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 Table of Contents  
SYMPOSIUM: SIMULATION IN MEDICAL EDUCATION
Year : 2017  |  Volume : 3  |  Issue : 1  |  Page : 66-71

High-fidelity anesthesia simulation in medical student education: Three fundamental and effective teaching scenarios


1 Department of Anesthesiology, The University of Toledo Medical Center, Toledo, OH, USA
2 Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, USA

Date of Web Publication7-Jul-2017

Correspondence Address:
Kimberly D Jenkins
Department of Anesthesiology, The University of Toledo Medical Center, 3000 Arlington Avenue, Mail Stop #1137, Toledo, OH 43614
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJAM.IJAM_45_17

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  Abstract 


Simulation is a vital tool in the assessment and training of medical professionals and those in high-risk fields. Simulation-based education provides medical students an opportunity to learn crisis management and team-building skills in an environment that poses no risk to actual patients. Students are given exposure to high-intensity medical scenarios which require and encourage critical thinking and advanced interpersonal communication skills. They are also provided with immediate feedback through debriefing and an opportunity to apply new skills through the reproducibility of rare cases. The benefits of simulation in the training of medical students during their rotations through their anesthesia electives are infrequently assessed. We expose 3rd- and 4th-year medical students to our MetiMan Prehospital model mannequin for simulation. The simulations included pulmonary embolism, airway fire, and malignant hyperthermia. We used these simulated scenarios as tools for practical teaching and exposure to uncommon events. As assessed in follow-up evaluations, the medical students found the simulations useful in the immediate application of clinical skills during their patient encounters through their rotation. The purpose of this article is to review the benefits of simulation in high-risk fields and highlight its value in the medical education of students during their anesthesiology elective.
The following core competencies sare addressed in this article: Patient care, Practice-based learning and improvement, Medical knowledge, Interpersonal and communication skills.

Keywords: Anesthesiology, medical education, patient safety, simulation


How to cite this article:
Jenkins KD, Stroud JM, Bhandary SP, Lynem L, Choi M, Quick J, Goyal N, Papadimos TJ. High-fidelity anesthesia simulation in medical student education: Three fundamental and effective teaching scenarios. Int J Acad Med 2017;3:66-71

How to cite this URL:
Jenkins KD, Stroud JM, Bhandary SP, Lynem L, Choi M, Quick J, Goyal N, Papadimos TJ. High-fidelity anesthesia simulation in medical student education: Three fundamental and effective teaching scenarios. Int J Acad Med [serial online] 2017 [cited 2019 Oct 20];3:66-71. Available from: http://www.ijam-web.org/text.asp?2017/3/1/66/209849


  Introduction Top


Simulation is an invaluable tool in the evaluation and training of medical students and residents in the field of anesthesiology. Simulations allow replacement or amplifications of what real-patient experiences might be like with guided experiences.[1] Despite tremendous technological and societal improvements over the past several decades, health care, especially in the perioperative setting, is laden with high-risks.[2] One in every 150 patients admitted to a hospital dies.[3] Simulation provides an opportunity for a physician-in-training to gain the insight and experience of crisis management without posing danger to the patient. In the realm of health care risks versus benefits, simulation education provides all the benefits with no risk.


  The Benefits of Medical Simulation in Various High-Risk Fields Top


High-risk fields require intensive training that ready practitioners to handle challenging situations with reasonable ease and stress. The aviation industry has weathered decades of safety challenges using a rigorous curriculum called simulation-based training (SBT).[4] This method has been adapted for anesthesiology as well as other high-risk fields such as nuclear power, the military, and various medical fields including emergency and trauma medicine, intensive care, and cardiac arrest response teams.[5],[6] To maximize training safety and to minimize risk, aviation trainers have enhanced flight professionals' skills using crew resource management, through a specific SBT module designed for aviation crew members.[7] Other instances of cockpit resource management simulations include virtual cockpit simulators and virtual reality parachute flight simulators that prepare smoke jumpers for forest fires.[8]

There have been tremendous benefits to the use of simulation in aviation during the training of new pilots and in the continuing aviation education of more veteran/experienced pilots. These advanced skills in flight and passenger safety are gained at no risk to “real-life” passengers. The opportunity to expose pilots to rare, stressful scenarios in a repeated fashion is of great benefit to the flying public. As a result of safety improvements, SBT is mandated and culturally accepted by pilots and pilots in training as a reliable and trustworthy educational tool.[9]

There are also benefits of SBT for researchers and scientists in the exploration of nuclear energy technologies. Many of the computational tools currently used on nuclear reactors were initially developed in the 1970s. Researchers and scientists in Nuclear Energy Advanced Modeling and Simulation are developing new tools to predict the performance, reliability, and economics of advanced nuclear power plants. These new computational tools will allow researchers to explore low probability emergencies in ways that were previously impractical; from important changes in the materials of a nuclear fuel pellet to the full-scale operation of a complete nuclear power plant.[10] Computer simulation advances have also allowed the United States to monitor and maintain the nuclear weapons stockpile without nuclear explosive testing.[10]

The usefulness of SBT evident in the aviation and nuclear fuel industries has obvious parallel benefits to the field of anesthesiology. Anesthesiology requires that its practitioners are well-versed in the latest advancements in resuscitation, airway rescue, regional anesthetic techniques, and for any number of other perioperative scenarios in a structured, and measured environment with meaningful quantitative and qualitative results. Rare conditions, such as difficult airway management and malignant hyperthermia (MH), can be imitated to give trainees practice in patient management before encountering these challenges in a clinical context.[11] Supplementing the traditional apprenticeship model of anesthesiology training, SBT allows educators to strategically create training exercises in an environment that reduce patient safety concerns and permit repetitive engagement in common and rate practice scenarios.

