**5. Special role of the facilitator in ECMO simulation and the debriefing process**

The important role of facilitators in simulation education cannot be underscored. Firstly, facilitators should have a thorough understanding of ECMO physiology, patient physiology and their interaction. This forms the prerequisite for facilitators to react swiftly and accurately in real time according to the actions of learners, by manipulating the ECMO flow and pressure (through volume manipulation of the reservoir) and the physiological parameters (through the computer software). For example, when learners increase the ECMO pump speed excessively, the facilitator should make a series of changes to the circuit and patient parameters, which includes withdrawing volume from the reservoir to create a state of venous insufficiency, dropping the SpO2 and SvO2, creating mild tachycardia, and so on. More importantly, during the simulation exercise, facilitators have to denote key actions and behaviours that will be valuable for discussion in the subsequent debriefing session. As a result of the many roles and actions required of facilitators in ECMO simulation, most scenarios require the presence of at least two facilitators.

The other role of the facilitator is the debriefer. Debriefing, the reflective process in Kolb's learning theory provides an opportunity for learners to reflect upon their performance, resolve lingering questions and reinforce learning objectives. It is the most crucial part of simulation learning and was described as the 'heart and soul' of the simulation experience. The aim of debriefing is to constructively review 'what has happened' and 'why it happened' in the simulated event. In the 'frame-action-result' model described by Rudolph, learners have their own 'frames'—their assumption, knowledge and feelings that drive their 'actions', which in turn end up with different 'results' [9]. While actions and results are easily observable, frames are often invisible. A successful debriefer needs to act as a 'cognitive detector', to uncover the 'frame of mind' of the learners and to help them gain better insight of their own frames, so that behavioural change may follow.

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' conversation technique has been described to facilitate this process.

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 different tools and adopt a systematic approach during debriefing.

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


described a model that incorporates a modified manikin, an ECMO circuit and the hydraulic

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

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

The important role of facilitators in simulation education cannot be underscored. Firstly, facilitators should have a thorough understanding of ECMO physiology, patient physiology and their interaction. This forms the prerequisite for facilitators to react swiftly and accurately in real time according to the actions of learners, by manipulating the ECMO flow and pressure (through volume manipulation of the reservoir) and the physiological parameters (through the computer software). For example, when learners increase the ECMO pump speed excessively, the facilitator should make a series of changes to the circuit and patient parameters, which includes withdrawing volume from the reservoir to create a state of venous insufficiency, dropping the SpO2 and SvO2, creating mild tachycardia, and so on. More importantly, during the simulation exercise, facilitators have to denote key actions and behaviours that will be valuable for discussion in the subsequent debriefing session. As a result of the many roles and actions required of facilitators in ECMO simulation, most scenarios require the presence of at least two facilitators. The other role of the facilitator is the debriefer. Debriefing, the reflective process in Kolb's learning theory provides an opportunity for learners to reflect upon their performance, resolve lingering questions and reinforce learning objectives. It is the most crucial part of simulation learning and was described as the 'heart and soul' of the simulation experience. The aim of debriefing is to constructively review 'what has happened' and 'why it happened' in the simulated event. In the 'frame-action-result' model described by Rudolph, learners have their own 'frames'—their assumption, knowledge and feelings that drive their 'actions', which in turn end up with different 'results' [9]. While actions and results are easily observable, frames are often invisible. A successful debriefer needs to act as a 'cognitive detector', to

**5. Special role of the facilitator in ECMO simulation and the** 

module of the Orpheus Perfusion Simulator to produce a realistic simulation [7].

**4.3. Limitations**

**debriefing process**

construct of economical oxygenators [8].

142 Advances in Extra-corporeal Perfusion Therapies

simulate colour changes of the circuit blood [8].

