The More I Know, The Less Certain I Am

I’ve recently had cause to re-examine Dale Edgar’s ‘Cone of Experience‘. Like that fabulous educator from iTeachEM, Rob Rogers (@EM_Educator), this concept seems intuitive and demonstrates nicely the benefit of learning via different formats. I use it in talks to explore different learning styles.

Screen Shot 2014-07-24 at 3.28.00 pm

Except it’s bunk. Dale never ascribed percentages to the retention rate for each different mode of learning; rather the ‘cone of experience’ demonstrates the varying abstraction potential for each learning mode. Understanding that Dale’s model was centred around understanding the concretness of different material, not retention rates.

Why is this important? Because it’s not uncommon in medicine to come across the view that “there is only one correct way to do X

When I was a junior, following such rules made sense – they reduced the burden of having to ‘think’ too hard … and when such rules were imposed from a higher authority (invariably a gruff Consultant), failure to comply risked raising their ire! Of course it’s not just lack of years or having a steep authority gradient that encourages sticking to such rules. As humans we tend to seek the comfort of familiarity and our own experience when making decisions – hence the “I’ve always done it this way…” or “Textbook X (authored by eminent expert Y) tells us to do it this way, so I’m sticking with that…” or even the “The teaching is to do procedure X this way – anything else is negligent” conundrums.

Nowadays when someone asks me how to do something, I seem to find myself pausing more and more as I reflect on previous experience. No longer do I say “Chest drains? They’re easy, let me show you how” – instead I pause “Well…it can be difficult…let’s talk about it, then I’ll help & guide you through one” as I recall not the vast majority of easy ones, but the difficult cases, the errors made, the complications…and am keen to relay this tacit experience bro e through mistakes to my colleague.

Some recent debates on social media have been relevant. Over on doctors.net.ukfora, we’ve had examples of :

- experienced clinicians ‘told off’ by physios for eliciting lower limb reflexes in a seated patient “the ONLY way to do reflexes is with patient laying down”

- anaesthetists laying into emergency physicians over options for safe sedation of the haemodynamically compromised patient in VT (with the usual cliched ‘needs RSI‘, through ‘mustn’t use ketamine because of strain on heart‘ through to ‘just zap them and apologise‘). Kudos to Cliff Reid & Ed Valentine for keeping their cool in that debate!

Meanwhile there’s been a useful Twitter and Google+ exchange on dogma around use of femoral traction devices (FTDs) for splinting of femoral fractures in the presence of a pelvic fracture

There are plenty of other discussions that crop up – cricoid force, checklists for crisis, thrombolysis in stroke, acceptable modifications to RSI etc etc

In all of these discussions, it’s not uncommon to see people looking for “rules”. In the recent examples,

- physio wanted a rule that all lower limb reflexes are elicited in supine patient

- anaes colleagues wanted to use propofol RSI for the patient in VT and berated use of ketamine

- traditional teaching is to avoid use of FTD in presence or suspected presence of pelvic fracture; some paramedics were lookign for guidance on rules whether to use a FTD or not. Wise words from experienced paramedic/retrieval practitioner Dave Tingey “clinical judgement is the key – especially where there is little or no evidence” – he emphasised focussing on patient outcome, not rules for a process!

FOAMed – tacit knowledge sharing with global community

People ask me why I use social media for learning. For me the attraction of FOAMed is that it addresses the issues where there is clinical uncertainty. If you are looking for absolutes (as when learning the craft of medicine or to pass exams) then stick to the textbook teachings. If you are looking to test yourself and continue to explore the expanding frontiers of knowledge, then use FOAMed. It opens up the world of #dogmalysis and enables corridor conversations with clinicians worldwide. Some of what you encounter is bunk…some is golden. The trick is to filter, engage, question and unlike politicians, don’t stick to one party line.

Even if “the more you know, the less certain you are!”

"My way or the highway" Guessing PM Abbott would not be amenable to uncertainty
“My way or the highway”
Guessing PM Abbott would not be amenable to uncertainty

Rural Prehospital Care Survey

The phrase “critical illness does not respect geography” is often quoted, reflecting the fact that mishap can affect anyone, anytime, anywhere.

We are lucky to have excellent tertiary level emergency departments & intensive care units in Australia to deliver specialist care. Developments such as FOAMed help to narrow the knowledge-translation gap from publication to practice. Furthermore, the widespread dissemination of information via asynchronous learning (such as slide sets, podcasts, videos hosted on websites, or corridor conversations via twitter) means that geographical isolation alone is no excuse for the rural clinician to be the ‘weak link’ in provision of care.

But Australia is a vast continent – making the provision of immediate care problematic in the more rural & remote areas. Certainly we have excellent prehospital & retrieval services; but although road and rotary-wing responses are rapid, they are limited in timely response when distances are large. The sheer size of Australia means that even responses by fixed-wing aircraft may take hours to arrive. My job as a rural doctor is to deal with ‘anything & everything’. We offer primary care as a core skill, along with a smattering of emergency care. Many rural doctors have advanced skills in obstetrics, anaesthetics and surgery. ACRRM considers involvement in local disasters and emergencies as part of the rural doctor primary curriculum skill set. It makes sense that the doctors with ongoing exposure to resuscitation & airway management (typically rural GP-anaesthetists) are called when there is a rural emergency.

But is the involvement of rural doctors a good thing?

Perhaps not. The experts in delivery of prehospital care are those with specific training and resources – classically State-based ambulance services, supported by services with retrieval expertise (eg: RFDS, CareFlight, HEMS, medSTAR etc). As a hypothetical, I think that if I was involved in a vehicle rollover, I would want to be looked after by the experts, not an ‘enthusiastic amateur’ GP.

So there is the dilemma. The further from a tertiary centre, the longer it will take for retrieval services to arrive. The more remote you are, the more likely that ambulance responders will be unpaid volunteers, not career intensive-care level paramedics…and the more likely that local clinicians will need to be involved in care.

A 2012 survey of rural GP-anaesthetists surprised me; just under 60% of responders stated that they had been involved in some form of pre-hospital incident in the previous 12 months. However of those responding, very few had training in prehospital care, very few had equipment to deliver care and most were tasked to the scene in an ad hoc manner (no formal call out criteria). As a consequence, the quality of responder on scene is highly variable – you may get a senior rural doctor with regular exposure to advanced airway management…or you may get a relatively inexperienced GP with very little emergency experience, let alone skills useful to prehospital care.

I can certainly empathise with the notion of ‘no room for enthusiastic amateurs, leave it to the experts’. Yet interestingly, the request for rural clinicians to attend such incidents came from the experts in prehospital care – ambulance comms and retrieval coordinators, usually because of the severity of the incident and dearth of readily available resources.

You can watch a summary of the issue here from the smacc2013 conference.

Role of the rural clinician in prehospital care?

There are several systems worldwide aimed to deliver immediate care when and where needed.

At a basic level, community first responder schemes such as PulsePoint and GoodSAM (smartphone activated medics) allow crowd-sourced delivery of basic life support to patients even before ambulance services arrive. Responders are typically volunteers, with senior first aid, paramedic, nursing or medical qualifications who are prepared to respond if an incident (cardiac arrest, impact brain apnoea) happens in the immediate vicinity. Activation is via the GPS in smartphones.

At the top end of prehospital care are ambulance and retrieval services, with trained teams, dedicated equipment and service delivery aimed solely at best practice.

