**Emergent Procedure Training in the 21st Century**

Ernest E. Wang *NorthShore University HealthSystem,University of Chicago Pritzker School of Medicine USA* 

#### **1. Introduction**

94 Emergency Medicine – An International Perspective

Zhou, S. B. and W. Q. Zhang (2011). "The discussion of clinical teaching in emergency

Zhou, X. P. (2007). "Discuss the application of "seven emotions" to cure and cause diseases

46-47.

*Medicine* 29(6): 69.

department of TCM hospitals " *Chinese Journal of Traditional Chinese Medicine* 9(16):

into TCM emergency nursing." *Journal of Guiyang College of Traditional Chinese* 

Procedural competency is a substantial part of the emergency physician's (EP) skill set. Emergency Medicine (EM) is unique in that the practicing EP must be comfortable with a wide array of procedures that have the following features: 1) They span the entire human body and cross many disciplines in medicine and surgery; 2) There are both invasive and non-invasive procedures; 3) They occur at unpredictable frequencies and never on a schedule; 4) They often need to performed under significant time-pressure; and 5) The patients they need to be performed on are often critically ill and unstable.

The Model of the Clinical Practice of Emergency Medicine (EM Model) serves as the guide for the content expertise that EPs are expected to have as active practitioners in the specialty. The EM Model was first developed in 2001 by the Core Content Task Force II and involved the collaboration of six EM organizations: the American Board of Emergency Medicine (ABEM), the American College of Emergency Physicians (ACEP), the Council of Emergency Medicine Residency Directors (CORD), the Emergency Medicine Residents' Association (EMRA), the Residency Review Committee for Emergency Medicine (RRC-EM), and the Society for Academic Emergency Medicine (SAEM).(1) It has undergone biannual revisions with the most recent revision in 2009. The EM Model specifies the types of procedures representative of the domain of emergency medicine (Table 1).(2) These include procedures such as: airway techniques, anesthetic techniques, bedside and procedural ultrasonography, obstetrics, resuscitation, head and neck procedures, thoracic procedures, skeletal procedures, vascular access, wound management, genitourinary procedures, gastrointestinal procedures, lumbar puncture, and others.

The procedures in the EM Model can be roughly divided into two groups, high and low frequency, and two types, higher and lower risk (Table 2). EPs need to be able to perform high frequency procedures precisely and reliably so as to minimize complications and morbidity. EPs need to be able to be proficient with infrequent high risk procedures so that when the situation arises (usually unpredictably and under significant time pressure), they have the greatest chance to complete the procedure successfully.

Prior to the advent of simulation-based trainers, traditional training opportunities consisted of cadaveric experience or through the apprenticeship model, succinctly described by the ubiquitous medical adage "See one, do one, teach one." These methods provided limited training opportunities due to expense and scarcity (cadavers) or due to unpredictable

Emergent Procedure Training in the 21st Century 97

Cricothyrotomy

ventilation Cystourethrogram Pericardiocentesis Thoracentesis

abscess Removal of rust ring Lateral canthotomy Peripheral venous cutdown Delivery of newborn Gastric lavage Escharotomy

 Compartment pressure measurement Bladder catheterization (Suprapubic) Drainage of peritonsillar

 Neonatal resuscitation Cutaneous cardiac pacing Transvenous cardiac pacing

 Regional anesthesia Paracentesis Tooth stabilization Excision of thrombosed hemorrhoid

nose, skin)

Foreign body removal (ear,

Gastrostomy tube replacement

Thoracotomy

 Foreign body removal (Airway) Percutaneous transtracheal

Higher frequency Lower frequency

Airway adjuncts

Intubation

Capnometry

Lumbar puncture

techniques Thoracostomy

 Local anesthesia Anoscopy Arthrocentesis Bedside Ultrasound Procedural Ultrasound Nasogastric tube Slit lamp examination

Tonometry

 Laryngoscopy Intraosseous infusion Incision and drainage Nail trephination

(nasopharyngeal airway, oropharyngeal airway)

Mechanical ventilation

 Non-invasive ventilatory management Sedation – analgesia for procedures

 Blood, Fluid, and Component Therapy Administration

 Control of epistaxis (posterior) Arterial catheter insertion Central venous access

 Cardiopulmonary resuscitation Fracture/dislocation reduction

 Bladder catheterization (Foley) Control of epistaxis (anterior)

 Wound closure techniques Fracture/dislocation

immobilization techniques

exist and relative risk is dictated by patient co-morbidities and clinical presentation. Table 2. Categorization of EM Model Procedures by frequency and risk\*\*.

