January 27, 2023
Often, most pediatric education and training, including simulation teams and equipment, tends to be centered at children’s hospitals and academic health centers, while the first place many pediatric patients present for emergency care is at community hospitals. To help get training resources into the hands of community pediatricians and emergency room physicians, the SimBox was born. Each SimBox includes “prepacked” ingredients that are available “off the shelf” to improve the preparedness skills in pediatric emergencies. Listen as Dr. Samreen Vora interviews the founders of this innovative solution to “democratize pediatric simulation”.
Dr. Angela Kade Goepferd: This is Talking Pediatrics, a clinical podcast by Children’s Minnesota, home to The Kid Experts, where the complex is our every day. Each week, we bring you intriguing stories and relevant pediatric health care information as we partner with you in the care of your patients. Our guests, data, ideas and practical tips will surprise, challenge and perhaps change how you care for kids.
Welcome to Talking Pediatrics. I’m your host, Dr. Angela Kade Goepford. Often, most pediatric education and training, including simulation teams and equipment, tends to be centered at children’s hospitals and academic health centers. But the first place many pediatric patients present, especially for emergency care, is at community hospitals. To help get training resources into the hands of the community pediatricians and emergency room physicians that need them, the SimBox was born. On this episode of Simulation Sessions with Dr. Samreen Vora, she interviews the founders of this innovative solution to democratize pediatric simulation.
Dr. Samreen Vora: Welcome to Talking Pediatrics at SIM sessions with Dr. Samreen Vora. Today we have two special guests that are going to be talking to us about a very special project that’s close to my heart, called the Emergency SimBox. Our first guest is Dr. Marc Auerbach, who is a professor of pediatric and emergency medicine at Yale, and the director of pediatric and inside two simulation at the Yale Center for Medical Simulation, and was also the founding co-chair of INSPIRE, which is the world’s largest simulation-based research network. Clinically, Dr. Auerbach is an attending in the Yale pediatric ED, and lives with his wife and two sons in Milford, Connecticut. Welcome, Marc.
Dr. Marc Auerbach: Thank you. So excited to be here and honored.
Dr. Samreen Vora: And our second guest today is Dr. Sofia Athanasopoulou, who grew up and attended medical school in Athens, Greece. She completed her pediatric residency at Yale and is currently a first-year pediatric emergency medicine fellow at Yale, and she’s been leading the SimBox team for the past two years. With a long-term devotion to pediatric global health, her goal is to use simulation-based medical education to demonstrate training in pediatric acute care. Welcome.
Dr. Sofia Athanasopoulou: Thank you so much for having us.
Dr. Samreen Vora: I’m so excited to talk to both of you. As I mentioned, this is a project that is close to my heart, and I’m excited to have a conversation about this open resource that started a number of years ago from a small grant from the American College of Emergency Physicians, ACEP, and has really grown into a resource that folks across the country, or rather, across the world, are using to improve pediatric, and now the adult emergency care provided to our patients and families. I’m wondering if, Dr. Auerbach, if you could start us off and maybe give us a little bit of background on how this work began.
Dr. Marc Auerbach: In my role as a pediatric emergency physician, we care for a lot of patients in children’s hospitals, or at least that was my perspective when I was completing my training. And I quickly recognized in some of my research and education activities that actually, the majority of ill and injured children, over 90%, initially present to a community hospital. And we found that there was a problem that really needed to be addressed, that most of the pediatric education that we were doing was within children’s hospitals, but most of the patient care was in community hospitals. So to address that problem, you, myself, and others began to brainstorm on an idea to have a minimum viable product that would allow for community emergency departments to conduct pediatric simulations with minimal resources.
And the initial idea was actually framed after getting a meal delivery kit. I’m not a very good cook. My wife is an excellent cook, and we received a meal delivery kit. I won’t disclose the name, I don’t have an affiliation with any of them, but in receiving that kit, I saw that it allowed me to become a reasonable chef, by having both the ingredients pre-packaged, the recipe, and really easy to use instructions. So in order to try to follow that model, we wanted to allow individuals working in community emergency departments a really off-the-shelf opportunity that would be delivered to them to provide emergency medicine, and specifically pediatric emergency medicine simulation-based training within their departments.
