Background: Opportunities for independent clinical decision making and teaching within the context of direct patient care are diminishing for all trainees and especially medical students. The queue of providers separating the medical student from the patient continues to grow. Contributing factors include liability issues, low threshold for senior level involvement, growing intolerance for “practicing on patients” and overall patient safety. These effects are only accentuated within the uniquely sensitive context of caring for children. “Distancing” of the medical student from the patient limits exposure to the patient-doctor-parent triad, an essential component of the care of the sick child. In addition, fewer bedside encounters limits objective evaluation and feedback for students in particular with regard to communication skills and delivery of care. Medical simulation offers a robust teaching tool to overcome many of these limitations and “fill the gap” in clinical exposures, conveniently providing HMS students with a wide range of safe and structured learning experiences around pediatric medicine.
Format/Frequency: The 4.5 hour course is held every 6-weeks at the Boston Children’s Hospital Simulator Program (SIMPeds) for all HMS medical students who gather from each of the affiliated institutions. Courses begin with a didactic overview of pediatric physiology followed by two high fidelity simulations highlighting respiratory and cardiovascular pathology as well as parent presence through the use of professional actors; an airway skills station is described below is also included. A gradient of parental complexity is experienced in successive cases. Simulations take place in dedicated simulator suites. Scenarios are paused from time to time to allow for teaching within clinical context using slide graphs, data, and projected images as necessary.
Airway Skills Station. Non-scenario based, hands-on and interactive session. Students are encouraged to use each piece of airway equipment on the mannikin with guidance by expert physician facilitators.
Participants: PGY3 Harvard Medical Students
Course Leaders: Marisa Brett-Fleegler, MD, Amanda Growdon, MD, Vincent Chiang, MD
- Basic airway equipment applied to the pediatric patient:
- nasal cannula – placement, adjusting flow
- “blow-by”, scoop mask – dialed vs. actual FiO2 in infants,
- inspiratory flow rate
- non-rebreather mask – tips to achieve adequate seal in babies,
- reservoir bags, high FiO2, one-way valves
- airway positioning – prominence of occiput, “sniffing”, jaw thrust
- oral and nasal airways – which one to choose, proper/atruamatic
- good mask seal – one and two-person technique
- “Ambu” style bag – principles, applications, O2
- supplementation, limits in infants
- “anesthesia” style bag (Mapleson) – need for fresh-gas source,
- advantages (CPAP, PEEP, able to assist spontaneous
- ventilation, better “feel” for patient)
- Adjunctive equipment:
- pulse oximeter – theory, artifact, pulse modulation
- end-tidal CO2 – types (mainstream vs side stream), advantages/
- limitations of each
Respiratory Scenario (Asthma)
Goals and Objectives:
- Recognize signs of increased WOB and accessory muscle use (increased inspiratory flow) and grunting (increasing PEEP) in the infant and child
- Asthma as a model of VQ mismatch and obstructive lung disease
- Understand aeration on pulmonary exam (quiet chest = no air movement)
- Understand risks of hypoxia and CO2 retention in infant
- Obtain pertinent history from parents
- Pulsus paradoxus
Cardiovascular Scenario (Shock)
Goals and Objectives:
- Recognize un/compensated shock in the infant
- Demonstrate initial management –access, fluids, fluids, fluids
- Assess end-organ perfusion – skin, mental status, urine output
- Appreciate HR dependency in children
- Explore acidosis and it’s relationship to buffering mechanisms.
- Explore degrees of tachypnea.
- Explore differential diagnosis of hypoxia in the child and infant
- Explore s/s of inadequate cardiac output in the infant