Somewhere in-between are systems integrate appropriately-trained volunteers to support ambulance services and deliver care before retrieval services arrive. Examples include the UK BASICS (British Association of Immediate Care Schemes) and NZ’s PRIME (Primary Response in Medical Emergencies). Responders are typically nurse or doctor, with high-level resuscitation skills (typically rural GP, emergency physician, intensivist). They are tasked under defined activation criteria and are trained, equipped and audited. UK BASICS are generally unpaid and work is taken on additional to NHS duties; PRIME is paid.

South Australia has an embryonic scheme, RERN (Rural Emergency Responder Network), utilising experienced rural doctors to respond to prehospital incidents in their community, only when attendance of a doctor will ‘value add’. This can be useful where local ambulance responders are volunteers, when local expertise (career paramedic) resources are overwhelmed and/or when arrival of specialist retrieval services will take some time. As such RERN responders are equipped with standard prehospital equipment, undertake ongoing training and case audit. Participation (and indeed attendance) is voluntary; remuneration is on a fee-for-service basis. You can download a presentation from Dr Peter Joyner here or watch a youtube video from CountryHealthSA featuring medSTAR’s Bill Griggs on the RERN model here.

Some other States have standardised Hospital ‘emergency bags’ for use in a disaster (such as Western Australia’s Parry Pack); yet no formal training for their use or clinician involvement in such incidents. NSW is leading the way with not just standardised equipment bags but also open-access training for rural clinicians.

So is the BASICS-PRIME-RERN model one which could be applied elsewhere in rural Australia? I think so, but only in certain locations and in certain circumstances. Clearly the ethos of rural doctors responding to local emergencies is congruent with that of ACRRM. Historically rural doctors were called as default; this has (sensibly in my opinion) been superseded by delivery of specialist care via ambulance or retrieval services, offering a far higher level of care.  Yet rural doctors are still being called, often by the same experts!

To continue with ad hoc responses by whichever local GP is available is nonsensical, especially without appropriate training and equipment. Equally to ignore the fact that many rural doctors have ongoing experience in initial emergency management and airway skills via work in local hospital ED and Theatre may deny rural patients access to lifesaving skills. Of course one has to be mindful that experience in the Operating Theatre or ED does not translate to the roadside and the experts remain paramedics and retrievalists…when available.

Other countries recognise the fact that there is a therapeutic vacuum between initial incident and arrival of retrieval services; that geographically-constrained countries such as the UK and NZ have these systems and yet Australia does not is puzzling, especially when considering the tyranny of distance and unique skill set of Australian rural clinicians.

Take the Survey

What do you think? The link below is to a survey which will go to rural doctors registered with ACRRM and the RDAA; however it would be good to get feedback from a wider cohort – from established retrievalists, from paramedics, from nurses – in fact, ANYONE who is involved in critical care.

CLICK HERE TO TAKE THE RURAL PREHOSPITAL SURVEY (5-10 MINS)

As Karel Habig said at smaccc2013: “Good critical care is good critical care, wherever you are.”

I think it would be good to ensure systems to deliver appropriate care where gaps exist. But it has to be something that rural doctors are prepared to engage in – and has to be embraced by other services.

To put it bluntly, either we include rural clinicians in the system or we do not. The latter may be ideal from a metrocentric perspective, insistent on gold-standard specialist-lead prehospital care. This is the service I would want as a rural patient! But a pragmatic approach recognises that there will be temporary service gaps due to distance or lack of available personnel and that plugging these gaps already involves rural clinicians – yet in an unstructured, unequipped and untrained manner.

I reckon that we can and should do better than that in Australia.

PROS

  • recognise that rural clinicians are already being called to attend prehospital incidents; ensure that such responses are by trained/equipped/audited responders, not ad hoc
  • utilise those rural clinicians with ongoing experience in trauma, emergency medicine and anaesthesia, who maintain skills through regular exposure in hopsital ED and Theatre
  • task rural clinicians only when their presence will ‘value add’ to the prehospital scene eg: IV access, ketamine for extrication, needle/finger/tube thoracostomy, prehospital airway management
  • establishment of State or Nationwide cadre of rural responders may provide extra resilience in case of disaster eg: earthquake, bushfire, flooding [and may be acceptable to existing State-based agencies]

CONS

  • prehospital environment is very different to hospital; requires skills best delivered by ambulance and specialist retrieval services, not amateurs
  • presence of a rural clinician may not value add (local GP arriving in boardshorts and thongs with no kit/training is worse than useless), detract from delivery of care by local resources
  • potentially high cost to equip and activate responders (PPE, prehospital kit, pagers etc)
  • relative infrequency of incidents carries risk of skill fade

Really interested in perspective from others.

https://docs.google.com/forms/d/1mWneu8ijC64O1yLblEFrNTFZ0xEDnNXD5JKzTfE6orQ/viewform?c=0&w=1&usp=mail_form_link

RSI Checklist App – Review

It is no secret that I am a fan of checklists. Not because they are a ‘how to guide’ (they’re not), but because of their proven potential to mitigate against error in high-risk tightly-coupled procedures. One such procedure is RSI. The consequences of omitting a single step (eg: failure to check ETT cuff, availability of back up equipment or appropriate drugs) can lead to disaster.

This year’s smaccGOLD saw Minh le Cong and myself go head-to-head in the infamous “Do Real Airway Experts Use Checklists?” debate. You can read more here - the answer being “of course airway experts should use checklists!”

Since then I am pleased to see that others in ED have been inspired to implement checklists in their ED…and for the creators of the Vortex Approach consider adding a checklist to their cognitive tool.

 

Checklist to complement The Vortex Approach
Checklist to complement The Vortex Approach

But a sensible checklist is more than a ‘tick and flick’ exercise – it should only contain key steps and ensure that the user does not lose situational awareness. Having audible cues (akin to an aircraft terrain alert warning to “pull up, pull up”) would be useful during preoxygenation and during intubation attempts.

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$1.29 on the Australian App store – it’s a UK-based app so presume available internationally

So I was delighted to be able to beta test the iRSI app. This is the brainchild of Dr Ben Taylor, a UK doctor who is near to completion of specialist training (I struggle with the notion of calling such doctors trainees). You can download the iRSI app via iTunes – it’s optimised for iPhone and listed as an iPhone iOS app, but works perfectly well on iPad.

 

iRSI checklist app - brainchild of Dr Ben Taylor, irsi.co.uk
iRSI checklist app – brainchild of Dr Ben Taylor, irsi.co.uk

 

The app itself is simple – four main checklist screens which can be run through during a standard period of pre-oxygenation.

 

IMG_4200
RSI App Start Screen

 

Once select ‘RSI’ as an option, the user is guided through four screens – checks of patient, drugs, equipment and team.

 

Step 1 - PATIENT
Step 1 : PATIENT

 

Step 2 : DRUGS
Step 2 : DRUGS

 

Step 3 : EQUIPMENT
Step 3 : EQUIPMENT

 

Step 4 : THE TEAM
Step 4 : THE TEAM

Running through the checklist takes around 60 seconds and can be achieved during preoxygenation. There are additional submenus for airway assessment, adjuncts for difficulty, prevention of desaturation and crisis management if needed.