Dr. Samreen Vora: And I remember when you first put this box together, that meal kit included a couple of different pieces, and so I don’t know if you want to talk a little bit about what those pieces were and what was available to folks.
Dr. Marc Auerbach: We worked with a number of other individuals on our team that had a shared passion for what I’d like to describe as democratizing pediatric simulation, so really making it available to the masses. And what we did was put together, through some grant support from the American College of Emergency Physicians, a box that actually included an inflatable low-cost mannequin, an infant mannequin, a book that really followed the Blue Apron style of having a list of what equipment and resources were needed, and a step-by-step guide, as well as a concept of a video that that book linked to, that the individual could go to on either a tablet or a desktop computer that would allow them to display vital signs of that patient. And our focus for the first year of this work was really trying to address what I think is a critical time period, that first five minutes of when that pediatric patient arrives.
Dr. Samreen Vora: Our box, when you described that video, it was a prerecorded video, so no one had to change vitals or run a mannequin. And the mannequin that you’re describing was really a simple CPR doll that was inflatable. So you’d take it out of the box, you’d inflate it, put it on the bed, and the goal was around that first five minutes, right? People coming up and using their own equipment in their space with their team and running this drill. Sometimes I think about the meal kit as well, and they say it’s a gourmet meal. It could be a little bit intimidating. So same with simulation right here, you’re going to run a pediatric sim, versus hey, we’re going to run a drill, first five minutes, here’s everything you need, just put it on the bed and do it.
And so it was a fascinating experience, us getting those booklets printed, providing the resource, which was kind of the recipe, the ingredients. My admin, Crystal Walker, and our team here at Children’s Minnesota was really amazing in really partnering and sending out those kits across the country. I feel like we even sent out some internationally, or maybe some folks picked them up when we were at our conference with our booth. So it’s really cool having that kit and that mannequin that folks could use, that wasn’t hard to use.
Dr. Marc Auerbach: I just want to comment there that “wasn’t hard to use” is all in the eye of the beholder. So one of the things that surprised us-
Dr. Samreen Vora: Absolutely.
Dr. Marc Auerbach: … And our user experience were that some of the sites actually were hooking the mannequin, which was supposed to be inflated by mouth, as a little balloon up to the wall oxygen. So we did have some mannequins that exploded. We did have cases where there were issues with Wi-Fi access. So I think within this sort of product development, minimal viable product framework, I love your assumption that people know nothing about cooking with some of these meal delivery services, and we don’t want to make them an executive chef. We want to put a dinner on the table. And with this, our goal was really to assume that people knew nothing about simulation and little about pediatrics and provide all those resources. The other elements that I think we underestimate to start off, were the debriefing resources. Initially we provided a framework for debriefing, but in the more recent iterations of this, I think that the most impactful elements have actually been the resources for semi-scripted debriefing that actually includes some of the content expertise and beautifully designed graphics by one of our colleagues, Maybelle Kou, who really has an eye for digital education.
Dr. Samreen Vora: Those are so important, all of those pieces that you mentioned, as we were looking at our information after we had sent out those first kits and the feedback that we got, and we even had some sessions online to kind of meet with folks who are using it to get that feedback. So yeah, I really appreciate you kind of bringing out those points. It is in the eye of the beholder. I think it’s, easy or not, it’s really helpful to get that feedback and then develop it. And I love that you shouted out Dr. Maybelle, who, this is probably my second podcast episode where she’s getting a shout-out, so we definitely need to get her on an episode and talk directly to her about all the amazing work she’s doing. So I appreciate that.
It sounds like this product, we built it and then it’s had a number of iterations, and as we were initially shipping things and this mannequin across the country, but our model shifted. And I’m wondering, Marc, if you could elaborate a little bit more of where you just started kind of talking about how things shifted, and then maybe even how things shifted even further with the pandemic.
Dr. Marc Auerbach: So I think similar to any product, and we actually had one of our colleagues on the team who had some experience with product development at Apple, that was really useful to think about this as an iterative process. And what we did was we really looked at the utilization in the first few iterations of this. Were people not just ordering or receiving the box, but actually using it? So prior to the pandemic, we started to see some uptick in utilization, but also recognize that people were still intimidated to use this, that opening up the kit was being done, but perhaps using it on a regular basis was still intimidating, because of a lack of confidence and confidence in simulation in pediatrics specifically. So one of the structures that we tried before the pandemic was this idea of remote mentoring, or remote sponsorship, or remote coaching, any of those terms.
