Use of a virtual patient simulator to teach cardiac arrhythmia recognition and management to final-year medical students

Introduction

Cardiac arrhythmia management, particularly life-threatening arrhythmias, remain a topic of significant anxiety among newly qualified doctors. Although arrhythmia training is part of the curriculum for numerous final-year medical students, the tendency is for it to be taught in a didactic way. Thus, at Princess Alexandra Hospital NHS Trust, a district general hospital in the UK, we developed a final-year medical student teaching session for arrhythmia recognition and management using a virtual patient monitor and simulator.

Methods

The aims of the session were to give students both practical real-time experience, using the software developed by Laerdal,¹ and the ability to discuss recognition and management strategies with their peers. In total, six tutorials were organised with 8–10 students in each. The sessions consisted of four case scenarios, with the first three involving the tachyarrhythmias supraventricular tachycardia, fast atrial fibrillation, atrial flutter, ventricular tachycardia and ventricular fibrillation, and the final case involving the bradycardias second-degree heart block and third-degree heart block. With each case, students were able to discuss among their peers what they believed to be the right treatment and why. The virtual simulator enabled a real-time patient monitor to be present on the overhead screen, with dynamic information such as the cardiac rhythm, blood pressure and oxygen saturation. Once the treatment had been instigated, the virtual simulator allowed changes to occur to the patient’s parameters based on the appropriate response. After the first three scenarios were completed, the tachyarrhythmia algorithm was discussed, and after the final case the bradycardia algorithm was discussed with the students. The algorithms used were those advocated by the UK Resuscitation Council.² After all the cases were completed, the students were taken within the simulation suite, and the practicalities and application of direct current synchronised cardioversion and transcutaneous pacing were demonstrated. Please see table 1 for a list of the cases and the suggested discussion points.

Table 1.

List and explanation of the four clinical cases, discussion points and suggested format

Clinical cases	Discussion points (for all cases)
1. Patient with supraventricular tachycardia with a heart rate of 180 Not responsive to vagal manoeuvres Patient initially not clinically compromised Given adenosine Develops low blood pressure Requires synchronised DC cardioversion	Interpretation of ECG Clinical assessment of patient Non-invasive manoeuvres Treatment of non-compromised patient; treatment of compromised patient Discussion of the pharmacodynamics of medications Consideration of long-term management, such as anticoagulation, as appropriate
2. Elderly patient with atrial flutter Initially not compromised Given beta-blocker/calcium channel blocker Develops atrial fibrillation Given more treatment Develops chest pain, requires DC cardioversion
3. Patient with ventricular tachycardia Initially not compromised Given amiodarone Develops ventricular fibrillation Start chest compressions	After the four cases: Practicalities and application of DC synchronised cardioversion demonstrated on a high-fidelity manikin Practicalities and application of percussion and transcutaneous pacing demonstrated on a high-fidelity manikin
4. Postmyocardial infarction patient with Mobitz type 1 heart block Initially not compromised Progresses to Mobitz type 2 and then third-degree heart block Given atropine and consideration of pacing

DC, direct current.

Results

We received 34 feedback forms in total. Students were asked to rate on a score from 1 to 5 how highly they rated the session based on the following: ‘Relevance of topic to Audience’, ‘Well and clearly structured’, ‘Variety of teaching/learning activities’, ‘Clarity of presentation’, ‘Active involvement of participants’ and ‘Overall Evaluation of Session’. All students gave each section a rating of 5.

Students were asked to comment on the sessions. Feedback included the session being avery good practice for recognising and treating rhythms; very good to have a monitor during the sessions; great experience doing it with the sim computer; good to talk through scenarios; and really good method to teach this topic.

Discussion

This teaching method provided an enjoyable and interactive teaching session for the medical students. The use of a virtual simulator and a patient monitor, along with the associated sounds, allowed students the opportunity to become immersed in the teaching event but in a safe, structured and comfortable environment. The main advantage between using the virtual simulator and students participating in high-fidelity simulation is the ability for all students to openly discuss topics surrounding recognition of abnormal rhythm, what parts of the assessment were vital and what the management plan should be, and this technique is particularly useful when teaching difficult topics. Likewise, the use of both experiential learning, learning by doing and social constructivism, building on previous knowledge by learning from each other, enabled learning to become embedded. The presence of multiple cases ensured that all four aspects of Kolb’s cycle,³ namely concrete experience, reflective observation, abstract conceptualisation and active experimentation, were achieved. This enabled students to practise what they had learnt from previous cases, allow this knowledge to influence the way they approached new cases and further develop their understanding of the concepts surrounding arrhythmia recognition and treatment. As this type of teaching uses a ‘pause-and-discuss’ methodology, it can be run with a single instructor, as long as the instructor is comfortable operating the virtual simulator and conducting a tutorial at the same time. In fact, it could be argued that having only one tutor ensures that the session is more synchronised and cohesive.

Conclusion

The use of a virtual simulator can provide a unique and highly enjoyable teaching session for medical students and beyond. The next step would be to investigate the impact that such a teaching session has on the knowledge and clinical skills of the students, as well as their abilities as newly qualified doctors in the very near future.