How does SIM work?

How a SIM case is run

Overview of running a case:

•Cases are designed to give learners the opportunity to work as a team to diagnose and treat common emergent presentations 

•Cases are designed to accommodate 4-5 learners at a time filling the following roles: Team lead, Historian, Physical exam, Airway, and Procedures

•8-10 minutes of active case time (or untimed in practice)

•10-20 minute debrief after the case

•Teams are graded on clinical management, communication, and teamwork

Resources required to run a case:

•5 learners per team

•2-3 moderators to give history, PE, control the mannequin, provide consults, labs & imaging when prompted by team

•SIM case that moderators thoroughly review beforehand

•1 mannequin with vitals on screen

•1 crash cart with equipment required for the case (e.g. BVM, intubation supplies, defibrillator, etc.)

•1 white board

•Any other task trainers required for the case (e.g. chest tube trainer, LP trainer, etc.)

See SIM alternatives section below for alternatives if you do not have access to the above items

SIM case positioning

Positions in a SIM case

•Team lead – organizes communication, initiates pauses, and makes final decisions on orders

•Historian – talks with patient and family to collect a history and keeps them in the loop

•Physical exam – performs physical exam on patient

•Airway – closely monitors vitals, keeps patient informed, and intubates when necessary

•Procedures – Connects patient to monitors and performs any required interventions

Ideally, each member should switch positions frequently to get broad exposure to each role.

See below for a more detailed explanation of each role

See SIM alternatives section below for alternatives methods to divide roles

Positions in a SIM case (detailed)

Team lead:

· Asks the Team to don universal precautions

· Gives direct orders for what ought to be done after hearing the intro

· Asks Airway to secure the airway & breathing

· Asks Physical exam to check for pulses

· Asks Procedures to put the patient onto the monitor

Team lead never has their hands on the patients but should have their eyes on the patient at all times. The lead will be facing the vitals monitor and is in charge of monitoring the vitals and giving updates if the patient appears to be changing. As team lead it is your job to coordinate the rest of your team members. You will call case pauses to discuss the patient status as well as work with your teammates to come up with a series of differentials. 

Team lead will direct the code in the event of a crashing patient.

Physical Exam:

· Secures the "C" the ABC’s (circulation)

· Waits for Team lead's cue before performing full exam

· Checks heart and lung sounds

· Performs head to toe basic physical exam with focus on the organ system(s) relevant to the case

Physical exam will help secure the ABCs and will work to find any physical findings. When I have seen physical exam do well they often engage with the patient. They are sure to ask “does this hurt?”, “what does it feel like”, “where is the pain the worst?”, etc. while doing the examination.

Physical exam will initiate CPR in the event of a crashing patient.

Airway:

·Secures the “A" and "B" the ABC’s (airway and breathing)

·Performs any intubation

·Provides oxygen if necessary, via NC, NRB, BVM, etc

·Stabilizes C-spine if the patient is flipped

·Communicates with patient and keeps them Informed throughout the case

The best way to secure the patient’s airway is to tap the patient on the shoulders and ask them how they are doing. If the patient is able to respond, then you know that the patient has a non- compromised airway and is able to breath. If the patient is unresponsive you should report this to the team lead immediately as ABCs are NOT intact.

Airway will manage the airway in the event of a crashing patient.

Historian:

·Collects Information from the patient, family, or EMS

·Helps to keep family or patient calm In the case so the team can focus

·Relays a focused history to the team

·Always collects PMHx, medication allergies, and current medications

·Mnemonics such as OLDCARTS or OPQRST can be helpful to collect pertinent information

·Call consultants when needed

The Historian is constantly active and engaging with both the patient/ family and team lead. This role Is crucial to keep everyone involved on the same page.

Historian will record interventions on the white board and keep the team following ACLS algorithms in the event of a crashing patient. 

Procedures:

·Establishes "OMI"

     ·Places blood pressure cuff, finger pulse oximeter, and ECG monitor leads

·Places IV if needed

·Performs any procedures (other than intubation) as needed: chest tube, needle decompression, paracentesis, tracheostomy, etc.

·Performs POC ultrasound Including the E-FAST exam

·Gives medications

·Writes all orders and ddx on the white board

Procedures will have a constantly variable role. Specific tasks during the case will depend on patient presentation but will always perform any intervention that is required.

Procedures will place defibrillation pads and alternate with Physical exam to perform CPR in the event of a crashing patient. 

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Flow of a SIM case (see below for the suggested case flow)

Case flow

Terminology

Pause - Case pauses (called huddles in the TeamSTEPPS model) are brief (45 second-1 minute) meetings with every member of the team to establish situational awareness

Disposition - Teams decide where the patient will go from the ED. Options may include discharge, admission to medicine floor, admission to ICU, or emergent surgery.

Consultants - moderators acting as specialists to give hints in the case such as Cardiologists to help interpret ECGs, pharmacists to help with medication choices, General Surgeons to help determine if surgery is appropriate, etc.