So we tried to connect with those people, train them up before the pandemic, again, with usually a phone call or some type of conference call. This was pre all of us being excited about Zoom. And then the pandemic came and certainly there were lots of challenges, but I think some opportunities came up where when we were not on full restriction, we were tele-debriefing or co-debriefing with some of these individuals. When we were on full restriction, we actually went into some Zoom rooms and began to do this with a verbalization of the processes, as opposed to providing the care in the clinical setting. But again, using that same SimBox, and again, having that individual champion in the community emergency department, but now on that same Zoom, having an academic children’s hospital specialist that was there, hopefully to just support them and make them feel more confident and back them up.
Dr. Samreen Vora: I will add in here, I’m sure our listeners now are like, “Hey, where can I access this?” So I’m going to throw this in here but I’ll say it again later, but emergencysimbox.com. It’s actually super simple. You hop on the website, we’re not mailing out mannequins or dolls that you can blow up anymore, but it’s easy to access and anybody can access these cases. So over the last two years, there’s been a lot of growth. And Dr. Athanasopoulou, I know you kind of had led some of this initiative and you’re taking it to the next level. Can you share a little bit about how you became involved in this project and how it’s aligned with your interests?
Dr. Sofia Athanasopoulou: I met with Marc I think three years ago as an intern, and we were discussing about the different projects that would be interesting, and he connected me with the rest of the SimBox team. As you know, it was a larger team that was involved in SimBox initially. Dr. Elizabeth Sanseau was leading the team for the first few years, and then I gradually took over from her, and it’s been truly one of the highlights of my academic career, working with Dr. Sanseau and Dr. Kou and Dr. Auerbach. I started by updating most of the existing cases to a new cohesive structure template and then helped create many new cases, like the newborn resuscitation, postpartum hemorrhage, burn trauma.
We now have a total of 12 pediatric emergency cases, and we also created a curriculum for cases to be used by EMS providers and pre-hospital providers, so how would pre-hospital providers take care of sick pediatric patients. It’s been one of the most creative and fun things to do, and it’s been truly an honor to get to work with such amazing people, Dr. Maybelle, Dr. Sanseau, and Dr. Auerbach, and learn from them and see them as kind of lifelong mentors.
Dr. Samreen Vora: There’s a pretty big team in that first go around, and I don’t know that we can name them all, and I want to make sure we’re acknowledging it was a really incredible team that kind of pulled together the thought leadership on this, and it’s really cool to hear. Well, we started with that one case, it was one meal you could make, and now it’s all these different options, 12 cases. That’s pretty incredible. Been really cool to hear. As you came on board onto this project and took that leadership, Dr. Athanasopoulou, you’ve continued to really scaffold what this box looks like and who can use it. And so I heard you mention a few different audiences, which is a growth from what it initially was. I wonder if you could expand on that a little bit.
Dr. Sofia Athanasopoulou: Dr. Maybelle Kou is leading the adult SimBox, especially with the pandemic, even pediatric emergency providers, we’ve been taking care of older patients, up into their 20s, so there’s definitely a need for especially pediatric providers to know how to take care of adult patients. So Dr. Maybelle Kou is leading that effort, and then I helped create an EMS curriculum, so adjusted most of our cases for what would make sense and realistically happen in the pre-hospital setting. And it was a particularly eye-opening and humbling experience, both through creating these cases and also running these cases with EMS teams, both in Connecticut, throughout the U.S., all the way to Alaska to learn more about their incredible expertise and skillset, which is quite different than my pediatric emergency medicine skillset. So it’s been a great experience and I do hope that this can be a tool that pre-hospital providers across the country, or maybe the world, can use to better prepare to take care of this rare sick [inaudible 00:14:06].
Dr. Samreen Vora: And it’s really just cool to hear how you’ve kept up with advances in technology and you’ve taken this feedback and not just diversify the audiences, we can provide this resource too, and support to provide better pediatric care, but also the technology pieces as we’ve adjusted. Right? Dr. Auerbach mentioned at the beginning, hey, internet might be an issue for some folks. Getting even that mannequin to them might be challenging. So we try to adjust as we go along to make it more accessible to as many people as possible. And so I’m also curious to hear a little bit more about some of those changes, how we’ve incorporated new technology, and other things that have come up in the last two years.