\*\* Categorization of the procedures in this table recognizes that local variations in procedural frequency

chance presentations (clinical patient care). As a result, it was not uncommon for residencytrained graduates to have little or no experience with rarely performed procedures. It also resulted in the potential for incomplete or unrefined command of the necessary steps for successful completion of complex or high stress procedures. Recent changes in residency

Higher risk

Lower risk

\* Adapted from the 2009 Model of the Clinical Practice of Emergency Medicine

Table 1. Procedures and Skills Integral to the Practice of Emergency Medicine\*.

\* Adapted from the 2009 Model of the Clinical Practice of Emergency Medicine

Table 1. Procedures and Skills Integral to the Practice of Emergency Medicine\*.


\*\* Categorization of the procedures in this table recognizes that local variations in procedural frequency exist and relative risk is dictated by patient co-morbidities and clinical presentation.

Table 2. Categorization of EM Model Procedures by frequency and risk\*\*.

chance presentations (clinical patient care). As a result, it was not uncommon for residencytrained graduates to have little or no experience with rarely performed procedures. It also resulted in the potential for incomplete or unrefined command of the necessary steps for successful completion of complex or high stress procedures. Recent changes in residency

Emergent Procedure Training in the 21st Century 99

solving and evaluation, and opportunities for repeated performance to refine behavior."(8) McGaghie et al. have further defined the necessary conditions for DP to be effective (Table 4).(9-10) These features are listed in order of reported frequency (percent) among the final BEME pool of 109 articles.These include immediate feedback, repetition, increasing levels of difficulty, clinical variation, simulation providing valid representation of clinical practice,

1. Feedback is provided during learning experiences (47%) 2. Learners engage in repetitive practice (39%) 3. Simulation is integrated into an overall curriculum (25%) 4. Learners practice tasks with increasing levels of difficulty (14%) 5. Simulation is adaptable to multiple learning strategies (10%) 6. Clinical variation is built into simulation experiences (10%) 7. Simulation events occur in a controlled environment (9%) 8. Individualized learning is an option (9%) 9. Outcomes or benchmarks are clearly defined or measured (6%) 10. The simulation is a valid representation of clinical practice (3%)

\*Adapted from McGaghie et al. Lessons for continuing medical education from simulation research in undergraduate and graduate medical education: effectiveness of continuing medical education: American College of Chest Physicians Evidence-Based Educational Guidelines. Chest. 2009 Mar;135(3

Literature across multiple medical disciplines supports the efficacy of simulation based procedural training with deliberate practice. Wong et al. demonstrated that repetitive practice of cricothyroidotomy on mannequins leads to reductions in procedural performance times and improvement in success rates.(11) Barsuk et al. demonstrated improved safety and decreased central line infections after simulation-based central venous catheter insertions.(12) Draycott et al. demonstrated improved neonatal outcomes after shoulder dystocia training.(13) Andreatta et al. reported that simulation-based mock code training significantly correlated with improved pediatric patient cardiopulmonary arrest survival rates.(14) A meta-analysis performed by McGaghie et al. reported that simulationbased training with DP is superior to traditional clinical medical education in achieving

Additionally, Weinger argues that, in order to achieve the maximal desired effect, procedural skills acquisition and retention likely occur in a dose-response relationship, similar to drug pharmacology, with the best retention achieved using intermittent regular repetition over time rather than in single-day course training.(16) Interval simulation training over time makes intuitive sense, allowing for consolidation of training lessons and refining of muscle memory. Learners can break down procedures into their basic steps and focus on those particular steps that they have more difficulty with or feel they need to work

Table 4. The Ten Conditions Necessary for Effective Deliberate Practice\*.

and a controlled environment.(9-10)

Suppl):62S-68S.

specific clinical skill acquisition goals.(15)

work hour restrictions may also lead to limitations in clinical patient contact. The RRC-EM has recommended that residency graduates be exposed to a core group of procedures and resuscitations during residency training (Table 3).(3) The guidelines specify that these experiences may occur during patient care or in simulations.


