The potential role of high fidelity medical simulation for mass casualty incident training

Disaster medicine: The potential role of high fidelity medical simulation for mass casualty incident training

Kobayashi, Leo

With a dramatic increase in highly visible and costly mass casualty incidents over the past few decades, disaster planning and preparedness now represent a prominent part of health care policy and practice. Apart from the upsurge in natural calamities that has accompanied population growth and dispersal as well as global climactic change, willful acts of mass destruction and indiscriminate injury have also cropped up at a disturbing rate. Consequently, significant effort has been directed towards improving the initial management of disastrous events through anticipatory and mitigatory interventions.

The study of disaster medicine, focusing on pre-event planning, emergent medical care and public health measures, has matured rapidly in the past few years through quantum leaps in networking, communications, and computer technologies. Examination of prior events and intercession with ongoing disasters has become much more sophisticated, timely, and pertinent. We now have the opportunity to apply hard-won knowledge to prepare for the next catastrophe.

Implementation of preventive, preparatory, and training protocols has been avidly recommended in the hope of minimizing the harmful consequences of these large-scale events.1,2 Proactive educational exercises may also serve to lessen the loss of life, limb, and property.3 Such measures may range from simple regular fit-testing of protective gear, to complex multifactorial computer simulations evaluating hospital bed availability in the event of a community-wide disaster.4


Who needs to be trained?

For rescue workers potentially responding to mass casualty incidents, adequate training must be established, implemented, and maintained to en-sure their safety, the optimal care of their patients, and the best interest of the public. In some form, these efforts should reach prehospital and hospital-based healthcare providers, law enforcement, fire department personnel, and disaster relief organizations (e.g. American Red Cross). Hospital, state and federal administrators need to be active participants in disaster education and become proficient in incident management, resource planning and allocation, and interagency coordination.

Who thinks we should train?

With significant cost and effort, the US Department of Health and Human Servicesi Office of Emergency Response has developed a standardized Web-based program for all National Disaster Medical System (NDMS) field teams. The Department of Defense has been involved with a weapons of mass destruction (WMD) Domestic Preparedness Program for health care providers, but availability is limited.5 Several organizations, including the American College of Emergency Physicians (ACEP), have recommended the inclusion of disaster education in prehospital, nursing, medical school, residency, and post-graduate curricula.2,6 Notably, the American Red Cross has developed a training center geared to prepare its workers for situations involving WMDs.

What needs to be taught?

Educational experiences for disaster responders must be accurate, thorough, relevant, and up-to-date. They need to impart a specialized medical knowledge-base and increase the interface with other agencies. Dissemination of key factual knowledge encompassing natural, bioweapon, chemical and nuclear hazards has to take place. Furthermore, the basic tenets of disaster management n triage, decontamination, communications, incident command, transport n have to be successfully conveyed. The ability to rapidly form multi-disciplinary work teams that communicate and function effectively has to be cultivated. Relevant areas of expertise generally beyond the scope of basic training are crisis psychology, tactical training, and hazardous materials (HazMat).

Adding to the complexity of disaster training is the need to teach specific and unique skill sets, which are uncommonly utilized, yet will need to be performed efficiently when the need arises. As no amount of training will be able to fully prepare for all contingencies, a flexible and dynamic approach to disaster response has to be encouraged. Finally, attrition of knowledge after training is to be expected, creating the need for ongoing training and refresher courses.

How do we currently train?

Lectures and seminars are a large component of any disaster curriculum. Emergency Medical Technician (EMT) courses at all levels incorporate presen-tations covering the basic elements of disaster response. Emergency Medicine residencies would be expected to do the same, but attainment of such a goal is not uniform.1 Already burdened with full schedules, medical and nursing schools rarely venture into the realm of disasters. Moreover, a recent ACEP task force analysis of available disaster-related courses for EMTs, nurses, and physicians found them unsatisfactory relative to expert panel-derived teaching objectives.6 An effort by the Office of Emergency Response to create a uniform curriculum has led to a novel Web-based course in disaster training, although access is limited to NDMS members.

A central activity in disaster training should be simulation. Disasters are chaotic, and the responses so multi-faceted and necessarily labile, that recreating a calamitous event is a better way to teach, reinforce, and test concepts not readily transmitted by the lecture format. By constructing stressful situations that adjust and update themselves in real-time to participant decisions and actions, simulation can cultivate dynamic problem-solving for disaster management. In addition, teamwork and familiarity between personnel from various responding departments and agencies can be fostered during multi-disciplinary simulations.

The scale and nature of the simulated disaster may vary from itable-topi computer re-enactments and field exercises with local, state, and federal agency interfacing, down to more moderately scaled disaster drills with cooperation between a few local units or departments.7,8 Published accounts of recent large-scale exercises, such as the 1999 Wisconsin joint civilian-military field maneuver i Wake-Up Calli involving bioweapon terrorism and the multi-agency crisis administration and consequence management exercise iTOP OFF,i are available.9,10

How does high fidelity simulation fit in?

As with any simulation, the higher the fidelity of the disaster exercise, the greater the immersion in the training experience. Current disaster simula-tions use actors and volunteers as well as low-fidelity manikins in the role of victim. Physician participation in the role of interactive ismart simulated casualtiesi who directly observe and debrief trainee rescue workers has been one method of enhancing simulation.11 Low-fidelity manikins feature life-like form and surface features, can undergo life-support interventions such as intubation and CPR, but do not exhibit physiologic behaviors such as breathing or blinking. In contrast, invasive or dangerous interventions cannot be practiced on individuals portraying victims, albeit they may be fully interactive and irealistic.i

High fidelity medical simulation (SIM) technology can help overcome the obstacles and the resultant disconnect between preparatory exercise and actual incident. Fully programmable to display physiologic responses to injury and absolutely free of the restrictions inherent to live patient actors, SIM allows for ipractice without riski and greater verisimilitude.12 SIM scenarios can bring the distressing, distracting sights and sounds of disasters and their victims to life, ultimately helping reconcile the theory with practice of disaster response. Taking care of a moaning, breathing, moulaged manikin with deteriorating vitals signs in a field setting while wearing a HazMat suit can only assist in improving the incident-readiness of rescue personnel.


What exactly is high fidelity simulation?

Simulation training is well established in other complex, high-risk industries such as aviation, nuclear power, and the military, all of which are regarded as high reliability organizations. Anesthesiologists pioneered the use of realistic high fidelity interactive patient simulators in the mid-1980s. However, only recently has simulation technology come into more widespread medical use, and its full potential for medical education has not been realized.

SIM allows for clinical scenarios using life-sized computerized patient manikins that respond in real-time to a variety of clinical interventions and pharmacologic agents, letting medical educators control situational learning. Computer-driven manikins cost $30,000 to $200,000 and are capable of verbal communication, accurate representation of physical exam findings (airway compromise, lung and cardiac sounds, pulses, etc), and physiologic responses to drug and treatment interventions. Realistic representations of actual treatment settings allow simulation participants to suspend disbelief and immerse themselves in the exercise.

SIM is currently used in various instructive settings to improve clinical decision-making and psychomotor skills, e.g. airway management and trauma resuscitation. Additionally, a role for SIM lies in the systematized reduction of medical error through teamwork and procedure training with instructive debriefing. The appeal of reproducible enactments embodying critical, stressful real-life situations, without risk of harm to patients or staff, is clear. Drawbacks such as the cost, operation, and maintenance of simulator facilities are not negligible; however, improved funding and national interest in disaster response after recent terrorist events may prove opportune. Extension of SIM training to the field of disaster medicine is logical and to be expected.


How do we integrate SIM technology to improve disaster training?

A disaster exercise outline is presented (see diagrams) to demonstrate how SIM technology may be integrated into responder disaster training, with the focus on the design and planning aspects of a proposed SIM implementation. Chemical agent exposure was chosen for its medical complexity, predilection towards interventions readily performed on manikins, opportunity for performance of rescue activities in personal protective equipment (PPE), applicability to WMD and accidental chemical releases, and the distinct possibility of disaster actualiza-tion. A just-published account of SIM-enhanced chemical warfare response education in Israel was instructive in conception of this proposal.13

The presence of SIM in this par-ticular exercise should accomplish the following goals:

1. accurately simulate a WMD disaster with subsequent prchospital and hospital response to the exposure, specifically:

*incident command




* transport

* treatment

* resource management

* debriefing

2. provide clinical stimuli and generate a learning environment above and beyond what is attained with current disaster train-ing

3. achieve maximal training with minimal risk to rescuers and “victims”

4. observe and record critical actions in real-time, then evaluate and debrief participants

5. allow participants to become fa-miliar with SIM technology

6. fine-tune SIM technology for the special needs of disaster exercises

These are in addition to the standard objectives of an exercise not enhanced by SIM technology, namely to assemble multi-disciplinary teams for educational interaction and cooperation, to field-test and familiarize rescuers with communications equipment and PPE in the context of chemical WMD hazards, and to assess prehospital and hospital medical response to disaster conditions.


