Planning a Multi-Casualty Trauma Scenario: Uplifting the Fidelity Through Hybrid Simulation

Fatimah Lateef *

Corresponding Author: Fatimah Lateef, FRCS (A&E), MBBS, FAMS (Em Med), Senior Consultant, Dept of Emergency Medicine, Singapore General Hospital, Professor, Duke NUS Graduate Medical School, Yong Loo Lin School of Medicine, National University of Singapore and Lee Kong Chian Medical School, Nanyang Technological University, Director, SingHealth Duke NUS Institute of Medical Simulation (SIMS).

Copy Right: © 2023 Fatimah Lateef, This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Received Date: March 28, 2023

Published Date: May 01, 2023

 

Abstract

Major trauma management requires a rapid, organized and structured approach. When encountering a real major trauma patient, it can be overwhelming and daunting for a novice practitioner or a medical student. Time delays have been closely linked to higher morbidity and mortality. Simulation-based trauma training can help learners familiarize themselves and inculcate a systematic, step by step approach. This can be repeatedly practiced to reach proficiency. For the single patient scenario it is less complex but for multi-casualty and mini-mass casualty and even for large scale disaster response, the situation calls for a very organized, methodical approach with some degree of adaptability and flexibility at ground zero. Conceptualizing, planning and executing simulation-based multi-casualty trauma training is a good educational platform. In this paper, the author shares how the planning and use of hybrid simulation concepts and preparation can uplift these trauma training scenarios and enhance the elements of learning, realism and fidelity. Issues linked to the planning and execution are discussed with detailed sample scenarios for reference as well.    

Hybrid simulation refers to  the use of at least two simulation tools or modalities in combination, to enhance the scenario, increase its fidelity and improve the inter-phasing as in eal world scenarios. Multiple types of simulation modalities can also be used within the same scenario and this is most appropriate in the context of multi-casualty trauma situations.

Keywords: Hybrid simulation, trauma, multi-casualty.

Intruduction

Simulation is the replication of clinical scenarios to reflect real world situations. It is conducted in a simulation laboratory or controlled environment which allows learners to make mistakes and practice repetitively until mastery or proficiency is attained. It can also be conducted in situ, ie. in the actual clinical environment such as the intensive care unit, the emergency department or the wards. Simulation has widespread applications today, not just in teaching and training but also in assessment as well as research, across many disciplines of healthcare and medicine. It is impactful because it offers immersive, experiential and realistic replication of learning, that also enables deliberate, repetitive practice. (1-5) Simulation-based training provides learners a safe space to develop their skills, capabilities, clinical reasoning processes as well as decision making. The ability to repeatedly learn and relearn allows them to attain proficiency with a deeper understanding. With this, their ability to learn by application can also be strengthened through the use of integrated teaching by faculty in order to attain curriculum objectives. This simulation based learning impact on healthcare and medical related education is now supported by very comprehensive and robust evidence in the literature and this applies to both the acquisition of technical and non-technical skills. (2, 3, 5-10)

 

Hybrid simulation on the other hand refers to the use of at least two simulation modalities in combination, to enhance the scenario, increase its fidelity and improve interfacing as in real-world practice. Hybrid simulation can also refer to the utilization of multiple types of simulation modalities in the same scenario or setting (11-15)

 

Management of trauma is time dependent. This is the reason for stipulating time guidelines such as the platinum 10-minutes and the ‘golden hour’, post-incident. Delays have been linked to increased incidence of both mortality and morbidity. The rapid identification as well as management of trauma casualties is very crucial. (16-18) Having standardized guidelines such as the Advanced Trauma Life Support, is definitely helpful to set the stage for systematic approaches as well as rapid and robust follow up. (19) To excel and be familiar with these complex trauma management, simulation-based training has become commonly used as a mode of training. With the wide spectrum of clinical trauma scenarios which can be created with the current moulage capabilities and technologically driven models, there is greater realism, as well as a more exciting and stimulating learning climate for learners. (20-26)

The Simulation Curriculum: Trauma Scenario Creation

The following section represents the systematic steps in coming up with hybrid trauma simulation scenarios: (14, 15, 27-29)

a. Planning and Conceptualization

Planning is the first step and a fundamental determinant of how the simulation experience will turn out as well as its success. The physical, psychological and environmental fidelity, must be decided and prepared in coming up with the plans. This has to be done in a systematic and logical fashion, targeted to the level of the learners being trained.  There are infinite possibilities to the spectrum of scenarios, both single and multi-casualty, as well as larger scale, disaster response type simulation. The learning goals that are set, will dictate the simulation training design. It may focus on skills-based training (linked to medical knowledge, skills and communications) or scenario-based ( where the focus is on teamwork, prioritizing  debriefing and reflection for example). The planning of the curriculum will help decide on what resources are needed for the hybrid simulation, the time frame required for the conduct of the simulation training, the incorporation of inter-professional elements ( as most trauma cases will be managed by inter-professional teams today) and also the assessment of both technical versus non-technical skills. The training must also support the learning by clinical reasoning in these trauma scenarios. Other considerations with trauma hybrid simulation training would include: (30-33)

