Teaching bedside cardiologic examination skills using "Harvey", the cardiology patient simulator

Incorporation of Simulation in Graduate Medical Education: Historical Perspectives, Current Status, and Future Directions

Technological advancement and improved training strategies have transformed the healthcare practice environment in the last few decades. Simulation has evolved as one of the leading training models for the next generation of healthcare professionals. Simulation-based training enables healthcare professionals to acquire knowledge and skills in a safe and educationally oriented environment and can be a valuable tool for improving clinical practice and patient outcomes. The field of healthcare simulation has been rapidly growing, and various graduate medical education programs around the world have started incorporating this modality into their curricula. In graduate medical education, simulation-based training helps implement an outcome-based curriculum that tests the trainee's actual skill level as the primary factor for the trainee's competency rather than relying on the current model of a predetermined training period. However, the major challenge revolves around developing an educational curriculum incorporating a simulation-based educational model, understanding the value of this new technology, the overall cost factor, and the lack of adequate infrastructure. Hence, embracing the full potential of simulation technology in graduate medical education curricula requires an innovative approach with participation from institutions and stakeholders.

Face validity of a virtual reality simulation platform to improve competency in endoscopy: a prospective observational cohort study

Background and study aims  Virtual reality endoscopic simulation training has the potential to expedite competency development in novice trainees. However, simulation platforms must be realistic and confer face validity. This study aimed to determine the face validity of high-fidelity virtual reality simulation (EndoSim, Surgical Science, Gothenburg), and establish benchmark metrics to guide the development of a Simulation Pathway to Improve Competency in Endoscopy (SPICE). Methods  A pilot cohort of four experts rated simulated exercises (Likert scale score 1-5) and following iterative development, 10 experts completed 13 simulator-based endoscopy exercises amounting to 859 total metric values. Results  Expert metric performance demonstrated equivalence ( P  = 0.992). In contrast, face validity of each exercise varied among experts (median 4 (interquartile range [IQR] 3-5), P  < 0.003) with Mucosal Examination receiving the highest scores (median 5 [IQR 4.5-5], P  = 1.000) and Loop Management and Intubation exercises receiving the lowest scores (median 3 [IQR 1-3], P  < 0.001, P  = 0.004), respectively. The provisional validated SPICE comprised 13 exercises with pass marks and allowance buffers defined by median and IQR expert performance. Conclusions  EndoSim Face Validity was very good related to early scope handling skills, but more advanced competencies and translation of acquired clinical skills require further research within an established training program. The existing training deficit with superadded adverse effects of the COVID pandemic make this initiative an urgent priority.

Effectiveness of high- and low-fidelity simulation-based medical education in teaching cardiac auscultation: a systematic review and meta-analysis

Simulation-based medical education (SBME) is an evolving method of teaching cardiac examination skills to healthcare learners. It has been deliberated how effective this teaching modality is and whether high-fidelity methods are more effective than low-fidelity methods. This systematic review aimed to assess the effectiveness of high-fidelity SBME in teaching cardiac auscultation compared with no intervention or another active teaching intervention (low-fidelity SBME) using evidence from randomized controlled trials (RCTs).

Literature searches were performed on Medline, Embase, PsychInfo and Cinahl. RCTs that compared the effectiveness of high-fidelity simulation against no intervention or high-fidelity simulation against low-fidelity simulation in teaching cardiac auscultation to healthcare learners were included. Outcomes were knowledge, skills and satisfaction relating to cardiac auscultation education. Data were analyzed using Review Manager 5.3 software.

Seventeen RCTs (n = 1055) were included. Twelve RCTs (n = 692) compared high-fidelity simulation with no intervention. The pooled effect sizes for knowledge and skills were 1.39 (95% confidence interval [CI], 0.39–2.38;

This review’s findings suggest that high-fidelity SBME is an effective teaching method for cardiac auscultation education. Interestingly, there was no significant difference in knowledge or skills among learners when comparing high-fidelity simulation with low-fidelity simulation. Further research is needed to establish the effectiveness of different forms of SBME as educational interventions.

