Experience of Simulation-Based Training in a Developing Country

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To the Editor:
Simulation-based medical education can be an effective method for learning about rare and critical conditions. It has been used with trainees to teach them how to handle difficult and dynamic airway conditions.1,2 However, it is difficult to adopt in developing countries because it requires expensive equipment, advanced facilities, and experienced staff members. Nonetheless, we conducted simulation-based airway management training as an official development assistance project in a developing country. Herein, we share our experience.
Sri Lanka is an island nation in the Indian Ocean, south of India. In 2014, the population was approximately 20 million and the per capita GDP was US$3800.3 The country suffered considerable material and human damage from the tsunami in December 2004. At that time, it was noted that the lack of appropriate emergency medical systems was a problem.4,5 Since 2004, the Korean government has expanded support for Sri Lanka, primarily for tsunami-recovery projects.6 As a part of this support, emergency medical facilities (preliminary care units) were built at 2 provincial hospitals, namely, Avissawella and Tangalle. To train medical staff at these facilities, Korean emergency physicians were dispatched in 2013 and 2014 for 1 week per year. The program covered basic life support, advanced cardiopulmonary life support, abdominal sonography, wound management, and airway management. Simulation-based training (SBT) was used primarily for the airway management program. All instructors were board-certified emergency physicians and resident directors at their respective hospitals. The course consisted of a short didactic session, a skills station, and small-group immersive simulation training using a high-tech mannequin. Two scenarios, anaphylaxis and chest trauma, were examined. A SimMan 3G patient simulator (Laerdal Medical, Stavanger, Norway) was provided for this training.
There were several challenges to overcome in conducting SBT in Sri Lanka. First, it was difficult to transport the high-tech simulator. Prior cooperation and coordination with the Sri Lankan government, especially customs, was essential for dealing with the expensive, bulky, and heavy simulator. It was very helpful to our program to obtain support from the Ministry of Transportation via a local contact before our visit. Second, preparations for assembling the simulator and solving mechanical problems that could occur onsite were necessary. There was no local branch office of the simulator manufacturer that could provide technical support for our program. Thus, all instructors received 2 sessions of technical training in assembling the simulator and troubleshooting in Korea. Furthermore, an emergency contact for technical support over the phone was set up by the branch office of the manufacturer in Korea. In particular, the battery had to be checked because the electricity supply might be unstable. There were several incidents of power failures during our program. Nevertheless, that problem was easily solved once new batteries, prepared for the simulator and computers, were made available. The batteries had to be charged as often as possible and be fully charged before the daily training program. Third, trainees should be given sufficient time to become accustomed to the simulator. In the first scenario of the first day, all the attendees seemed to “freeze up.” Therefore, instructors should modify the educational strategy. Sufficient time was provided before and during the training to provide an opportunity to make medical decisions. Fourth, it was difficult to identify the characteristics and educational level of local staff during the preparation phase. Thus, instructors should be flexible in developing scenarios and operating simulations. All instructors carefully reviewed the feedback papers of all attendees and modified the content and management methods after the daily program. Fifth, SBT requires prior knowledge of the skills of attendees.
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