What makes the app more useful, are the inclusion of :

  • integrated calculators for paediatric doses, emergency drugs and equipment sizes
  • tidal volume calculations based on ARDSnet for weight, height and IBW
  • integrated protocols for airway assessment, optimising oxygenation, failed intubation & anaphylaxis (references emcrit.org and resus.me FOAMed sites)
  • audible, tactile and visual alarms at preset intervals during preox and intubation attempts.

The latter takes advantage of the built-in audio alarm, vibrate and torch functions of the iPhone (iPad), corresponding to audio-tactile-visual cues as RSI progresses. I think this is invaluable, as offers a predetermined cue to encourage the intubator (or assistant) to consider alternative strategies as time progresses. This may help mitigate against task fixation, a problem in many airway catastrophes.

 

The Roc Clock - alarms during prolonged efforts to secure airway
The Roc Clock – alarms during prolonged efforts to secure airway

Nice touches are the ability to pre-select preferred choice of induction agents (from thiopentone-propofol-ketamine-etomidate-midazolam) and neuromuscular blocker (suxamethonium or rocuronium).

Thio-Sux traditionalism or Rocketamine? Your choice.
Thio-Sux traditionalism or Rocketamine?
Your choice.

Whilst the inclusion of propofol may induce apoplexy in some, hopefully the ability to either turn on or off cricoid pressure as a default will assuage them.

 

Cricoid ON or OFF? Your choice with iRSI
Cricoid ON or OFF? Choice is yours with iRSI

One thing I was concerned about was the potential to become too focussed on the app itself, rather than the intubation. I think that Ben’s done a good job – the user can preselect options appropriately and dip in/out of the app for critical stages eg: checklist alone or intubation attempt timer.

I don’t think that the app aims to replace proper airway evaluation and training, nor management of airway crises – but it does offer a readily-accessible form of an RSI checklist, useful drug and equipment calculators as well as timers with alarms for critical steps.

Future modifications might include

  • use of fentanyl as coinduction agent
  • calculators for standard infusions (particularly relevant for post-RSI sedation in ED, ICU or PHEC)
  • data logging to allow audit of intubation, offering possible synergy with the airwayregistry.org.au study and similar audits overseas.

So have a look at the RSI app and feedback any suggestions to Dr Ben Taylor. He’s done a GREAT job….

More details at iRSI.co.uk

BELOW IS A DEMO USING REFLECTOR APP AIRPLAY from iPAD to MACBOOK AIR.

Audio was overdubbed during a rainstorm on a remote beach – sorry about the background of heavy surf and rain!

https://vimeo.com/100875493

 

I think iRSI app opens the way forward – we all have smartphones and tablets to hand – integrating cognitive aids, audio/tactile/visual alerts, checklists, crisis algorithms and data-logging is a powerful way to improve safety.

Stroke Unit – Decision Makers Away with the Fairies

I’ve never been a fan of the term ‘cerebrovascular accident’. The term accident implies that there is no underlying reason for the pathology. Indeed, there was a push some years ago by the BMJ to ban the term ‘accident’ in medicine, as it implies that they are a chance occurrence or an ‘act of God’.

Stroke

It is actually interesting to explore the etymology of the term ‘stroke’. In times gone past, it was not unknown for formerly fit members of the community to head off into the fields or forest for a hard day’s work…then be discovered at the end of the day with a unilateral paralysis and difficulty speaking. Yet there was no visible injury. Hence the concept of having been attacked by the Faery Folk or ‘Elf-struck’ – subsequently contracted to ‘stroke’.

Whilst we learn about the pathophysiology & workup of stroke, I used to be somewhat nihilistic about outcome. I often tell patients and their relatives that one of three outcomes is likely – to get better, to get profoundly worse….or to stay the same. That’s not to say that I skimp on history and examination, appropriate investigations nor aggressive treatment of modifiable of risk factors. As a rural doctor I am well-placed to address risk factors well before people progress to cerebrovascular disease, as well as to have the ‘difficult’ discussions with them & family regarding prognostication if and when a stroke occurs.

All this changed with advances in stroke care.

The topic of thrombolysis in stroke is often discussed in FOAMed circles, with differing opinion on effectiveness between emergency and stroke physicians. One thing though has always seemed clear  the benefit of dedicated stroke pathways offering streamlined access t one-stop investigation and management of stroke patients, as well as use of validated triage systems such as the ROSIER score to enable direction of such patients to the stroke unit.

The best results appear to come from those which are based in a dedicated ward

By doing the LITTLE things well (timely recognition, early assessment and investigation, bundled care), it seems that stroke networks and stroke units offer patients the best chance. This is akin to the ‘aggregation of marginal gains’.

A 2013 Cochrane Review highlighted the benefit of dedicated stroke units. This review of 28 trials, involving 5855 participants, showed that patients who receive stroke unit care are more likely to survive their stroke, return home and become independent in looking after themselves.

So – best care is to send your stroke patient to a stroke unit. Or so I thought.

I recently admitted a stroke patient. Prior to this she was independent in her own home. She has controlled hypertension and a pacemaker. She’s had a previous stroke, managed in a tertiary hospital stroke unit, from which she made a full functional recovery after some weeks in rehabilitation. So when she presented, several hours after likely onset of her second stroke, it seemed only sensible to send her away to a stroke unit. She and family are loathe to leave the community, but understood that her best chance of recovery lies with all the benefits that a stroke unit can offer, not least rehab. So they are prepared to take a trip to the tertiary hospital for best care.

I spoke to a very lovely stroke registrar who apologised profusely and told me that, due to funding cuts, the stroke unit is now only able to accept patients under the age of 70.

That’s right – 70 years of age

Let’s face it – this is a financial decision, not a clinical one. Age doesn’t factor into the ROSIER score. It certainly didn’t factor into my patient’s eligibility for stroke unit care on the last occurrence. Whilst I can understand denying stroke unit care on the basis of poor premorbid function and poor chance of meaningful recovery, it seems nonsensical to exclude patients from stroke unit care on basis of age alone.

I have no doubt that my patient will be well cared for on a general medical ward. They may even receive visits from the same stroke physicians, physiotherapists and speech therapists as on the stroke unit. But studies suggest that it is the provision of a defined geographically separate unit dedicated to stroke care is the deciding factor in improving functional discharge.

As clinicians we may obsess over implementation of tools such as the ROSIER score, pros/cons of thrombolysis and need for bundled care in stroke networks and stroke units. But ultimately all this comes to nought if there are no beds, and decisions to admit to a stroke unit are made on basis of age, not other clinical criteria.

The stroke registrar encouraged me to make a noise about the limitations on beds. For most people, this issue will not be one that concerns them – until a family member is affected. Meanwhile politicians do not have to look these patients in the face. An honest political system would be prepared to put these issues front and centre, to acknowledge that rationing is needed and to explain why, despite encouragement to work until 70 until you are eligible for a pension, if you have a stroke in retirement you won’t get stroke unit care.

Making decisions based on age alone and not premorbid function seems inherently ageist – and is a policy I find hard to defend.

Should age alone be a reason to deny stroke unit care?

What do YOU think?

Is age alone a valid cutoff for stroke care?

If you are going to argue that equivalent care can be offered on a general medical ward, then it begs the question – why have stroke units? Has Cochrane got it wrong?

 

ETM course coming to Adelaide, SA

I am delighted to hear that Dr Andy Buck and team are running an ETM course in Adelaide in October this year. ETM is a great course for anyone involved in the trauma team – EM docs, anaesthetists, rural docs, surgeons, intensivists.