Simulation Training in the ICU

Because of an emphasis on patient safety and recognition of the effectiveness of simulation as an educational modality across multiple medical specialties, use of health-care simulation (HCS) for medical education has become more prevalent. In this article, the effectiveness of simulation for areas important to the practice of critical care is reviewed. We examine the evidence base related to domains of procedural mastery, development of communication skills, and interprofessional team performance, with specific examples from the literature in which simulation has been used successfully in these domains in critical care training. We also review the data assessing the value of simulation in other areas highly relevant to critical care practice, including assessment of performance, integration of HCS in decision science, and critical care quality improvement, with attention to the areas of system support and high-risk, low-volume events in contemporary health-care systems. When possible, we report data evaluating effectiveness of HCS in critical care training based on high-level learning outcomes resulting from the training, rather than lower level outcomes such as learner confidence or posttest score immediately after training. Finally, obstacles to the implementation of HCS, such as cost and logistics, are examined and current and future strategies to evaluate best use of simulation in critical care training are discussed.

[Medical simulation as a tool in the training of perinatal professionals]

Though technology plays an increasingly important role in modern health systems, human performance remains a major determinant of safety, effectiveness and efficiency of patient care. This is especially true in the delivery room. Thus, the training of professionals must aim not only for the acquisition of theory and practical skills on an individual basis, but also for the learning of teamwork systematically. Training health professionals with simulation enhances their theoretical knowledge and meets formal requirements in literacy, technical skills and communication. Therefore, we intend to explore how, in perinatal care, training with simulation is actually a key teaching tool in initial education and in perpetuation of knowledge. We will approach three main aspects: individual, collective (team) and the impact of simulation in medical practice. The choice of this educational strategy improves the clinical skills that are required for optimal performance in complex, unpredictable and high-stake environments such as the delivery room. Nonetheless, the long term clinical impact of simulation and whether it's modalities, technical or not, are beneficial to the mother and the newborn are areas still to be explored.

Teaching cardiopulmonary auscultation in workshops using a virtual patient simulation technology - A pilot study

Auscultation is currently both a powerful screening tool, providing a cheap and quick initial assessment of a patient's clinical condition, and a hard skill to master. The teaching of auscultation in Universities is today reduced to an unsuitable number of hours. Virtual patient simulators can potentially mitigate this problem, by providing an interesting high-quality alternative to teaching with real patients or patient simulators. In this paper we evaluate the pedagogical impact of using a virtual patient simulation technology in a short workshop format for medical students, training them to detect cardiac pathologies. Results showed a significant improvement (+16%) in the differentiation between normal and pathological cases, although longer duration formats seem to be needed to accurately identify specific pathologies.

Simulation in Cardiology and Cardiothoracic and Vascular Surgery

Cardiologists and cardiac surgeons are rapidly embracing the use of realistic patient simulators and virtual reality devices to allow mastery of complex techniques, planning of complicated procedures, crisis management of infrequently seen diseases and complications, and development of medical team work. Simulation can certainly be used for these purposes in surgical education but provides only the “tip of the iceberg” of the knowledge needed by the competent cardiothoracic, vascular, or general surgeon. Is simulation really the way to learn how to perform actual surgical procedures? This review will describe available surgical simulation technology, and define some of the problems to be solved for validation and general acceptance.

Simulation-based training for cardiac auscultation skills: systematic review and meta-analysis

OBJECTIVES

The current review examines the effectiveness of simulation-based medical education (SBME) for training health professionals in cardiac physical examination and examines the relative effectiveness of key instructional design features.

METHODS

Data sources included a comprehensive, systematic search of MEDLINE, EMBASE, CINAHL, PsychINFO, ERIC, Web of Science, and Scopus through May 2011. Included studies investigated SBME to teach health profession learners cardiac physical examination skills using outcomes of knowledge or skill. We carried out duplicate assessment of study quality and data abstraction and pooled effect sizes using random effects.

