Revolutionizing Anesthesia Training Through Innovative Simulation featuring Dr. Dan Raemer

Embark on a journey through the evolution of clinical simulation with Dr. Dan Raemer, a pioneering engineer-turned-medical simulation expert whose career has bridged gaps between technology and healthcare education. In his conversation with us, Dr. Raemer pulls back the curtain on his transition from developing life-saving medical devices to shaping the world of mannequin simulators for anesthesia training. His partnership with Jeff Cooper and their innovative work at Massachusetts General Hospital and Brigham and Women's Hospital laid the groundwork for the simulation technologies we see today. Delving into the captivating history and turning points in this field, Dr. Raemer's stories offer a masterclass in the persistence and innovation that have revolutionized simulation-based education.

Meanwhile, Dr. Raemer shares his inspiring story, demonstrating that a career path can take a turn into the extraordinary when fueled by curiosity and a knack for asking the right questions. As a bioengineer who found his calling in anesthesia simulation, his approach to effective debriefing has become a cornerstone of the simulation philosophy at the Center for Medical Simulation. His tales shed light on the human side of this tech-driven field, reminding us that it's the people behind the technology who truly make a difference. Tune in for these gripping narratives and leave with a newfound appreciation for the intersection of technology and human touch in the ongoing quest to improve healthcare through simulation.

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Transcript

Disclaimer/ Interact Solutions Ad/ Intro: 0:00

The views and opinions expressed in this program are those of the speakers and do not necessarily reflect the opinions or positions of anyone at Innovative Sim Solutions or our sponsors. This episode of The Sim Cafe is brought to you by InteracSolutions. Interact Solutions is a revolutionary and cost-effective audio-visual simulation learning management system developed for instructors to record, organize, schedule, annotate, and debrief student simulations, delivering timely, evidence-based feedback. solution is a revolutionary and cost-effective audio-visual simulation learning management system developed for instructors to record, organize, schedule, annotate and debrief student simulations, delivering timely, evidence-based feedback. Interacsolution is an ideal complement to your existing curriculum and can be customized for your simulation center. Contact Interact Solution today. Welcome to The Sim Cafe, a podcast produced by the team at Innovative Sim Solutions, edited by Shelly Houser. Join our host, Deb Tauber, and co-host, Je rrod Jeffries as they sit down with subject matter experts from across the globe to reimagine clinical education and the use of simulation. So pour yourself a cup of relaxation, sit back, tune in and learn something new from The Sim Cafe.

Deb Tauber: 1:31

Well, welcome back to The Sim Cafe, thank you very much. Today, Jerrod Jeffries and I are here with Dr Dan Raemer. Dr Raemer is the founding President of the Society for Simulation and Healthcare and has just so many things he's done, and we are so truly honored to have you as a guest today. today Jarrod Jeffries and myself are here with Dr Dan Raemer, and Dr. Raemer is the founding President for the Society for Simulation and Healthcare and has just so many things he's done, and we are so truly honored to have you as a guest today. Thank you so much.

Dan Raemer: 1:57

Well, thank you for inviting me. It's a pleasure.

Jerrod Jeffries: 1:59

I'll kick it off. We were chatting a little bit before we went live, but for your journey into simulation has been pretty robust and quite vast, so maybe we can try to put some touch points on different areas around your journey into simulation. Would you give us some color there?

Dan Raemer: 2:18

Sure. So I was an engineer by training. I have a PhD in bioengineering and my specialty was feedback control systems. And with feedback control systems and the mathematics behind it one does a lot of modeling, and modeling is a form of simulation, and so I saw myself from a very early time I think they were covered wagons back when I did my PhD for a very long time I saw myself as a simulationist and I wound up working for the anesthesia department at Brigham and Women's Hospital in Boston in the early 1980s, and in that job I was a device inventor type person. They gave me a job to kind of have free reign in the clinical environment and to try to develop things to improve anesthesia care, and so I did do that, and in the course of doing that I did lots of simulations to prove my devices effective.

