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Foundational Analysis to Support Simulation Training System Design
Event Type
Poster Presentation
TimeThursday, April 152:00pm - 3:00pm EDT
LocationEducation and Simulation
DescriptionSimulation-based training systems should be tailored to the actual work environment of the envisioned audience of learners. After building an augmented reality (AR) based training system for combat medics, we began to explore strategies for adapting the training to medical students. While people who provide medical care on the battlefield and people who practice medicine in a hospital need to know how to treat traumatic injuries, there are vast differences in how they are trained. Foundational research into the work environment has implications for training design, especially with regards to training content and delivery.

We conducted a foundational analysis to inform the different requirements for systems built to support combat medic training and medical student education. We discussed simulation training needs with combat medicine and emergency medicine instructors, observed training in both contexts, and conducted a commercial needs assessment as part of a market research effort. The needs assessment included interviews with simulation facilitators, simulation center directors, and nursing and medical school instructors.

There are many factors that influence the simulation training needs for combat medics and medical students. First, the context in which they provide care differ in important ways. Combat medics must be prepared to deliver care in battlefield conditions with the equipment and supplies they carry with them. They may have to care for patients in austere conditions for several hours or days until the patients can be evacuated to a higher level of care. Medical students are training to deliver care in controlled settings such as hospitals and outpatient offices while working with other members of a healthcare team. They have access to more resources to help diagnose and treat patients (e.g., diagnostic laboratory tests, imaging equipment, other experts).

The educational curricula of combat medics and students in medical school also differ in ways that impact simulation training design. Medical school is designed to provide students with a general medical education to serve as a foundation for later specialty-specific training. There is an emphasis on understanding the underlying anatomy, physiology, and pathophysiology and how they relate and manifest in human disease. Combat medics enter training specifically to become medics, and their curriculum focuses on the rapid identification of life threatening injuries, their associated treatments, and developing procedural competency from a much earlier time in their training. Combat medics tend to receive more hands-on training earlier than medical students.

Implications for Simulation Training Content:
Medics and physicians are trained to evaluate some types of injury cues differently, due to their different care delivery contexts. Combat medics are often in environments where noise is an issue – they may be in a noisy helicopter, or their ability to use tools such as stethoscopes are inhibited by their helmets. Therefore, they are taught to pay attention to visual and tactile cues. Physicians are able to use stethoscopes and operate with less background noise, so can use auditory cues. For example, in recognizing a tension pneumothorax (in which one lung is not inflating as fully as the other lung), a combat medic is trained to feel for and look at the rise and fall of the patient’s chest to identify any asymmetry in movement. A physician’s training mostly emphasizes listening to breath sounds in both sides of a patient’s chest with a stethoscope to identify lung pathology.

Training content also needs to accommodate differences in treatment goals, scope of care, and how learners are assessed. Combat medics mostly treat trauma injuries obtained on a battlefield (e.g., massive hemorrhage, airway injuries, tension pneumothorax, etc.). Their treatment goals include stabilizing the patient enough to be transferred to a higher level of care. Because physicians treat a variety of medical conditions in addition to trauma, medical students must first learn how to assess patients using physical exams and medical history to narrow down the list of possible causes that led to a patient’s current state. Learners in these two domains are evaluated differently, and the content of a training system should be tailored appropriately. Combat medics are evaluated on competency of implementing appropriate interventions under battlefield conditions. Medical students are evaluated on how well they conduct the patient assessment; implementing therapeutic interventions is less critical at this stage of their medical education.

Implications for Simulation Training Delivery:
Differences in work environment and educational curricula also impact how simulation training is delivered. Combat medics are often trained by experienced medics who are currently assigned to be instructors. While these instructors may be expert medics, their skills as instructors vary widely. Medical school instructors choose to be instructors, teach regularly, and have more opportunities to develop and refine their instructional skills. Simulation training is delivered differently in the two contexts. Simulation training often occurs in a dedicated simulation center for medical students, but in classroom or field environments for combat medic trainees. Because many medical schools have dedicated simulation facilities, they also are likely to have dedicated staff who are well trained in how to set up and run simulations.

The features built into a simulation training system need to accommodate differences in instruction and debrief style. Both types of instructors benefit from support in setting up simulation scenarios; however, medical school instructors might tailor existing scenarios on the fly to address a perceived gap in the learner’s performance (e.g., increase the heart rate until the learner recognizes the missed cue of fast heart rate). During scenario debriefs, combat medic instructors identify correct and incorrect actions often organized around a standardized scoring rubric. Medical school instructors are more likely to engage in a tailored discussion with the learner to explore the learner’s understanding, uncover misconceptions, and consider implications for similar cases. A training system built for both audiences must support both types of debriefing activities.

Physicians work as the leaders of a multidisciplinary healthcare team and therefore often train in teams. Limited resources in simulation centers also necessitate team training for medical students. Combat medics are often put through simulations individually, although other students may watch as they wait their turn. An AR simulation training system with multiple headsets could support different team roles in medical school training. For combat medic training, multiple headsets can support students as passive observers as they wait their turn in the “hot seat,” as this more accurately reflects their role on the battlefield as solo practitioners.

Summary and Conclusions:
Superficially, it seems that training scenarios for recognizing and treating trauma would be applicable to a range of emergency medicine practitioners. However, training optimized for one environment may have important drawbacks when implemented in a contrasting environment. As we began to transition training designed to support combat medics to a medical school audience, we uncovered important differences in training culture that influenced both training content and training delivery.

To develop effective simulation training, system designers should understand the context in which the learners will train and work. While combat medic and medical school students both learn about attending to patients suffering from traumatic injuries, the training system requirements for each group differ in significant ways. Specific variables to consider include context of care; educational curricula; treatment goals, scope of care, and learner assessment criteria; instructor skill, culture, and resources; debrief practices; and team versus individual training.

Acknowledgements
This work is supported by the US Army Medical Research and Materiel Command under Contract No. W81XWH-17-C-0162. The views, opinions and/or findings contained in this paper are those of the author(s) and should not be construed as an official Department of the Army position, policy or decision unless so designated by other documentation.