I am writing this partly in response to Victoria Brazil’s Ice Blog Simulation moulage: Bang for Buck? Let me be clear – I love her stuff and can’t really keep up with her brilliance. However, I must take an unacademic view about the aforementioned piece.
2. the degree of exactness with which something is copied or reproduced.
the adaptability of an organism to changes in its environment or differences between its various habitats.
As background, I started in university as some kind of crazy card carrying empiricist/socialist doing a degree initially in science, but switched majors after getting hit by the Philosophy bug…. very much to my parent’s chagrin (on hind sight many years later, Philosophy does not offer a lot of job prospects although I definitely think it changed my world view in an incredibly positive way. Don’t tell my parents, but they had a good reason to be skeptical. I subsequently also got a degree in physiology and the combination of both have made me a much stronger paramedic).
When I switched to philosophy, I started to focussing on Philosophy of Science and Ethics. I think I was trying to look like Bruce Cockburn (because of the “IMF, Dirty MF”), reading Kuhn, Feyerabend, and I was drawn eerily to Rorty…. who was not an empiricist. I viewed myself as a warrior, philosophy, poet with the rounded spectacles as an important intellectual appendage (see below).
I tried to make the university experience a clean one – scientific, reasoned, even austere – I was intellectual after all right? I needed reasoned thought based on research, and we were beginning to see the beginning of EBM so I decided I better be a rigid empiricist. Funny thing on hindsight is my warrior poet phase was all bluster – Rorty had it right that the human experience told through stories and tales was closer to the truth. Joseph Campbell’s views of the Power of Myth was also important to our culture. These things have brought me to the unscientific views I am about to propose.
I need to explain some history. I was finishing up my honours degree in Philosophy and was struggling with some issues in the Philosophy of Biology (My thesis was going to be on the notion of species and I had not yet fully digested to later Wittgenstein to approach that this was a “family resemblance” issue and I was simply a fly in a bottle not seeing my way out). I was re-ended in a car accident and could not study for an extended period. I went back to lifeguarding to support myself financially.
After a short time of lifeguarding, I began teaching. I knew that one of the things that lifeguard often had to deal with was vomitus – drowned resuscitated patients vomited copiously. I needed lifeguards to experience this first hand, as well as have the empathy of lying strapped to a spineboard with vomit in their mouth so they sense the urgency of rolling them and clearing their airway. I found this combination of orange juice, cheezies, parmesan cheese, pasta sauce with pasta and, depending on how you felt, chunky beef soup. It smelled, looked and even tasted like vomit (don’t ask me how I know…. all I will say is I grew up in Manitoba…. you could get cheap beer off sales when under the age of 18 if you looked old enough. I learned much about regurgitation the hard way. On a somewhat funny note other, the actual recipe is a sore spot for my wife and I – she made a meal with some of the contents of my recipe when we were dating and I suggested mid-meal that is you added some orange juice, this could be the perfect vomit recipe. Needless to say, I am not always the best romantic). I know that lifeguards got better in unlikely but possible future treatment of regurgitation through this experience.
Here was the clincher, though – I met one of my previous student on the street. I asked her where she was lifeguarding and she said she did not pursue it. When I asked her why, she mentioned the vomit training. I was horrified and apologized profusely to her – I never want to discourage students. She stated adamantly that she was incredibly thankful she had that experience because she found out that she could not do the job – could not handle vomit – and she thought that it was truly possible she would have had PTSD had she experienced it in real life. It did not matter that it was unlikely – it just mattered that it was possible. She had gone on successfully to pursue other careers. As crazy as this sounds, vomit made me realize the importance of fidelity.
I want to move on to a more recent experience – an experience of insanity perhaps. For what is now approaching 2 years, I have cogitated on 45 seconds of my career that I will probably never do – a cricothyrotomy. This is the most complex procedure from the stress, timeliness, and due to the infrequency of the procedure. I can tell you having recently reviewed a few cases that did not go perfectly, I have been doing this wrong when I practice and teaching this wrong for far too long. The story of this journey actually started in 2012 when we did a cadaver lab in 2012 in a train the trainer for a roll out of AIME ALS for our advanced paramedics. Two of my mentors Dr. Alec Ritchie and Dr. Nick Balfour gave me the honour of being the only paramedic to do a needle cricothyrotomy (there was not the opportunity for everyone to do it). This was the beginning of a journey.