Dan Raemer: 3:29

So one you might be familiar with I have a patent on the chemistry for a colorometric CO2 indicator, the device that you put on the end of an endotracheal tube to tell you that you're in the right tube the trachea and so for that I had to come up with simulations of CO2 expirations in order to make the colorometric indicator turn color, and so I saw myself really very much on the technical side of simulation when mannequin simulators first came to be, my colleague at Massachusetts General Hospital, jeff Cooper who, by the way, just received the Society for Simulation Pioneer Award this past year he had undertaken this project to fund efforts to develop mannequin simulators, and that was in the early 1990s, 1991 or 1992. And just because I was invited, I went on a field trip with him and several other anesthesia providers to look at the simulation efforts in Gainesville, florida, the work that was done by Nick Ravenstein Sr. That eventually led to the METI company being formed, and that was the genesis of that. And I thought what they were doing was kind of cool and it was actually pretty technical at the time. So interesting fact is that they were interested in teaching anesthesia residents how to maintain and debug problems with an anesthesia machine, and so they wanted to build a little device that they could attach to the anesthesia machine that would breathe. And so they did that. They put a test lung on an anesthesia machine and they wanted it to respond in various other ways, and so eventually a simulator, a mannequin, grew out of the test lungs in order for them to simulate various things that could happen in anesthesia, and so you know, that was sort of right up my alley and thought it was interesting. But I kind of decided that they were doing a great job with that. I had other things to work on and so I set it down.

Dan Raemer: 6:06

And then in the early 1993, I think it was Massachusetts General Hospital and Brigham and Warman's Hospital merged, and Jeff Cooper and I had the same job at that point in our respective institutions we were both the directors of biomedical engineering, and so when the news hit that the two hospitals had merged this was unthinkable we called each other up and I called him and I said Jeff, do I work for you or do you work for me? And he said I don't know what happened. And I said we've merged and we're one department now. And so we got together and we plotted for how we would make this transition.

Dan Raemer: 6:54

And so when Jeff tells the story, he says he had just started the simulation program in Boston which was to be really the first anesthesia oriented training center based on work of David Gaba at Stanford. And he thought to himself this is great, dan will take over the biomedical engineering department and I can now devote my time to the simulation program. Well, things turned out the opposite and I wound up running the simulation program and he became the head of both biomedical engineering departments and ultimately that worked into a great partnership where Jeff kind of served as the CEO. He was the person who interacted with the outside world of the simulation program and I was the person inside developing the cases and the scenarios and the courses and the mannequins and props and all of those sorts of things which were all pretty much brand new. It was a clean slate. We were able to make things and do things that hadn't been done before.

Jerrod Jeffries: 8:15

And, during the time, were you creating everything in-house by yourself, because there's no suppliers for this equipment at this time.

Dan Raemer: 8:22

Correct, except for the mannequins. So one thing that Jeff did in those years up until 1993 is he felt that for simulation to be successful it would have to become commercial. The two simulation efforts that he funded were one at Gainesville and one at Stanford. There were a couple of others, there was one in Toronto, Canada, and there was one in Pittsburgh, and so he felt they needed a commercial mannequin instead of their homemade mannequins that were, you know, he was funding and that were evolving.

Dan Raemer: 9:06

So he went to the companies, went to several companies with his colleagues from those institutions and tried to get them to get into the simulator business, and he was successful at that, and so the METI company came out of the Florida effort. It turned out that the Florida people and the Stanford people didn't get along CIDI completely, and so the Lockheed Martin Aerospace Company developed a simulator as well, and so, yeah, so that became the what was it called the Eagle Simulator, and it got bought out. It is now the Canadian company that makes it. It became CAE. Actually they switched corporations at one point, so it became the original CAE mannequin, and so METI and CAE were the two available mannequins in the early 1990s.

Jerrod Jeffries: 10:16

So in early 90s of course there's Gainesville and the Florida activity, and then even on the California side there's the Lockheed with Eagle Simulator, CAE comes in, and this is the mid 90s, even before other larger corporations or other corporations are involved.