Dr. Sofia Athanasopoulou: It all comes back to feedback that we have received from users. We’re currently on the version 4.0, and I anticipate that there’s going to be many more versions of SimBox in the future. Participants and facilitators were asking, how can we make this more interactive and more user-friendly? And we’ve played with many different technologies using hot keys and links on the notes section of the existing YouTube videos, but we wanted to make this even more interactive and kind of like make-your-own-adventure. We came across Vimeo, and we’re now piloting this new version of the videos. So the facilitator is still going to be streaming on full screen the video, but then within the video, there’s embedded clickable hot keys or buttons. So there’s a dropdown button where the facilitator can press on maybe different parts of the video, so the narrated pre-brief, or the dispatch, or the sign-out, or the debrief, so they can easily navigate within the video.
And then within the actual 10 minutes of the simulation, as you know, there’s many different stages. So for example, for a newborn delivery case, there’s the first minute, which is the delivery and the warm, dry, stimulate phase, and there’s the positive pressure ventilation phase. There’s the intubation phase, there’s a clinical recovery phase. So depending on what the participants are doing, the facilitator can just click on the screen and be transferred to the corresponding part of the vital signs and patient video. And hopefully that’s going to be a more natural way of navigating the content, spending as much time as people want in the different parts of the debrief, or in different parts of the simulation. And I’m really excited to get feedback about this and see if people like it, if people find it easier to use, and what feedback they have about how we can make it even better.
Dr. Samreen Vora: I’m curious, Dr. Auerbach, do you have anything to add to that piece of it?
Dr. Marc Auerbach: We have a younger audience that might be on, so Black Mirror, for those Amazon folks that have seen Black Mirror, this video sort of follows a similar style that’s called an interactive video. But the other piece that I think, again, I want to highlight the iterative nature and the scaffolding of this work, as a simulation educator working largely in sim centers, and I know that you have a similar role, Dr. Vora, I hadn’t really thought outside the box, getting back to a box analogy. And I think that we tend to give people vital signs and this high technology, very expensive plastic simulator. And what our team heard from some feedback was that having images of a patient, and this is one thing that we’ve started to explore more recently, first it was actually my son laying on the ground and shaking.
Dr. Marc Auerbach: And this was for our seizure patient, and it was really striking to hear from these individuals, not that this was as good as a high technology simulator, but that actually was better, because with the high technology plastic simulator in our sim center, that seizure was more difficult to evaluate.
The vital signs are still an important part, but I would say that one of the things I’m most excited about now is starting to explore collaborations with individuals within this community of medical educators that are leveraging real patient videos, and trying to look at how we can not only integrate changes in vital signs, but perhaps changes in the actual clinical scenario or video, and really does that graphical representation, either as a pictograph, as we discussed, where we use some images in one of our burn simulations, or perhaps even a real patient video with hemorrhage, or with an active birth going on, how that can engage the learners. And at least what we’ve seen so far from that is really augmenting what’s on the screen with additional cognitive load is both challenging but also helpful. So we don’t want that video of the child to be really evolving quite significantly over time, because they found that was a big cognitive load burden.
It was hard to follow. But having that as a cue, so the facilitator can say, if the team asks, is the patient still seizing? Look at the monitor and now see a patient that maybe has their eyes closed and is no longer shaking, or is the baby out, looking at the screen and seeing the baby coming out of the mom at that time. So I think that was another example of user-centered feedback guiding this work initially, again, just a trial of one of my children and some other people’s children, and we were sort of like, should we do this? It’s not really that fancy. It’s kind of lame, actually. It did cost me a couple Lego sets. And actually hearing the feedback from individuals, not only was it helpful, but it was actually augmenting their experience, potentially beyond some of their experiences with the high technology simulators, which was hard for me to swallow as someone who has exposure to what the budgets of those are and how much they cost.