• The mechanism
• Place of incident, location
• Number of casualties
• What injuries to showcase, manage
• Equipment requirements
• Time factor
• Assessment points/ use of checklists

In this paper, our focus is on simulating multi-casualty trauma scenarios, as well as how to uplift the simulation with the use of hybrid simulation techniques.

b. Moulage and Special Effects

Moulage capabilities have certainly altered the face of simulation. Its brings scenarios to life and enhances realism and fidelity. It also helps support the imagination and creativity of the simulation technologist or personnel trained in this procedure. Moulage can be done on both standardized patients as well as mannikins, and be incorporated into the hybrid simulation. It can range from simple, basic moulage to more complex special effects. In trauma cases, moulage certainly has been helpful to inject realism to the narrative. For trauma scenarios, injuries such as abrasion, bruises (contusions), variety of wounds, lacerations, avulsions, amputations, punctures and different degrees of burns can be depicted. Besides these, more generic effects such as shock (cold, clammy, thread pulse), cyanosis, sweating, bleeding, vomitus etc can also be moulaged.

 

c. Staging the Scene/ Environmental Fidelity

The decision on location of the scenario and how to set the scene to depict the mechanism of the incident in trauma is important. In some institutions, props are used to re-create scenarios.  This can be left to the ingenuity of each group and faculty planning the trauma simulation. The use of hybrid simulation should be planned in an integrated fashion.

d. Standardised Patients (SP), Manikins and others

SPs are trained actors who simulate a variety of medical scenarios to enhance the level of realism of the enactment. They have to be briefed and given a manuscript to follow. They will also need to be moulaged with the respective injuries as deemed necessary. This has to be explained to the SPs beforehand so they are in agreement. Similarly, the manikins of a wide variety can be used; from the high fidelity 3G Sim-Man to lower fidelity ones which cannot re-enact certain capabilities, but are good enough to showcase certain types of injuries. Often each manikin and SP is tagged with a card or the frequently used MedTag, which summarizes their triage categories, types of injuries and important or succinct findings. (34) Training the SPs on “acting out” the scenario and also how to respond to questions is also important. Dry runs are often conducted before the actual day of the simulation. If there are scenarios which require the SPs to have wearable technology affixed to them, they have to practice and be put through dry runs to test out the performance.(35) High fidelity manikins are life-size and can simulate many functions such as breathing, pulses, heart sounds, pupillary reactions and others. This can help “connect” with the learners. The latter have to be given an orientation to these capabilities especially if they are using these high fidelity equipment for the first time. This is done during the “Pre-briefing” session. (29, 36)

 
e. Assessment of Performance

The points of assessment as well as the skills and competencies to grade will depend on the learning objective set for the hybrid simulation scenario. Matrix and checklist can be used as well. They are helpful with some degree of standardization across faculty making the observations. In trauma scenarios, some of the commonly assessed skills include:

• Initial approach
• Proper conduct of primary and secondary survey
• Ability to pick and identify all the relevant injuries, especially the serious and life-threatening ones

 

Non technical skills assessed include teamwork, communications and others (Table 1). Table 1 is an example of a team performance matrix developed locally, with some aspects of cultural nuances taken into account.

 

Faculty must come together prior to the simulation session to agree upon the marking scheme, even with the use of checklist and matrix, as being fair and  consistent with different groups of learners is important.

f. Conduct of Debrief, Evaluation and Feedback (3, 6,9, 10, 37-39)

This is carried out in a similar fashion to other types of simulation-based learning and will not be elaborated here( as it is not the main subject of this paper).

 

Multi-casualty Hybrid Trauma Simulation Plans

Some sample scenario plans with details of the hybrid simulation needs and models are depicted in Tables 2 and 3 below

For Table 2, the scenario is:

The collapse of a 6 storey building, located at the foot of a hill during heavy downpour in the monsoon season. The scene has to be set appropriately in a large and spacious hall or room. In some instances props may be added, but this is not necessary. The 11 casualties detailed in Table 2 will be prepared accordingly with the relevant instructions for SPs and moulage for the manikins, with the appropriate injuries. They may also be tagged with the relevant information using the Medtag cards. (34)

 

Limitations

Even s hybrid simulation uplifts the fidelity, there are still limitations. There may be the inability to reliably and accurately re-create the exact clinical scenario, with the chaos, distractions and some of the stressors. However adequate planning can overcome some of these barriers, to a certain extent. Also standardized patients are actors where the actual, invasive procedure cannot be performed on. High fidelity manikins are very costly to procure and something not achievable by all centres and institutions. Thus the proper planning, innovative approach and execution of hybrid simulation can be very useful in overcoming some of these limitations and challenges.