I teach and Direct on the international ATLS-EMST programme – and whilst I believe in the usefulness of the ATLS approach for the initial management of trauma, it frustrates me that the ATLS course is aimed at a fairly basic level, doesnt cover anything to do with trauma team management and omits much of the useful #FOAMed quality education that is available.

ETM covers all this. You can read a review of ETM by Dr Jeram Hyde from one of the early  Melbourne-based courses in November last year.

http://kidocs.org/2013/12/etm-course/

Better still, get yourself along to ETM in Adelaide this October – its way cheaper than EMST, shorter wait list to get on a course and has way better content for modern trauma management!

Details at http://etmcourse.com/first-interstate-etm-course/

I hope to see some of you there! Get in quick though….

Capnography & Procedural Sedation

I’ve been a convert to use of ETCO2 monitoring for not just anaesthesia in the OT or ED, but also for procedural sedation. This is driven in part by results of the NAP4 audit and also from colleagues in the FOAMed world. Perhaps I am over cautious, but my use of ETCO2 extends to monitoring of the sedated psych patient, for whom I consider administration of agents such as IV midazolam (or occasionally ketamine) once olanzapine wafers have failed, to be a standard of care.

So I was surprised by the statement over at EMTrends.org suggesting “no benefit to routine capnography in procedural sedation”. You can read a summary of the paper here or look up the reference in Anaesthesia & Analgesia (2014) 119(1) 49-55.

This paper looks at patients undergoing minor gynae procedures by non-anaesthetists in a Dutch hospital. Interestingly NONE received supplemental oxygen (despite being administered propofol). The authors state that the incidence of hypoxaemic incidents in the 206 patients with ETCO2 monitoring was not significantly better the 209 patients for whom ETCO2 was not used.

Fair enough – until you look at the rate of hypoxaemia (SpO2 < 91%) in both groups:

25.7% with capnography

vs

24.9 without capnography

That is pretty poor IMHO.

 

For the record, I think I will continue to advocate for :

- routine use of supplemental oxygen if using neuroleptics

- routine use of capnography

 

You can read more about ETCO2 here - as my friend Casey Parker of BroomeDocs says “It gives you A-B-C in one squiggly line”

The Trainee Is Going To Land the Plane Today

I am obviously something of a medical dinosaur. I trained in the UK. Once qualified as a doctor, I spent a year as a ‘House Officer’ befoer being granted full registration with the UK General Medical Council (the term House Officer based on the time when newly qualified doctors were compulsorily resident on the hospital grounds). Career progression was fairly straightforward, from House Officer…to Senior House Officer…to Registrar (post Membership exams)…then Senior Registrar…then finally Consultant. The Australian system is similar, from Intern…through to Resident…Senior Resident…Registrar…Consultant (post Fellowship). I gather the Americans run along the lines of Intern-Resident-Attending.

But all has changed. Speaking to Brits looking to migrate to Australia to escape the imminent collapse of the NHS, I am increasingly befuddled by the newspeak nomenclature of doctors-in-training. They seem to refer to themselves as FY1/FY2s (or F1s, F2s), CT1s, STs. They are forced to jump through arcane hoops (what the Dickens is an ARCP?). Moreover, they seem to be universally referred to as ‘trainees’.

 

trainee

 

Hearing a doctor being introduced as ‘Steve the ST4 trainee’ makes it sound as if Steve is here on work expereince from the local school, rather than a fully-qualified doctor, with several years postgraduate training under his belt, Membership of the College of Physicians and only a few months away from being a Consultant.

Meanwhile, every other man-and-his-dog seems to be granted some sort of increasingly long job title - it seems that everyone is a Consultant nowadays, or a Specialist – even if that means they are a ‘Consultant Specialist Podiatric Surgeon’ (or podiatrist to you and me) or a ‘Senior Specialist Nutritional Consultant’ (or dietician).

Some Human Resources officers in NHS Trusts even insist that doctors are not allowed to put the title ‘Doctor’ (Dr) on their name badges as this ‘would be confusing for patients’ as they are ‘just trainees’.

This, for some reason, makes me sad. It also cements in my mind the utter crassness of ‘Human Resources’, implying that people are objects to be manipulated, like widgets…rather than individuals. Highly trained and professional individuals in the case of those undertaking postgraduate training in the NHS.

In these days of #hellomynameis, one would think that it would be important to be clear not just about one;s name, but also about one’s seniority (or otherwise) in the medical hierarchy. The progression from House Officer through Registrar to Consultant was fairly clear, even to the lay public.

I can only gather that the abandonment of the title ‘Doctor’ and the confusing mishmash of names, as well as the general all-encompassing naming of these doctors as ‘trainees’ is about control. It certainly isn’t about being clear to patients.

“Good evening ladies and gentleman. We hope you have enjoyed your flight on British Airways flight 4567. Jane the trainee will be landing the aircraft shortly”

Which would you prefer as a patient? To be operated on by “Steve the trainee” or “Steve, Senior Registrar to Mr Spratt”?

Names are important, as are titles. Use them. A recent survey on Doctors.Net.UK supports the profession’s preference for the abandonment of the generic term of ‘trainee’. Yes these doctors are still undergoing training – but lets not forget that they are already qualified as doctors and are undergoing an arduous postgraduate training. Referring to them as ‘trainees’ really does imply that they have wondered in off the street for a few weeks work experience and are not to be trusted.

You can access the survey results and comments here.

The author is on DNUK and remains anonymous.

 

EVO competition now open

Wondered what all the fuss is about regarding smacc, the critical care conference held in Sydney 2013 (#smacc2013), Gold Coast 2014 (#smaccGOLD) and due again in June 2015 in Chicago (#smaccUS)?

It sure is a great conference, full of cutting edge resuscitation and critical care, along with a dollop of educational subversion, innovation and just plain good fun. The content is relevant to any who care for critical patients – not just intensivists, but ED docs, rural clinicians, paramedics, nurses, students. No hierarchy, just quality meducation and passion.

If you haven’t yet considered attending, check out the smacc content online – in the true spirit of FOAMed, the content from smacc is available online as podcasts, downloadable slidesets and videos.

You can access the videos via the VIMEO channel HERE - or if you prefer to listen as you run, drive, walk, shovel snow or laze on a beach – you can get the audio podcast version via iTunes HERE.

Content is also available via RSS feeds from various affiliated websites – try the excellent Intensive Care Network (ICN), PreHospital&RetrievalMedicine (PHARM), RuralDoctorsnet (RDN) and of course LifeIntheFastLane (LITFL).

Equipment Videos Online

To continue the theme of a gift that keeps on giving, the EVO competition was announced today. The premise is simple – get together a team (can be from 1 to 5 members) and create a short (< 5 mins) video to showcase a piece of equipment relevant to critical care. It can be a ‘how to use’, a ‘how to troubleshoot’ or even a ‘how to improvise’.

Instructions are HERE

EVO-Logo-on-White

Why bother? Well, each month a winner will be announced – from 1 Aug 2014 through to 1 June 2015, a few weeks before smaccUS. And the prize each month? A ticket to smacc!

This is genius – not only does this encourage smacc participation – it also generates more quality FOAMed content. I am looking forward to seeing the videos as they come online.