RESULTS

We identified 18 articles for inclusion. Thirteen compared SBME to no-intervention (either single group pre-post comparisons or SBME added to other instruction common to all learners, such as traditional bedside teaching), three compared SBME to other educational interventions, and two compared two SBME interventions. Meta-analysis of the 13 no-intervention comparison studies demonstrated that simulation-based instruction in cardiac auscultation was effective, with pooled effect sizes of 1.10 (95 % CI 0.49-1.72; p < 0.001; I(2) = 92.4 %) for knowledge outcomes and 0.87 (95 % CI 0.52-1.22; p < 0.001; I(2) = 91.5 %) for skills. In sub-group analysis, hands-on practice with the simulator appeared to be an important teaching technique. Narrative review of the comparative effectiveness studies suggests that SBME may be of similar effectiveness to other active educational interventions, but more studies are required.

LIMITATIONS

The quantity of published evidence and the relative lack of comparative effectiveness studies limit this review.

CONCLUSIONS

SBME is an effective educational strategy for teaching cardiac auscultation. Future studies should focus on comparing key instructional design features and establishing SBME's relative effectiveness compared to other educational interventions.

The use of computers for perioperative simulation in anesthesia, critical care, and pain medicine

Simulation in perioperative anesthesia training is a field of considerable interest, with an urgent need for tools that reliably train and facilitate objective assessment of performance. This article reviews the available simulation technologies, their evolution, and the current evidence base for their use. The future directions for research in the field and potential applications of simulation technology in anesthesia, critical care, and pain medicine are discussed.

The Ventriloscope® as an innovative tool for assessing clinical examination skills: appraisal of a novel method of simulating auscultatory findings

BACKGROUND

Simulation is increasingly used as a teaching tool and in assessment. The Ventriloscope® (VS) is a new auscultation simulator. This modified stethoscope allows pre-recorded sounds (activated wirelessly) to be integrated with a simulated patient (SP, professional actor).

AIMS

This study explores the instrument's potential for overcoming limitations of current objective structured clinical examination (OSCE) assessment by increasing validity while retaining reliability.

METHODS

After training SPs to synchronise the device with their breathing (recreating abnormal signs), we evaluated the VS during a third year undergraduate medical student OSCE. Students (n =  385), examiners (n = 19) and SPs (n = 10) completed post-exam questionnaires which were analysed using a coding framework. OSCE performance data were analysed using Stata 10.

RESULTS

When 'compared to their usual stethoscope' 40% of students found no difference in using the VS; 69% found it easier to identify sounds; 68% found examination with the VS very or fairly realistic when 'compared to examining a real patient'. Examination scores were comparable with other OSCE stations.

CONCLUSIONS

The VS reliably provided consistent 'abnormal' auscultatory signs within an OSCE framework. Using a VS may increase OSCE validity, allowing examiners to assess students' application of knowledge in a realistically simulated setting. The VS can help bridge the gap between simulation and real patients.

Medical simulation in respiratory and critical care medicine

Simulation-based medical education has gained tremendous popularity over the past two decades. Driven by the patient safety movement, changes in the educational opportunities available to trainees and the rapidly evolving capabilities of computer technology, simulation-based medical education is now being used across the continuum of medical education. This review provides the reader with a perspective on simulation specific to respiratory and critical care medicine, including an overview of historical and modern simulation modalities and the current evidence supporting their use.

A simulation course on lifesaving techniques for third-year medical students

BACKGROUND

The University of Virginia School of Medicine discontinued animal vivisection in February 2004 for teaching lifesaving procedures to third-year medical students. Consequently, a 1-day course using simulation technology was developed to meet objectives previously covered in the animal laboratory. The authors sought to evaluate the course and hypothesized that the students' confidence in lifesaving procedures as well as their acceptance of simulation technology as a teaching tool would increase.