Dan Raemer: 10:32

Yes, absolutely. It's sort of a funny story. The Laurdal people became interested in a kind of backdoor way, and so what happened was neither company knew how to make the plastic body. The CAE corporation was both companies. Actually both companies were. Their engineering base was flight simulators, and so they could make all the electronics and the gears and the whistles and arms that moved and eyes that blinked and all of those kinds of things. But they didn't know how to make the body.

Dan Raemer: 11:14

And it turned out that there was a company in Plano, Texas, called Medical Plastics, that made a full body mannequin that was hollow, and both companies bought the same mannequin and put their simulator in it, and so the two competitive mannequins in 1994 or so were identical looking. So then one year, at one of the conferences it was a few years later Medical Plastics hired an engineer who said, gee, this isn't so complicated, and he wrote a software program to operate their very own mannequin. Well, this did not sit well with the two companies who were buying their body from them, and there was this great fight that happened at the meeting that I was witness to, with lots of yelling at each other, and so medical plastics agreed not to compete with the two companies that they supplied the body to Gore. Lairdall was there, and he was visiting to see what this was all about, and so he wound up buying medical plastics and their software, and so it became the Lairdall mannequin.

Dan Raemer: 12:43

This frightened both the CAE and the METI people, and they had to come up with their own body now, because they didn't want to be competing with the company that was about to undersell them, and so they went out and they got mannequins made from other companies, some of which didn't look that good, and so, anyways, La came along and instead of costing $200,000, which was the price for the original METI and CAE mannequins the price dropped to the $20,000, $30,000 range, and that changed the whole business. Mannequins became affordable to everyone, and the technology improved, and it took us a long time, but we're starting to get there where the mannequins, at least, are somewhat human-like and actually work.

Jerrod Jeffries: 13:46

Certainly, and I'm with the advancements of technology, the cost is coming down even more so. Absolutely To that point, though, Dan, so and I want to respond by some organizational stuff too. But what have you seen? Some of the biggest challenges in terms of simulation, growth throughout the decades, meaning one such example you just mentioned right, $200,000 down to $30,000, for example.

Dan Raemer: 14:12

Yeah, I think it's.

Dan Raemer: 14:15

I think the biggest challenge has been from the outset, and continues to be, the lack of general acceptance of the medical community and the hospital system community.

Dan Raemer: 14:33

And so, even though the idea of simulation makes incredible sense to all of us and if you've ever talked about what you do at a cocktail party, the layperson thinks they don't already do that, and so you know it just makes all the sense in the world but because of the way the medical community developed in the world and in the United States as an apprenticeship and one where it's self-governed, and lots of other reasons, I think the notion that physicians can learn their craft in other ways than the apprenticeship is a pretty you know there's a lot of resistance to it, and so you know.

Dan Raemer: 15:26

I think the biggest challenge has been to get the participation of people at all levels. The nursing community has been much better about it, at least at the training level, and to some extent medical schools have come around and they have some simulation, but extending simulation to the crafts themselves so that every team practices on a regular basis, whether you're a newbie or an experienced practitioner, that whole concept hasn't really taken hold in a widespread way, and I think it's a tough thing to convince the world is cost-effective. So I think that's the number one challenge. It's not technology.

Jerrod Jeffries: 16:25

No, and I think Deb and I have said on previous episodes, it's always the default is this is the way we've done it, and it's the way we've always done it. And culture change, of course, is immensely difficult, but when it comes to I learn like this, it should be done like this. I mean, we're seeing the same thing even with pieces of AI, right? It's like, oh, you can't use AI because that's not possible. But it's like I know it's just like the internet is coming Right, right, it's just changing.

Dan Raemer: 16:49

Yeah, these things take a generation almost, or a chunk of a generation, and so I say that that's the most difficult problem. But it wasn't very long ago that I started my career in the big scope of things and there was only a handful of people doing simulation in the world. And now you go to the IMSH meeting and there are 4,500 people there. So it's obviously growing in spite of those difficulties of acceptance and technology and training and all sorts of other potential limitations.

Jerrod Jeffries: 17:31

And to that, what surprises me? Or sorry, it doesn't surprise me. It's just incredible to see that how many young people are at these conferences.