This is the very essence of FOAMed – generation of quality educational material, available to all. The EVO competition is one way to achieve this. So get your video kit out, get a few mates and shoot a quick video for EVO.

If you’re looking for inspiration, then there’s plenty out there. I’ve got a few short videos in the ’50 Shades of Brown’ section on KIDocs

The Australian College of Rural & Remote Medicine ran a similar competition last year with their #JAMIT series (just a minute instant tutorial) – here’s one from Minh on setting up a quick n dirty adrenaline infusion.

So come on – I’m looking forward to seeing some of the tips n tricks out there from the FOAMed world.

Oh – and if anyone has already made a short video on troubleshooting the Oxylog 2000+ for the ‘occasional user’, do me a favour and bung up online – it’s the workhorse of rural EDs here in Australia and I haven’t (yet) got around to doing this. Beat me to it!

 

 

 

 

You’re Amazing – Keep it Up!

So I was grinning from ear-to-ear when I received an airmail envelope from the UK – inside was a message. No name, just a card. UK-stamp, sent from London…

Mystery Card - along with many other EM colleagues in UK, USA & Oz
Mystery Card – along with many other EM colleagues in UK, USA & Oz

Card 2

 

As far as I can gather, many other clinicians around the globe have received one of these – mostly amongst the EM & Crit Care community.

So far no-one has owned up to this delightful surprise.

 

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I’m pretty sure plenty of other clinicians have received one of these little boosters

If you have, don’t be shy – send a photo for the collage

 

Of course there are rumours – Rob Rogers (@EM_Educator) showed a slide at smaccGOLD of cards given out at Starbucks coffee with a similar message (I think it was in the ‘Get Creative’ workshop I attended).

 

BpItT6fIYAAX3GW

 

So it is not a huge leap to assume it was one of the smacc attendees…most likely one who lives or has been in the UK recently. I have my theory as to the identity – more theories abound in the twittersphere…

No matter who sent these cards (and I thank you for mine), it was a lovely gesture of camerarderie and a nice little morale booster.

“I kind of don’t want to know who’s sending them. Anonymity is part of the kindness”

Jesse Spurr @Inject_Orange

Which makes me wonder – how often do we we acknowledge & say ‘thank you’ for the efforts of others in our work? One of the earliest lessons I learned as an intern (or housedog in the UK), was to befriend the porters, the ladies in the hospital shop, the cleaners, laboratory, admin and nursing staff. We talk about ‘making things happen’ in emergency medicine – wise clinicians realise that our efforts in the resus room require the support of a whole raft of people.

Similarly in the FOAMed community, I am grateful for the help I have had with my learning and professional development. This is delivered via inspirational blogs, listening to inspirational speakers, lovingly-crafted talks made available for free download – and supported by ongoing global ‘corridor conversations’ with like-minded folk through social media.

As much as I have been supported by this, I try to pay back – this week has been notable by a collaborative review of sim apps, a to-&-fro exchange on refinements to an exciting new cognitive aid from an anaesthetic colleague, getting a letter in the British Journal of Anaesthesia and mentoring an EM trainee who was inspired by my talk at smaccGOLD and wishes to implement an RSI checklist in his own organisation.

This is what I love about the FOAMed ethos – the willing sharing of ideas and the ever present enthusiasm to ‘pay on’ the meducational love within the FOAMed community

Already the offers of a shared beer and catch up are trickling in for smaccUS in Chicago.  Due to the expected numbers of attendees and the need to ensure a truly top shelf event surpassing even smacc13 and smaccGOLD, the dates have been pushed back to June 23-26 2015. Read about the reasons for the SMACC 2015 move to June.

 

So – to you all – thank you

You’re awesome

Keep it up!

 

I am working on a small surprise for colleagues in the FOAMed community

Catch up with me in Chicago for a special gift

smaccUS 23-25 June 2015
See you at smaccUS 23-25 June 2015

Simulation Apps – Review

This review of iOS apps for simulation use was conducted by Dr Tim Leeuwenburg (@KangarooBeach) and Dr Jonathon Hurley (DrJHurley). Tim is a rural GP-Anaesthetist in South Australia and a passionate advocate of ‘guerilla sim’. Jonathon is an EM trainee in the UK and keen on human factors and simulation in EM. We reviewed :

Jonathon has prepared a SPREADSHEET for download, comparing the features of all Apps reviewed

Pre-publication peer review of the post was kindly provided by Jesse Spurr (@Inject_Orange)

 


Why use in situ Sim at work?

Many clinicians are embedding simulation training into their practice.If it is done well, sim training allows :

  • exploration of team work and human factors
  • exposure to infrequent but high-stakes crisis situations
  • development of tacit knowledge
  • development of  ‘stress inoculation’
  • interdisciplinary team training using all clinicians who are involved in a case – doctors, nurses, paramedics, orderlies etc

High-performing teams, such as those in retrieval services, incorporate sim into their day-to-day practice. To my mind there is far more ‘bang for buck’ in delivering regular on site sim using own team, equipment and protocols than the notion of once yearly ‘upskilling’ or the use of expensive course and sim centre sessions which occur away from the workplace. This approach is inspired by experts such as Jon Gatward & Jesse Spurr, who espouse the concept of mobile sim

This is borne out by evidence, showing only a 1-2 % difference between high-fidelity and low-fidelity sim training. The 2012 paper from Rosen provides an excellent review of in situ simulation and is recommended reading (J.Cont. Ed Hlth Prof 32(4) 243-254). Click on the link to view a PDF.

There are plenty of resources out there in the #FOAMed world for those of you considering sim. I would recommend :

Some useful papers include :

Eppich et al (2011) Simulation-BasedTeam Training in Healthcare. Sim Healthcare 6 S14–S19

Kennedy, C. C., Cannon, E. K., Warner, D. O., & Cook, D. A. (2014). Advanced Airway Management Simulation Training in Medical Education. Critical Care Medicine, 42(1), 169–178.

Lorello, G. R., Cook, D. A., Johnson, R. L., & Brydges, R. (2014). Simulation-based training in anaesthesiology: a systematic review and meta-analysis. British Journal of Anaesthesia, 112(2), 231–245

Marshall SD & Flanagan B. (2010) Simulation-based education for building clinical teams. J Emerg Trauma Shock : 360-8

Petrosoniak, A., & Hicks, C. M. (2013). Beyond crisis resource management. Current Opinion in Anaesthesiology, 26(6), 699–706.

Rosen et al (2012) In Situ Simulation in Continuing Education for the Health Care Professions: A Systematic Review. (2012) Journal of Continuing Education in the Health Professions 32(4) : 243–254

Shapiro, M. J., Gardner, R., Godwin, S. A., Jay, G. D., Lindquist, D. G., Salisbury, M. L., & Salas, E. (2008). Defining Team Performance for Simulation‐based Training: Methodology, Metrics, and Opportunities for Emergency Medicine. Academic Emergency Medicine, 15(11), 1088–1097

Schmutz & Manser (2013) Do team processes really have an effect on clinical performance? A systematic literature review. British Journal of Anaesthesia 110(4) 529

Tannenbaum S et al (2012) Teams Are Changing: Are Research and Practice Evolving Fast Enough? Industrial and Organizational Psychology 5:2–24

Weaver SJ, Salas E, King HB. (2011) Twelve Best Practices for Team Training Evaluation in Health Care. Jt Comm J Qual Patient Saf.  37(8) : 341-9


 

You can see how GSA-HEMS use sim training from this video, submitted as their smaccGOLD SIMWars entry

There are a few options for delivering sim in the workplace – what Jon Gatward calls mobile sim (I prefer ‘guerilla sim’). Key to this is the ability to deliver focussed sim sessions in the workplace – whether at the end of each ward round, as a scheduled session during the ED shift, in the operating theatre, in the ICU etc.