METHODS

The course was designed in a two-session format. The first session (first half of the day) concentrated on individual procedure skills, utilizing part-task trainers. The second session (second half of the day) used a Medical Education Technologies Inc. (METI) Emergency Care Simulator (ECS) full-body patient simulator to present a major trauma scenario. The study design was a prospective, pretest-posttest study without a control group. A 10-question pre and post survey used a Likert scale to explore students' confidence in their skills as well as their acceptance of simulation technology. A course evaluation used a similar Likert scale for evaluation of the course substations, the trauma scenario, and students' self-assessment of their skill levels as well as a 100% point scale for an overall rating of the course.

RESULTS

A total of eight 1-day courses were successfully held over 2 years with a total enrollment of 240 students utilizing 20 instructors inclusive of faculty, residents, and other emergency medicine health care providers. For the pre and post survey results, there was a significant increase in students' confidence in performing lifesaving procedures as well as their acceptance of simulation as a teaching tool (P < 0.05 for each question with pre n = 222 and post n = 226). For the course evaluation results (n = 190), all of the course substations were rated in the good to excellent range and the course received an overall score of 97.55 +/- 7.23% out of 100%. Furthermore, students reported a significant increase in their skill level (P < 0.05).

CONCLUSION

This lifesaving techniques course utilizing simulation technology successfully covered objectives previously taught with animal vivisection, increased students' confidence levels in performing lifesaving procedures and was highly accepted by the medical students.

The history of simulation in medical education and possible future directions

INTRODUCTION

Clinical simulation is on the point of having a significant impact on health care education across professional boundaries and in both the undergraduate and postgraduate arenas.

SCOPE OF SIMULATION

The use of simulation spans a spectrum of sophistication, from the simple reproduction of isolated body parts through to complex human interactions portrayed by simulated patients or high-fidelity human patient simulators replicating whole body appearance and variable physiological parameters.

GROWTH OF SIMULATION

After a prolonged gestation, recent advances have made available affordable technologies that permit the reproduction of clinical events with sufficient fidelity to permit the engagement of learners in a realistic and meaningful way. At the same time, reforms in undergraduate and postgraduate education, combined with political and societal pressures, have promoted a safety-conscious culture where simulation provides a means of risk-free learning in complex, critical or rare situations. Furthermore, the importance of team-based and interprofessional approaches to learning and health care can be promoted.

CONCLUSION

However, at the present time the quantity and quality of research in this area of medical education is limited. Such research is needed to enable educators to justify the cost and effort involved in simulation and to confirm the benefit of this mode of learning in terms of the outcomes achieved through this process.

A brief history of the development of mannequin simulators for clinical education and training

Simulation for medical and healthcare applications, although still in a relatively nascent stage of development, already has a history that can inform the process of further research and dissemination. The development of mannequin simulators used for education, training, and research is reviewed, tracing the motivations, evolution to commercial availability, and efforts toward assessment of efficacy of those for teaching cardiopulmonary resuscitation, cardiology skills, anaesthesia clinical skills, and crisis management. A brief overview of procedural simulators and part-task trainers is also presented, contrasting the two domains and suggesting that a thorough history of the 20+ types of simulator technologies would provide a useful overview and perspective. There has been relatively little cross fertilisation of ideas and methods between the two simulator domains. Enhanced interaction between investigators and integration of simulation technologies would be beneficial for the dissemination of the concepts and their applications.

A brief history of the development of mannequin simulators for clinical education and training

Simulation for medical and healthcare applications, although still in a relatively nascent stage of development, already has a history that can inform the process of further research and dissemination. The development of mannequin simulators used for education, training, and research is reviewed, tracing the motivations, evolution to commercial availability, and efforts toward assessment of efficacy of those for teaching cardiopulmonary resuscitation, cardiology skills, anaesthesia clinical skills, and crisis management. A brief overview of procedural simulators and part-task trainers is also presented, contrasting the two domains and suggesting that a thorough history of the 20+ types of simulator technologies would provide a useful overview and perspective. There has been relatively little cross fertilisation of ideas and methods between the two simulator domains. Enhanced interaction between investigators and integration of simulation technologies would be beneficial for the dissemination of the concepts and their applications.

