Abstract
To the Editor:
Simulation provides an opportunity for students to experience patient presentations that are infrequently encountered in the clinical environment. A growing body of evidence suggests that simulation can improve skills, protocol adherence, teamwork, and possibly patient outcomes.1,2 In the wilderness setting, simulated patient care experiences include the integration of factors such as terrain and weather. Because many wilderness emergencies occur only rarely, simulation in the backcountry setting allows students exposure to situations they may not encounter otherwise.
Traditionally, simulation in wilderness medical education has been done with actors playing the role of patients, with moulage and artificial scenes to add realism. 3 Although these scenarios have been beneficial in providing lessons in teamwork and group dynamics, more recent efforts utilize technology to improve simulation efficacy. Lareau et al 4 examined student perceptions of high-fidelity simulation in an advanced wilderness life support course. Participants rated the value of a high-fidelity simulation mannequin as a teaching tool and indicated that they hoped that the device would be used more frequently in future courses. One disadvantage of this approach is the high cost of the simulator (more than $30,000), as well as the risk of damaging the device. Saxon et al 5 evaluated a low-fidelity approach, using improvised materials such as tubing, tape, pork ribs, and other inexpensive items to create scenarios. While this approach sacrifices realism, it dramatically reduces costs and effectively increases performance.
We tested a middle-of-the-road approach and assessed students’ perceptions of “augmented” simulation training using electronic tablet technology. Medical students (n = 14) in a wilderness medicine elective were randomly assigned to one of two groups. Each group was exposed to both simulation types: group 1 participated in an augmented anaphylaxis case followed by a traditional trauma case, and at the same time, group 2 participated in a traditional anaphylaxis case followed by an augmented trauma case. The experiment was approved by the Institutional Review Board of Columbia University.
The traditional cases involved a patient actor with minimal moulage and descriptive prompts delivered by a moderator. The augmented simulation also involved an actor with moulage, but replaced verbal descriptions of examination findings with images and sounds on an electronic tablet. Evolving findings, such as hemorrhaging wounds, were displayed as video. Auscultated findings, such as respiratory sounds, were played on the tablet as well. Figure 1 depicts an example of the preceptor interface. Figure 2 illustrates how the tablets were used to portray findings. After the scenarios, the participants completed a questionnaire with Likert-type scale questions and a comments section.
The preceptor interface in tablet augmented simulations.
Images urticaria and angioedema were overlaid on patient actors during the augmented scenarios.
All participating students completed the questionnaire. In our small sample, responses indicated that students thought that the overall learning experience was enriched by the augmented simulation, and that the added realism attributed to the tablet-driven scenarios allowed for better visualization of the simulated cases. On a scale ranging from 1 (strongly agree) to 5 (strongly disagree), students generally thought that they learned from the enhanced simulation (mean 1.61, SD 0.79), and that they learned more from the enhanced simulation than from the unenhanced simulation (mean 2.39, SD 1.22). Few students felt distracted by the additional technology of the enhanced scenarios (mean 3.95, SD 1.14).
Narrative comments were consistent with the quantitative data. One student reported, “I felt pictures and video added immensely to the realism as far as clinical assessments and actual physical findings in the cases. Plus, they made them more fun!” Another commented, “Video is a leap toward improvement as are audio cues. More dynamic changes would utilize more the enhancements.” Critical comments referred to technical aspects of the simulation. One student wrote, “Audio was hard to hear.” And another wrote, “Sometimes not every student could see the tablet screen.” Another student also noted, “It takes a while to get used to sim environments. Having to ask preceptors for all the findings takes away from the experience [in traditional simulation]….Having to discriminate sounds and images [on the tablet] requires us to use clinical skills.” Preceptors noted more consistent presentation from one group to the next, fewer disruptions for clarification, more accurate appreciation of symptom severity, and more rapid achievement of critical actions.
Electronic tablet augmented simulation offers a balance between fidelity and practicality. Tablets are relatively inexpensive ($400 to $800) compared with other simulation technology, are lightweight, and are easier to protect from damage and to replace if needed. Using tablets allowed facilitators to choose from a variety of different stimuli based on the perceived clinical course of the patient. This “choose your own adventure” format helps show students what can happen both positively and negatively based on their actions. The tablets also reduced the need for exposition, minimizing interruptions in the scenario. Finally, given that tablets are becoming increasingly common in the educational setting, the potential exists for instructors to create and easily share physical stimuli and case descriptions.
As with any simulation device, the tablets add an artificial element that would not be present in a real scenario. Moreover, the devices have a finite battery life. There is also risk of malfunction or environmental damage. Some students reported difficulty due to screen glare and low audio levels. These issues could be addressed with antiglare covers and louder recordings. Furthermore, this method does not allow for procedural practice as did the models mentioned above. Lastly, the small sample size of this pilot study limits the extent to which the results can be generalized.
Electronic tablet augmented simulation may represent an additional tool by which to improve medical instruction in the austere setting. Further research would be needed with a larger population to verify these results and to objectively demonstrate its effectiveness as a teaching tool. The applicability of the technique will increase as wilderness educators begin to develop a robust library of video and audio resources to use during simulated cases.