Such sessions do not need to incorporate expensive technology and are WAY easier (and I would argue, more relevant) than visiting a dedicated sim lab. Principles of mobile sim are :

  • it is done during the working day, in the workplace
  • it is interdisciplinary
  • it can be done ‘on-the-fly’
  • it can be done on the cheap
  • it delivers the same quality learning as traditional sim
  • it is flexible to workplace and clinician needs

This wonderful slide showing the ‘pharmacology of sim’ – shows the clear benefits of repeated low fidelity mobile sim vs a one off high-fidelity sim session ie: as “spaced review”

The Forgetting Curve - repetition (lo fi, high rep sim) aids Retention
The Forgetting Curve – repetition (lo fi, high rep sim) aids Retention

 

Considerations for in situ  Sim

Planning, Time, Location

Every simulation session should have a defined lesson plan and allow sufficient time for both the simulation scenario and debrief. Rather than focus on tasks (how to insert an IV, how to defib) the real power of sim is to explore cognitive bias and other human factors – in a crisis, it’s often not what you know, but how effectively you can apply it that matters. There is a considerable cost differential in sim delivered on a dedicated course (eg: Effective Management of Anaesthetic Crises, EMAC) in a dedicated facility (eg: simulation centre) vs a short session (planned or opportunistic) delivered in the workplace, preferably using the usual resus bay, theatre or ward environment.

Equipment

Use of the standard equipment used in your location is necessary (there is no point practicing IO access with an EZ-IO drill if your facility only has the Bone Injection Gun); a training box of expired kit (ETT, LMAs, PEEP valves and so on) is easy to procure.

Similarly expired drug stock (dantrolene, adrenaline vials etc) ensure that participants get to practice drawing up and preparing drugs under situations of a simulated crisis. Opening glass vials and preparing infusions is worth practicing under a simulated crisis – I am a huge fan pf ‘action cards’ at the head of the resus bed to aid this process, rather than having to search through the A4 compendium of drug protocols held t the Nursing staiton.

Patient

Some centres use simulated patients – actors or stray medical students who are briefed to the scenario. They are expensive and it isn’t ethical to defibrillate them or cannulate them, let alone perform CPR. Hence most use mannikins. There are expensive models which can simulate voices, breath sounds, heart sounds, collapsed lungs and have add ons to allow cannulation, central line insertion, catheterisation and so on – such as Laerdal’s Sim Man - but the are NUTS expensive, with ballpark costs $17K to $110k. Crazy.

Most hospitals have access to a Resuscitation Mannikin of some sort, with ResusciAnne (modelled on the death mask of an unidentified woman drowned in the River Seine, L’Inconnue de la Seine) the most popular CPR trainer out there.  I am still waiting for Tor Ecleve’s proposed update as displayed on lifeinthefastlane, namely Resusci Sharon & CPR Tracey.

In a push, ANYTHING will function as a patient; at smaccGOLD our SimWars team trained using Simon Carley’s conference satchel as a patient – we didn’t need to practice procedures…but we did need to practice teamwork, and rehearsing a scenario around a ‘bag patient’ sufficed, even to the point of inducing stress overload in the team leader. I’ve run sim training sessions using a cheap clothes mannikin purchased on eBay to run a perimortem C-section scenario…a $5 toy doll to practice neonatal resuscitation….and even a teddy bear as mock patient. However even the simplest sim can benefit from use of real equipment and a simulated monitor…

SimWars fracas at smaccGOLD :  "Team leader, this scenario is grillin' my corn"

 

Finesse

It’s the little things that make or break a good sim scenario. This might include the use of a confederate (covered nicely by Jesse Spurr in the ‘Plants in Simulation‘ post), the use of appropriate adjuncts (X-rays, labs, clinical photographs), use of moulaged blood, amniotic fluid and so on.

Some of the sim apps allow some nifty features – being able to flash up an X-ray, ECG, lab results or a clinical photograph to the monitor can help prompt the participants.

One of my favourite additions is that of patient phrases - these can be streamed to a small bluetooth speaker hidden within the mannikin (‘Am I having a heart attack?”). I have a vision of collecting some soundbites from various celebrities amongst the critical care community (can you imagine Minh le Cong asking “have you used the RSI checklist?” or John Hinds saying “Please use cricoid pressure!”).  I can but dream…

“…sound effects from confederate taking photos of the “birth” blew the midwives minds when they put the Doppler on a cloth sack and heart fetal heart rate. The crying neonate adds realism to successful resus and then subsequent ambient noise for maternal resus”

Jesse Spurr (nurse educator and sim gur who blogs at The Injectable Orange) has a great pearl – use your smartphone to host a foetal Doppler sound and newborn crying sound during obstetric or neonatal resus sims; a confederate can pretend to take photos using the smartphone and unleash the relevant sound effect.

Simulation Monitors

This is where modern technology comes to the fore; pretty much everyone has access to a smartphone or tablet nowadays. Numerous commercial apps allow one to convert an iPad screen into a simulacrum of a patient monitor, controlled via Bluetooth or Wi-Fi from another iPad or smartphone. There is no longer a need for an expensive ‘Sim Man’ or sim centre; one can instead deliver realistic realtime practice using the technology in your pocket.

Below I review several of the available options, with particular consideration to affordability, ease of use, fidelity and functionality. Links to associated websites are provided.

NOTE : Neither reviewers have shares or a financial interest in any of the products shown.  iSimulate kindly provided a $100 iTunes gift card to facilitate download of the various simulation apps on trial.

 


Trialling the Sim Apps

Here I review five different sim apps. Sadly the budget didn’t run to purchase of a Sim Man ($17K to $110K) …and to be honest, I do not think that the SimMan product can be justified except in the larger dedicated sim centres. Again it is far better to run ‘guerilla sim’ in your location, as low fi, high rep sim. The following iPad / iPhone apps were trialled :

Key review items include COST – EASE OF USE – FIDELITY – FUNCTIONALITY aspects. I scored each aspect out of five :

  • 0 – avoid
  • 1 – low bang for buck
  • 2 – functional, but needs improvement
  • 3 – average
  • 4 – actually, quite good
  • 5 – GRILLS MY CORN

I have also included a short video of each in use, mostly showing student monitor screens. The videos were made using AirPlay (built into iOS devices and streamed to a macBook Air running the program “reflector” to record video. It’s probably the easiest workaround for capturing an iPad screen, other than by using a standard recorder.

Reviewers were Dr Jonathon Hurley (Emergency Medicine, UK) and Dr Tim Leeuwenburg (Rural GP-Anaes, Australia)


 

EKG TRAINER (Walter Crittenden)

Tim : This app was only $2.99 from the app store, and at first glance appears to compare well with the SimMon app, albeit with only one option for a monitor (to be honest, I don’t think this matters – in my hospital alone there are four different monitors and it’s not useful to get hungup on expecting sim apps to mimic all commercial products).

