John J. Schaefer

Simulators and difficult airway management skills.

Although difficult airway management remains one of the leading factors in anaesthetic deaths, there have been tremendous advances in the field in the last few decades. The question is, are advanced airway management skills being taught and used? Of the numerous training tools available, simulators have the advantages of providing whole‐task learning with the potential to change behaviour and, when applied to large groups of trainees, the possibility of achieving standardized application of the safest practices for a range of scenarios limited only by the creativity of the program designers. Partial‐task trainers include computer‐based software programs and simulators. Full‐scale simulators include a variety of products from several manufacturers. To take full advantage of simulators as educational tools, curricula should be designed around a set of educational objectives that address the objectives of learning in all three skill domains (cognitive, psychomotor, and affective). Simulation experiences using partial‐task or whole‐task trainers should be coupled whenever feasible with a structured clinical experience in airway management. This can best be achieved through a dedicated airway management rotation. Monitored procedure logs may also be used. Whether using a simulator or in a clinical rotation, experiences should be graded, for example, gaining experience in an adult population before gaining experience in paediatrics and in each population mastering airway management skills for common scenarios before advancing to more complicated techniques such as fibreoptic bronchoscopy.

From Resusci-Anne to Sim-Man: the evolution of simulators in medicine.

Simulators were introduced in education as a tool to make advanced training standardized, less expensive, and without danger to those involved. In 1922 in the United States, Edward Link presented his homemade flight simulator, which became common place in both military and civilian aviation, known as the “Link Trainer.” However, several decades passed before this form of training became accepted in medicine. Already in the early 1960s, Peter Safar had become involved in medical simulation through opportunistic exposure and innovative research. Interested in potential reversal of death from accidents and medical problems causing cardiac arrest, he was disturbed by the poor results of the current resuscitation technique of nonbreathing victims. In discussions with Dr. James Elam, Peter Safar learned that artificial ventilation could be efficiently provided with normal arterial blood gases in anesthetized individuals simply by blowing into the endotracheal tube (1). In the late 1950s, as chief anesthesiologist at Baltimore City Hospital, Dr. Safar undertook his daring experiments on sedated and curarized volunteers. He demonstrated unequivocally the lack of effect of arm lift/chest pressure ventilation efforts, whereas exhaled air provided through mouth-to-mouth ventilation was not only superior but also resulted in both adequate oxygenation and CO2 elimination. This study was published in JAMA in 1958 (2), and Peter Safar reported on his results at an anesthesiology/cardiopulmonary resuscitation congress in Norway. In 1961, Bjorn Lind and other prominent Norwegian anesthesiologists, who participated in this congress, brought the idea of providing appropriate cardiopulmonary resuscitation training equipment to the attention of Asmund Laerdal, a successful entrepreneur in Stavanger, Norway, whose main business was the manufacturing of toys made of soft plastic materials. Laerdal promptly designed a full-size training mannequin for mouth-to-mouth ventilation. The airway could be obstructed, and it was necessary to use hyperextension of the neck and forward thrust of the chin to open the airway before initiating insufflation of air into the mannequin by mouth-tomouth technique as described by Peter Safar. At the recommendation of Dr. Lind, Asmund Laerdal visited Peter Safar in Baltimore for a demonstration of his mannequin. At that time, Kowenhoven, Knickerbocker, and Jude had just published their observation, showing that external chest compression could produce blood flow in cardiac arrest victims. Peter Safar advised Asmund Laerdal to include an internal spring attachment to the chest wall that would permit simulation of cardiac compression; thus, the possibility of training the ABC of cardiopulmonary resuscitation on the simulator was born, with A standing for airway, B for breathing, and C for circulation. This early simulator of a dying victim not breathing and without a heart beat became known as Resusci-Anne, and its utilization rapidly spread around the world. In 1968, Ake Grenvik of Sweden joined Peter Safar’s critical care medicine training program in Pittsburgh. He realized the many problems in training physicians to use proper technique when managing critically ill and injured patients, in whom relatively minor complications could create life-threatening problems leading to death. Through the close collaboration between Peter Safar’s department of anesthesiology and critical care medicine on the American side and the Laerdal Corporation in Norway on the European side, Ake Grenvik, too, became very much involved in the exchange of ideas between Pittsburgh and Stavanger. After Asmund Laerdal’s premature death of cancer in 1981, his son Tore Laerdal became the leader in their Norwegian family business. He continued the traditionally close relations and support of the Safar group. Having used a Link trainer as a former flight surgeon in the Swedish Air Force, Ake realized the need for advanced simulation training in critical care medicine and made repeated recommendations for the Laerdal Corporation to expand into modern computerized simulation technology. The Laerdal Corporation wisely awaited the right opportunity to start this expansion. In 1995, only two, and very expensive, human simulators were available in the United States. At that time, Dr. Peter Winter served as chairman of the department of anesthesiology and critical care medicine after Peter Safar, who had withdrawn into his International Resuscitation Research Center for full-time investigations in the field of reanimatology. Peter Winter had the foresight to acquire one of the available simulators, although at the very high cost of approximately

Cooperative learning using simulation to achieve mastery of nasogastric tube insertion.