\* Covered in separate Procedural Competency Guideline recommendations in the RRC-EM guidelines Table 3. RRC-EM Recommended Guidelines for Procedures and Resuscitations.

#### **2. Procedural skill acquisition**

In the 21st century, the "See one, do one, teach one" model has been rendered outmoded by the several factors. The general patient public is growing intolerant of being used as a training vehicle for novices and will often decline procedures from physicians with little experience. The Institute of Medicine's 1999 report, "To Err is Human" has propelled the patient safety movement in health care so that practitioners are have become more aware of there responsibilities to patients to first do no harm. Finally, the emergence of realistic procedural task trainers have brought simulation-based training to the forefront of medicine as a way to bridge the experiential gap between the novice and the expert.

Ziv et al. described physicians' moral imperative to use simulation-based training as this: "The use of simulation wherever feasible conveys a critical educational and ethical message to all: patients are to be protected whenever possible and they are not commodities to be used as conveniences of training."(4) Studies have shown that patients are more willing to have procedure performed on them by physicians who have undergone simulation training first. (5-7)

The guiding principle behind the efficacy of simulation-based procedural training is the concept of "deliberate practice" (DP). According to Dr. K Anders Ericsson, "Expert performance can be traced to active engagement in deliberate practice (DP), where training (often designed and arranged by their teachers and coaches) is focused on improving particular tasks. DP also involves the provision of immediate feedback, time for problem-

work hour restrictions may also lead to limitations in clinical patient contact. The RRC-EM has recommended that residency graduates be exposed to a core group of procedures and resuscitations during residency training (Table 3).(3) The guidelines specify that these

experiences may occur during patient care or in simulations.

Cardiac pacing Central venous access

Procedural sedation Cricothyrotomy Disclocation reduction

Pericardiocentesis Vaginal delivery

Chest tubes

Intubations Lumbar Puncture

**2. Procedural skill acquisition** 

first. (5-7)

Adult medical resuscitation Adult trauma resuscitation ED Bedside ultrasound

Pediatric medical resuscitation Pediatric trauma resuscitation

\* Covered in separate Procedural Competency Guideline recommendations in the RRC-EM guidelines

In the 21st century, the "See one, do one, teach one" model has been rendered outmoded by the several factors. The general patient public is growing intolerant of being used as a training vehicle for novices and will often decline procedures from physicians with little experience. The Institute of Medicine's 1999 report, "To Err is Human" has propelled the patient safety movement in health care so that practitioners are have become more aware of there responsibilities to patients to first do no harm. Finally, the emergence of realistic procedural task trainers have brought simulation-based training to the forefront of medicine

Ziv et al. described physicians' moral imperative to use simulation-based training as this: "The use of simulation wherever feasible conveys a critical educational and ethical message to all: patients are to be protected whenever possible and they are not commodities to be used as conveniences of training."(4) Studies have shown that patients are more willing to have procedure performed on them by physicians who have undergone simulation training

The guiding principle behind the efficacy of simulation-based procedural training is the concept of "deliberate practice" (DP). According to Dr. K Anders Ericsson, "Expert performance can be traced to active engagement in deliberate practice (DP), where training (often designed and arranged by their teachers and coaches) is focused on improving particular tasks. DP also involves the provision of immediate feedback, time for problem-

Table 3. RRC-EM Recommended Guidelines for Procedures and Resuscitations.

as a way to bridge the experiential gap between the novice and the expert.

solving and evaluation, and opportunities for repeated performance to refine behavior."(8) McGaghie et al. have further defined the necessary conditions for DP to be effective (Table 4).(9-10) These features are listed in order of reported frequency (percent) among the final BEME pool of 109 articles.These include immediate feedback, repetition, increasing levels of difficulty, clinical variation, simulation providing valid representation of clinical practice, and a controlled environment.(9-10)


\*Adapted from McGaghie et al. Lessons for continuing medical education from simulation research in undergraduate and graduate medical education: effectiveness of continuing medical education: American College of Chest Physicians Evidence-Based Educational Guidelines. Chest. 2009 Mar;135(3 Suppl):62S-68S.

