IMPLEMENTATION
The initial run of the simulation curriculum was implemented on February 22, 2023, and ended on May 17, 2023, with 5 events. Participants included internal medicine PGY1 residents, third-year medical students, and fourth-year physician assistant students. Internal medicine residents ran each scenario with a subject matter expert monitoring; the undergraduate medical trainees partnered with another student. Students were pulled from their ward rotations to attend the simulation, and residents were pulled from electives and wards. Each trainee was able to experience each planned scenario. They were then briefed, participated in each scenario, and ended with a debriefing, discussing each case in detail. Two subject matter experts were always available, and occasionally 4 were present to provide additional knowledge transfer to learners. These included board-certified physicians in internal medicine and pulmonary critical care. Most scenarios were conducted on Wednesday afternoon or Thursday.
The CIL provided 6 staff minimum for every event. The staff controlled the manikins and acted as embedded players for the learners to interact and work with at the bedside. Every embedded RN was provided the same script: They were a new nurse just off orientation and did not know what to do. In addition, they were instructed that no matter who the learner wanted to call/page, that person or service was not answering or unavailable. This forced learners to respond and treat the simulated patient on their own.
Survey Responses
To evaluate the effect of this program on medical education, we administered surveys to the trainees before and after the simulation (Appendix). All questions were evaluated on a 10-point Likert scale (1, minimal comfort; 10, maximum comfort). The postsurvey added an additional Likert scale question and an open-ended question.
Sixteen trainees underwent the simulation curriculum during the 2022 to 2023 academic year, 9 internal medicine PGY1 residents, 4 medical students, and 3 physician assistant students. Postsimulation surveys indicated a mean 2.2 point increase in comfort compared with the presimulation surveys across all questions and participants.
DISCUSSION
The simulation curriculum proved to be successful for all parties, including trainees, medical educators, and simulation staff. Trainees expressed gratitude for the teaching ability of the simulation and the challenge of confronting an evolving scenario. Students also stated that the simulation allowed them to identify knowledge weaknesses.
Medical technology is rapidly advancing. A study evaluating high-fidelity medical simulations between 1969 and 2003 found that they are educationally effective and complement other medical education modalities.6 It is also noted that care provided by junior physicians with a lack of prior exposure to emergencies and unusual clinical syndromes can lead to more adverse effects.7 Simulation curriculums can be used to educate junior physicians as well as trainees on a multitude of medical emergencies, teach systematic approaches to medical scenarios, and increase exposure to unfamiliar experiences.
The goals of this article are to share program details and encourage other training programs with similar capabilities to incorporate simulation into medical education. Using pre- and postsimulation surveys, there was a concrete improvement in the value obtained by participating in this simulation. The Nightmare on CIL Street learners experienced a mean 2.2 point improvement from presimulation survey to postsimulation survey. Some notable improvements were the feelings of preparedness for rapid response situations and developing a systematic approach. As the students who participated in our Nightmare on CIL Street simulation were early in training, we believe the improvement in preparation and developing a systematic approach can be key to their success in their practical environments.
From a site-specific standpoint, improvement in confidence working through cardiac, respiratory, and neurological emergencies will be very useful. The anesthesiology service intubates during respiratory failures and there is no stroke neurologist available at the CTVHCS hospital. Giving trainees experience in these conditions may allow them to better understand their role in coordination during these times and potentially improve patient outcomes. A follow-up questionnaire administered a year after this simulation may be useful in ascertaining the usefulness of the simulation and what items may have been approached differently. We encourage other institutions to build in aspects of their site-specific challenges to improve trainee awareness in approaches to critical scenarios.