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Lifelike mannequins, advanced technology and seasoned staff provide a range of simulations to make everyone from new nurses to surgical residents more confident and better trainedDoug Nicholson

Lifelike mannequins, advanced technology and seasoned staff provide a range of simulations to make everyone from new nurses to surgical residents more confident and better trained.

Mr. Clooney isn't responsive. He's recovering from emergency surgery after a motor vehicle collision. His breathing is slow – just six breaths per minute. When the nurse enters his room, she knows right away something isn't right. She calls her colleagues for help, and a group of four nurses enters the room. They look a little nervous. Understandably: It's their first day on the job.

What better place to work out the jitters than here: Nursing Orientation Day at Sunnybrook Canadian Simulation Centre. Mr. Clooney is a very real-looking, computer-operated mannequin, also known as a simulated patient. He has a pulse. He breathes, talks, moans and groans.

That is, when Susan DeSousa, Simulation Centre Co-ordinator, speaks into a microphone from the simulation control room. She also controls Mr. Clooney's vital signs, and determines how he reacts to the interventions.

"The simulation isn't meant to replace the participation in the operating room. It is meant to enhance it," says Dr. Shady Ashamalla, who trains staff in laparascopic surgery in Sunnybrook's Simulation Centre.

Photgraph By: Tim Fraser

"These scenarios always have a focus on teamwork and communication," DeSousa says. "There are other learning objectives. In Mr. Clooney's case it's about demonstrating respiratory and airway management, but there is always an element of communication involved."

New nursing hires at Sunnybrook are required to attend the simulation session as part of their corporate nursing orientation. In 2012, more than 250 nurses attended the simulation education day. It ensures that new staff understand hospital protocols, and practise essential elements of teamwork and communication with their colleagues.

Mr. Clooney's nursing staff safely administer the appropriate dose of a drug called Narcan, after they determine through various phone calls to the on-call physician and the rapid response team (also DeSousa in the control room) that he's having a reaction to the morphine he's been given for the pain.  Narcan is the antidote. The patient's condition improves, the scenario ends, and the team regroups in the debriefing room.

DeSousa talks through the scenario with the participants, who admit it was challenging and hard to communicate with others, as well as the observers who've been watching the situation unfold via a video link-up. They go over each step, with DeSousa offering tips and reminders about how to make a situation like Mr. Clooney's run a little smoother: introduce yourself when you enter a room if you don't know your colleagues; delegate tasks by name or pointing. By the time the team is ready for its next scenario, it's clear they've taken DeSousa's advice to heart.

Established in 1995, the Sunnybrook Canadian Simulation Centre was the first of its kind in the country. Through hands-on experiential learning, the centre provides multi-disciplinary, advanced health-care education to all levels of learners, from medical students to long-time physicians. Simulation mannequins and other advanced technologies allow trainees to experience very true-to-life scenarios in a controlled environment, with the ultimate goal of enhancing patient safety. In 2012, 1,415 people attended education sessions in the simulation centre.

This year, it celebrated the opening of its new surgical skills suite, an expanded 800-square-foot skills centre where basic and complex surgical skills will be taught to trainees of all levels. Evidence suggests simulation is particularly useful in teaching reproducible situations or technical skills that are used often in surgery.

Dr. Shady Ashamalla, a surgical oncologist, leads the laparoscopic surgery program. He says that while the observed apprenticeship model he trained under is effective, there is room for improvement.

"When I was training, the attending surgeon showed the trainee how to do it and then increasingly allowed the trainee to try different tasks," he explains, adding there was classroom work and lectures. "Gradually, you do more and more, and soon you are doing the whole surgery, and soon after you are teaching it." Now, in addition to the observed apprenticeship, there's simulation.

"It used to be that simulation was something trainees could do in their spare time, if they had any," Dr. Ashamalla says. "The University of Toronto is the first general surgery training program in the country to include simulation in the core teaching curriculum. Trainees have always had teaching time with lectures and now we have integrated simulation into that."

Simulation sessions with Dr. Ashamalla focus on basic and advanced technical skills, like knot-tying in minimally invasive surgeries. "The goal is to create a pre-trained novice," he explains. "The simulation isn't meant to replace the participation in the operating room. It is meant to enhance it. No one would say to someone, 'Here's a violin, watch closely while I play it. Practise it once a week on your own and then you are going to perform a concert.'"

When Dr. Ashamalla's surgical trainees enter the operating room, they already have the basic skills. They are much more comfortable and confident, and therefore are much more prepared to learn.