Table 4. The Ten Conditions Necessary for Effective Deliberate Practice\*.

Literature across multiple medical disciplines supports the efficacy of simulation based procedural training with deliberate practice. Wong et al. demonstrated that repetitive practice of cricothyroidotomy on mannequins leads to reductions in procedural performance times and improvement in success rates.(11) Barsuk et al. demonstrated improved safety and decreased central line infections after simulation-based central venous catheter insertions.(12) Draycott et al. demonstrated improved neonatal outcomes after shoulder dystocia training.(13) Andreatta et al. reported that simulation-based mock code training significantly correlated with improved pediatric patient cardiopulmonary arrest survival rates.(14) A meta-analysis performed by McGaghie et al. reported that simulationbased training with DP is superior to traditional clinical medical education in achieving specific clinical skill acquisition goals.(15)

Additionally, Weinger argues that, in order to achieve the maximal desired effect, procedural skills acquisition and retention likely occur in a dose-response relationship, similar to drug pharmacology, with the best retention achieved using intermittent regular repetition over time rather than in single-day course training.(16) Interval simulation training over time makes intuitive sense, allowing for consolidation of training lessons and refining of muscle memory. Learners can break down procedures into their basic steps and focus on those particular steps that they have more difficulty with or feel they need to work

Emergent Procedure Training in the 21st Century 101

Fig. 2. Ultrasound guided simulator for vascular access and regional anesthesia.

http://www.simulab.com/product/ultrasound-trainers/centralineman-system

http://www.bluephantom.com/details.aspx?pid=51&cid=

http://www.bluephantom.com/details.aspx?pid=51&cid=

Fig. 1. Central Line Trainers.

on. These concepts are familiar to anyone who has ever learned to play a musical instrument. The argument of the dose-response relationship of simulation was supported by Conroy et al. in a recent study demonstrating competence and retention of lumbar puncture training skills using interval reinforcement.(17)

Another consideration in simulation procedural training is the "first cut" experience. Prior to simulation task trainers, procedures such as cricothytomy were performed on cadavers and the initial incision through the cricothyroid membrane could only be performed "natively" once. After that, subsequent learners could not experience the first cut sensation. With the development of procedural simulators, each learner can not only experience the first cut experience, but they can experience it over and over again.

#### **3. Available procedural simulation**

In recent years, the commercial availability of procedure specific task trainers has significantly increased. Additionally, the fidelity (or realism) has improved as well. These improvements allow medical professionals who teach using simulation modalities, otherwise known as "simulationists," to provide better procedural training for their students.

There are commercially available simulators for just about every procedure listed in Table 2. Central line simulators such as those shown in Figure 1 (Simulab Corporation, Seattle, WA. www.simulab.com; Blue Phantom, Redmond, WA. www.bluephantom.com) allow for ultrasound guided vascular access practice where the learner can repeated perform the vessel cannulation and insert the entire central line as many times as necessary until proficiency is reached. In addition to vascular access, certain models can also provide simulated regional anesthesia training (Figure 2).

Common procedures such as lumbar puncture can be practiced using task trainers such as that shown in Figures 3 (Limbs and Things, LTD, Savannah, GA. www.limbsandthings.com). These models have the added ability to simulate obese and elderly patient lumbar anatomy using "obesity" and "senior" lumbar blocks (Figure 3B). These add to the difficulty levels that can be simulated. Infant lumbar puncture simulators (Figure 4) can be used to teach the procedure on an age- and size-appropriate model (Limbs and Things, LTD, Savannah, GA. www.limbsandthings.com).

Trauma procedures such as tube thoracostomy and surgical cricothyrotomy using systems such as TraumaMan® (Simulab Corporation, Seattle, WA. www.simulab.com) have become viable alternatives to cadaver based training because the skin on the trainer can be replaced (Figure 5). This allows for the very important "first cut" visual and tactile experience that is necessary for developing the cognitive and manual skills necessary for these procedures.

Focused Assessment with Sonography for Trauma (FAST) can be performed with varying levels of difficulty (Figure 6). The Blue Phantom FAST Exam Real Time Ultrasound Training Model (Blue Phantom, Redmond, WA. www.bluephantom.com) is one of the few ultrasound simulators that has adjustable internal bleeding levels to increase or decrease the level of difficulty. "Realistic internal bleeding in each organ space that can be adjusted by the user to simulate a wide variety of effusion states including: small, medium and large effusions or no effusions at all around the liver, spleen, heart, and bladder."

