**3. Scenario design in ECMO simulation**

low occurrence but potentially life-threatening events. As a result, continuing education is essential to ensure the success and safety of an ECMO programme. Due to the inherent characteristics of ECMO service provision, the implementation of such educational activities is not straightforward. Firstly, professionals who undergo training for ECMO are usually experienced health-care providers. The learning processes of experienced adults are more complex, requiring assimilation of newly acquired knowledge with past experiences and roles. In these instances, learning will be more effective when the teaching is learner-centred and the learner is actively engaged. Secondly, the low-volume nature of severe ECMO complications renders training by apprenticeship difficult. Thirdly, while most ECMO runs are uneventful, in situation when crises occur, ECMO care providers have to respond emergently and proficiently under a stressful environment and often in a team-based approach. Fourthly, the provision of

ECMO care often requires critical decision-making across specialties and professions.

Traditional ECMO teaching modalities like reading, didactic lectures, water drills (referring to deliberate practice in a closed-loop ECMO circuit model, e.g. changing the oxygenator or using the hand crank) and practices in the animal laboratory (where a living animal is cannulated to simulate human responses) primarily focus on cognitive and technical skills, with little emphasis on behavioural skills like communication and leadership that are fundamental during training for ECMO. ECMO simulation has rapidly evolved as an effective learning methodology that supplements traditional teaching modalities. It creates a standardized, controlled, safe and repeatable environment that aims to mimic the realistic clinical environments, so that new skills can be learnt and practised without doing harm to patients and learners.

In this chapter, we discuss simulation training in ECMO from the perspectives of human learning theory, simulation programme setup (including scenario design, equipment and

Simulation is often considered simply as an exercise where learners perform actions in an environment simulated to resemble reality, and facilitators are present to ensure its smooth running and to lead a discussion afterwards. As a relatively new method of teaching in medical education, there are often misunderstandings about simulation training and inadequate knowledge of its execution. High-quality simulation is backed by evidence-based educational

Kolb's theory on experiential learning forms the foundation of simulation-based education. In his theory, learners enter the learning cycle through experiencing an event—either a real patient experience or simulated activities ('concrete experience'). Afterwards, through selfreflection or reflection assisted by facilitator ('reflection'), a new insight of the event is created ('abstract conceptualization'). Finally, this new insight is applied in a similar simulated or

Neil Flemming's VARK model describes four modalities in an individual's preferred method of learning—Visual, Auditory, Reading and Kinesthetic [2]. Different individuals learn more

theories and includes purposefully designed scenarios and well-trained facilitators.

resources), debriefing, current evidence and future challenges.

136 Advances in Extra-corporeal Perfusion Therapies

real-life event ('active experimentation') [1].

**2. Human learning models and simulation-based education**

Scenario design is one of the key elements in simulation education. On designing a scenario, thorough understanding of the background, training needs and experience of learners is essential. In particular, meticulous attention must be paid to tailor the learning goals and objectives to the target learner. The goal of a scenario refers to the overall educational mission the learners are expected to achieve. Detailed objectives may be made up of cognitive, psychomotor, behavioural or affective component [4]. As an example, the goals and objectives for novice ECMO learners would be different from experienced ECMO learners in a scenario of ECMO blood pump failure. For the novice, the goal would be 'to switch to a standby machine in emergency setting', with objectives including 'recognize blood pump failure and its related physiological changes' (cognitive) and 'acquire the technical skill of using hand crank' (psychomotor). For the experienced learner, the goal may be more advanced, such as 'demonstration of teamwork in managing blood pump failure crisis', achieved through the objective of 'demonstrating effective communication and leadership skills' (behavioural), in addition to the cognitive and psychomotor skills. **Table 1** lists examples of common scenarios used in an Asia-Pacific ELSO Adult ECMO Training Course and **Table 2** illustrates the goals and objectives of some of these scenarios.

Some deviation of simulation scenarios from the real-world practice is acceptable. Especially for novice ECMO learners, they are expected to adopt the role of the ECMO specialist during simulation learning, regardless of their current position as senior consultants, junior doctors, nurses or perfusionists. This is to ensure competency in the various aspects of troubleshooting and response to ECMO emergencies after they undergo training. This training concept reflects the reality that


**Table 1.** Examples of scenarios in adult ECMO simulation training (adopted from Asia-Pacific ELSO Adult ECMO Training Course, Queen Mary Hospital).


many ECMO centres nowadays adopt a mixed ECMO care model, with the ECMO team consisting of physicians, nurses, perfusionists and respiratory therapists [5, 6]. The other advantage of including mixed roles in simulation is the possibility of modifying the focus of training as the team matures, to aspects such as leadership, communication and teamwork during emergencies. Furthermore, simulation scenarios can be adjusted according to the characteristics of the respective ECMO team and health-care institution. The scenario design for institutions using a bedside nurse ECMO care model will be different from that using a perfusionist care model.

