**4. Setup of a high-fidelity and immersive simulation**

High-fidelity simulation usually involves full-body manikins set up in environments made to simulate real-life situations. The presentation of changing patient physiology data and machine or physiological parameter alarms is used to mimic realistic health-care settings and elicits desired responses from learners. This is in contrast to water drills, considered low-fidelity simulation, which runs in the form of deliberate practice in a static and alarm-free environment. High-fidelity simulation is an immersive experience for the participant and offers the opportunity to introduce knowledge through challenging and reflecting upon learners' individual responses. It is also a useful tool to introduce concepts related to team-based care.

#### **4.1. Simulation environment**

A variety of clinical environments involving ECMO care may be simulated, for example, ICU, operating theatre and emergency room. In institutions without dedicated simulation facilities, one can consider setting up the simulation model in an unoccupied cubicle in the ICU or the emergency room to achieve contextual reality.

**Figure 1.** Basic setup of a high-fidelity ECMO simulation environment. A confederate (dressed in blue scrubs) participated

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**Figure 2.** Left upper and lower panels—hidden volume reservoir and tubings inside a pediatric manikin; and the setup of a volume reservoir (photos courtesy of Dr. Mark Ogino). Right panel—ECMO circuit setup with additional pressure

transducers (in red) for circuit pressure display.

in this scenario (adopted from Asia-Pacific Adult ECMO Course, Queen Mary Hospital).

Typical equipment for veno-venous ECMO simulation will include an intubated manikin (e.g. megacode Kelly) attached to a mechanical ventilator. Arterial lines, drug infusion devices and Foley catheters may be added as necessary. Essential physiological parameters, for example, arterial blood pressure, pulse rate, ECG rhythm, SpO2 and central venous pressure should be clearly displayed (**Figure 1**), and these should be controlled remotely by a compatible computer programme (e.g. Laerdal SimMan).

#### **4.2. Manikin modification and incorporation of an ECMO circuit**

A commonly used method in ECMO simulation is to connect the access and return cannulae of the ECMO circuit to a volume reservoir hidden inside the manikin (**Figure 2**, left upper panel). Access ports on the volume reservoir are mandatory (**Figure 2**, left lower panel) to allow manipulation of volume and hence pressure status within the ECMO circuit in different simulation scenarios. For example, access insufficiency is simulated by withdrawal of fluid from the reservoir, causing collapse of the reservoir, a decreased ECMO flow, and a negative access pressure. Circuit air entrainment may be simulated by the controlled introduction of air into the circuit. Additional modification may be required for the display of pressure changes, depending on the ECMO machine used—the Medos Deltastream and Maquet Cardiohelp systems display the operating pressures directly on the screen of the ECMO consoles, whereas older ECMO systems like the Maquet Rotaflow require connection of pressure transducers to different parts of the ECMO circuit (**Figure 2**, right panel). Lansdowne et al. Education Curriculum on Extracorporeal Membrane Oxygenation: The Evolving Role of Simulation Training http://dx.doi.org/10.5772/intechopen.76656 141

By fine-tuning the expected roles of participants, flexibility in meeting the training needs of individual centres can be met, although possibly at the expense of lack of standardization and

High-fidelity simulation usually involves full-body manikins set up in environments made to simulate real-life situations. The presentation of changing patient physiology data and machine or physiological parameter alarms is used to mimic realistic health-care settings and elicits desired responses from learners. This is in contrast to water drills, considered low-fidelity simulation, which runs in the form of deliberate practice in a static and alarm-free environment. High-fidelity simulation is an immersive experience for the participant and offers the opportunity to introduce knowledge through challenging and reflecting upon learners' individual responses. It is also a useful tool to introduce concepts related to team-based care.

A variety of clinical environments involving ECMO care may be simulated, for example, ICU, operating theatre and emergency room. In institutions without dedicated simulation facilities, one can consider setting up the simulation model in an unoccupied cubicle in the ICU or

Typical equipment for veno-venous ECMO simulation will include an intubated manikin (e.g. megacode Kelly) attached to a mechanical ventilator. Arterial lines, drug infusion devices and Foley catheters may be added as necessary. Essential physiological parameters, for example, arterial blood pressure, pulse rate, ECG rhythm, SpO2 and central venous pressure should be clearly displayed (**Figure 1**), and these should be controlled remotely by a compatible com-

A commonly used method in ECMO simulation is to connect the access and return cannulae of the ECMO circuit to a volume reservoir hidden inside the manikin (**Figure 2**, left upper panel). Access ports on the volume reservoir are mandatory (**Figure 2**, left lower panel) to allow manipulation of volume and hence pressure status within the ECMO circuit in different simulation scenarios. For example, access insufficiency is simulated by withdrawal of fluid from the reservoir, causing collapse of the reservoir, a decreased ECMO flow, and a negative access pressure. Circuit air entrainment may be simulated by the controlled introduction of air into the circuit. Additional modification may be required for the display of pressure changes, depending on the ECMO machine used—the Medos Deltastream and Maquet Cardiohelp systems display the operating pressures directly on the screen of the ECMO consoles, whereas older ECMO systems like the Maquet Rotaflow require connection of pressure transducers to different parts of the ECMO circuit (**Figure 2**, right panel). Lansdowne et al.