Table 5 provides a partial listing of commercially available procedural task trainers for emergency medicine relevant procedures.

on. These concepts are familiar to anyone who has ever learned to play a musical instrument. The argument of the dose-response relationship of simulation was supported by Conroy et al. in a recent study demonstrating competence and retention of lumbar puncture

Another consideration in simulation procedural training is the "first cut" experience. Prior to simulation task trainers, procedures such as cricothytomy were performed on cadavers and the initial incision through the cricothyroid membrane could only be performed "natively" once. After that, subsequent learners could not experience the first cut sensation. With the development of procedural simulators, each learner can not only experience the first cut

In recent years, the commercial availability of procedure specific task trainers has significantly increased. Additionally, the fidelity (or realism) has improved as well. These improvements allow medical professionals who teach using simulation modalities, otherwise known as

There are commercially available simulators for just about every procedure listed in Table 2. Central line simulators such as those shown in Figure 1 (Simulab Corporation, Seattle, WA. www.simulab.com; Blue Phantom, Redmond, WA. www.bluephantom.com) allow for ultrasound guided vascular access practice where the learner can repeated perform the vessel cannulation and insert the entire central line as many times as necessary until proficiency is reached. In addition to vascular access, certain models can also provide

Common procedures such as lumbar puncture can be practiced using task trainers such as that shown in Figures 3 (Limbs and Things, LTD, Savannah, GA. www.limbsandthings.com). These models have the added ability to simulate obese and elderly patient lumbar anatomy using "obesity" and "senior" lumbar blocks (Figure 3B). These add to the difficulty levels that can be simulated. Infant lumbar puncture simulators (Figure 4) can be used to teach the procedure on an age- and size-appropriate model (Limbs

Trauma procedures such as tube thoracostomy and surgical cricothyrotomy using systems such as TraumaMan® (Simulab Corporation, Seattle, WA. www.simulab.com) have become viable alternatives to cadaver based training because the skin on the trainer can be replaced (Figure 5). This allows for the very important "first cut" visual and tactile experience that is necessary for developing the cognitive and manual skills necessary for these procedures. Focused Assessment with Sonography for Trauma (FAST) can be performed with varying levels of difficulty (Figure 6). The Blue Phantom FAST Exam Real Time Ultrasound Training Model (Blue Phantom, Redmond, WA. www.bluephantom.com) is one of the few ultrasound simulators that has adjustable internal bleeding levels to increase or decrease the level of difficulty. "Realistic internal bleeding in each organ space that can be adjusted by the user to simulate a wide variety of effusion states including: small, medium and large

Table 5 provides a partial listing of commercially available procedural task trainers for

training skills using interval reinforcement.(17)

**3. Available procedural simulation** 

simulated regional anesthesia training (Figure 2).

emergency medicine relevant procedures.

and Things, LTD, Savannah, GA. www.limbsandthings.com).

effusions or no effusions at all around the liver, spleen, heart, and bladder."

experience, but they can experience it over and over again.

"simulationists," to provide better procedural training for their students.

http://www.simulab.com/product/ultrasound-trainers/centralineman-system

http://www.bluephantom.com/details.aspx?pid=51&cid= Fig. 1. Central Line Trainers.

http://www.bluephantom.com/details.aspx?pid=51&cid=

Emergent Procedure Training in the 21st Century 103

http://www.simulab.com/product/surgery/open/traumaman-system

Fig. 5. TraumaMan® System for tube thoracostomy and surgical cricothyrotomy.

http://www.bluephantom.com/product/FAST-Exam-Real-Time-Ultrasound-Training-

Model.aspx?cid=532

Fig. 6. FAST scan simulator.

http://limbsandthings.com/us/products/lumbar-puncture-epidural-simulator-mk-2/ Fig. 3. Adult lumbar puncture simulator.

http://limbsandthings.com/us/products/pediatric-lumbar-puncture-simulator/ Fig. 4. Pediatric lumbar puncture simulator.

