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Creating realistic simulation environments is critical for effective simulation. There are several types of fidelity (realism) in a simulation. The manikin or simulator represents only one aspect of realism. Psychological fidelity is enhanced by making the scene and circumstances real to the learner.  In this simulation teaching theater located at the Charleston Area Medical Center Institute Life Support Training Center in Charleston, W.Va., an operating room scene has been recreated. Features include a working OR table, medication infusion pumps, and an anesthesia machine connected to medical gases.

A plasma video monitor does double duty in this simulation room. As seen here, it displays the waveforms and monitor readings from the simulator in a large format so that everyone in the room can see what is happening with the patient. During debriefing, the screen displays the video recordings of the simulation session. Plasma or LCD monitors can be used for this function or ceiling mounted LCD projectors.














Simulators in all levels of fidelity come in a variety of patient sizes including this infant simulator. This Laerdal SimBaby features a touch screen monitor that displays waveforms and monitor readings. Many simulators now available including features such as spontaneous chest rise with breathing, and palpable pulses, heart and lung sounds. Some now have skin responses such as cyanosis.  





























For some skills, a full-bodied simulator is not needed to provide a highly realistic simulation. Here, a team performs a diagnostic peritoneal lavage on a SimuLab TraumaMan simulator. Advances in simulated tissue have made many surgical and emergency procedures highly realistic.













Adequate debriefing capabilities are essential for a good simulation. Video cameras and microphones mounted in the simulation should capture the full range of simulation activity. Several companies provide complete audio/video recording capabilities for simulation centers. Some simulators come with their own built in video recording and playback capabilities.
















Simulators can be modified either with custom injury kits available from the manufacturer or by using a standard trauma moulage kit to create injuries or conditions needed for the simulation.

Simulators are well suited for crisis interventions such as cardiac arrest management. Here, a team of residents manages a simulated cardiac arrest patient. All clinical data needed for decision making such as pulses, respirations, responsiveness, and EKG are being supplied by the simulator. The instructor role with a high-fidelity simulator is substantially different than when using a low-fidelity manikin.   


























This control room features a large one-way mirror to allow observation of the simulation room. The room also features multiple cameras that can be monitored from the computer control stations.

As simulation has become more entrenched in healthcare provider education programs, more companies are making simulators to mimic more conditions or anatomic functions. In this case, the physician faculty is demonstrating shoulder injection in a Limbs and Things shoulder simulator. This unit features feedback tools that inform the instructor or learner if the needle has been placed properly. A series of lights on the control unit will indicate proper needle placement.   











When conducting a simulation, it is vital to have working medical equipment available for the learner to use with the simulator. Nothing should be faked, Defibrillators, oxygen delivery devices, medications, IV supplies, or suction, may all need to be employed to create a successful simulation.   

























The Harvey cardiopulmonary assessment simulator represents some of the earliest simulation technology, yet it still provides the best learning experience available for cardiac assessment. Developed in the late 1960’s at the University of Miami, Harvey has recently undergone a significant redesign that makes this simulator an option for more simulation programs.  

When designing a simulation room, it is important to add features that not only enhance the clinical realism but also provide support for the instructor. Note the white board mounted on the wall. The instructor can use the of board for notes and diagrams, effectively creating an interactive learning experience at the simulator’s bedside rather than conducting a separate lecture in a classroom.  








Not all simulations need to be conducted in a simulation center. “In Situ” simulations, or simulations conducted in the healthcare providers’ workplace, can be very effective. By taking the simulator to the actual patient care area, the simulation can test more than just medical knowledge and skill.  Logistics and operating procedures unique to the patient care area can be tested, thus creating a much more real and comprehensive experience. In this example from The Children’s Hospital of Philadelphia, all the simulator equipment is housed on a mobile cart that can be wheeled into the patient room.















Simulation learning space needs to be flexible in order to accommodate a variety of simulators – ranging from full-bodied manikin-based simulator to smaller part-task trainers such as the IO access trainer shown here. A major consideration in designing any simulation center is adequate equipment storage. This area is often overlooked in early design phases.


Creating realistic learning environments may require inventive techniques. In this example, an actual ambulance module – complete with working lights – was built inside a room at the simulation center at the University of Miami.  






















With the simulator on the ambulance cot, learners can conduct patient assessments and interventions in a highly realistic environment. This photo shows a simulated ambulance interior with simulator in the Stavanger Acute Medicine Foundation for Education and Research in Stavanger, Norway.


Simulation center design must also include mechanical functions such as medical gas supply. This often means installation of a tank system to supply medical air and oxygen.






























Room layout and design must consider many factors such as what type of simulation scenarios will be conducted, the need for support equipment such as crash carts, and how many people will be working through the simulation at one time. Control room space for the simulator is also important. In this example of a METI ECS simulator at the West Virginia School of Osteopathic Medicine, the control room is located behind the one-way mirror on the left side of the room.  














To add realism in this simulated operating room, custom digitally created image wallpaper was applied to the walls to create an amazing effect.


Simulation is continuing to evolve. Sophisticated virtual simulators such as this bronchoscopy simulator by Immersion Medical including realistic computer graphics combined with haptics devices that allow the learner to feel the instrument moving through the virtual patient.  
























This simulator is housed in a working ambulance allowing for assessments and treatments to be done while the vehicle is in motion. The custom ambulance from Norway has a special seat for the simulator operator to control the simulator’s responses.

All photos by David Rodgers (Copyright)