**4. Setup of a high-fidelity and immersive simulation**

generalizability across centres.

140 Advances in Extra-corporeal Perfusion Therapies

**4.1. Simulation environment**

the emergency room to achieve contextual reality.

**4.2. Manikin modification and incorporation of an ECMO circuit**

puter programme (e.g. Laerdal SimMan).

**Figure 1.** Basic setup of a high-fidelity ECMO simulation environment. A confederate (dressed in blue scrubs) participated in this scenario (adopted from Asia-Pacific Adult ECMO Course, Queen Mary Hospital).

**Figure 2.** Left upper and lower panels—hidden volume reservoir and tubings inside a pediatric manikin; and the setup of a volume reservoir (photos courtesy of Dr. Mark Ogino). Right panel—ECMO circuit setup with additional pressure transducers (in red) for circuit pressure display.

described a model that incorporates a modified manikin, an ECMO circuit and the hydraulic module of the Orpheus Perfusion Simulator to produce a realistic simulation [7].

uncover the 'frame of mind' of the learners and to help them gain better insight of their own

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The detailed techniques to achieve an effective debriefing are out of the scope of this chapter. Nonetheless, it is worthwhile to mention some of the main principles. As a rule of thumb, confidentiality with regard to learners' performance should be strictly complied, so that they feel safe to express themselves, especially after difficult, stressful, or poorly performed scenarios. Mutual respect and trust among learners and debriefers are essential to encourage free communication. Debriefers should positively acknowledge the contribution and motivation of the learners. Even when faced with an apparently 'poor' performance, debriefers should remain curious and explore the reasons behind the behaviour [10]. The 'advocacy-inquiry' conversa-

Simulation educators have developed frameworks to facilitate the debriefing process. Scholars from the Center for Medical Simulation at Harvard Medical School advocate a threestep model (reaction, understanding and summary), while those from the Winter Institute for Simulation Education and Research (WISER) of University of Pittsburgh use the 'gather, analyze, and summarize' (GAS) debriefing tool. Debriefers should familiarize themselves with

Heading forward, efforts are underway to enhance the quality of debriefing by developing assessment tools. In The Debriefing Assessment for Simulation in Healthcare (DASH), the fol-

In a recent survey from the United States, lectures (99%), water drills (99%) and bedside training (99%) remain the chief training modalities for new ECMO specialists. Forty-six per cent of ECMO centres had an ECMO simulation programme. ECMO centres with access to a simulation centre, those with higher case numbers and pediatric cardiothoracic ICU are more likely

Simulation-based ECMO education is a growing research area with increasing evidence to support its effectiveness. Earlier publications were mainly descriptive and focused on the setup and content of simulation courses and the evaluation of the learner [12, 13]. Some studies

frames, so that behavioural change may follow.

tion technique has been described to facilitate this process.

different tools and adopt a systematic approach during debriefing.

lowing aspects are considered the key elements of a good debriefer:

**1.** establishes an engaging learning environment; **2.** maintains an engaging learning environment;

**3.** structures debriefing in an organized way;

**5.** identifies and explores performance gaps; and

to have an ECMO simulation programme [11].

**6.** assists trainee achieve or sustain good future performance.

**6. Current evidence and status of ECMO simulation**

**4.** provokes engaging discussions;

#### **4.3. Limitations**

A major limitation in ECMO simulation is the cost of medical devices and ECMO consumables. The abovementioned simulation models all require a functioning ECMO machine and a complete ECMO circuit, including the oxygenator, that are subject to wear and tear. The availability of equipment and the costs of replacement are real economical concerns, especially for newly developed centres. The advent of 3-D printing technologies may hold promise for the construct of economical oxygenators [8].

Other limitations arise from the technological parts of the simulation. For instance, it is difficult to simulate the difference in colour of oxygenated and deoxygenated blood, which is important in scenarios related to recirculation and oxygen supply failure. Other technical difficulties include simulating blood clots in the oxygenator and access line chattering. Ongoing research to overcome these challenges is underway, such as the use of thermochromic fluid to simulate colour changes of the circuit blood [8].