And Dr. Vora, just to go with our wider audience who may not be acute care providers, we are a very open and grassroots group, and we have had individuals that have approached us with concepts for cases related to things like pediatric agitation and suicide and/or other things that primary care pediatricians might encounter. So in addition to looking at the content and potentially using it, please feel free, if any of the listeners are interested in leveraging this type of approach for either training their healthcare teams or potentially even training their families, we’d be very eager to collaborate.
Dr. Samreen Vora: Absolutely. And we just opened, at Children’s Minnesota, an inpatient mental health unit, and I can only imagine all the different ways this training could help a variety of healthcare professionals. And you even mentioned families, so potentially simulations or this type of drills for caretakers that are taking care of complex children. So many possibilities. Just to kind of wrap up stuff, I’m curious to hear from both of you, what do you see the future holding for this emergency sim box?
Dr. Sofia Athanasopoulou: I truly believe in the power of real patient videos, and I do hope that moving forward, we’ll be able to have diverse patients, diverse pathology on videos. I think it’s going to make a big difference on the impact of this educational product. And then what we like to do is kind of streamline the process and make it easier for people who are interested in creating a case to do so with the minimal amount of effort needed from their end. So how can we make the process easy for people interested to create a case on, as Dr. Auerbach mentioned, agitation or anything similar to that? How can they create their own case, publish it, and then be a part of SimBox?
Dr. Samreen Vora: Dr. Auerbach, would you like to share what your mental model is, where the future might take us?
Dr. Marc Auerbach: Yeah, so I would absolutely echo that comment about scale and coming up with ways of scaling what we would describe as potentially a disruptive innovation in medical education, and particularly in medical education, in community hospitals and EMS agencies for continuing professional development. And for those that aren’t familiar with that term, it’s work by Clayton Christensen and a really cool concept that the idea that you want something that’s good enough that it will be used by a lot of people and be effective and might not be the best of breed. And I used that term before, minimum viable product. And I love the vision that our team has had and how that vision has continued to change. But our goal really, to start this work again, is more on the implementation side. So democratizing medical education best practices that include experiential learning and debriefing. And I think we’ve made some great strides in that, but there’s really a much broader community out there that I would say we can use to both create content, as well as to disseminate and implement content.
So it is thrilling to me to hear from an individual when I’m out working as a community educator, doing a high fidelity simulation now, from a participant saying, “Oh, I want to tell you about this really cool thing. It’s called SimBox, have you heard of it?” And to me, the fact that people are finding it outside of us yelling this from up high, through ACEP, and finding this through connections, a lot of nursing organizations are now starting to get engaged and using this, and nurse educators. And one of the things that was so exciting to me with that is they really commented what our goal was, which is make it really easy for them to do pediatric education well. And that’s actually what they framed without me saying it. I found this thing. I know that your high fidelity sim was really hard to plan.
It was great. It was so much better than I could have done. But there’s this other thing out there that really I think is so cool, and I do hold back and I try to make sure that I echo their positivity and don’t go into the details of where this came from, because I think it’s such a different place now, and it’s on the shoulders of so many of us. And I think it has been a group effort. And again, as was mentioned with this, expanding the capacity by creating a standard process for case creation. I love that analogy of the cook because we want to bring in other food types, right? We don’t want everything to be one type of cuisine. So thank you so much for the opportunity to share on this, and I learned so much chatting with both you today.
Dr. Samreen Vora: So for those listening out there, the resource that we spoke about is out there for you to use right now, you just go to emergencysimbox.com and you’ll find all the ingredients for Sim in a Box, to run your own preparedness drill for you and your team. And when you do, reach out to us. Let us know how it went, and if you have other ideas, please feel free to reach out and chat with us. Thank you for joining me today on Sim Sessions with Dr. Samreen Vora.
Dr. Angela Kade Goepferd: Thank you so much, Dr. Vora.
Dr. Marc Auerbach: Thank you. It was an honor.
Dr. Angela Kade Goepferd: Thank you for joining us for Talking Pediatrics. Come back each week for a new episode with our caregivers and experts in pediatric health. Our executive producer and showrunner is Ilze Vogel. Episodes are engineered, produced, and edited by Jake Beaver. Amie Juba is our marketing representative. For more information and additional episodes, visit us at childrensmn.org/talkingpediatrics, and to rate and review our show, please go to childrensmn.org/survey.