Simulation in critical
care training has
exploded over the
last decade, but
its application to
neurocritical care has
been met with some
skepticism. High-fidelity
simulation aims to
create safe learning
environments that
mimic real-life scenarios. This involves accounting for the actions
or elements to be learned, the interactions between them and
key environmental factors. Employing high-fidelity simulation to
train physicians in the management of neurological illness is not a
new concept. It dates back at least to the 1960s when Dr. Howard
Barrows described the use of standardized patients to “effectively
enact coma, seizures, sensory loss, reflex changes and blindness.”
Proponents for the use of high fidelity simulation training in
neurocritical care report multiple unique benefits, including:
1) Exposure to rare but fundamentally important diseases
Fellows are frequently the initial decision makers for in-house
emergencies and need baseline competency in neurologic
emergency management at the start of their training. However,
this is often not the case, as trainees enter fellowship from diverse
backgrounds (e.g., neurology, neurosurgery, internal medicine,
anesthesiology, emergency medicine). Even for neurology and
neurosurgery residents, work hour restrictions and regionalization
of care may limit exposure to core elements of practice. Creating
a simulated orientation or incorporating it into an existing one
can serve to quickly bring a group of learners to a unified starting
point. This can also account for institution-specific environmental
factors, which may differ from previous training.
2) Direct observation and timely feedback
In traditional didactic sessions, the ability to retain and apply
content is difficult to assess. High-fidelity environments allow
for direct observation of and timely feedback on trainee
performance. During a simulated scenario, one can observe a
trainee’s situational awareness, problem-solving skills, leadership
ability, effectiveness of communication and command of available
resources without risk of harm to patients. Performance can then
be debriefed in real-time without concern that the trainee is not
cognitively able to process the feedback, which can be the case
following an actual acute patient event.
3) Learner evaluations are consistently higher for simulated curricula
Surveys given to trainees have repeatedly shown overwhelmingly
positive feedback regarding the perceived utility of simulated
exercises. The hands-on nature of simulation commands better
attention and participants frequently note forgetting they are in a
training environment. Not only do trainees report the experiences
as enjoyable, but also that they feel a greater sense of confidence in
their ability to perform in clinical practice.
4) Simulation can be made accessible via an online platform
Serious games are medical gaming programs that can be
designed as single or multiplayer virtual environments. They
afford many of the benefits of in-person simulation and have the
added benefit of being accessible anytime and anywhere. They
also have the potential to overcome many of the limitations
specific to using high-fidelity simulation for neurological
presentations. They present a relatively untapped opportunity for
neurocritical care education.
While some have successfully incorporated simulation into their
neurocritical care training curricula, others frequently site the
following three limitations as reasons for avoiding doing so.
1) Inability to accurately simulate neurological findings for
advanced trainees
Requiring the advanced learner to accept a standardize patients’
give-way weakness as real can subconsciously compromise the
scenarios’ degree of fidelity. Furthermore, many focal findings
are neither able to be enacted by standardized patients nor
programmed into currently available simulators.
2) Neurological emergencies often co-manifest
A patient with a subarachnoid hemorrhage who seizes, rebleeds
and begins to herniate is one possible neurological
equivalent to the “mega-code” scenarios of ACLS. Individually
simulating each disease scenario does not adequately prepare
the trainee to prioritize and multitask. However, simulating
multiple neurological processes simultaneously increases the
potential for variability in interpretation of key signs and
symptoms. This creates uncertainty for educators designing
curricula who need to be able to predictably cue learners
through the intended learning objectives.
The State of
Neurocritical
Care Simulation
Training: Have We
Fallen Behind?
Catherine Albin, MD, and Deepa Malaiyandi, MD
Catherine Albin, MD Deepa
Malaiyandi, MD
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