ESO Endorsed Simulation Course: Acute Stroke Management Challenges and Decision Making Processes

An event to remember: an unprecedented in-situ advanced simulation training course for acute stroke management endorsed by ESO took place in Niguarda Hospital, Milan, on the 24^th and 25^th of January. This breakthrough event drew medical professionals from all over Europe, promising high-fidelity simulation experience and the opportunity to join together and exchange expertise. As well as helping to hone their critical thinking and decision-making skills, the course allowed participants to explore the relationship between neurologists and neuroradiologists during stroke treatment, increasing the flow of communication to enable higher quality performance in acute stroke treatment. Not only did participants have the opportunity to work on simulated stroke clinical cases, but in addition they were able to experience task training of endovascular procedures of thrombectomy using a 3D flow model. All this, under the supportive supervision of esteemed professionals in the field, delivered with an infectious enthusiasm for the “simulation bug”.

Practice makes perfect. We all grow up with this “mantra”, with the knowledge that no skill is developed without practice, persistence and patience. Repetition brings mastery: this is the simple yet powerful message that reverberated throughout this unconventional training venue, a cordoned-off corridor within Niguarda hospital, buzzing with the anticipation of almost forty participants in attendance from all over Europe. Presiding over the attendees, a masterful team of instructors, neurologists and neuroradiologists: Paola Santalucia, Ignazio Santilli and Luva Valvassori from Milan; and from Lubeck, André Kemmling.

The stage is set as the introductory presentation by neurologist Paola Santalucia unfolds, detailing the human factor; detailing the harsh reality, that in America alone the third leading cause of death is medical error. A cause, she goes on to argue, that is potentially preventable – with the use of simulation. If it’s good enough for the world of aviation, which legally requires pilots to complete their training using the simulator first designed and built by Edwin Link in 1927, then why not for the world of medicine? Statistics show that after implementation of the simulator during pilot training, the number of aircraft incidents decreased by 50%.

The two-day course incorporated two simulation methods using mannequins and simulated patients played by human beings, each  role play, in ER and in angio suite was followed by a debriefing. This is a key sequence for simulation. For the first day, a team of international simulation competitors, trained by Dr Santalucia herself, assisted in setting the mood – with the first patient arriving at the evaluation in ER. The whole Neuroradiology Department at Niguarda Hospital, Milan, was made available for the simulation setting: ER, CT scan and two Angio suites. The entire setup was connected by cables and cameras in order to project the stroke patient’s pathway on to large portable screen at the head of the corridor where all the participants were seated.

Participants began with the first entry to ER, the clinical stage, and watched as the stretcher was then wheeled into the Angio suite to complete the endovascular treatment. The physical transition between the two locations created a depth and reality to the scenario that is not present during simple role play discussion. The participants believed in their cases.

On Day 2 the participants were introduced to the high fidelity mannequins, as well as being divided into two smaller groups that could work in parallel on different stroke cases, specifically receiving hands-on training using the Penumbra endovascular flow model simulators. After each case the “cinema lights” were turned off and the course trainers presented for the most crucial aspect of each role play: the debriefing of the case. With artful precision, trainers elicited information from participants by asking a series of mostly open questions, stimulating self-evaluation, engaging attendees and creating the attitude of learning form “mistakes”. Simulation courses as this one wholeheartedly follow Benjamin Franklin’s famous adage: ‘Tell me and I forget, teach me and I may remember, involve me and I learn.’

The final moments of the course finally arrived, but without ceremony. There were no lessons to review; no notes to go over, no information round-ups. This was a personal experience for each individual, and each took home something different. For Anita, from Macedonia, it was a clearer knowledge of the thrombectomy procedure, a procedure, she feels, that is the future of stroke treatment; for Visnja, from Serbia, it was the rewarding exchange of ideas with colleagues, plus the fresh experience of a simulation course itself. Those approached for feedback all commented on the unity of the event, citing the value of this unusual gathering, openly infected by the “simulation bug” that, hopefully, will plant a seed in each respective country.

From the development of simulation in healthcare in in the 1960s, within the field of anaestheology by Dr. David Gaba, finally the merits are being spread and experienced throughout different medical disciplines.  For all questioned, funding in their home countries was a concern for simulation centre development. However, this course also demonstrated with great force the creativity and use of ‘to-hand’ resources, such as live simulated patients instead of expensive technology, that could help those seeds to grow into trees.