Simulating haemorrhage in medical students


This article is a descriptive report of a novel way of teaching the cardiovascular response to progressive haemorrhage in a first year medical undergraduate setting using simulation. Simulation may provide the means to allow students to see in practice the theoretical knowledge they have gained from lectures, thus giving clinical relevance to that knowledge, which may improve retention. A progressive haemorrhage is simulated in a volunteer medical student by applying sub-atmospheric pressure to the air surrounding the lower body using a lower body negative pressure (LBNP) chamber. This sub-atmospheric pressure will result in ‘pooling’ of blood in the vessels (particularly veins) of the legs and pelvis. This ‘pooling’ will reduce the amount of blood returning to the heart (venous return) thus mimic the effects of loosing blood from the cardiovascular system. The body responds by engaging various physiological responses to blood loss. To demonstrate these responses a range of cardiovascular parameters are monitored throughout the demonstration to allow students to observe the response to progressive haemorrhage. One of these parameters is cardiac stroke volume, which is monitored by using a portable ultrasound device. In addition to demonstrating an important principle of physiology which students are likely to have encountered in their lectures, using the ultrasound device also fulfils an objective set out by the General Medical Council (GMC) to familiarise medical students with clinically relevant two-dimensional imaging equipment early in their studies.


Conclusion: Durham University Medical Programme uses a LBNP chamber as a simulation to reinforce didactic teaching of the cardiovascular response to haemorrhage. The use of simulation in medical education is becoming increasingly more commonplace as its potential benefits are recognised. The simulated haemorrhage may provide the means to allow students to see the theoretical knowledge they have gained from lectures in a ‘clinical’ context, which ultimately may improve knowledge retention.

Educational leadership: a core clinical teaching skill?

Leadership has been emphasised as a core element for organisational effectiveness and healthcare improvement in public, private and voluntary sectors. Leadership development programmes have been introduced to support clinical innovation and educational change for current and aspiring leaders in clinical settings, in schools and in other contexts such as public health, general practice and higher education. This article describes a number of leadership development programmes specifically designed and delivered for healthcare educators and clinical teachers and considers the place of leadership and leadership development in contemporary healthcare education. It explores the nature of leadership development programmes, offering models and ideas around the core components and structures of leadership development programmes for healthcare educators. The article suggests that leadership should be included as a core element of all healthcare education programmes.

Investigating new approaches to facilitating the learning of female pelvic examination for health care professionals

This paper will focus on a new approach within the UK to teach female pelvic examination to undergraduate medical students. The use of Gynaecological Training Associates (GTA) (non-medical females trained to teach pelvic examination while themselves being examined) by students is not a new concept and has been used in America and Scandinavia since the 1970’s. However, in the UK, GTA’s are rarely used. The discussion will follow how one GTA programme is being developed at Southampton General Hospital, and drawing heavily from pedagogy how the sessions are being planned.

Using simple learning objects to enhance early skills learning

Clinical skills centres commonly employ a mixture of peer physical examination, live simulated patients, real patients and training models/aids to facilitate clinical skills learning. A wide array of training models are now commercially available, ranging from part-task trainers to high fidelity manikins. However, they are relatively expensive and models to demonstrate or complement a specific skill may not exist. In particular, medium-high fidelity simulators may not be used to their full potential at the basic skills level and the cost-benefit ratio has to be considered. We suggest that there is an alternative solution in some cases: centre staff can create simple cheap learning objects to illustrate some of the context, findings, or application of basic examination skills. Unfortunately, very few of these locally derived learning objects are shared more widely in the literature. One of the reasons for lack of dissemination may be problems in designing meaningful evaluation strategies for these objects. This paper describes the development and deployment of four learning objects introduced into early clinical skills learning within the medical programme at The University of Auckland: (1) percussion tubs to illustrate different percussion notes, (2) hen’s eggs for demonstrating transillumination, (3) an intravenous fluid set to illustrate principles of jugular venous pressure, and (4) socks with objects inside to help develop descriptive skills for palpation. Formal evaluation of the objects has not been carried out. However, informal feedback from students was positive. Through using the objects, students were able to gain insights, confidence and understanding. All of the objects offer immediate feedback to the students which they found rewarding. In conclusion, we feel that simple, cheap learning objects can play an important role in early skills learning. Although there are some barriers to formal evaluation, we hope to encourage other centres to share their innovations and evaluation strategies.