Dan Raemer: 17:40

And they're 20s right Like 20s yes.

Jerrod Jeffries: 17:43

Because they're just thirsting for this type of intersection of technology and health care, and they love it.

Dan Raemer: 17:49

It's a sexy field. When you think about it, you can do good things and you don't have to be in the firing line. If you will this thing clinically, you can be really contributing and have a good life. It's a very appealing field to people.

Jerrod Jeffries: 18:06

And it's to that because I've been in simulation now for quite a while too because of some family history, but when it you have the ability to help change and help adopt that change and have your ideas heard and actually implement better practices and able to help save lives, I mean that's lack of it, yep absolutely Absolutely.

Deb Tauber: 18:29

Dr Raemer, can you tell us a little bit about the CMS, what you did there? You were there for a long time. You've created a legacy. Other guests have mentioned you during podcasts.

Dan Raemer: 18:41

Yeah, sure. So it's really odd I'm such an odd duck, I guess. So I'm trained as an engineer. I mean, I'm a bioengineer. I've had a keen interest in physiology and in medicine. I did spend a little bit of time clinically. At the beginning of my career I worked on a heart surgery team and I ran the intraortic balloon pump. So I spent a couple of years kind of practicing clinically. But that's the extent of my clinical certification.

Dan Raemer: 19:17

So when I came to CMS, all of the courses were taught by anesthesiologists. And one day one of them said to me why don't you debrief this case? And it was quite a technical case involving an anesthesia machine problem. And I said, okay, well, I'll give it a try. And it actually went okay. And I thought, huh, that's surprising, because I have no business teaching these people anything. And then a couple of weeks later the person who was supposed to teach the course didn't show up. And so there I was and I had to run all the cases and debrief them.

Dan Raemer: 19:59

And somehow I don't even remember. It's just I know it happened, but I don't remember the details of the day. But I was able to kind of work my way through the cases and debrief them based on what I heard my colleagues do before and of course I could ask a lot of very naive questions and people appreciated that. And as time went on and I continued doing this, I realized that I had a huge advantage over my physician colleagues in debriefing the cases because I was not threatening to the learners and even though my colleagues tried not to be, they were competitors in a way.

Dan Raemer: 20:49

It was sort of a funny dynamic and as the courses became actually more high stakes, so Jeff Cooper managed to convince the chiefs of anesthesia of four Harvard teaching hospitals to come and take a course and everybody thought this was a great idea and everyone was excited about it. And all of our clinician instructors turned to me and said you have to do all the debriefing. And I said why? And they're the boss, I can't debrief my own boss. And I was like, okay, I don't get it, but I'm happy to do it. And of course the chiefs were so mature and thoughtful and they performed in a very different way than their faculty did.

Dan Raemer: 21:48

And I started to realize that if you're curious enough and you see your role as getting people to talk about their thinking, that things became self-debriefing that no matter who the participant was, no matter what level they were, no matter, they could have the Nobel Prize in the topic of the case you were doing, and if you were curious as a debriefer, you could get them to teach everybody about it, no matter what they did. Even if they screwed up, they would freely admit it and talk about it. And so, as a debriefer, I realized that that was the key to be curious. Never ask a question. You know the answer. To always ask a question that you wonder about.

Dan Raemer: 22:45

And that kind of changed everything and that became, with the help of lots of others, CMS's philosophy, and we started to get asked to give instructor courses, and so we developed a curriculum with Jenny Rudolph.

Dan Raemer: 23:05

She was actually a PhD student and I was an advisor that did her dissertation research with her, and so she was an obvious person to bring on board. And Robert Simon joined us and we had several people who were very thoughtful about education and about how people give feedback, and also some spectacular clinicians, and so CMS was able to develop an instructor course that seemed to just resonate with people. It became very popular. We gave it all around the world. There are thousands of people who have taken that course, week-long course, and I think they benefited especially from that notion of curiosity. So I became mostly by teaching it to other people I became very good at it, I think, and so I could model how to ask questions in a curious way that really elicited thoughtful and revealing responses from participants, and so that was really how that evolved, and I think what I became known for among my colleagues is being a good debriefer.