Trauma Assessment Training with a Patient Simulator: A Prospective, Randomized Study

BACKGROUND

Patient simulators are computer-controlled mannequins that may increase realism during trauma training by providing real-time changes in vital signs and physical findings during trauma scenarios. We hypothesized that trauma assessment training on a patient simulator would be as effective as training with a more traditional moulage patient/actor.

METHODS

This study was conducted during a surgery intern orientation at two academic trauma centers. Interns (n = 60) attended a basic trauma course, and were then randomized to trauma assessment practice sessions with either the patient simulator (n = 30) or a moulage patient (n = 30). After practice sessions, interns were randomized a second time to an individual trauma assessment test on either the simulator or the moulage patient. Two surgeon-judges rated each intern live and on video for completion of 50 predetermined assessment objectives (total score) divided into sections (primary and secondary survey, general performance, diagnostic studies/procedures, and plan) and the identification and management of an acute neurologic deterioration in the test patient (event score). Multiple linear regression with random student effects was used to estimate the independent effects of all study variables.

RESULTS

Within randomized groups, mean trauma assessment test scores for all simulator-trained interns were higher when compared with all moulage-trained interns (71 +/- 8 vs. 66 +/- 8, respectively; p = 0.02). Simulator training independently showed a small but statistically significant improvement in both the total score and the event score (+4.6 and +8.6, respectively; p < 0.05).

CONCLUSION

Use of a patient simulator to introduce trauma assessment training is feasible and compares favorably to training in a moulage setting. Continued research in this area of physician education is warranted.

Learning the thyroid examination--a multimodality intervention for internal medicine residents

BACKGROUND

Many physicians have inadequate physical diagnosis skills and cannot detect thyroid abnormalities on physical examination.

PURPOSE

To evaluate a multimodality intervention to improve thyroid examination skills using a prospective controlled trial in first-year residents enrolled in an academic internal medicine program.

METHODS

The intervention group received a 60-minute educational session during which an endocrinologist described anatomical landmarks, thyroid abnormalities, and examination techniques using a slide show, computerized animation, videotape, and live demonstration on a volunteer with goiter. Residents examined a normal and a goitrous thyroid under the observation of a preceptor and received an evidence-based handout on the thyroid examination. The control group received no specific intervention. Examination technique and identification of thyroid abnormalities were blindly assessed in 2 stations of an objective structured clinical examination (OSCE).

RESULTS

Of the 19 residents in the intervention group and the 20 in the control group, 6 (32%) and 3 (15%), respectively, observed the neck for thyroid abnormalities (P = 0.3), 17 (90%) and 16 (80%) used proper hand position (P = 0.7), and 13 (68%) and 15 (75%) had the patient swallow while the neck was palpated (P = 0.7). There was a significant difference in the mean scores based on thyroid physical findings during the OSCE between the intervention and control groups (100 vs. 52.5 [maximal possible score = 200], P = 0.047).

CONCLUSION

A 1-hour multimodality learning session furthered the ability of first-year internal medicine residents to detect thyroid abnormalities.