i-DREAM Project: Interactive Diabetes Research Evidence Application in Management

A major barrier to providing effective healthcare is implementation of research evidence. i-DREAM (Interactive Diabetes Research Evidence Application in Management) is an interactive educational computer tool that helps clinicians make evidence-based decisions based on individual patient’s clinical parameters such as blood pressure (BP), HbA1c% and lipid profile. The aim of the study was to investigate the impact of teaching evidence-based medicine to health care professionals using this program as an educational tool.


Methods: The usefulness of i-DREAM was assessed based on its ability to help clinicians understand the management of 10 important clinical problems, based on implementation of 12 relevant clinical trial/guidelines in diabetes. A complex hypothetical case note was devised with 10 clinical problems to match trial profiles and given to 100 clinicians (2 diabetes nurses, 7 pharmacists and 91 doctors) to identify the clinical problem, recommend a management plan and cite research evidence. 2 points were given for a correct answer, and 1 for a wrong answer or no response. The points for each problem were then multiplied, giving 8 points for a clinical problem solved and hence a Global score of 80 points. i-DREAM was then demonstrated to the participants over a 30 minute session, and the score recalculated based on the same case note within the next 7 days.


Results: At baseline, the clinicians scored 8.0/10 on problem identification and 6.1/10 on management recommendation score. Clinicians were aware of 0.8 trials out of the 12 used. The Pre-i-DREAM Global score was 31.8/80. After i-DREAM, the problem identification score improved to 9.5/10(p<0.001) and the management recommendation score to 8.2/10(p<0.001). Trial awareness improved to 5.4/12(p<0.05) and global score post-i-DREAM to 52.4(p<0.01).


Conclusion: i-DREAM can serve as an effective interactive tool to the multi-professional diabetes care team to advise on evidence-based management plans, thereby bridging the gap between daily and desired practice.

Is it possible to prepare medical students for clinical years using a laboratory based education programme?

Introduction: The new Cardiff/Swansea Graduate Entry programme has provided a unique opportunity to compare the preparation of students for clinical training by comparing an integrated, case based course with a more traditional course. In particular, we were interested in the effect of the students having a nine-week period of clinical placement compared to a full clinical year


Methods: We administered a qualitative questionnaire to an entire cohort of students. Data were analysed using a grounded theory approach.


Results: Despite being the first cohort of a new course, students described the learning environment in the first two years as high quality. They felt well prepared for their clinical years despite the reduced direct clinical exposure.


Discussion: Data suggests that laboratory based clinical skills teaching is as effective as the traditional ward based teaching. Students found they were well prepared for clinical placements. Concerns that they would have problems in the clinical environment were largely unfounded. Problems the students encountered were mainly administrative. Suggestions included a clinical induction programme as suggested elsewhere in the literature. We confirmed that the transition to the clinical environment can be challenging, and that medical students continue to have difficulty adapting to ward based teaching.

The evaluation of a ward simulation exercise to support hospital at night practitioners develop safe practice

The University of Dundee Clinical Skills Centre developed and facilitated a generic skills course for the emergency assessment of patients as part of the Introductory Hospital at Night (H@N) Programme within the local NHS Trust. As part of the course a Ward Simulation Exercise (WSE) was developed to provide an effective means of providing individual practitioners with feedback on performance. The University of Dundee School of Nursing and Midwifery has also developed a Masters in Advanced Practice (Nursing) with key modules to address the learning needs of H@N practitioners including modules in Clinical Assessment and Diagnosis, Clinical Sciences for Advanced Practice and the Principles of Acute and Critical Care. This paper describes how the WSE was developed, implemented and evaluated.

Initial evaluation of the use of experiential learning in teaching clinical skills to trainee physicians

The aim of this study was to evaluate a Royal College of Physicians accredited, one day, Senior House Officers’ clinical skills course. Questionnaires were given to 11 Senior House Officers, prior to attendance, at completion, and three months after. Prior to the Course, participants felt competent in three to eleven of the twelve skills included. Post Course questionnaires revealed participants found the Course overall to be of benefit. At three months, it was reported that practice had changed and confidence levels had increased. On reflection, participants found the Course valuable, stimulating and relevant to their specific learning needs. We conclude that this form of teaching is an effective way of developing clinical skills in trainee physicians.