A. B.

Fig. 3. Adult lumbar puncture simulator.

http://limbsandthings.com/us/products/lumbar-puncture-epidural-simulator-mk-2/

http://limbsandthings.com/us/products/pediatric-lumbar-puncture-simulator/

Fig. 4. Pediatric lumbar puncture simulator.

http://www.simulab.com/product/surgery/open/traumaman-system Fig. 5. TraumaMan® System for tube thoracostomy and surgical cricothyrotomy.

http://www.bluephantom.com/product/FAST-Exam-Real-Time-Ultrasound-Training-Model.aspx?cid=532

Fig. 6. FAST scan simulator.

Emergent Procedure Training in the 21st Century 105

As we move further away from organic (cadaveric and animal) models, new areas are emerging to provide EM trainees and practitioners with alternative methods for experiential

In addition to the features of current simulators, improvements to current simulators are being developed both commercially and by simulationists who desire to bridge the gap between what is currently available and what can be possible. Examples include modification of a Laerdal SimBaby to include an integrated umbilical cannulation task trainer,(18) homegrown hybrid cricothyrotomy simulators using synthetic skin and sheep

The future of procedural simulation will likely lie in the development and convergence of haptic technology and virtual reality. Haptics is a type of tactile feedback technology that allows the reporting of a learner's touch pressure forces through a virtual interface. Haptics development has been led by the surgical disciplines where its use in laparoscopy, gynecology, urology, endoscopy, ophthalmology, dentistry, ENT, and robotic surgery have advanced training and technical skills. Simbionix (Simbionix USA Corporation, Cleveland, OH. www.simbionix.com) has created a Mentor Series of VR simulators for laparoscopy, angiography, bronchoscopy, endoscopy, endourology and TURP, percutaneous access,

For EM skills, a haptic-based VR trainer is now commercially available for IV insertion (Figure 6 - Laerdal Medical, Wappingers Falls, NY. www.laerdal.com). Work by Loukas et al. reported that this simulation model enhanced the skills of inexperienced subjects significantly and that "The VR simulator demonstrated construct validity for three different levels of experience. The number of attempts over a series of equal difficulty scenarios provides a valuable alternative to the traditional measures of the learning curve."(21) Investigations in cardiology-based simulation also support the utility of a VR-enhanced

Investigational trainers are being developed for endotracheal intubation,(24) lumbar punctures,(25) and cricothyrotomy,(26) with other haptic-enhanced physical models or VR procedural trainers likely to follow. Other opportunities for enhancing EM procedural training include improved seldinger technique simulation(27) and ultrasound practice(28-9)

Virtual reality integration with remote learning opportunities will likely be available in the future as well. Alverson et al. have reported the feasibility and acceptability by students in the use of VR simulation integrated into a Problem Based Learning (PBL) session, "... as well as multipoint distance technologies that allowed interaction between students and tutors in different locations."(30) The authors believe this method of interactive experiential learning

One can imagine that, in the future, web-based VR simulation learning network will be widely available. In this type of learning system, instructors around the world, using a shared VR learning platform, upload metadata for a specific procedural task (i.e. difficulty airway scenarios using a haptic-enhanced VR intubation program) to a central server. These cases can then be accessed at any local training center for training and validation purposes.

larynx/trachea,(19) and homegrown epistaxis task trainer simulators.(20)

**4. Future of procedural simulation** 

practice and maintenance of skills.

hysteroscopy, and pelvic examination.

to improve hand-eye coordination.

can be widely applied in a distributed network or on site.

experience. (22-23)

Table 5. Commercially available procedural task trainers.

While these trainers are continuously improving with each model generation, most current task trainers are not yet able to provide simulated training with increasing levels of difficulty, providing significant clinical variation, and providing a valid representation of *clinical practice.* These three deficiencies with respect to the ten conditions required for deliberate practice described earlier still need to be addressed before procedural simulation will be able to adequately simulate human tissue. *Until then, there will still be a gap between simulated practice and performance in patient care.*

#### **4. Future of procedural simulation**

104 Emergency Medicine – An International Perspective

Table 5. Commercially available procedural task trainers.

