Detailed physical examinations frequently provide important information needed to assess the cardiovascular system. The first step in evaluating patients with palpitations is to determine whether or not their symptoms are actually due to arrhythmias. Palpation of the carotid and radial arteries is simple and often an underutilized lowcost method [1]. Pulse characteristics must be assessed simultaneously and carefully for rate (tachycardic, normal, or bradycardic, or any irregularity), and volume. Irregular pulse can be regularly irregular e.g. bigeminy or irregularly irregular e.g. atria fibrillation [2]. Although arrhythmias are easily assessed with an electrocardiogram

(ECG) and Holter monitoring to determine the type, precise palpation of the arterial pulse helps in diagnosing arrhythmias, even asymptomatic ones, and is also necessary to determine blood flow adequacy. Although it is simple for medical staff to understand the importance of palpation, many undergraduate students do not realize their arterial pulses as cardiovascular events and how they are related to their own physiology. There is likely dissociation between their knowledge and reality. Handson experience of their own normal pulse and pulses of arrhythmias, even with virtual reality devices, should deepen their understanding of cardiovascular physiology.

Development of human patient simulators (HPSs) began in the late 1960s and accelerated in the late 1980s and early 1990s [3]. HPSs are used at medical centers, universities, and colleges in the USA and throughout the world [3,4]. HPSs are also used in the education and training of healthcare professionals and undergraduates in scientific inquiry [3,5-7]. They are used to teach basic skills, such as respiratory physiology and cardiovascular hemodynamics, and advanced clinical skills, e.g. management of difficult airways, tension pneumothorax, pulmonary embolism, and shock [3]. However, we could not obtain an HPS scenario that focused on the palpation skill of arterial pulses and arrhythmias.

We created an original simple training scenario of arterial pulses and arrhythmias so that the students can realize the relationships between pulses and cardiovascular hemodynamics. The palpation training was evaluated by preand postexamination and a questionnaire. Ethical approval for this study was granted by the Kitasato University Medical Ethics Committee, 6 September 2011, Section B 11-76.

The training scenario including 10 arrhythmic pulses combined with normal pulses or weak pulses was manually created with the scenario editor of the HPS.

After the scenario was manually loaded and run, arrhythmia menu was listed in a control window (Figure 2). Requested arrhythmia pulses were presented on radial and cervical artery of the HSP. The mean of test scores was significantly improved from 23.8 ± 2.8 of pretest to 72.9 ± 3.4 of posttest (mean and SE, N = 25, p < 0.00001) (Table 1). Questionnaires and general written comments were very positive (e.g. “promotes critical thinking,” “practice without risk,” etc.) Ninety-six per cent of the students rated the simulator training as “excellent” or “very good”.

HPS has various basic functions and a scenario constructor/editor to create a new training scenario of specific clinical cases. Many various scenarios were created and presented throughout the world. Most scenarios are focused on learning how to recognize and treat rare, complex, and clinical problems. However, to our knowledge, this study is the first in which an HPS scenario has been focused on palpation with arrhythmias, basic but important skills. Arterial pulse waveforms, such as normal, water-hammer pulse, bifid pulse, and pulsus alternans, are usually monitored on a polygraph screen in practice. The volume of the pulse is a subtle sign to recognize low and high volume pulse (increased, normal or reduced) [1]. This medical skill requires years of experience with many patients and many careful examinations [1,2]. The pulsation and arrhythmias could not be realized even with standardized patients (actors and actresses trained to portray patients with specific clinical symptoms and conditions). Although this study mainly intended to deepen the participants’ knowledge and interest in cardiovascular physiology, not to increase their clinical skills, they will assess pulsation exactly on real patients in the clinical setting.

The contemporary HPS has palpable pulses, heart, breath, and bowel sounds and the arm for intravenous infusion [4]. However, time was required for faculty to become sufficient familiar with the technology to be able to use it effectively for student learning [6,8]. We also recognized the mechanical limitations of the HPSs with

making the scenarios. All mechanical parameters of the HPSs must completely be set in scenarios because the parameters are independent, not linked with other parameters, and constant. The used HPS can pulsate arteries as only normal, weak, or none, not perfectly replicate various pulse waveforms. In 1982, Kreitenberg et al. [1] created a simple teaching device for examination of the arterial and venous pulse that created palpable pulses with changing mechanical cams. The device exactly reproduced physiologic tracings of arterial pulsations, normal, bisferious, hyperkinetic, alternans, slow-rising, and anacrotic and dicrotic waves. For ECG, although the HPS simulates a fibrillated baseline of AF on a monitor screen, pulse volume on the artery is not changed without manual setting of arterial systolic and diastolic blood pressure in a scenario. RR intervals of AF are relatively constant, which may be misleading to understand real AF pulses. These results revealed inadequacies of current HPSs and suggest possible details and functions of the next generation of HPSs that would be more accurate and realistic. However, participants’ evaluations revealed positive reviews of this palpation experience in HPS. Confucius said, “I hear and I forget. I see and I remember. I do and I understand.” Likewise, students’ experience of palpation could indirectly deepen their understanding of arrhythmia and bridge the gaps between cardiovascular physiology and clinical phenomena.

We created an original palpation training scenario to detect pulses in the radial artery. The palpation training was evaluated with preand post-examination scores and positive comments. We also recognized the incompleteness of HPSs and that the details and functions of future HPSs can technically be improved.

We thank Robert E. Brandt (Founder, CEO, and CME, MedEd Japan, Suginami, Tokyo, Japan) for helpful advice on the English language in the preparation and editing of this manuscript.