medical personnel. For Braun, further technological improvements could be made, such as having a mannequin s skin colour change to represent various medical conditions. In order to train on specific real-life situations that have gone wrong in the past, scenarios from critical incident reporting systems have been partly incorporated into DRF Luftrettung s training an approach that could be extended in the future, said Braun. Whilst Cox sees value in ongoing improvements to mannequins to make them ever more realistic, CEGA is set to take air medical simulation training further: [We are] investigating opportunities for a bespoke training facility within a mock-up plane, negating the need to ground an operational aircraft. Ideally, this environment would offer realistic sound, light and motion at a European base, for the utilisation of all crews. For Garcia, the future of air-medical simulation training relies on the flexibility to fit each learning objective: The combination of all kinds of simulation training works best for us. They all have their specific advantages. Sometimes, we use different tools and simulate [multiple] situations at the same time to create chaos: That is how it can be in real life. WAYPOINT AIRMED & RESCUE 41
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