The National Institutes of Health Clinical Center, Bethesda, Maryland, USA, is a 250-bed hospital that is unique in that its primary mission is research. It has select training fellowships but no residency programs and no affiliation with a medical or nursing school. A believer in simulation-based education, the chairman of the Critical Care Medicine Department started the simulation program with the purchase of a Laerdal SimMan and audiovisual package in 2003. So far, all of the funding for the program has come from this single department. The program was started with the simple, focused goal of teaching critical care medicine fellows, and planned eventually to expand it to postgraduate nursing education as well. This chapter shares the perspective gained by the authors on how to make an effective program with a small budget and a small space work. They relate, "Our very first scenarios were Advanced Cardiac Life Support types written by several cardiologists and a clinical nurse specialist for the intensive care unit. A major obstacle was that these staff were struggling to program scenarios with the 'flowchart' type approach in the Laerdal SimMan software, with minimal instruction on how to do so. This led to a great deal of frustration as it was time consuming and complex to try to anticipate all trainee moves and plan a response to them in a preprogrammed way. Eventually, these volunteer educators gave up and refused to continue to do it this way, thinking they would just have to change vital signs 'on the fly.' Since simulation was not a major emphasis of their careers, these individuals had little motivation to struggle with the simulator and for several months, it was not used at all.".
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