There appear to be displays for ECG, SpO2, NIBP and RR. The lack of ETCo2 may be a limiting factor for those in ED, ICU, Theatre or Prehospital. Sadly I was unable to get anything to display other than ECG. This allowed selection of several waveforms including :

NSR-A/flutter-Sinus Brady-1st degree AVB- 3rd degree AVB-Sinut tach, A/fib-ST elevation, SVT- Bigeminy-VT-VF-Asystole

There also appears to be an option to connect two iPads via Bluetooth, but I was unable to make this work over the 72 hour trial period of testing. Linking to the developer’s website didn’t reveal any more clues on how to make this work and indeed the website appeared neglected.

So – at first glance this offers more ECG waveforms than SimMon, but lacks connectivity, ability to select other parameters and omits ETCo2. For the price this is not bad, but I could probably do as well with a few laminated photos of different monitor screens and run a sim like that! That way I would have saved $2.99 for a coffee…

  • COST – $2.99
  • EASE OF USE – 1/5
  • FIDELITY – 1/5
  • FUNCTIONALITY – 1/5 (essentially ECG strip only) on iPad, 2/5 on iPhone
  • TOTAL SCORE – 1/5

 

Jonathon :  I had the same experience.

iPad: Appears to be a ‘work-in-progress’ with just the ECG simulation working. The screen to change the other parameters wasn’t even finished, with ‘Label’ displaying instead of the value of the parameter.

iPhone: All parameters work, although there are no waveforms for sats / BP / RR.

I could connect iPhone (teacher) to iPad (student) and the displays mimcked each other, but when connecting the other way around sats, BP and RR just read zero. Connectivity was slow and the app would frequently hang trying to connect.

VF wouldn’t work.

Would maybe give this 2/5 for functionality (iPhone version) but otherwise agree with the scoring.

  • COST – $2.99
  • EASE OF USE – 1/5
  • FIDELITY – 1/5
  • FUNCTIONALITY – 2/5  on iPhone, 1/5 on iPad
  • TOTAL SCORE – 1/5

 

 

DART SIM (ECG RHYTHM & MONITOR SIMULATOR, STAR CPR San Diego)

Tim : The DART Sim app seemed to have good reviews on iTunes. It was fairly easy to start up, but the monitor screen appeared very cluttered an was hard to navigate. Swiping one’s finger across numerics allowed entering and change of values via keyboard; swiping over waveform hide/shows the waveform for each of ECG, BP, SpO2 and ETCO2.

Whilst ETCO2 waveforms could be changed via a drop down menu which was clearly labeled, the ECG waveform was controlled from a ‘keypad’ in bottom left of screen numbers 1-25.

By preselecting a number, different ECGs can be displayed – but this of course requires one to know which number corresponds to which ECG. I found this annoying, as reliance on a ‘key’ made rhythm switches on the fly almost impossible.

There are options to pace and to defibrillate; I gather there are also options to purchase scenarios, ECGs, CXRs and labs – I could not justify this, as the screen clutter and general difficulty in navigating the app made me immediately discount this as an option for sim.

I was also unable to make a connection with a controller iOS device via either WiFi or Bluetooth; there is a free DART remote app available which I gather is used in the suite of DART products.

On the positive side, there was a help function within the app which led to several splash screens of info in dense type, and a PDF manual.

  • COST – $16.99
  • EASE OF USE – 2/5
  • FIDELITY – 1/5
  • FUNCTIONALITY – 2/5
  • TOTAL SCORE – 1.5/5

Jonathon : this is the one I’m least keen on.  It doesn’t look like a real monitor screen at all.  It can do basic monitoring such as heart rate and rhythm, sats and respirations, but most of the more advanced features are premium add-ons, including the ability to remote control the simulator.  It does have a simulated defib and pacing unit, but the clunkiness of the interface lets this down as a potential positive.  

Doesn’t simulate a generic monitor so will likely confuse students. DART remote allows scenarios to be built but appears quite complex, requiring a lot of time to input.

I quickly discounted D.A.R.T Sim from my options for use in teaching.

  • COST – $16.99
  • EASE OF USE – 2/5
  • FIDELITY – 1/5
  • FUNCTIONALITY – 2/5
  • TOTAL SCORE – 1.5/5

 

 

SIM MONITOR (Med-eSim Apps)

Tim : I struggled initially to get SimMonitor to work, but was aided by the funky video below.

Sadly however I could only tolerate about 45 seconds of this before the soundtrack made me want to hurl the iPad across the room. Thankfully by this stage I had gleaned enough to at least work out how to connect the student and teacher iPads and display waveforms.

Connection was relatively easy; the teacher screen allows selection of a wide variety of ECG waveforms and ABP, SpO2 and ETCO2. These changes are rapidly reflected on the student monitor. The next ECG can be selected and ‘queued;, allowing rapid progression through rhythm changes without fumbling. A CPR option displays the typical ‘CPR hump’ seen. There is a defib button, but this just discharges a fierce crackling (think mad scientists and Igor) rather than the usual ‘charge-ready-defib’ of more sophisticated trainers.

I also struggled to get the ETCO2 to display and to turn on/off other waveforms, other than by maniacally swiping at the monitor and hoping that waveforms would appear/disappear – hardly conducive to a good sim.

I understand that there are options to purchase more ECGs, image libraries and lab results – I did not pursue this, as although the app worked, it didn’t seem worth the money to pursue this further, given the poor fidelity of the monitor screen and difficult navigation.

There is a small sound library which was quite fun to use. This app is clearly better than the EKG trainer and DART SIM already reviewed, but lags behind the next app (which can be confused with SimMonitor, namely SimMon)

  • COST – $17.99
  • EASE OF USE – 2/5
  • FIDELITY – 2/5
  • FUNCTIONALITY – 2/5
  • TOTAL SCORE – 2/5

Jonathon : SimMonitor is a little better than the previous (DART SIm/EKG Trainer); it looks like a monitor screen and can be remote controlled by Bluetooth.  However, it is quite limited in its options e.g. the number of different sats traces that can be displayed. There is no defib or pacing function. It does however have a limited sound library, although these are not particularly high fidelity.

  • COST – $17.99
  • EASE OF USE – 2/5
  • FIDELITY – 2/5
  • FUNCTIONALITY – 2/5
  • TOTAL SCORE – 2/5

 

 

SIM MON (Castle Anderson Apps)

Tim : At $21.99 SimMon is clearly affordable. It is also incredibly easy to set up; it can either be run on two iOS devices (iPhone or iPad to control, another iPad as monitor screen) or as a standalone device (waveforms and numerics can be changed by touching the screen and selecting appropriately).

Initially I was very excited to see option to select one of four separate monitors in the ‘settings’ menu (Datex Ohmeda AS3, Nellcor N100, DataScope Passport 2 & Agilent ACMS M1177A) – however the actual screen displays do not change, just the audible tones, The only other thing that can be changed in this menu was the units for ETCo2 – as either kPa, mmHg or as a percentage (not a unit I am familiar with for this variable).

The display allows FOUR waveforms (ECG, SPO2, Arterial Waveform & ETCO2), with numeric values by the side. Additionally RR and a timer can be activated.

