Lectures and other didactic activities such as problem-based learning discussions centering on dynamic patient situations often revolve around patient vital signs and their change with various therapies and interventions. Options for displaying vital signs are limited to prepared slides or handwritten values or trends written on “blackboards.” Displaying of the patient's vital signs “live” allows faculty and trainees to interact, thus creating a tabletop simulation session, which can be useful in discovering the trainees understanding and comprehension of the concepts presented. Moderate capability simulators such as the Laerdal SimMan allows for the operator to control the vital signs presented on the monitor and when combined with the SimMan mannequin one can create a very realistic simulated patient encounter. However, the presence of the mannequin simulator may not always be needed to achieve the goals of the exercise or lecture. In addition, the presence of the mannequin may make portability a problem and could distract participants from the more important elements of the discussion. Screen-based simulators have been shown to be effective teaching tools when used by students in a variety of settings.1–3 In this report, we describe the use of commercial mannequin simulator software to generate, control, and project vital signs on a projector screen, with an appearance identical to that of its normal companion monitor that can be set up in less than 5 minutes (Fig. 1).
MATERIALS AND METHODS
Laerdal SimMan software version 3.3.1(Laerdal Medical, Stavinger, Norway) is installed on a laptop computer running Microsoft Windows XP as described in the manufacturer's instructions. Alternatively, the laptop accompanying a functional SimMan can be disconnected from all mannequin links and used as such. Any video projector with either VGA or S-video inputs can be connected to a computer with either of these outputs (Fig. 2) and serve as the “monitor.” Running the SimMan software in a two-screen mode generates the monitor display. Instructions for displaying on the second screen are provided in Figure 3.
Content of Monitor Display
Although the projector/monitor can be used with any of the monitor displays in the SimMan software package (selected in the “View → Select Patient Monitor Setup” pull-down menu), it may be more desirable to prepare a series of custom displays that can be added in layers as your lecture or discussion unfolds. For example, an emergency or critical care scenario would start with a monitor displaying a noninvasive blood pressure, oxygen saturation, and electrocardiogram (ECG) display as one would normally find in the emergency department. If the trainees decide to place an arterial line, a switch in monitor display to the next layer containing an arterial line can be made using the “View → Select Patient Monitor Setup commands.” With this method of using layered monitors, the screen quickly changes without any change in the vital signs or scenario. Similarly, additional layers with central venous pressure, pulmonary artery, and end tidal CO2 waveforms can be added on according to the flow of the scenario and choices made by trainees. Displays can be customized by entering the “Edit → Edit monitor Setup” menus and either creating a new monitor configuration or modifying an existing design and saving it under a new name. Monitor settings are saved in the default folder allowing future use.
When programming monitor displays, the author has found it useful to select the “Idle” option in the “Initial State” dialog box when setting up the first monitor of a series. With this selection, the monitor screen appears blank until the SaO2, ECG, and non-invasive blood pressure devices are selected for use. Otherwise, the monitor is filled with prompts such as “leads off/ no sensor/touch when sensor connected.” In scenarios where one of the objectives is to have trainees make and defend decisions regarding monitoring, the author found the screen prompts artificial and distracting.
So far, this technique has been applied in a number of training sessions in anesthesiology and critical care education, which are listed later. Participants have not been formally surveyed on their views regarding this technique; however, the author has found that adding this modality to existing lectures has generated additional interest and engagement of trainees.
Anesthesia Residents and Lecture on Vasoactive Drugs
After a traditional introduction to mechanisms and actions of inotropes and vasopressors and pharmacologic profiles, the monitor was used to play “name that drug” in which hemodynamic changes from a common baseline were displayed. A single monitor was used with display of ECG, arterial line, SaO2 and EtCO2.
Critical Care Residents and Fellows and Problem-Based Learning Discussion on Sepsis and Septic Shock
An emergency department patient presents with hypotension and confusion. Trainees are expected to demonstrate knowledge of patient evaluation and institution of early goal-directed therapy. Layered monitors (as described earlier) are used to display procedural interventions such as line placement and intubation. Vitals are changed live, according to pharmacologic and other interventions performed by the team.
Small Groups and Departmental Conferences, “Live” Case Conferences, and M&M
Vitals of cases under discussion are displayed as part of the presentation.
Internal Medicine Residents and Morning Report Discussion
Facilitated discussions of high-risk medical ward patients and their care.
We have not investigated into whether this modality of instruction leads to better performance in clinical practice, but it is certainly a reasonable avenue for further investigation.
Educational activities in certain domains of medicine focus on the acquisition and control of important physiologic functions that are displayed on bedside monitors. With use of the simulation technique presented here, the presenter can turn a standard lecture into a tabletop simulation session including the ability to present vital signs, x-ray, and ECG data, thus the discussions can take on a real-time dimension that may prove to be more engaging and memorable than traditional classroom sessions. We have chosen to present the use of the Sim-man software because it is the program that we are most familiar with, but it might be possible to use other simulation software in a similar fashion.
1.Nyssen AS, Larbuisson R, Janssens M, et al. A comparison of the training value of two types of anesthesia simulators: computer screen-based and mannequin-based simulators. Anesth Analg
2.Youngblood P, Harter P, Srivastava S, Moffett S, Heinrichs WL, Dev P. Design, development, and evaluation of an online virtual emergency department for training trauma teams. Simul Healthc
3.Owen H, Mugford B, Follows V, Plummer JL. Comparison of three simulation-based training methods for management of medical emergencies. Resuscitation