*simulated practice and performance in patient care.*

While these trainers are continuously improving with each model generation, most current task trainers are not yet able to provide simulated training with increasing levels of difficulty, providing significant clinical variation, and providing a valid representation of *clinical practice.* These three deficiencies with respect to the ten conditions required for deliberate practice described earlier still need to be addressed before procedural simulation will be able to adequately simulate human tissue. *Until then, there will still be a gap between*  As we move further away from organic (cadaveric and animal) models, new areas are emerging to provide EM trainees and practitioners with alternative methods for experiential practice and maintenance of skills.

In addition to the features of current simulators, improvements to current simulators are being developed both commercially and by simulationists who desire to bridge the gap between what is currently available and what can be possible. Examples include modification of a Laerdal SimBaby to include an integrated umbilical cannulation task trainer,(18) homegrown hybrid cricothyrotomy simulators using synthetic skin and sheep larynx/trachea,(19) and homegrown epistaxis task trainer simulators.(20)

The future of procedural simulation will likely lie in the development and convergence of haptic technology and virtual reality. Haptics is a type of tactile feedback technology that allows the reporting of a learner's touch pressure forces through a virtual interface. Haptics development has been led by the surgical disciplines where its use in laparoscopy, gynecology, urology, endoscopy, ophthalmology, dentistry, ENT, and robotic surgery have advanced training and technical skills. Simbionix (Simbionix USA Corporation, Cleveland, OH. www.simbionix.com) has created a Mentor Series of VR simulators for laparoscopy, angiography, bronchoscopy, endoscopy, endourology and TURP, percutaneous access, hysteroscopy, and pelvic examination.

For EM skills, a haptic-based VR trainer is now commercially available for IV insertion (Figure 6 - Laerdal Medical, Wappingers Falls, NY. www.laerdal.com). Work by Loukas et al. reported that this simulation model enhanced the skills of inexperienced subjects significantly and that "The VR simulator demonstrated construct validity for three different levels of experience. The number of attempts over a series of equal difficulty scenarios provides a valuable alternative to the traditional measures of the learning curve."(21) Investigations in cardiology-based simulation also support the utility of a VR-enhanced experience. (22-23)

Investigational trainers are being developed for endotracheal intubation,(24) lumbar punctures,(25) and cricothyrotomy,(26) with other haptic-enhanced physical models or VR procedural trainers likely to follow. Other opportunities for enhancing EM procedural training include improved seldinger technique simulation(27) and ultrasound practice(28-9) to improve hand-eye coordination.

Virtual reality integration with remote learning opportunities will likely be available in the future as well. Alverson et al. have reported the feasibility and acceptability by students in the use of VR simulation integrated into a Problem Based Learning (PBL) session, "... as well as multipoint distance technologies that allowed interaction between students and tutors in different locations."(30) The authors believe this method of interactive experiential learning can be widely applied in a distributed network or on site.

One can imagine that, in the future, web-based VR simulation learning network will be widely available. In this type of learning system, instructors around the world, using a shared VR learning platform, upload metadata for a specific procedural task (i.e. difficulty airway scenarios using a haptic-enhanced VR intubation program) to a central server. These cases can then be accessed at any local training center for training and validation purposes.

Emergent Procedure Training in the 21st Century 107

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[6] Graber MA, Wyatt C, Kasparek L, Xu Y.Does simulator training for medical students

[7] Lammers RL, Temple KJ, Wagner MJ, Ray D. Competence of new emergency medicine

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[9] McGaghie WC, Siddall VJ, Mazmanian PE, Myers J; American College of Chest

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[14] Andreatta P, Saxton E, Thompson M, Annich G. Simulation-based mock codes

[15] McGaghie WC, Issenberg SB, Cohen ER, Barsuk JH, Wayne DB. Does simulation-based

[16] Weinger MB. The pharmacology of simulation: a conceptual framework to inform

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[18] Sawyer T, Hara K, Thompson MW, Chan DS, Berg B. Modification of the Laerdal

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required for successful cricothyroidotomy?: a study in mannequins.

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performance of the lumbar puncture procedure in a task trainer model. Simul

SimBaby to include an integrated umbilical cannulation task trainer. Simul Healthc.

http://www.laerdal.com/doc/245/Virtual-I-V-Simulator

Fig. 7. Virtual I.V.™ Simulator.

