Simulations & Procedural Training

Procedural Training

All residents are expected to perform a broad range of procedures during internship year training, which include thoracentesis, paracentesis, central venous catheterization, arterial catheterization, and lumbar puncture. In order to preserve patient safety and ensure all trainees are skilled in performing invasive maneuvers, our staff participates in simulation-based procedural training. Trainings include a combination of online videos, small group didactics and hands-on experience with task trainers.

Additionally, residents may select a dedicated week as the "Procedure Resident." During this week the resident’s sole responsibility is to be available to perform a broad range of diagnostic and therapeutic procedures for inpatients on medical floors and intensive care units. Simulation training and 1:1 faculty education are incorporated into every “procedure week.”

Ultrasound Training

Given the expanding role of bedside ultrasound for both diagnostic and procedural guidance, BIDMC has integrated a formal ultrasound curriculum into the training program. Annual academic half-days are dedicated to procedural and ultrasound training which include physics, knobology, vascular ultrasound, and thoracic ultrasound under the direction of trained faculty from the Division of Pulmonary and Critical Care Medicine. In addition, residents will learn the basics of transthoracic echocardiography during their rotations in the CCU and on the cardiology service. Ultrasound machines are available in each of the medical ICUs as well as in the simulation center, and we rely on ultrasound guidance for many invasive procedures.

Central Line Training

Lifelike partial task trainers provided in the simulation and skills center at BIDMC are utilized to train the medicine residents in proper technique used in central venous catheter insertion. A didactic session is followed by a hands on one on one session with an experienced instructor. Training is focused on proper sterile technique, anatomical landmark identification, and proper insertion technique. Ultrasound use in central venous line insertion is also covered during each session.

Triggers Training

When patients outside of the ICU acutely decompensate, they also comprise a particularly vulnerable population. If they need ICU admission, they have exceptionally high mortality rates compared to patients admitted from the emergency department, surgery, or the recovery room. More importantly, ward patients who deteriorate to critical illness typically have a period of several hours of clinically obvious physiologic instability before their catastrophic decompensation. Failure to act on these signs of decompensation can result in suboptimal care and delays in ICU transfer that are associated with marked increases in mortality rates.

The triggers simulation is designed to place the learner in situations in which specific changes in a patient’s condition requires them to evaluate and treat the change(s). By diagnosing and treating these changes in a rapid and accurate manner the patients condition will return to a nominal state, thus preventing undesired outcomes. Simulating trigger situations enables the learner to perform the above tasks in a safe, non-judgmental learning environment. Peer review and one to one instruction by an attending physician are commonly employed to improve the learner’s knowledge and performance. It is hoped that by using simulation to introduce the learner to situations they may commonly see on the wards will, their ability to rapidly diagnose and treat these situations will improve, thus improving patient outcomes.

The use of our high fidelity mannequin is essential in performing the trigger scenarios. The ability to realistically recreate patient conditions allows us to immerse the learner in every situation. This level of realism is key to improving the learner’s knowledge base. We also employ the use of the same equipment and materials that the learner will use on the wards, including the same style code cart and defibrillator. Furthermore, the use of a professional, highly experienced nursing staff during triggers training sessions carries the realism of the situation to an unparalleled level.

Communication Training

Communication skills training exist in a variety of settings in medical education. Standardized family members are used to emphasize skills in facilitating family meetings, recognizing and responding to emotion and discussing death with dignity. Standardized family members include former patient or family member volunteers who are formally trained in simulation and feedback. Additional elements of communication skills training include reframing code status discussions, “talking about death” and consent practices.

Leadership

Code Team Leadership

Multi-disciplinary, resident led simulated codes are facilitated in the Carl J. Shapiro Simulation and Skills Center (SASC) intensive care unit, outfitted with all of the same monitoring equipment, and medical devices used throughout our medical center and on high-fidelity SimMan simulators. The ability to realistically recreate patient conditions allows us to immerse the learner in the situation, thus recreating the feel of a real cardiac arrest situation. Each simulated code is led by a rising junior resident inclusive of learners from nursing, and pharmacy. These trainings provide opportunities for the rising junior resident to solidify ACLS algorithms, challenge not only his or her knowledge base, practice skills of running a code, and include elements of team dynamic and resource management. All medical residents participate in the curriculum during the spring of their intern year.

Resident as Leader

The Resident-as-Leader curriculum aims to facilitate the transition from intern to resident role by familiarizing residents with fundamental characteristics of effective inpatient team managers, to incorporate these skills on the general medicine wards, and to focus training the role of residents as leaders of healthcare teams.

Resident as Teacher

Peer and near peer-teaching are incorporated into the simulation training curriculum in order to enhance teaching skill development. Opportunities to teach in simulation include facilitating and debriefing during medical student and intern clinical simulation encounters, and communication skills training. Dedicated faculty oversee resident run simulation and debriefing encounters to provide direct observation and feedback of teaching skills.

Frequently Asked Questions

Do you have opportunities to perform procedures?

We have an entire rotation dedicated to performing procedures, including central lines on the floor, lumbar punctures, paracenteses, thoracenteses, and arthrocenteses. There is a dedicated teaching attending on this rotation to provide teaching and instruction. We were one of the first Internal Medicine programs to create and adopt such a procedure teaching service. For more information, please see "Creation of an Innovative Inpatient Medical Procedure Service and a Method to Evaluate House Staff Competency" and the Agency for Healthcare Research and Quality. In the ICUs, the primary team will perform all procedures on their patients. In addition, BIDMC has cutting edge technology in the simulation center for practicing central line placement, running codes, and refining care of an unstable patient.