"If a trainee enters the OR and their main focus is how to hold the instruments while the attending surgeon is teaching a more complex aspect of the surgery, the trainee will absorb very little of this," he says. "They are concentrating on holding the scalpel right. Through simulation, holding the instrument becomes routine for the trainee and so they can absorb the other important information from the teaching surgeon – and become more advanced. This improves their technical skill at a much more efficient pace. Whether it's swinging a golf club, playing the piano, landing a jet or removing a cancer, technical skill will always be dependent on intense practice and repetition, and there lies the value of simulation."

For cardiac surgeon Dr. Fuad Moussa, using simulation to teach the highly technical off-pump coronary artery bypass procedure just made sense.

After a heart attack – caused by a narrowing or blockage in the arteries that supply blood to the heart – a cardiac surgeon builds a graft to go around the blockage and open the blood flow. Usually, the heart is stopped and the grafts are created. During off-pump coronary artery bypass (or beating-heart surgery) the cardiac surgeon builds the graft while the heart continues to beat on its own.

"It's highly technical and challenging," Dr. Moussa says. "Where I learned, 99 per cent of cases were done on a beating heart. To have the boss turn to you and say, 'Okay, now your turn,' it's overwhelming. When I came to Sunnybrook, I knew I would have to teach this procedure. I thought, there has to be a better way to teach this than the way I learned it. There just has to be."

Dr. Moussa set out to complete his master's degree in medical education and develop a better way to teach beating-heart surgery, using simulation. Working in collaboration with engineers from Colombia, and an educational scientist at the Wilson Centre for Research in Education in Toronto, Dr. Moussa mapped out the operation. The team analyzed the steps involved and found certain reproducible elements throughout the procedure. They arranged the tasks from the lowest level of complexity to the highest, then broke them into four different learning steps in a workshop. From there, Dr. Moussa worked with engineering students at the Universidad Pontificia Bolivariana in Colombia to build the beating-heart simulator.

"We were then able to conduct the workshop with surgical residents," he explains, "and found that the education using this framework for off-pump coronary bypass was effective and well-received by the participants." He has since received a grant through the Sunnybrook Education Research Committee to study it further with the hope it will be added to the cardiac surgery curriculum at the University of Toronto in the near future.

Post-graduate cardiac surgery resident Dr. Dimitrios Tsirigotis participated in Dr. Moussa's simulation session in August 2011. He was quite early in his surgical development at the time and reports the exercises were beneficial.

"The sessions served to make me feel more confident in that I left with a better understanding of some of the details associated with the procedure," he says. "Although it is difficult to judge the effect of a single-weekend exposure on my technical skills, I do feel that dedicated practice time with these techniques was helpful in making me more mindful of the technical nuances involved. The addition of simulation-based training techniques certainly augmented my educational experience, and I believe it can be used to optimize our training as residents."

Dr. Tsirigotis is now focusing his own academic efforts on surgical education with an emphasis on simulation-based training for technical skills. This past summer, he designed and implemented a boot camp for junior cardiac residents so they could get up to speed with some of the basic technical skills. He also worked with a larger team to design and conduct a preparation camp for incoming surgical residents.

Back in the simulation centre, Mr. Xu has extremely low blood sugar – he's moaning and groaning. A nurse enters the room, confidently introduces himself, and when Mr. Xu doesn't respond, he calls to his colleagues.

This time, a group of nurses enters the room. They introduce themselves one by one and each goes to task. Soon, Mr. Xu's blood sugar is back to normal. A voice over the speaker says: "Simulation over. Great job, everyone. Thank you."

The nurses can begin their first shift in their new workplace with clarity and confidence.

Critical care residents and fellow practise an ultrasound-guided procedure.

Photgraph By: Doug Nicholson

Simulation plays a key role in training for extremely rare situations or cases that can't be reproduced.

"This is often compared to the aviation industry. Pilots train hours and hours for various complex crash scenarios through simulation," says Dr. Shady Ashamalla, a surgical oncologist. "No one would ever crash a plane just so they could practise landing, and most pilots won't ever have to face the crash situation in real life. But, through simulated emergency scenarios, they are trained in these rare events so that should a crash ever occur, they can reach deep in their memory bank and respond appropriately."

A similar approach is now used to train new as well as experienced surgeons.

"There are complex situations in operating that I'm grateful to have never faced," Dr. Ashamalla says, "but should these scenarios arise, I would want to have practised or rehearsed this situation and be ready to spring into efficient action."

Cardiac surgeon Dr. Fuad Moussa agrees. He is in the midst of creating simulation scenarios for the cardiac surgery team based on extremely rare catastrophes. The surgeons, residents, anesthetists and nurses will all participate, he says. "People always say, 'Practice makes perfect,' but it's actually, 'Perfect practice makes perfect.' Simulation has such tremendous potential for education and training."

This content was produced by The Globe and Mail's advertising department, in consultation with Sunnybrook. The Globe's editorial department was not involved in its creation.

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