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Role of moderators

Moderators will take on the role of guiding the case according to team actions. The above diagram illustrates the suggested role of each moderator throughout the case. 

Moderator 1 will present the chief complaint "one-liner" ("This is a 67 YO Male who presents with chest pain"), tell Physical exam whether breathing and circulation are intact ("breath sounds are heard bilaterally and 2+ femoral pulses felt"), present physical exam findings throughout the case, and constantly change the mannequin and vitals monitor to reflect the current scenario.

Moderator 2 will tell Airway whether airway is intact ("The patient is speaking and his airway is intact"), tell History the HPI and PMHx acting as the patient, family, or EMS, and provide labs and imaging results when they are requested by the Team.

Moderator 3 will act as a consultant, providing hints to the Team throughout the case whenever team members ask for consultations (radiology, cardiology, general surgery, etc), receive hand-off using SBAR when if the patient is admitted, and provide labs and imaging results when they are requested by the Team.

Vitals may be presented using physiology-driven simulation software, simple interactive vitals monitors (download one here) or simply writing them on a white board. Vitals should include HR, rhythm strip, BP, SpO2, RR, and temp. Moderators can also include more advanced metrics when relevant to the case such as blood glucose, EtCO2, and A-line MAP. See figure 1 below

Physical exam can be gleaned from examining high-fidelity mannequins or through a "Q&A" method. Learners should elicit findings by asking specific questions. For example, asking "are cranial nerves intact?" is insufficient. Appropriate dialogue may appear as follows:

   Physical exam: "Looking at the pupils, do they constrict with light?"

Moderator: "Yes, you have PERRLA."

Physical exam: "Looking in the mouth, what do I see? Is a gag reflex present?"

Moderator: "There is no elevation of the soft palate and the uvula is deviated right."

History should be requested in a Q&A format similar to OSCE-style encounters. Moderators should refrain from giving information not solicited by learners unless a hint may be needed. If the patient cannot give a history in the clinical context, the moderator may act as family members or EMS. Appropriate dialogue may appear as follows:

   Historian: "When did this chest pain start?"

Moderator: "It started about an hour ago."

Historian: "Can you describe It for me? Does it radiate or get worse with activity?"

Moderator: "It's a constant, stabbing pain in the center of my chest. But it doesn't radiate anywhere."

Lab results can be shown digitally or simply written on a white board in the fish-bone format. To aid more novice learners, reference ranges or arrows indicating high/low values should be provided. See figure 2 below

Imaging/ECG can be provided (without interpretation) as a digital image or printed on paper. See figures 3 and 4 below

Case debrief

Debriefing is a critical component of medical simulation as it provides an opportunity for learners to reflect on their performance, identify areas for improvement, and integrate new knowledge and skills into their practice. Debriefs should be led by moderators, first asking teams what went well and allowing them to self-reflect. Afterwards, teams can be asked how they can improve their team work and communication. Moderators should provide constructive feedback. 

Then, moderators can use the remaining time to discuss clinical areas for improvement. When feasible, thorough debriefs are preferred. They should last 10 to 20 minutes.

 

Effective debriefing can promote patient safety and improve communication among healthcare providers. Here are some tips for holding an effective debriefing session in medical simulation:

 

Create a Safe Learning Environment: Before starting the debriefing, it is important to create a safe learning environment where all learners feel comfortable sharing their thoughts and experiences. The debriefing session should be confidential and non-judgmental, and learners should be encouraged to share their perspectives on what did or did not work in the scenario. The facilitator should also establish ground rules for the debriefing session, such as avoiding blaming or shaming behaviors.

 

Use a Structured Debriefing Approach: A structured debriefing approach can help ensure that all aspects of the simulation experience are covered and that learners have a clear understanding of what they did well and what could be improved. During the debriefing phase, the facilitator should focus on asking open-ended questions, such as "what went well in the simulation?", "what could you have done differently?", "do you think everyone was on the same page?". This is opposed to directly calling learners out for particular behavior, unless that behavior was entirely unsafe or unprofessional. This type of structured debriefing improves rapport between the learners and the moderator while also helping learners get the most out of the session. The debriefing session should also include a discussion on how to improve communication among healthcare providers, such as using clear and concise language, closed loop-communication, and huddles.

 

Focus on Key Learning Points: After the communication and teamwork aspects of the case have been explored, the moderator can move on to a teaching role and explain the clinical aspects of the case. The moderator should explain how the case ideally should flow, working through ddx and management, and then provide specific feedback where teams strayed from the appropriate work-up. "White board teaching" where the moderator draws out diagnostic and pathophysiologic concepts is a great way to encourage learner interaction.

 

Leave Time for Questions: Learners may have a large range of emotions after a case from excited and encouraged to defeated and frustrated. Give learners an opportunity to ask any questions they have about team dynamics or clinical management so that they feel their concerns are valid and are being addressed to improve their simulation experience. Because engaging in SIM can make learners quite vulnerable, addressing specific concerns learners have will increase buy-in from team members.