250,000. Drs. Rene Gonzales and John Schaefer of his Department were appointed director and associate director, respectively, of this simulation center at the University of Pittsburgh. These two ingenious young anesthesiologists designed a far less expensive, much more practical, realistic, and mobile simulation module, which was patented. The Medical Plastics Limited Corporation in Texas assumed responsibility for manufacturing of this new simulator. This company was From the Safar Center for Resuscitation Research (PMK) and the Department of Critical Care Medicine (AG, PMK), University of Pittsburgh School of Medicine, Pittsburgh, PA.

Validation of simulated difficult bag-mask ventilation as a training and evaluation method for first-year internal medicine house staff.

Traditionally, psychomotor skills training for nursing students involves didactic instruction followed by procedural review and practice with a task trainer, manikin, or classmates. This article describes a novel method of teaching psychomotor skills to associate degree and baccalaureate nursing students, Cooperative Learning Simulation Skills Training (CLSST), in the context of nasogastric tube insertion using a deliberate practice-to-mastery learning model. Student dyads served as operator and student learner. Automatic scoring was recorded in the debriefing log. Student pairs alternated roles until they achieved mastery, after which they were assessed individually. Median checklist scores of 100% were achieved by students in both programs after one practice session and through evaluation. Students and faculty provided positive feedback regarding this educational innovation. CLSST in a deliberate practice-to-mastery learning paradigm offers a novel way to teach psychomotor skills in nursing curricula and decreases the instructor-to-student ratio.

Board 551 - Technology Innovations Abstract Modifying MegaCode(r) Kid: Adding Chest Rise (Submission #221)

Introduction The past decade has witnessed the increased use of patient simulation in medical training as a method to teach complex bedside skills. Although effective bag-mask ventilation (BMV) is a critical part of airway management, the quality of training in this skill has been questioned. Methods First-year internal medicine house staff (novices) were used to evaluate a computerized patient simulator as a tool to teach difficult BMV. A novice group and an expert group (certified registered nurse anesthetists and anesthesiologists) were tested to validate the simulator’s ability to distinguish between these 2 skill levels. Results The difference between the novice and expert groups in the ability to perform difficult BMV was statistically significant (P < 0.0001). Brief training for novices led to a 100% pass rate and competence as measured by the simulator. Simulation training was effective in increasing the ability to ventilate a simulated difficult-to-ventilate patient (P < 0.0001). Conclusions This study suggests that this computerized patient simulator was validated as a simulation model for teaching difficult BMV and differentiating skill levels in BMV. Using the simulator with brief training on difficult BMV allowed new internal medicine house staff to successfully ventilate a simulated difficult patient.

Improving medical crisis team performance.

Introduction/Background HealthCare Simulation South Carolina (HCSSC) owns several VitalSim® manikins that do not have the capability for chest rise. However, these manikins have breath sounds. When HCSSC developed a particular need for a child manikin with both chest rise and breath sounds, but did not have the funds to purchase a new simulator, the simulation specialists at the Medical University of South Carolina (MUSC) Healthcare Simulation Center developed a method for adding chest rise to an existing MegaCode Kid®. Methods To create synchronized chest rise with the existing breath sounds in MegaCode® Kid, the MUSC simulation specialists created a circuit that “listens” for breath sounds and subsequently triggers a solenoid to inflate a SimMan replacement breathing bladder under the MegaCode® Kid’s chest skin. The circuit is comprised of the following components. Note: Components are standard and can be purchased from various outlets; prices are estimates: 1 LM224 Quad Operational Amplifier (Op-Amp)

Training mannequin for management of normal and abnormal airways

0.25; 1 LM258 Dual Operational Amplifier (Op-AMP)

Medical simulation training coming of age

0.50; 2 LM555 Timers @

RESULTS OF SYSTEMATIC PSYCHOMOTOR DIFFICULT AIRWAY TRAINING OF RESIDENTS USING THE ASA DIFFICULT AIRWAY ALGORITHM & DYNAMIC SIMULATION

0.20 =

Recent advances in airway management in anesthesiology: An update for otolaryngologists

0.40; 1 SPDT Reed Relay