 

Conclusions

Simulation offers a conducive immersive, environment for learning and training. Whilst it can help refresh practitioners’ knowledge and skills of infrequently performed procedures and rarely encountered clinical cases, simulation based learning is very useful to train for proficiency in common, “bread and butter” type of cases. (40-43) The incorporation of Hybrid simulation elevates th scenario experience, increases the immersiveness and realism and bring the learners one step closer to the real clinical scenario or situation as they would encounter it.   Especially in trauma cases and those involving multiple casualties, the systematic steps and robust approach requires practice to inculcate familiarity, focus and the level of respect needed in approaching such clinical patients, as well as working with inter-professional colleagues. (44) It can certainly help uplift the usual traditional educational experience or classroom teaching.  Eventually, all training is conducted to help advancement of patient care. (45)

 

References

1. Sorenson JL, Navne LE, Martin HM et al. Clarifying the learning experiences of healthcare professionals with in situ and off site simulation based medical education: a qualitative study. BMJ Open 2015; 5(10): e008345

2. Battista A. An activity theory perspective on how scenario based simulations support learning: a descriptive analysis. Adv Simul 2017; 2 : 23

3. Lateef F. Simulation based training: Just Like the Real Thing. Journal of Emergencies, Trauma and Shock 2010; 3(4): 348-352

4. Pek JH, Wong E, Lateef F. Simulation training for emergency teams. Edu in Med J 2015; 7(4): e39-e44

5. Pothiawala S, Lateef F. Simulation training in Emergency Medicine: an integral component of residency curriculum. Hong Kong J Emerg Med 2012; 19(1): 41-46

6. Barleycorn D, Lee GA. How effective is trauma simulation as an educational process for healthcare providers within the trauma networks? A systematic revew. Int Emerg Nurs 2018; 40: 37-45

7. Gardner AK,Ahmed RA, George RL et al. In situ simulation to assess workplace attitudes and effectiveness in a new facility. Simul Healthc 2013; 8(6):  351-358

8. Miller D, Crandal C, Washington C et al. Improving team work and communications in trauma care through  insitu simulations. Acad Emerg Med 2012; 19(5): 608-612

9. Alsaad AA, Davuluri S, Bhide VY et al. Assessing the performance and satisfaction of medical residents utilizing standardized patients versus manikin simulated training. Adv Med Edu Pract 2017; 8: 481-486

10. Motola I, Devine L, Chung H et al. Simulation in healthcare education: A best evidence practical guide. AMEE Guide No 82. Med Teach 2013; 35(10): e1511-e1530

11. Terzioglu F, Yucel C. A new strategy in nursing education: from hybrid simulation to clinical practice. Nurs Edu Today 2016; 39: 104-108

12. Brown WJ, Tortorella RAW. Hybrid medical simulation: a systematic literature review. Smart Learning Environments 2020; 7: 16

13. Sanko J, Shekhter I, Rosen L et al. Man versus machine: the preferred modality. The Clin Teacher 2012; 9: 387-391

14. Lateef F. From data to stories: Humanising medicine in the age of technology. Edu in Med J 2014; 6(1): Doi: 10.5959/eimj.v6i1.236

15. Lateef F, Too XY. The 2019 WACEM Expert Document on hybrid simulation for transforming healthcare simulation through mixing and matching. Position Paper. Journal of Emergency, Trauma and Shock 2019; 12: 243-247

16. Abhilash KPP, Sivananda A. Early management of trauma: he golden law. Curr Med Issues 2020; 18(1): 36-38

17. Maegele M. In acute trauma care, time matters but is not everything. JAMA Surg 2019; 154(12): 1125

18. Hu W, Freudenbrg V, Gon H et al. The golden hour and field triage pattern for road trauma paients. J of safety Research 2020; 75: 57-66

19. Advance Trauma Life Support 10th Edition, Americal College of Surgeons, Committee on Trauma, Chicago, Il 2018. Available at : https://bulletin.facs.org/2018/0/atls-10th-edition-offers-new-insights-into-managing-trauma-patients/

20. Saber DA, Strout K, Caruso LS et al. An interprofessional approach to  continuing education with mass casualty simulation: planning and execution. J Contin Edu Nurs 2017; 48(10): 447-453