Assessment of a bronchoscopy simulator

The study objective was to validate a flexible bronchoscopy simulator by determining if it could differentiate between expert and novice bronchoscopists. A subsequent evaluation phase was then done to determine whether use of the simulator would improve the rate of bronchoscopy skill acquisition for new pulmonary fellows. A multicenter prospective cohort study was performed using a bronchoscopy simulator. Three cohorts were evaluated based on the number of bronchoscopies previously performed: "experts" (> 500, n = 9), "intermediates" (25 to 500, n = 8), and "novices" (none, n = 11). Each participant performed two simulated cases with performance measures being recorded by the simulator. Performance measures that distinguished between groups were then used to evaluate the learning curve for new fellows training on the simulator. A randomized-controlled trial was then conducted comparing the quality of bronchoscopy performance for new pulmonary fellows who were trained either with conventional methods or with the simulator. Expert bronchoscopists performed better on the simulator than intermediates who performed better than novices in terms of procedure time, percentage of segments visualized, time in red-out, and wall collisions. Training of new fellows demonstrated that after performing 20 bronchoscopic simulations, the skill level acquired with the simulator significantly improved in terms of speed, percentage of segments visualized, time in red-out, and collisions. Fellows trained on the simulator performed better than fellows trained using conventional methods during their first actual bronchoscopies as assessed by procedure time (815 versus 1,168 s, p = 0.001), a bronchoscopy nurse's subjective quality assessment score (7.7 +/- 0.3 versus 3.7 +/- 2.5, p = 0.05), and by a quantitative bronchoscopy quality score (percentage of segments correctly identified/procedure time, 0.119 +/- 0.015 versus 0.046 +/- 034, p = 0.03). In conclusion, the bronchoscopy simulator was able to accurately assess bronchoscopy experience level. Training new fellows on the bronchoscopy simulator leads to more rapid acquisition of bronchoscopy expertise compared with conventional training methods. This technology has the potential to facilitate bronchoscopy training and to improve objective evaluations of bronchoscopy skills.

Virtual reality bronchoscopy simulation: a revolution in procedural training

BACKGROUND

In the airline industry, training is costly and operator error must be avoided. Therefore, virtual reality (VR) is routinely used to learn manual and technical skills through simulation before pilots assume flight responsibilities. In the field of medicine, manual and technical skills must also be acquired to competently perform invasive procedures such as flexible fiberoptic bronchoscopy (FFB). Until recently, training in FFB and other endoscopic procedures has occurred on the job in real patients. We hypothesized that novice trainees using a VR skill center could rapidly acquire basic skills, and that results would compare favorably with those of senior trainees trained in the conventional manner.

METHODS

We prospectively studied five novice bronchoscopists entering a pulmonary and critical care medicine training program. They were taught to perform inspection flexible bronchoscopy using a VR bronchoscopy skill center; dexterity, speed, and accuracy were tested using the skill center and an inanimate airway model before and after 4 h of group instruction and 4 h of individual unsupervised practice. Results were compared to those of a control group of four skilled physicians who had performed at least 200 bronchoscopies during 2 years of training. Student's t tests were used to compare mean scores of study and control groups for the inanimate model and VR bronchoscopy simulator. Before-training and after-training test scores were compared using paired t tests. For comparisons between after-training novice and skilled physician scores, unpaired two-sample t tests were used.

RESULTS

Novices significantly improved their dexterity and accuracy in both models. They missed fewer segments after training than before training, and had fewer contacts with the bronchial wall. There was no statistically significant improvement in speed or total time spent not visualizing airway anatomy. After training, novice performance equaled or surpassed that of the skilled physicians. Novices performed more thorough examinations and missed significantly fewer segments in both the inanimate and virtual simulation models.

CONCLUSION

A short, focused course of instruction and unsupervised practice using a virtual bronchoscopy simulator enabled novice trainees to attain a level of manual and technical skill at performing diagnostic bronchoscopic inspection similar to those of colleagues with several years of experience. These skills were readily reproducible in a conventional inanimate airway-training model, suggesting they would also be translatable to direct patient care.

Prehospital and hospital-based health care providers' experience with a human patient simulator

OBJECTIVES

To ascertain the level of acceptance of a human patient simulator as a training tool among a diverse group of health care providers. Secondary objectives were to elucidate its most useful aspects for training and find ways to improve upon the simulation experience.

METHODS

A satisfaction survey was conducted regarding the use of a human patient simulator from July 1999 to February 2000. The survey consisted of five questions with a five-point Likert scale (5 being the most favorable score) and three questions that asked for qualitative written feedback on the simulator experience. The survey was handed to 78 consecutive participants immediately after their experiences and collected immediately after it was filled out to ensure a 100% response rate to the overall survey. Qualitative responses were placed into categories by theme, and a sum was calculated for each category.