**Table 2.**Examples of goals and learning objectives of common ECMO simulation scenarios (C= cognitive, P=psychomotor,

Understand the importance of complete circuit check in ECMO emergency.

Education Curriculum on Extracorporeal Membrane Oxygenation: The Evolving Role of Simulation Training

(C) Recognize patient desaturation, loss of color difference in ECMO limbs.

(C) Recognize presentation of circuit air entrainment—abnormal noise from ECMO circuit, decrease ECMO blood flow with corresponding change in patient's

(C) Recognize potential source of air entrainment—negative pressure side. (P) Complete circuit check to identify source of air and stop further entrainment. Technical skill for circuit de-airing or technical skill to change to new circuit. (B) Teamwork and communication skills during circuit de-airing, changing ECMO

Understand the cause of venous insufficiency and its management.

Understand the physiology of recirculation and its management.

negative venous pressure, decrease ECMO blood flow.

(C) Recognize presentation of venous insufficiency—drainage limb chattering, more

(C) Recognize the cause of venous insufficiency—hypovolaemia, excessive pump speed, inappropriate drainage catheter position; and their respective management.

(C) Recognize the presentation of recirculation—desaturation without problems in ECMO blood flow and oxygen supply, loss of color differential in drainage and return

(C) Recognize the causes of recirculation—close proximity of drainage and return

Diagnose and manage circuit air entrainment.

hemodynamic and physiological parameters.

circuit, and patient resuscitation.

(P) Systematic circuit check and potential sites of oxygenation supply disconnection.

http://dx.doi.org/10.5772/intechopen.76656

139

**Scenarios Goals and learning objectives**

Objectives:

Objectives:

Objectives:

Objectives:

limb, elevated SvO2.

cannula, excessive pump speed.

B = behavioural) (adopted from Asia-Pacific ELSO Adult ECMO Training Course, Queen Mary Hospital).

Oxygen supply failure Goal:

Circuit air entrainment Goal:

Venous insufficiency Goal:

Recirculation Goal:


**Scenarios Goals and learning objectives**

Goal:

**Scenario Topic Examples**

138 Advances in Extra-corporeal Perfusion Therapies

Emergencies in ECMO care Blood pump failure

Patient management Venous insufficiency

Routine ECMO circuit management External compression on return tubing

Objectives:

Objectives:

Objectives:

pump obstruction.

(P) Systematic circuit check.

Diagnosis of oxygenator failure.

coagulopathy blood picture.

(P) Circuit check for clot in oxygenator.

Management of blood pump failure.

(P) Technique of using hand crank.

of patient's hemodynamic and physiological parameters.

Understand the change in circuit pressure related to preload and afterload conditions.

Heater failure with hypothermia

Permissive hypoxaemia in VV ECMO

Ventricular fibrillation in VA ECMO Differential hypoxaemia in VA ECMO

Oxygenator failure

Oxygen supply failure Circuit air embolism

Tension pneumothorax

Recirculation

**Table 1.** Examples of scenarios in adult ECMO simulation training (adopted from Asia-Pacific ELSO Adult ECMO

(C) Recognize high return pressure with drop in ECMO blood flow signifying post-

(C) Recognize features of oxygenator failure – elevated transmembrane pressure, decrease oxygenator function, clot in oxygenator, disseminated intravascular

(C) Recognize presentation of blood pump failure—loss of ECMO blood flow, change

(B) Communication to call for help for resuscitation and patient stabilization.

External compression on

Oxygenator failure Goal:

Training Course, Queen Mary Hospital).

Blood pump failure Goal:

return tubing

**Table 2.**Examples of goals and learning objectives of common ECMO simulation scenarios (C= cognitive, P=psychomotor, B = behavioural) (adopted from Asia-Pacific ELSO Adult ECMO Training Course, Queen Mary Hospital).

many ECMO centres nowadays adopt a mixed ECMO care model, with the ECMO team consisting of physicians, nurses, perfusionists and respiratory therapists [5, 6]. The other advantage of including mixed roles in simulation is the possibility of modifying the focus of training as the team matures, to aspects such as leadership, communication and teamwork during emergencies.

Furthermore, simulation scenarios can be adjusted according to the characteristics of the respective ECMO team and health-care institution. The scenario design for institutions using a bedside nurse ECMO care model will be different from that using a perfusionist care model. 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 generalizability across centres.