Available waveforms include :

  • ECG : NSR-AF-A/flutter-Junctional-LBBB-RBBB-ST elevation-SVT-VF-VT
  • SpO2 : Normal & Poor Perfusion
  • Arterial : Normal-Poor Perfusion-Under Dampening-Over Dampening
  • ETCO2 : Normal-Broncospasm [sic]-Severe broncospasm [sic]-Leaky Tube-Subsidising Relaxant-No reading

Touching on either waveform or numeric allows changes; waveforms are selected by menus, numerics changed by swiping up (increase) or down (decrease). Maybe I have got fat fingers, but I found it too easy to inadvertently change the parameter above or below the desired setting, which could be a problem.

In fact, the more I think about it, this IS a problem – the SimMon does not allow pre-recording of scenarios – all changes are made ‘on the fly’ either from the controlling iOS device or from the display monitor. This it is vital that any changes are made quickly and accurately.

Interestingly the ONLY alerts that I could elect to deterioration were changes in the audible tone of measured values – no alarms, which is in contrast to the usual in-built alarms on most monitors.

I could use this app for teaching on courses – it is cheap and allows changes to be made rapidly. I have seen it used on the ETMcourse to good effect. However the lack of functionality is frustrating and the lack of ability to trend values over time, to select from pre-planned options and flip rapidly from one rhythm (and associated values) to another is frustrating. Similarly absence of alarms and defib/pacing/AED options limits utility.

  • COST – $21.99
  • EASE OF USE – 4/5
  • FIDELITY – 2/5
  • FUNCTIONALITY – 2/5
  • TOTAL SCORE – 2.5/5

Jonathon : SimMon has many more options for sats and ETCO2 traces.  Again it can be remote controlled by another iPad or iPhone, and I find this the best out of the reasonably priced apps. It looks like a real monitor and the parameters can easily be adjusted and enabled / disabled as needed.  There are no built-in scenarios so parameters have to be changed individually, and there is no pacing or defib function. S

cores are as above, except I’d give this 3/5 for functionality. As it stands this is my choice for teaching until I can convince the Trust to invest in ALSi!

  • COST – $21.99
  • EASE OF USE – 4/5
  • FIDELITY – 2/5
  • FUNCTIONALITY – 3/5
  • TOTAL SCORE – 3/5

The SimMon demo is below :

Video review is below :

Auckland HEMS comment here on their experience of using SimMon – as a bridge until purchase ALSi !

 

ALSi (iSimulate)

Tim : Along with their CTG app (CTGi), ALSi is a fully-functioned app from iSimulate. It is an order of magnitude more in cost than the other apps, but certainly delivers in functionality and fidelity.

It comes neatly packaged with two iPads, wi-fi base station (bluetooth connectivity is OK), housed in a tough transport monitor bag from Neann (makers of excellent prehospital bags) and encloses chargers, power cords and sphygmanometer cuff, ECG leads and pulse oximeter. There is enough space inside the bag to store a few adjuncts such as ETT, laryngoscope, EZ-IO, IVs , LMAs and other adjuncts. Or your lunch…

Connection is simple via wi-fi or Bluetooth. Once started the app opens a huge variety of options, including

  • huge library of ECGs (electrolyte abnormality atrial and ventricular dysrhythmias, arrest rhythms, paeds rhythms, trauma, conduction abnormality etc)
  • variety of ETCO2, SPO2 and NIBP waveforms
  • quickpick library of scenarios which allow change of ECG, SpO2, ETCo2 and BP); these can either be activated immediately or allowed to trend over as little as 10 secs to as much as 15 minutes
  • sound libraries, which can be customised (add own sound effect, brilliant for streaming to a bluetooth speaker hidden in mannikin)
  • image and lab libraries, fully customisable
  • option of monitor, AED or defib screen modes
  • -pause, alarm mute and screen invert functions

It’s probably best to just download and have a play – ALSi offer a free 28 day trial. You will need two iPads to make this work – but it is worth it.

  • COST – $4.9K for lifetime licence, or $1K per annum subscription
  • EASE OF USE – 4/5
  • FIDELITY – 5/5
  • FUNCTIONALITY – 5/5
  • TOTAL SCORE – 4.5/5

Jonathon :  ALSi is definitely the premium simulator.  It resembles a monitor, has defib and pacing functions, and scenarios which include steps which can be auto-activated by the defib – no more obvious clues about when a rhythm is about to change.  It simulates CPR and PEA with one tap of a button.  Custom parameters can be added.  The sound library is good and can be added to. The big down side of ALSi is the price – buy in to lifetime licences is thousands of pounds, which is only within reach of institutions.  The full kit is only a little more, and truly resembles a monitor in a bag with ECG and sats leads, although they are not functional – could achieve this with out-of-date kit from medical electronics.

Its price means this would be an institutional purchase rather than a personal one, so may have implications for sim practitioners in institutions where sim isn’t a budget priority.

  • COST – $4.9K for lifetime licence, or $1K per annum subscription
  • EASE OF USE – 4/5
  • FIDELITY – 5/5
  • FUNCTIONALITY – 5/5
  • TOTAL SCORE – 4.5/5

 


 

THE VERDICT?


 

  • ALSi                       4.5/5
  • SimMon                2.5/5
  • SimMonitor          2.5/5
  • DART SIM            1.5/5
  • EKG Trainer          1/5 (NB: iPhone version scored 1.1/5)

 

Any decision on purchase of a sim app will be guided by needs, functionality and affordability.

Although not trialled, Laerdal’s SimMan seems to be the traditionally preferred choice by standalone simulation centres. But SimMan is CRAZY expensive and not suited to mobile sim – a major drawback, as concentration of simulation in a dedicated centre fails to address the peculiarities of different teams, equipment and locations. Far better to have an option that allows sim on the floor in ED, OT, ICU, wards or even consulting rooms and pre-hospital. There is just no point in having one-off sim in a sim centre unless supported by regular low-fi repetitive sessions as mobile sim.

ALSi is in a league of it’s own amongst the iOs apps tested - yes it’s more expensive than the other iPad based apps, but the sheer range of options, the personalised support and the future vision make it the preferred choice of serious resuscitationists. ALSi is used for training in Australasian ALS course, by leading retrieval services such as RFDS, medSTAR and GSA-HEMS, by paramedic training organisations and by tertiary hospitals.

SimMon is a distant second, but far less functioned than ALSi – think of it as an old kiddies pushbike compared to the Mercedes-Benz of ALSi. It is clear that are comparing apples with oranges when put ALSi up against it’s rivals.

The other apps are little more than toys – cheap, but nowhere near approaching the fidelity or functionality of ALSi. Not Mercedes-Benz, not even pushbikes – perhaps those little plastic toys you get in Xmas crackers…

Jonathon : Overall, ALSi is the highest-fidelity sim app and is great for institutions.  As I’m a trainee and rotate all around the region, it’s unlikely that I’m going to be able to convince every Trust to buy it so for me, SimMon is my favourite.  It’s the best of the reasonably priced apps and adds a lot of realism to scenarios.

Tim : Although it may seem pricey, ALSi offers a robust and realistic training package at fraction of the cost of only serious rival (SimMan, $17-110K). The after sales support is superb and the price is easily covered from most educational budgets and is easily affordable by an institution. I quarantined two days worth of rural upskilling grant to purchase mine. I would recommend it if you are serious about running sim in the workplace or as on courses. Whilst pricier than the other apps, it is still far, far, far cheaper than the only other contender, Laerdal’s SimMan. It is also highly portable allowing regular repetition of sim training in the workplace rather than in a sim lab.

In short, ALSi “grills my corn”

 

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