21. Jorm C, Roberts C, Lim R et al. A scale mass casualty simulation to develop the non technical skills  medical students require for collaborative teamwork. BMC Med Edu 2016; 16: 83

22. Lavraga-GarciaB, Quintara-Diaz M, Guiterrez A. Simulation-based education in trauma management: a scoping review. Int J Environ Res Public Health 2022; 19: 13546

23. Bentley S, Iavicolli L, Boeha L et al. a simulated mass casualty incident triage exercise. Sim Wars. MedEdPORTAL 2019; 15: 10823

24. Van Dilen CM, Tice MR, Patel AD et al. Trauma simulation training increases confidence levels in prehospital personnel performing life savinbg interventions in trauma patients. Emerg Med Int 2014; Article ID5437490. https://dx.doi.org/10.1155/2016/5437490

25. Lima DS, De-Vasconcelos IF, Queiroz EF et al. Multiple victims incident : training proposals and teaching. Rev Col Bras Cir 2019; 46(3): e20192163

26. Khajehaminian MR, Ardalan A, Keshtkar A et al. A systematic literature review of criteria and models for casualty distribution in trauma related mass casualty  incidents. Injury 2018; 49(110: 1959-1968

27. Committee IS. INACSL. Clinical simulation in Nursing 2016; 12: 39-47

28. Lateef F, Suppiah M, Chandra S, Yi TX, Darmawan W, Peckler B et al. Simulation centres and simulation based learning during the time of Covid 19: a multicenter best practice position paper by the World Academic Council in Emergency Medicine. Journal of Emergencies, Trauma and Shock 2021; 14(1): 3-13

29. Lateef F. The SP in Asia: are there unique considerations. Am J of Emerg and Crit Care med 2020; 3(1): 31-35

30. Lateef F. At the core of interprofessional collaborative practice: How Emergency Physicians are leading the way during COVID 19 and into the new norm. American Journal of Emergency Medicine and Critical Care  2021; 4(1): 14-20

31. Fatimah Lateef. IPE, IPP and team science: learning together, working together. Edu In Med J 2018; 10: 81-91

32. Armenia S, Thangamathesvaran L, Caine AD et al. The role of high fidelity team-based simulation in acute care settings. Surg J 2018; 4(30: 136-151

33. Kuhlenschmidt KM, Houshward N, Bisgaard E et al. Simulation-based skills training in trauma: a much needed confidence boost. J Am Coll Surg 2020; 231: S256

34. Smith L, Wilbur WJ, Rindflesch T et al. Medtag: a collection of medical annotations. Available at : https://www.researchgate.net/publication/234785358

35. Lebel K, Chennel V, Boulay J et al. Quantitative approach based on wearable sensors to assess and identify motion and errors in techniques during training of transfers of simulated c-spine injured patients. J Healthc Engineering 2018: 1-9

36. Lateef F. Maximising learning and creativity: understanding psychological safety in simulation-based learning. Journal of Emergencies, Trauma and Shock 2020; 13: 5-14

37. Lateef F. Clinical reasoning: the core of medical education and practice. Int J of Internal and Emerg Med 2018; 1(2): 1015

38. Lateef F. Tying in situational awareness, clinical reasoning and clinical judgment through case based discussions in Emergency Medicine. Curr Research in Emerg Med 2022; 2(2): 1024

39. Rossler  KL, Kimble LP. Capturing readiness to learn and collaboration as explored with an inter-professional simulation scenario: a mixed methods research study. Nurs Edu Today 2016; 36: 348-353

40. Ericsson KA. Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains. Acad med 2004; 79(10 Suppl): S70-S81

41. Gross IT, Abrahan DG, Kumar A, Noethe J, Shilkofski NA, Pell P et al. Rapid cycle deliberate practice as a method to improve airway management skills: a randomized controlled simulation study. Cureus 2019; 11(9): e 5546

42. Rosman SL, Nyirasafari R, Buwiza HM, Cimcihoza C, Camp EA, Weiner DL et al. Rapid cycle deliberate practice versus traditional simulation in resource-limited settings. BMC Med Edu 2019; 19(0): 314

43. Sullivan S, Campbell K, Ross JC et al. Identifying non technical skills deficiencies in trainees through inter-disciplinary trauma simulation. J Surg Edu 2018; 75: 978-983

44. Borgohain B, Khonglah T. Developing and organizing a trauma system and mass casualty management: some useful observations from the Israeli Trauma Model. Annals of Med and health Sciences Research 2013; 3(1): 85-89

45. Petrosoniak A, Fan M, Hicks CM et al. Truma resuscitation using insitu simulation teams training (TRUST ) Study, latent safety threats and evaluating using framework analysis and review. BMJ Quality and safety 2020; 30(9). Doi: 10.1136/bmjqs-2020-011363