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TeamSTEPPS Communication

One of the objectives of SIM cases is to promote effective and efficient team communication in order to promote safe patient care. In that vein, SIM incorporates communication tools outlined by the TeamSTEPPS curriculum. The following are tools used to aid in communication that should be prioritized throughout cases along with examples.


Team communication

SBAR is a technique that communicates critical information about a patients condition. SBAR is often used throughout SIM when calling consultants and at hand-off at the end of the case.


Situation - what is going on with the patient?

Background - what is the clinical context?

Assessment - what do I think is going on?

Recommendation - what should I do next?


In SIM cases, it is generally recommended to have the historian communicate with consultants, though this could in practice be performed by any team member. An example of SBAR is as follows:

Historian: “Hi, Medicine, we have a consult for you.”

Moderator: “Go ahead.”

Historian: 

•“We have a 72 YO F in the ED who presented with abdominal pain.” [Situation]

•“She had an ERCP 1 week ago for choledocholithiasis and is now presenting with epigastric pain & vomiting. Vitals stable.“ [Background]

•“Her lipase is elevated and I am concerned for pancreatitis. We have started fluid, pain control, and antiemetics.” [Assessment]

•”I feel that she warrants admission to your service. Could you come take a look?” [Recommendation]

Moderator: “Of course. Could you please call GI and add them to the loop. We will be down shortly.”


Call-outs can be used to provide critical information efficiently while keeping everyone on the team informed. It is essential that the person calling-out direct their attention to whomever they are addressing either by saying that person’s name, position, or making eye-contact. An example follows:

Team lead: “Airway, status?”

Airway: “Airway clear.”

Team lead: “Physical exam, breath sounds?”

Physical exam: “heard bilaterally.”

Team lead: “And blood pressure?”

Physical exam: “114/90 manual.”


Check-backs, a type of closed loop communication, act similar to call-outs but ensure that the information the sender gives is received. Check-backs are particularity helpful for interventions. Again, it is essential that the sender direct their attention to whomever they are addressing.

Team lead: “Push 1 amp epi”

Procedures: “1 amp epi push”

Team lead: “Heard.”


Team events

Briefs are used at the beginning of a case to identify team members’ roles as well as to discuss the plan for the case. The brief is essential for setting a precedent of a calm, organized communication climate. An example is as follows:

Moving clockwise around the bed

Team lead: “I am Taylor, team lead.”

Historian: “I am Tina, historian.”

Physical exam: “I am Amogh, physical exam.”

Airway: “I am Jack, airway.”

Procedures: “I am Dale, procedures.”

Moderator: “This is a 45 YO F complaining of acute chest pain.”

Team lead: “Everyone don PPE. Jack (points at Airway) asses airway and breathing. Amogh (points at Physical exam), asses circulation.  Dale (points at Procedures) establish monitors and IV.”


Huddles (also referred to in this guide as pauses) are quick, impromptu meetings that establish situation awareness and establish a plan. These huddles are dynamic depending on the situation but may appear as follows.”

Team lead: “Let’s take a pause” 

Everyone stops what they are doing unless it is CPR

Team lead: “Airway, updates?”

Airway: “The patient has become obtunded and is desatting, should we consider intubation?”

Team lead: “how are the breath sounds? Is he on oxygen?”

Airway “diminished bilaterally. He’s on 8Ls NRB”

Team lead: “Historian, do you have any new info?”

Historian: “Yes, his wife reports he likely overdosed on benzodiazepines.”

Team lead: “Okay, Airway, prepare for intubation. Procedures, gather 20 mg etomidate and 80 mg rocuronium.”

Airway: “Preparing for DL intubation”

Procedures: “Pulling 20 of etomidate and 80 of roc. Let me know when to push” 


SIM Alternatives

In settings where It may not be feasible to have all of the required equipment or people to run SIM cases as described above, some alternatives exist.

What if I don't have access to equipment or a SIM lab? SIM cases can be run around a table with paper cases and a white board. Don't be discouraged by lack of access to equipment. What is most Important is having buy-in from team members and motivated moderators.

What if my teams are smaller such as only four people? In situations where five team members are unavailable, a case can be run with four team members by combining roles. The Team lead and Airway should always be single roles, but Physical exam or Historian can be combined with Procedures as needed.

What if I don't have three moderators? Cases can technically be run fairly easily with two moderators or even just one. In these cases, team members will have to order the case components linearlly to accomidate the one moderator. Teams should ask for history first, then physical exam, and then interventions, etc. instead of asking for all at once.

What if I need to do SIM virtually? Virtual SIM platforms exist and can be used to teach clinical medicine and team dynamics just like In-person SIM. These platforms have significant limitations but can still be effectively used. See the resources tab for virtual platforms.

The above text and graphics are adapted from the Emergency Medicine Simulation Case Book by Taylor Terlizzese ©2023