Deb Tauber: 24:24

Yes, you've been known to have a gift.

Jerrod Jeffries: 24:28

It's also interesting to me that both things that you mentioned, you know, with anesthesiology and this simulation, with the overlap with Jeff Cooper, and then now this CMS course, like both of the things, kind of happened by accident in a way. It wouldn't be, intentional by any means.

Dan Raemer: 24:47

Serendipity is amazing. You just you know, I'm so fortunate, as everyone is, who has a career you just happen to be in the right place at the right time and you have to be willing to have an open mind to things and take them on. And so I mean I could have said no. There was a time early on in simulation where just didn't seem to be catching on and I thought, oh well, I'll just leave this and do something else. And somebody convinced me that I should stay, and he was a very wise man and he thought it was valuable and anesthesia chief, by the way and he talked to me and he said you're really good at this.

Dan Raemer: 25:32

I think you need to stay here because something's happening that hasn't happened before, and so, but you know, just being open to hearing those kinds of things and taking advantage of them, I think is key, because those opportunities come along in a career lifetime and seems like serendipity, it seems like by accident, but it's not really. It's really pretty natural. And I think the key is to be able to say to yourself ah, this just seems risky and it doesn't all make sense, but I have a good feeling like this is something I should try to do and if you could put yourself in that place. You take advantage of those opportunities and what seems like an accident is actually a little more intentional than seems from the outside.

Deb Tauber: 26:24

Yeah, some pretty profound information you've shared so far. Do you happen to have a favorite or most impactful simulation story with your vast experience?

Dan Raemer: 26:36

Yeah, so I have lots of them. I could go on for days here, but one of my favorites was we. You know, as I explained, we started in anesthesiology, and so all of the courses and cases that we did were Anesthesia oriented. Robert Simon later joined us at CMS, was a government contractor who worked for the Defense Department in aviation training for the most part, and he had gotten a contract to train emergency departments in safety, and as part of that he wanted to measure safety and have this very elaborate research project, and so he wound up coming to CMS bringing some of his emergency medicine study participants to see if Simulation would be helpful in training them about safety, and he got this, because in aviation they always had simulation. He developed safety programs in a military helicopter crews and so he had the benefit of having a helicopter simulator and he thought the one thing lacking in medicine is they don't have a medicine simulator. And he Stumbled upon CMS and he brought this emergency medicine team and so we set up the very first emergency medicine simulation course, and it was fairly elaborate.

Dan Raemer: 28:09

I had the help of two emergency physicians that got recruited by the chiefs of emergency medicine, and one of them was and was a resident and we ran our first course and the very first case we did with the CAE Eagle mannequin at the time. Midway through the case, all the vital signs went flat and Smoke started coming out of the mannequin and the team, to my amazement, said a sisterly and they started pumping on the chest and treating but you know, the completely electrically dead mannequin. And you know, at some point we called the case and and I didn't debrief it one of the emergency physicians debriefed it as a, you know, a cardiac arrest leading to a sisterly. I was like, oh my god, what are we gonna do? We've done half of one case and we have all these people and they paid all this money. What are we gonna do? I just like and the mannequin is now bride, I mean, the circuit boards had cooked and so this resident said well, I don't think this is a problem, dan, and I said what do you mean? Are you kidding? This is a crisis? He said yeah, but you know, I'll tell you what we'll do. He said have you got a whiteboard? And I said yeah, there's one on the door and we tore it off the door and he said let's just do the cases we were gonna do. I'll stand next to the mannequin and I'll write the vital signs on the whiteboard, I Assume I said okay, but it just didn't make any sense to me.

Dan Raemer: 29:58

And so we did the next case, with no working mannequin but a whiteboard, and it was a case very similar to one that we had done in anesthesia groups, and the participant response was exactly the same as it was with the live mannequin and I thought, oh my god, we did the whole course that way and it didn't change the outcome at all. They loved it, they thought it was terrific. I was devastated. I thought, you know, I thought I failed them because the technology didn't work. But it had nothing to do with the technology.