RESULTS

There was a high level of acceptance for simulation training among this diverse group, with Likert scores for the first two questions regarding general satisfaction of 4.74 +/- 0.126 (n = 77) and 4.77 +/- 0.126 (n = 78). Regarding the usefulness of each specific area of simulator training, the scores were 4.53 +/- 0.153 (n = 78) for patient assessment, 4.55 +/- 0.182 (n = 47) for treatment options, and 4.70 +/- 0.125 (n = 63) for response to treatment. There were 49 positive comments and nine negative comments. Realism (n = 26) and the ability to see response to treatment (n = 12) were the two most common positive comments. Negative comments focused on logistics of the simulator lab (n = 4) rather than the simulator itself.

CONCLUSIONS

In this sample, prehospital and hospital-based health professionals were accepting of human patient simulation as a new teaching tool with multiple useful applications.

Training bronchoscopists for the new era

Gustav Killian introduced bronchoscopy a little more than a century ago. At that time, the only way others could learn to perform bronchoscopy was by one-on-one tutoring, using a rigid bronchoscope with no side portals and no imaging devices such as a television camera and monitor. One-on-one teaching remains an integral part of learning how to perform bronchoscopy well, but many new technologies have emerged that make it far less labor intensive to train bronchoscopists. This article focuses on the training of bronchoscopists for the new era.

Accuracy and reliability of apical S3 gallop detection

This study assessed physician performance in detecting the apical S3 gallop using a cardiology patient simulator. Six physicians (two cardiology fellows, two medicine residents, and two attending physicians) performed two sets of 24 cardiac examinations that included the presence or absence of an apical S3 gallop. All the examiners were able to significantly alter the prior odds of an apical S3 gallop's being present, but the cardiology fellows had higher sensitivities. Sensitivity was lower for detecting soft S3 gallops, and specificity was lower when a diastolic murmur was also present. Physician performance in detecting apical S3 gallops is variable, but can be excellent.

A new cardiac auscultation simulator

We have successfully developed a new cardiac auscultation simulator by applying recently developed digital and computer technology, which digitally records, stores, modifies, and plays back heart sounds and murmurs characteristic of various heart diseases. The simulator is capable of playing back different heart sounds or murmurs at each auscultatory site (aortic, pulmonic, tricuspid, and mitral) of a human chest-sized mannequin (made of urethane foam), through four built-in speakers. We were able to listen to accurate reproductions of heart sounds and murmurs at the same timing as in real patients by any type of stethoscope used in routine medical practice. This compact and portable educational apparatus, which simulates realistic auscultatory sounds, will impact greatly on the medical training of cardiac auscultation for physicians, medical students, nurses, and paramedicals.

Teaching Cardiovascular Assessment

This article describes a learning module for teaching heart sound recognition and summarizes results of two studies testing the learning module. The module, built around a heart sound simulator, was effective with both graduate nursing students (n = 37) and experienced critical care nurses (n = 40). In each study, recognition of heart sounds improved significantly, and the knowledge gained was retained for at least 2 weeks.

A computerized simulator for critical-care training: new technology for medical education

A patient simulator has been developed for training, certification, modeling, and demonstrating problems in the management of critical-care patients. The Critical Care & Hemodynamic Monitoring Training System consists of a personal computer, software, and a replica of a human torso designed to enable students to practice critical-care medicine. The computer displays patient histories, laboratory results, treatment options, patient responses, and a real-time cardiac monitor. The torso apparatus is used to practice insertion of a hemodynamic monitoring catheter; the cardiac monitor displays catheter pressure readings as the catheter is advanced into the heart and also pulmonary artery and wedge position. Special screen calculators in the program may be used to determine hemodynamic, respiratory, ventilatory, and renal function indices. In contrast to previously described simulators and computer oriented instructional programs, this system contains no inherent data base. Instead, authors build a library of informative cases by using the hardware and software tools provided. Individual "modules" of patient information are authored, and these are transparently linked as a student undertakes management of a patient. Although this system is a technologic achievement, determination of its usefulness as an instructional tool or certification aid must come from broader use and controlled studies.