The Portable Sim Gym: An Eye-Opening Tool in Medical Education

The art of on-shift teaching is a skill that many attendings struggle with and aim to master, especially during a busy shift.

Limited research on this topic shows that approximately 6-20% of attendings teach during a shift. Even fewer studies characterize their teaching methods. One study showed that 25% of attendings taught on shift, with a majority of their techniques involving implicit teaching during patient-care discussions.1 While this is an important approach, we believe that providing additional tools for educators can enhance medical education.

Enter: The “Sim Gym.” It’s a novel concept — a portable task trainer for explicit, dedicated teaching of EM procedures.

Although published data on in-situ procedure training is limited, one study within U.K. medical literature highlighted a “tea trolley” being brought into an anesthesia resident workroom to teach residents difficult airway skills.2

We felt that a similar concept could be used in our ED by utilizing a portable trainer to teach procedures. We started with the lateral canthotomy. Lateral canthotomy is an example of a low-frequency, but high-risk, procedure that emergency physicians need to feel comfortable to perform. We wanted to improve the proficiency in performing a lateral canthotomy in the emergency department, as well as review indications and contraindications for this procedure. Due to limited real-patient experience of this type of procedure during a typical EM residency, it lends itself well to simulated training. The Sim Gym, as a portable task trainer, can easily be accessed during shifts to serve as an additional tool for educators and allow hands-on training for procedures such as the lateral canthotomy.

Goal: Create a portable, low-fidelity lateral canthotomy model, train residents while working on shift, and collect pre- and post-intervention data on proficiency.

Eligibility: All emergency medicine residents (PGY1-PGY3) working in the emergency department around 12 pm on Jan. 31, 2022, and Feb. 1, 2022.

Pre-intervention: A qualitative discussion assessing knowledge of indications, complications, and contraindications was performed prior to the intervention.


  • Over the course of two emergency department shifts (11 am-9 pm), 11 PGY1-3 EM residents participated in a 10-15 minute, one-on-one simulated session involving performing a lateral canthotomy.
  • A simulation case was created involving a trauma where a lateral canthotomy was indicated.
  • We created a Sim Gym that had multiple low-fidelity lateral canthotomy models using halloween masks, ping pong balls, and sutured in hair ties as described in the Nadir et al paper.3


  • A SurveyMonkey questionnaire consisting of seven questions was completed by participating residents after the intervention to assess knowledge retention.
  • An educational guide was emailed to all participating residents discussing indications, complications, contraindications, and procedure steps for a lateral canthotomy.

The post-intervention questionnaire included inquiries regarding comfort level of performing a lateral canthotomy; indications, contraindications and complications of the procedure; usefulness of the model; usefulness for on-shift education; and additional feedback. (See Table 1.)

Table 1: Knowledge and proficiency in EM residents (n=11) pre- and post-intervention.

Survey Question

Pre-survey (n = 11)

Post-survey (n =11)

Indications for lateral canthotomy









Usefulness of procedure model


45% extremely

27% very useful

27% somewhat useful

Comfort level after workshop


64% very confident

36% somewhat confident

Usefulness for on-shift resident education


18% extremely useful

55% very useful

27% somewhat useful

Additional feedback from our study’s resident-participants included, “Consider hosting ‘sim gym’ training during a less busy clinical time,” and, “Consider distribution of a smart-card that outlines the highlights of the procedure” to facilitate retention.

In medical education, simulation is a useful tool that encourages team building and problem solving in a safe environment. Although simulation occurs every month during our formal scheduled didactic sessions in the St. Joseph’s Medical Center Sim Lab, mock in-situs and on-shift simulation-based teaching are beneficial adjuncts. The theory behind these on-shift events is that training in the actual ED increases fidelity, provides a unique experience that triggers memory formation and future recall, improves patient safety, and serves as a fun and enjoyable outlet during otherwise stressful patient-care activities.4

During our two-day intervention, there was significant improvement in the comfort level of EM residents performing a lateral canthotomy, ranging from 36-64% feeling somewhat to very confident. During the pre-intervention discussion, all residents stated they had never performed one in their training to date.

Sim Gym Image 1.jpg

Sim Gym Image 2.jpg

All residents knew the indications for a lateral canthotomy. There was a 2.3-fold improvement (from 36% to 82% of residents) in knowing contraindications for lateral canthotomy. In addition, after the Sim Gym intervention, there was a 4.6-fold increase (from 11% to 82% of residents) in knowing the complications of a lateral canthotomy.

Residents reported that their comfort level improved after the simulation exercise, and knowledge of the procedure was generally high as ascertained on the post-intervention survey.

Limitations of this study included the small sample size as well as the short duration of time over which this study was conducted. In addition, the pre-survey data was collected through an informal discussion during the intervention, as opposed to through a formal survey.

The portable Sim Gym is a novel and innovative modality that facilitates dedicated, on-shift resident education and provides a tangible resource that attendings can use for explicit teaching. This versatile, portable trainer can be used for various EM procedures. It would be especially useful in training for low-frequency/high-risk procedures and would encourage increased exposure, repetition, and memory retention. Future studies could include retention and proficiency in other EM procedures, more qualitative pre-intervention collection of data, a larger sample size through a longer period of time, and feedback from on-shift attending physicians to assess the feasibility and usefulness of the task trainer.

Additional Resources


  1. Baugh JJ, Monette DL, Takayesu JK, Raja AS, Yun BJ. Types and Timing of Teaching During Clinical Shifts in an Academic Emergency Department. West J Emerg Med. 2021;22(2):301–307.
  2. O’Farrell G, McDonald M, Kelly FE. “Tea trolley” difficult airway training. Anaesthesia. 2015;70,104.
  3. Nadir N, Sattar I, Ahmed A. The halloween lateral canthotomy model. JETem. 2017;2(2):I17-20.
  4. Davis D, Warrington SJ. Simulation Training and Skill Assessment in Emergency Medicine. StatPearls. 2021 May 9.

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