#### **5. Summary**

Whatever form that emergency medicine procedural training takes in the future, one thing is clear – simulated training will be the mainstay for the initial introduction to the steps and mechanics involved in performing a procedure, for accelerating the technical skill acquisition learning curve for the procedure, and for the maintenance of competency of the skills once developed. The end result will be the delivery of higher quality, more uniform, and safer care at the bedside.

#### **6. References**

[1] American Board of Emergency Medicine. EM Model History.

 https://www.abem.org/PUBLIC/portal/alias\_\_Rainbow/lang\_\_en-US/tabID\_\_4224/DesktopDefault.aspx. Accessed October 10, 2011.

[2] American Board of Emergency Medicine. EM Model. https://www.abem.org/PUBLIC/portal/alias\_\_Rainbow/lang\_\_en-

US/tabID\_\_4223/DesktopDefault.aspx. Accessed October 10, 2011.


Whatever form that emergency medicine procedural training takes in the future, one thing is clear – simulated training will be the mainstay for the initial introduction to the steps and mechanics involved in performing a procedure, for accelerating the technical skill acquisition learning curve for the procedure, and for the maintenance of competency of the skills once developed. The end result will be the delivery of higher quality, more uniform,

[3] Accreditation Council for Graduate Medical Education. Emergency Medicine Guidelines.

[4] Ziv A, Wolpe PR, Small SD, Glick S. Simulation-Based Medical Education: An Ethical

http://acgme.org/acWebsite/RRC\_110/110\_guidelines.asp. Accessed October 10,

http://www.laerdal.com/doc/245/Virtual-I-V-Simulator

[1] American Board of Emergency Medicine. EM Model History.

[2] American Board of Emergency Medicine. EM Model.

Imperative. Acad. Med. 2003;78:783–788.

 https://www.abem.org/PUBLIC/portal/alias\_\_Rainbow/lang\_\_en-US/tabID\_\_4224/DesktopDefault.aspx. Accessed October 10, 2011.

 https://www.abem.org/PUBLIC/portal/alias\_\_Rainbow/lang\_\_en-US/tabID\_\_4223/DesktopDefault.aspx. Accessed October 10, 2011.

Fig. 7. Virtual I.V.™ Simulator.

and safer care at the bedside.

**5. Summary** 

**6. References** 

2011.


**6** 

Jiri Pokorny

*POMAMED, Prague, Czech Republic* 

**Emergency Medicine in the Czech Republic** 

The history of out-of-hospital emergency medicine begins many centuries ago. Efforts to help patients have been made by mankind for a long time. In principle, two approaches to providing professional medical assistance can be identified; either with medical help called to the affected person, or the person involved being transferred either to a shaman, a physician, or to a medical center. The story of in-hospital emergency medicine begins with the setting up of facilities designed to take care of and treat those affected in hospitals. The traditional model of provision of emergency care includes outpatient departments related to the individual branches of medicine. The 1960s saw the building of the first emergency

Pre-hospital emergency care has a long-standing tradition in this country. The predecessor of Prague's emergency medical service, referred to as the Prague Volunteer Protection Unit, was established as early as 1857 making it, together with the Budapest-based predecessor of emergency service, to the oldest emergency units within Europe. Just as in many other countries, the utmost priority of the emergency service was to transfer the patient to hospital faster and in a more patient-friendly manner than before. While both world wars, and the Korean and Vietnam wars, brought immense suffering to millions of people, they helped mankind make major progress in their knowledge regarding the provision of emergency care and management of trauma-related shock, as well as clearly showing the advantages of early acute surgery. Military experience has necessarily translated into the provision of emergency care outside the battlefield. Additionally, provision of emergency care had to reflect new insights into the pathophysiology and management of various types of shock,

It should be noted here that modern history of emergency medicine in the Czech Republic began to unfold in what was formerly referred to as the Czechoslovak Republic, as a country founded in 1918 and inhabited by the Czech and Slovak nations until its breakup

Several milestones can be identified in the evolution of emergency medicine in the Czech

**1. Introduction** 

departments in the United States (2).

intoxication, coronary heart disease, stroke, and so on.

**2. Milestones of emergency medicine in the Czech Republic** 

into the Czech Republic and Slovakia in 1992.

Republic including, in particular:

