The kinds of aid available for wound care training range from the very low tech to the very high tech. Low-tech tools include teaching by showing students pictures and diagrams of wounds and their proper care. Low-tech simulations include properly weighted manikins on which trainees can practice applying pressure and dressing wounds.
Hi-tech, or high fidelity, simulations available for wound care include manikins that breathe, bleed and sweat and whose vital signs respond to trauma and to treatment. The highest-end manikins are made out of artificial tissue that has been designed and developed to emulate human tissue in every way. Beyond that, there are also immersive virtual reality environments that duplicate locations such as emergency rooms, and mentoring systems that monitor a student’s every move, map those against the techniques used by established experts and provide feedback.
Wound care doesn’t always take place on the battlefield or in the emergency room. At the U.S. Army Burn Center in Fort Sam Houston, Texas, arriving nurses are trained on the routines of wound care for patients that may be hospitalized for long periods of time. The approach taken by the burn center is decidedly low-tech: They train on static manikins, practicing the application of pressure and the dressing of wounds without even a depiction of the wound itself. Burn center personnel say that their decisions are based on budgetary realities: These days they have to answer for every dollar that they spend.
Lieutenant Colonel Jodelle Schroeder, commander of the 126th Forward Surgical Team based in Fort Hood, Texas, believes that the greater the level of realism, the better the efficacy of the training. Few will disagree with that assertion, especially not the companies that make the more sophisticated simulations. “The more realistic we can make the training, the better,” said Schroeder. “This gets the attention of trainees as to what they are doing well and also where improvement is needed.”
Schroeder’s unit uses a combination of simulations in its training. “We sometimes use manikins with wounds affected on them with moulage kits for things like amputations, skeletal injuries, cuts and burns,” she said. “Sometimes we also use moulage kits on actual personnel and practice washing and dressing wounds on them.” Moulage refers to the art of simulating wounds often used in film and the theater.
“High fidelity simulations include an electronic component,” explained Sarah Shingleton, a wound care clinical nurse specialist at the U.S. Army Burn Center. “The manikin is connected to a computer which enables it to breath, cry, urinate and sweat. We would use high fidelity simulations for things like burn resuscitations and cardiac arrest. Trainees can apply chest compression and the heart rate changes based on the scenario. For wound care, we have found that level of high fidelity not to be necessary.”
“We mainly use high fidelity simulations for more complex scenarios,” agreed Major Scott Phillips, chief of clinical education and a senior clinical nurse specialist at the Burn Center. “Although we could use high fidelity simulations for wound care training, we think that the low fidelity alternatives are good enough to get the point across of how to clean and dress a wound.”
Industry types argue that the more immersive the training, the more effective it is. “The deeper the immersion, the better the learning experience and the longer that experience stays with the trainee,” said Eric Rohde, chief strategist, Medical Simulations for Intelligent Decisions. “They pick up the skills better and quicker with immersive training methods.” Intelligent Decisions developed virtual reality environments for a variety of medical and surgical training scenarios.
SynDaver Labs developed a product line originally designed to simulate healthy human tissue for educational purposes and to replace the use of animals in studies. The company has since branched out to creating trauma simulations in aid of training. “Our trauma models include applications for bullet wounds, severed limbs and soft tissue injuries,” said Christopher Sakezles, the company’s president and chief technology officer. “The trauma models are always made according to the specific needs of customers. For military customers, we have made models with a femur shattered by an AK-47 round or a traumatic amputation from an IED.”
Some of the more recent developments added to wound care simulations include adding pressure sensors to the simulated wound, according to Bob Buckman, vice president of sales and marketing at Operative Experience Inc. “This assures that the student is applying the appropriate amount of pressure to the wound and that it is properly packed,” he explained. “Another important innovation has been the simulation of coagulated blood. This also is a sign that the wound has been properly packed and dressed.”
Immersive medical simulations are analogous to military training simulations that provide after-action reviews to the trainees, according to Rohde. “A host of analytics follow on the training that can be used to better ‘Monday morning quarterback’ the actions of the medical personnel,” he explained. “The Holy Grail for training, especially in the military, is to quantify what soldiers or medics are learning and then improve performance in the next round by educating them on where they are missing something.”
The mentoring approach to simulated training developed by SimIS uses the Microsoft Kinect camera used in gaming systems to compare the actions of a trainee in a given situation against those of an expert performing the same procedure. “We developed the software to compare the two sets of actions,” said Justin Maestri, product manager for health care simulations at SimIS. “The system provides a readout that compares everything from how the instruments were handled to body mechanics.”
The Army Burn Center hosts 800 trainees annually from all branches of the military who learn wound care as part of a broader burn treatment mission in an eight-week internship. “Simulations allow our students to make mistakes and to learn from experience before dressing the wounds of actual patients,” said Phillips. “This is especially important for harder procedures such as applying dressings that go around the shoulder. The students can work on that in a fault-free zone using simulations.”
“It is all about learning the correct procedures and techniques,” added Shingleton. “The students can take as much time as needed without worrying about the patient being in pain.”
The course provided for nurses and medics at the Burn Center follow the classic formula of crawl, walk, run, said Shingleton. “Like any other kind of training, we first have to provide the students with knowledge,” she added. “We teach them about the levels of skin and how to differentiate superficial from deep wounds. The students start out in the classroom with a combination of lectures and interactive training. After that they will typically be given some bedside time, where they can see real wounds being treated.”
Back in the classroom, the students then get to practice wound care on the manikins. “They get dressed up in mask and gown and learn to take dressings off as in real life,” said Shingleton. “They learn how to clean the wound, how much pressure to apply, and how to hold the patient’s limbs while these procedures are being done.”
The Burn Center doesn’t use high fidelity manikins and doesn’t simulate wounds on the manikins. But the manikins must be properly weighted and flexible so that pressure can be applied and they can be manipulated like an actual patient. “There may be some use in manikins that display more anatomical features such as muscle and bone,” said Phillips. “The main thing that we accomplish is to establish the muscle memory involved in getting the procedures done in the right way. More sophisticated simulations cost a lot more money. We need justification for spending money these days.”
The Army Burn Center does go high tech with its use of a robot to provide images of wound care on actual patients to students sitting in a classroom. These images are used in training students not only locally, but also remotely by teleconference.
“One technology we use daily is a wound flow mapping system,” said Phillips. “This allows us to upload actual photos of patients and incorporate those into teaching. We can show students the progression of wounds from real patients rather than from a computer or a manikin.”
Around 90 percent of wound patients admitted to the Army Burn Center are now photographed, according to Shingleton. “They are photographed again whenever there is a major change in their condition and also as close as possible to discharge,” she said. “As a result, we have a vast repository of pictures that we can use to educate students on wound progression.”
“These ongoing pictures of patients are a good representation on the progress of wounds,” said Phillips. “Sometimes we take down dressings fairly often, especially if we are suspicious of infection. But lots of times we might go three to five days between dressing changes.”
Higher tech simulations tend to be used for training combat medics at lower-level, pre-hospital stages of care. Operative Experience Inc. (OEI) developed its combat trauma skills training simulators with a Small Business Innovation Research grant from the U.S. Army. OEI created training courses using high fidelity and anatomically correct simulators with pathology and wound patterns representative of combat injuries. The simulators consist of artificial tissues, including skin, bone, muscle, fascia, blood vessels and nerves, that can be operated on with standard combat surgical instruments.
OEI point-of-injury simulators emphasize training in damage-control and operative management of high velocity gunshot wounds. They enable instruction in, among other things, the vascular control of blood vessels, damage-control shunting of arteries and veins and amputations.
“We have simulations for use in training wound packing for pre-hospital treatment, such as packing hemostatic dressings on wounds resulting from high velocity gunshots,” said Buckman. “We are developing a new product with a substance that simulates blood and can show when hemorrhaging stops in response to the application of tourniquets, surgical sponges and gauze. We also provide training video with some of our models.”
CAE Healthcare has developed a series of sophisticated manikins with features designed to facilitate different types of training. “Our highest fidelity manikin, HPS, breathes, exchanges real gases, and has a physiology so that it can be used for anesthesia and other higher-end training programs,” said Richard Low, a group leader at CAE Healthcare Academy. “Other manikins, such as our iStan and METIman, are still high fidelity although not quite on the level of HPS. They were developed for more generalized medical training.”
CAE’s Caesar manikin was developed for the Army’s tactical combat casualty care course, although not specifically for wound care. “Caesar comes out of the box with an amputated leg and with a fully-functional airway for training on trikes, inserting needles in the chest and other such procedures,” said Low.
The manikin can be ordered with different types of injuries such as traumatic amputations so that it can be used to practice wound care. “The manikins can also be altered with a simulated wound kit that can portray bullet wounds and lacerations,” said Low. “The physiology of the manikin can be adjusted to mimic trauma and students can learn how to treat that. The manikins will respond differently when 500 units as opposed to 1,000 units of fluids are administered. Vital signs will change differently depending on whether the patient is treated immediately or whether there was a five-minute delay.” One of the biggest technology innovations in recent years, Low added, has been the ability to allow the manikin to wirelessly communicate with its controlling computer.
The original mission of SynDaver Labs was to develop artificial tissues that not only look and feel like real human tissues, but work like the tissue as well. “We attacked the subject from the inside out,” said Sakezles. “We now have 100 kinds of tissue, everything from mucous to bone, corneas and muscles, everything that goes into the makeup of the human body.”
SynDaver’s bodies are used primarily in classroom settings, both in the military and civilian sectors. “There is no analog with our products other than cadavers,” said Sakezles. “They are more expensive than cadavers, but they also bleed and breathe and have no biohazards associated with them.” The artificial bodies have been used with surgical simulators but are mostly used in research facilities.
Intelligent Decisions creates virtual reality environments that are accessed by users through a head-mounted display. The company is now working on a hybridized environment that integrates the virtual with the real in creating a medical training simulation.
So, for example, a wound care simulation could incorporate a virtual emergency room with an actual manikin simulating a wound and lying on a gurney. In this way the student would experience not only working on a simulated patient and perceiving the patient’s responses to treatment, but also the people, activity, noise and even the panic associated with the environment in which this treatment may be taking place.
“The virtual reality environment could include everything from people moving around to machines beeping to people screaming,” said Rohde. “It duplicates the increased stress of the real environment.”
“The camera and the software take into account that people come in different sizes,” noted Maestri. “The system is also manikin agnostic. It can use any manikin as long as our stickers are put in place to provide the tracking information we need.” The company develops specific mentoring simulations at the request of its customers.
Future simulation systems are likely to become all the more sophisticated. SynDaver is working on a new set of simulated tissues. “They will have their own internal embedded physiology thanks to a new electromechanical component,” said Sakezles. “Wireless controls can also be used to change the training scenario.”
Intelligent Decisions’ virtual reality environments will likely benefit in the future from holographic capabilities. “We are looking at ways to cultivate holographic media,” said Rohde. “Trainees will be able to practice tasks in a virtual environment using images from actual patients.”
“There are some really good simulations out there,” said Schroeder. “I’m not sure they are being used to the fullest extent. What I’d really like to see is people using them more. And I’d like to see the people who develop the simulations to really keep pushing the limit on them.
“Leadership has to be adamant that the use of simulations and moulage is important,” she added. “It serves the education and training of our caregivers and it also serves our patients well.” ♦
- Issue: 2
- Volume: 18