Simulated medical training bridges the COVID-19 divide
A high-tech medical simulation centre in Tunisia has found a solution to teaching technical clinical procedures online, meeting student and professional training needs during the COVID-19 pandemic while creating opportunities for remote learning and medical research across Africa.
The Honoris Medical Simulation Centre in the capital, Tunis, part of the Honoris United Universities network of African higher education institutions, opened on 10 November 2018, just 14 months before the pandemic struck in earnest.
It has been a valuable service to medical and nursing students, including those in professional training, whose learning experience has been hit especially hard by COVID-19.
Traditionally, medical and nursing training requires hands-on learning of a variety of different delicate procedures, from cannulation of veins, intubation and resuscitating patients in cardiac arrest to delivering babies and key-hole surgery. But, from February 2020, the pandemic has effectively shut down hands-on training in much of the world.
The centre has demonstrated a way to continue this vital work.
Developed by an international team of experts, the goal is to become the leading medical training simulation centre in North Africa, if not all of Africa. While these centres are commonplace in Europe and North America, there are only eight such simulation training facilities in Africa.
Simulation mannequins for efficient training
The Tunis-based simulation centre has four main units with state-of-the-art equipment. Each unit has a scenario room that is equipped with simulation mannequins that have a pulse, emit respiration sounds, and have artificial veins.
The mannequins can be adapted to simulate a variety of medical situations, including accident and emergency unit environments to intensive care, a high dependency cardiology ward and an obstetric unit to teach normal and complex birth procedures.
The scenario rooms are exact replicas of hospital wards with real hospital beds. The mannequin patients moan, cry out in pain and complain as monitors beep and scan their vital signs.
Behind a two-way mirror is a control room where training staff can assess, adjust and manipulate the simulated patients through automotive controls to create the fluctuations and crises that doctors, nurses, midwives and paramedics deal with every day.
Each unit has a briefing-debriefing room to set a medical scenario and provide a simulated medical history prior to trainees and trainers entering a scenario room and to debrief and evaluate the simulation afterwards.
The pedagogy is one of problem-based learning. Before COVID-19, the trainer would watch a trainee, only offering guidance when students ran into difficulties.
Centre director and retired surgeon Professor Chadly Dziri has implemented a rigorous evaluation and quality system. It uses the DASH (debriefing assessment for simulation in healthcare) system of evaluation as developed at the US’s Harvard Medical School.
“Good debriefing equals a good simulation,” Dziri said. His passion for rigorous evaluation has brought about a culture change within the unit so that no medical professionals may regard themselves as too qualified or experienced to learn from constructive feedback.
Dziri is also professor emeritus at the Medical School of Tunis at the University of Tunis El Manar (Université de Tunis El Manar) and former head of the B23 surgery department at the Charles Nicole Hospital, also in Tunis.
Dziri is intent on continuing to improve the system. He recalls how he set out fixing problems in the past. He told University World News that this was key to the centre’s provisional accreditation by the Society for Simulation in Healthcare (SSH) based in Washington, DC.
“I explained to the SSH what we were doing with the DASH process, and they were very satisfied,” he said. Full accreditation is a two-year process. The centre is one of two medical simulation units accredited by the SSH in Africa.
COVID-19 influences planning
The pandemic has had a profound effect on training. It has been difficult to maintain formal semesters and timetables planned long in advance.
Dziri explained: “It is not possible to plan. We started teaching workshops in February 2019, but one year later we had to stop.”
His first response to the crisis was to hold a webinar bringing leading medical educators together to discuss ways to continue the training in technical skills in a COVID-19-restricted world.
The webinar brought together medical educators from the Stanford Medicine Center for Advanced Pediatric & Perinatal Education (CAPE), the faculty of medicine at Tunis El Manar University, and the Centre d’étude de la Sensorimotricité (Motorsensory Study Centre) at the Paris Descartes University (Université Paris Descartes) to discuss the future of medical education at undergraduate and postgraduate level.
All participants reflected that a post-COVID world has yet to arrive and that student relationships with technology, colleagues, teachers and the learning process are still evolving.
They agreed that new learning styles have emerged from the pandemic, such as undergraduates often preferring to watch lectures in their own time in ‘catch-up’ mode rather than at fixed times in a collective way in synchronous lectures.
“We returned to face-to-face teaching in October 2020, but then again we had to stop [after a new wave of the disease], so we switched to online,” Dziri said. “The results were very bad; students really preferred hands-on [training]. Then we developed [a method] of learner direction using facilitation,” he said.
In November 2020, online sessions were offered using videos from previously recorded simulation workshops with the facilitator discussing the case with students in a more traditional seminar-style.
“We saw the KPI [key performance indicators], recommendations, and satisfaction go up, so we saw better results.” This means that if necessary, the centre would be well prepared to switch to online indefinitely, Dziri said.
Online learning an effective solution
Office manager Marwa Naimi told University World News that, “Online learning has opened the doors so we can work on future learning and remote learning.”
Dziri said that the online remote learning business is going well, but there is a need for human contact in education in general. As a result, if allowed by reducing lockdown restrictions in future, the team is willing to pivot back and forth between online and face-to-face teaching.
However, Dziri said that, although online directing of facilitators helps students learn how to deal with different health care scenarios, there is no substitute for developing the intuitive knowledge that comes from touching even a simulation mannequin.
Such physical training is key to the development of manual skills for general yet tricky procedures such as peripheral venous access for cannulation or intubation of patients in respiratory failure, as well as fine motor skills and hand-eye coordination for video-assisted laparoscopy and also ultrasound-guided assisted fertility.
Nurse anaesthetist and trainer Mouna Ben Rhouma told University World News that simulation training not only gave her important mental skills but muscle memory, too.
Ben Rhouma recalled a simulation of treating postpartum catastrophic haemorrhaging she undertook at another, similar, centre in Tunisia in 2015.
“Years later [in 2019], I was in a delivery room and the patient was bleeding out after delivering her child. Because of my training, I automatically knew what to do and how to do it. It takes seconds to save a life and I know I saved that woman’s life,” she said.
Looking ahead, Dziri said the centre is waiting for augmented and virtual reality technology. It is exploring potential innovation with a Tunisian start-up company called Alien Dimension, which is developing a virtual reality programme to train for normal delivery.
“We are working on the haptic sensation of a baby’s head at the moment. This would be the first of a suite of virtual reality and augmented reality educational tools the centre is developing,” he said.
Tunisian researchers from Honoris, led by engineer Professor Nidhal Rezg, designed a non-invasive ventilator, which would cost less than EUR400 (US$475).
Rather than producing a final product and incurring the problems of physical manufacture and shipping, the team coded open-source software that would instruct a 3D printer to print the components to build as many ventilators as required in any given hospital around the world.
Another new piece of equipment is a driving simulation machine designed as a tool for early detection of neurological deficits in degenerative diseases such as Parkinson’s and Alzheimer’s, as well as other forms of dementia.
The driving simulator is in line with the broad future vision for the simulation centre that simulation is not just about training medical professionals but also a tool for medical research.