When I first tried this procedure, I swear the dead guy moved! I was adept at the steps to perform a Melker cric, but after landmarking and turning to get my equipment, I kept sticking the needle into this solid structure. That structure was the thyroid membrane… I kept poking into that and man did a feel silly. Lesson one, once you landmark do not lose it!!! This changed my thinking and teaching. Next, I attended the inaugural AIME Advanced workshop in Halifax (a cadaver lab with specimen preserved in way that is similar to live patients). Not being trained as a physician and never having done surgical procedures, finding landmarks clearly, dealing with extensive subcutaneous tissue on some of the cadavers, and cutting through layers of tissue in that area was it’s own experience. There are so many things that none of the current cric trainers teach you (in essence they are plastic and barely able to provide the richness tissue experience allows. This is learning that is hard to describe and best simply felt). Next, there are things that cadavers cannot do – between multiple descriptions and videos, I came to realize that this procedure is almost entirely tactile and blind. The blood will get in the way of seeing the anatomy so you need to feel and know implicitly the anatomy. I had some friends who did computer design and 3D printing the model who used a combination of anatomy textbooks, medical studies, and comparison of online imagery during the process. I worked with them to design an anatomical model from scratch and we are currently working on other components. Then I needed to consider the cric within the prehospital environment. I cannot seem to plumb the depths of the complexity and yet simplicity of this all but I feel closer to a break through…
Upon reflection, these experience were just that – experiential. I would never have been able to perform this in real life if it had not been for the deeply personal experiences I had. I have come this to be essential to talking about fidelity. I am not discounting empirical study of fidelity but any study must look at the subjective component experienced combined with extreme task congruency to do it right. This is why the breathing blinking doll – what some people talk about as “fidelity” – misses the boat. It is plastic, the anatomy on some models is poor, there is an incongruency of task performance, and the environments in which they are places in no way simulate environmental fidelity (as a paramedic, I don’t know prehospital sims I have experienced or seen which are on hospital beds with ample space in every direction unlike the ambulances, planes and helicopters I typically work in).
Now, let’s come back to vomit because it is relevant to my point. James DuCanto is a mad genius with his SALAD intubating vomit trainer. One of his fellow Airway Illuminati is Yen Chow who I have been so fortunate to learn from – SALAD and otherwise. Finally, let me add a third to the mix – Mike Lauria, a former military PJ currently in medical school who talks a lot about performance under stress and stress inoculation training. DuCanto’s SALAD trainer is simple, but has taught me to do airway management as a paramedic significantly better. We get vomiting patients coming out from bars at 2 am after eating whole pizzas and being struck by cars. Both Jim and Yen have taught me techniques on how to deal with a vomit filled airway. Mike has taught me to deal with stress via inoculation training in those situations, and how to perform much better. The first time I experienced the SALAD trainer was the first thing in years that gave me the visceral stress response that I experienced when I first got in the job on some pretty intense calls. I have passed this type of training and lessons around dealing with stress along to students, and they have expressed extreme gratitude for the lessons as they first-hand as they see the value. This emotional end of performance is something I have come to believe important in the high stakes job I work in.
I want to suggest that we also need to take a humanistic view of fidelity (I am not suggesting that we abandon studying it, but just placing weight on the experiential end of things). We need to explore people’s experience and see if what we simulate is real to them. If we want to call it qualitative we can but sometimes science gets in the way of describing the world. I have a penchant for the EA Games’ Assassin’s Creed, but it’s not all the blood and the gore that always draws me (…ok, well a little sometimes…) – it is the fidelity experience of running around incredibly detailed scene, realistic parkour, and interaction I could mistake for real if I was completely immersed. Maybe that is where we need to be… and the only place to get there is through human experience.
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