The Providence-based Rhode Island Hospital Medical Simulation Center (RIHMSC) is composed of a simulation control room and simulator area, two trainee simulation-viewing areas, a conference room for audiovisual debriefings, storage and equipment rooms, and an office suite. The simulation area was designed to be flexible to accommodate multiple simultaneous simulations, recreate other patient care areas (e.g. operating room, intensive care unit, radiology suite), and conduct disaster exercises.

All aspects of actual hospital acute care areas, including triage and communications, resuscitation rooms, standard and advanced resuscitation equipment with medications, medical gases, and computer / imaging display capabilities, have been incorporated into the design. These can be configured to emulate prehospital triage and treatment stations as well. The audio-visual system consists of digital video recorders, viewing room video monitors for displaying patient data, wireless microphones for communication and individual participant recording, and an audiovisual editing setup to create educational materials for remote and off-line learning.

The RIHMSC utilizes SimMan (MPL/Laerdal) equipment and is capable of supporting five separately controlled computerized high fidelity manikins. The current setup includes a SimMan with fully computerized control and audiovisual interactive capability, in conjunction with an intubation and defibrillation-ready Laerdal ALS Skill trainer manikin. Scenarios involving multiple SimMan manikins have already been carried out successfully, and extension to disaster exercises engaging more than ten victims is within reach. RIHMSC is currently working with local disaster management agencies to realize a SIM-enhanced disaster simulation based on the suggested outline in this article.


1. Pesik N, Keim M, Sampson TR. Do US emergency medicine residency programs provide adequate training for bioterrorism? Ann Emerg Med 1999; 34:173-6.

2. American College of Emergency Physicians Terrorism Response Task Force. Positioning America’s emergency health care system to respond to acts of terrorism. Irving: American College of Emergency Physicians, 2002. download.cfm?resource=741

3. Institute of Medicine and National Research Council. Chemical and Biological Terrorism: Research and Development to Improve Civilian Medical Response. Washington, DC: National Academy Press, 1999.

4. Hirshberg A, Holcomb JB, Matrox KL. Hospital trauma care in multiple-casualty incidents: A critical view. Ann Emerg Med 2001; 37: 647-52.

5. United States Department of Defense. Report to Congress on response to threats of terrorist use of weapons of mass destruction. Washington, DC: United States Department of Defense, 1997.

6. Waeckerle JF, Seamans S, Whiteside M, et al. Executive summary: Developing objectives, content, and competencies for the training of Emergency Medical Technicians, Emergency Physicians, and Emergency Nurses to care for casualties resulting from nuclear, biological, or chemical (NBC) incidents. Ann Emerg Med 2001; 37: 587-601.

7. Hogan DE, Burstein JL. Disaster Medicine. Philadelphia: Lippincott Williams & Wilkins, 2002.

8. Tur-Kaspa I, Lev EI, Hendler I, et al. Preparing hospitals for toxicological mass casualties events. Crit Care Med 1999; 27:1004-8.

9. Tyre TE. Wake-Up Call: A bioterrorism exercise. Mil Med 2001; 166(Suppl.12): 90-1.

10. Inglesby TV. Observations from the Top Off exercise. Public Health Rep 2001; 116(Suppl.2):64-8.

11. Gofrit ON, Leibovici D, Shemer J, et al. The efficacy of integrating smart simulated casualties in hospital disaster drills. Prehospital Disaster Med 1997;12:97-101.

12. Gordon JA, Wilkerson WM, Shaffer DW, et al. “Practicing” medicine without risk: Students’ and educators’ responses to high-fidelity patient simulation. Acad Med 2001; 76: 469-72.

13. Vardi A, Levin I, Berkenstadt H, et al. Simulation-based training of medical teams to manage chemical warfare casualties. Israel Med Assoc J 2002; 4: 540-4.

Leo Kobayashi, MD, is Attending Physician, Department of Emergency Medicine, Brown Medical School.

Marc J Shapiro, MD, is Director of Medical Simulation Center, Rhode Island Hospital, and Assistant Professor, Department of Medicine, Brown Medical School.

Selim Suner, MD, is Assistant Professor, Department of Surgery, Brown Medical School.

Kenneth Williams, MD, FACEP, is Clinical Associate Professor, Department of Emergency Medicine. Brown Medical School.


Leo Kobayashi, MD

Department of Emergency Medicine

1 Hoppin Street

Coro Building, Suite 106

Providence, RI 02903

Phone: (401) 444-6237

Fax: (401) 444-5456


Copyright Rhode Island Medical Society Jul 2003

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