Dan Raemer: 30:42

So fortunately, emergency physicians don't sit there and watch the vital signs. They come into the bedside, they ask the nurse what the vital signs are, they get the information and then they make a decision. And so I didn't quite realize that they weren't used to the seeing the monitor continuously anyways. So holding the whiteboard up was perfectly fine for them and it was all about the problem that they were presented. If you presented them with an interesting problem that was at the edge of their practice, not something that you know, they could do with their eyes closed, that they had to think about it. It was compelling, and so long as a debriefing brought that out and got it discussed, the whole simulation really didn't matter all that much. It led me to be much more confident about every scenario that we ever did. After that I knew that, no matter what happened, the story that was embedded in what we were trying to do was the important thing.

Dan Raemer: 31:52

And so long as the story got told, everything would be fine. After that day I can't tell you how many simulator failures, simulation failures I experienced all kinds of crazy things didn't work or didn't happen and really it didn't matter all that much. So that was one of my favorite.

Jerrod Jeffries: 32:17

I love that lesson, but it actually leads me to another question and we need to wrap up shortly. But that question is where do you see the future of simulation going? Because I'm hearing the story sometimes a simulator doesn't matter, it's the resourcefulness of everything. But how do you see simulation evolving, especially with IMSH-24? We see how much technology and all these different aspects are there. I'd love to hear your thoughts on that.

Dan Raemer: 32:41

Yeah, so clearly the technology will change. Being a technology person, I'm always excited about that. I think the distance simulation stuff, the 3D glasses simulations all those new approaches are exciting. They work really well in lots of circumstances, but I don't think that they are the fundamental change. I think the fundamental change is how many different ways stories will be transmitted to people and how sophisticated will be in helping people analyze them, and so that may involve AI. It may involve other kinds of instructor training.

Dan Raemer: 33:31

The delivery platforms, obviously, are changing. That's the most obvious one on the surface, but I think we'll become more sophisticated in learning how to improve people's performance. We started off before the podcast talking about my tennis playing and my retirement. Every athletic sport has improved in the sophistication of how to get the most out of the human physiology, and so tennis players studying every muscle movement and analyzing how they swing the racket and the technology of the racket and the teams they have training them with nutritionists and strength coaches and sports psychiatrists and psychologists and the like, have improved every sport immensely, and so I think practicing health care needs to undergo that same kind of improvement. How do we improve people's performance? And simulations are part of that, and, as simulation moves inevitably in its technology, the figure out ways to more efficiently improve people's performance, I think is the future.

Deb Tauber: 34:55

Thank you, Thank you now in your retirement. Why don't you share a little bit about what you're doing in your retirement?

Dan Raemer: 35:02

Yeah, well, I play lots of tennis. I ride a bicycle 100 miles a week out into the farm country. Here. I am enjoying it immensely, but I miss my work. So I do review a lot of papers, I attend meetings and I'm on some committees and, most importantly, I have a lab in my garage. I have a 3D printer and I've been making various simulation devices, so I've made the fiber. Later I 3D printed a defibrillator and put electronics in it so that it works and it beeps and it makes all the sounds that a real defibrillator does, charges up and fires, but it doesn't deliver any energy, because I wanted to make a safe training defibrillator. So I'm pretty far along with that and I'm not sure what I'll do with it, but it's a fun hobby.

Jerrod Jeffries: 35:58

That's a long way from medical plastics laboratory back in the 90s with the companies visiting Ohio. You just 3D print in someone's garage now.

Dan Raemer: 36:10

Yeah, yeah, exactly, it takes about 14 hours, but it's simple in principle.

Deb Tauber: 36:18

Well, we really want to thank you so much for your time and all your contributions to medical simulation. Thank you.

Dan Raemer: 36:26

Well, thanks very much for having me. It's fun talking to you guys.

Deb Tauber: 36:30

We enjoyed hearing your story, that's for sure. Well, Jerrod and Dr. Raemer, thank you, Dr. Raemer, thank you and happy simulating.

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