Learning to talk with patients: feasibility of a volunteer simulated patient programme for first-year medical students

Background: Medical educators have the challenge of providing learner-centred education in patient-centred environments. Simulation provides an acceptable alternative to meeting students needs while not compromising those of patients. Professional actors contribute extensively to teaching and assessment of communication and other professional skills but are a relatively expensive resource. We wanted to provide our first-year students with a safe and effective means of developing communication skills relevant to interacting with patients.


Methods: We developed a simulated patient programme using volunteers to provide students with an opportunity to interview and receive feedback from members of our local community. This paper describes the development of the programme and evaluates its feasibility. We used observations, questionnaires and focus group interviews in the evaluation that included students, volunteer simulated patients and faculty.


Results: The results showed that the session is feasible and can be delivered with minimal additional costs although it requires careful planning. All participants rated the experience positively with benefits identified for students and volunteers. Areas for development include an elaborated role proforma to support volunteers in planning their patient role, and a more discriminating and extended feedback rating form for volunteers to assess students’ patient-centred communication skills.


Conclusion: Our feasibility study identified strengths of the programme and areas for development. Both students and Volunteer Simulated Patients (VSPs) reported benefits. The programme enabled lay members of our community to make a meaningful contribution to undergraduate medical education by providing experiential learning opportunities for novice students.

Designing a clinical skills programme: a partnership between students, patients and faculty

This paper describes the design and implementation of a clinical skills programme within a new UK medical school and the journey that students take in the development of their clinical skills base. The approach at Brighton and Sussex Medical School (BSMS) is to integrate clinical skills training horizontally and vertically throughout the course, providing an array of opportunities to develop specific skills and a variety of different methods including the use of purpose built clinical skills facilities and extensive patient contact. The focus of the design template was to ensure students would be able to understand the scientific and clinical basis for learning their skills and where to integrate them into their practice. This template is delivered using a building block approach, where students first develop basic skills, which are repeated and enhanced as the course progresses. The provision of extensive formative opportunities to test their own skills development including mock OSCEs and simulators has, in the eyes of the students, helped lead to high levels of competence being achieved in summative assessments. However, until the first cohort of students enter their postgraduate training and development phase, a definitive assessment of our approach to clinical skills is not possible. The feedback from students, patients and faculty thus far though, plus results from clinical skills assessments, indicate that our students are prepared for the delivery of effective patient care.

Examination of the ear: a structured teaching resource

Structured clinical examinations are widely used for assessment of medical students. We have previously proposed that a portfolio of structured teaching resources for individual clinical skills would be beneficial to students, and present a further example of such a teaching pack for examination of the ear and otoscopy.

Developing instructional videos in-house; notes from the front line

Blended learning is a combination of two or more teaching methodologies intended to enhance the learning experience. A group of School of Nursing Staff from Dublin City University recently completed a project to move towards a blended learning model for the practical skills element of one core first year nursing module. This involved the production and development of a bank of continually accessible online instructional videos which are now embedded in the module. The main focus of this paper is on the challenges encountered and solutions devised during the development, production and integration into the module of the instructional videos. The reasons for the shift to a blended learning model and the student evaluation of the videos are also discussed.

Peripheral Arterial Disease & Ankle Brachial Pressure Index (ABPI)

Peripheral arterial disease (PAD) is a condition that affects approximately 12-14% of the general population. As many as 75% of affected individuals are asymptomatic and consequently this condition goes largely under diagnosed and untreated. However, once a diagnosis of PAD has been made, regardless of symptoms, patients have a two to three times increased risk of mortality from MI’s and strokes. Due to the association of peripheral vascular disease with coronary and cerebral vascular diseases, early detection of this condition is essential in order to reduce morbidity and mortality. One method in doing this is to calculate the ABPI (Ankle Brachial Pressure Index). Unfortunately, calculating the ABPI using different techniques can produce significantly different results. This paper will attempt to demonstrate how one should obtain an ABPI competently and how one would interpret the results.

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