Utilization of simulators has many advantages for medical education:[12],[13],[14],[15],[16] (1) learning can be focused on the level of trainees with various levels of understanding or difficulties; (2) learners can either learn the whole procedure process or just focus on certain tasks of the procedures; (3) learners have the opportunity to repetitively practice procedures/scenarios in quick succession; (4) learners learn in an intellectually safe environment where they can be allowed to learn from their mistakes without guilt and with constructive criticism; (5) simulators can provide objective evidence of performance, offering potential for their use for assessment, both formative and summative.

Anesthesiologists have played a key role in the development of mannequin simulators and contributed to the development of simulation programs for education, training, and research.[17] The first computer-controlled mannequin simulator was SimOne manufactured by Denson and Abrahamson in the 1960s, but it was too large and expensive to apply to medical education.[18] In 1968, Gordon developed Harvey, a high technology cardiopulmonary simulator.[19] Harvey has since been used by medical students, nurses, residents, and attending physicians. Harvey is capable of simulating auscultation sounds, blood pressure, arterial pulses, precordial impulses, normal heart sounds, and murmurs.[20]

In summary, the educational benefits of simulation in medical education, that can be observed at any institution include: Deliberate practice with feedback, exposure to uncommon events, reproducibility, opportunity for assessment of learners, and absence of risk to patients [Figure 1].[21]
Figure 1: Educational benefits of simulation based training

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  A Single Institutional Effort in Anesthesiology Top


As mentioned above, The University of Toledo College of Medicine and Life Sciences currently utilizes the MetiMan Prehospital model for simulation. This mannequin is a state-of-the-art advanced tools for education in the modern era of simulation-based medical education.

The MetiMan is used by all medical students rotating through their anesthesiology electives during their 3rd and 4th year of medical school. These high-fidelity mannequins allow exposure to interesting high-yield scenarios. The simulation experience takes the seemingly “randomness” of the operating room (OR) and converts it to a well-constructed, standardized patient encounter that is uniform and reproducible.

Over the course of 18 months, we have exposed over 73 3rd and 4th year medical students to anesthesiology-centered curricula at the College of Medicine's Interprofessional Immersive Simulation Center (IISC). Here, the students are introduced to various infrequent intraoperative clinical scenarios faced by anesthesiologists. These experiences are opportunities for the medical students to work together in a simulated OR setting with real equipment and learn techniques for the management of several different perioperative crises. Below we will give examples and discuss the results and feedback from three important intraoperative SBT curricula/scenarios which have been identified as extremely useful to educational training efforts: pulmonary embolism (PE), airway fire, and MH.


  Pulmonary Embolism Simulation Top


In this first scenario, medical students participated in the management of an anesthetized patient experiencing an intraoperative PE and were expected to treat the cause and ensuing hemodynamic instability.

Case

A 66-year-old male presented for revision of a right total hip replacement due to a peri-prosthetic fracture. His medical history was significant for coronary artery disease with stent placement 3 years prior, controlled hypertension, controlled diabetes mellitus, and obesity. His home medications include low-dose aspirin, metformin, and lisinopril. Lisinopril was held the day before surgery. The perioperative cardiac evaluation was within normal limits. He is in the left lateral decubitus position, intubated, and under general endotracheal anesthesia.

The scenario begins with an initial PE that results in a slight decline in end-tidal carbon dioxide and oxygen saturation. The medical students were expected to respond by adjusting ventilator settings and checking the patency of the endotracheal tube. A second and larger PE then lodges into the pulmonary circulation causing significant hemodynamic changes and altered vital signs. At this time, the students are expected to approach the worsening hypoxemia with a more aggressive investigation, involving the development of a differential diagnosis. The students were to evaluate and treat for each differential diagnosis.

As the case evolves into significant hemodynamic instability due to a large clot burden, escalating supportive treatment becomes indicated. The learners are evaluated based on their response to the hemodynamic changes and extent of effective supportive care initiated that may result in a good outcome. An intraoperative PE is a diagnosis of exclusion, requiring the learner to have a high index of suspicion. Experience in our simulation center indicated that medical students engaging a scenario of PE took approximately 15–18 min before making the correct of PE.

Once PE was suspected, many of the students were unsure of the initial approach to management. Although a correct diagnosis was reached, students concentrated on intermittent vasopressor bolus administration, which briefly elevated the patient's blood pressure. Once a vasoactive drip was initiated, and anticoagulation was recommended, the scenario was complete.

In the debriefing period, the students were engaged in a review of PE risk factors, vasopressor administration, and differential diagnosis of a PE in an anesthetized patient. In addition, team-based patient care and acute crisis management were discussed in regard to an intraoperative scenario.

The medical students provided overwhelmingly positive feedback; however, some noted that this scenario might have been too advanced for their level of training. Many learners indicated that an anesthetized patient masked the common signs and symptoms of a PE and this scenario provided a good platform to discuss treatment for persistent hypotension, use of vasoactive infusions, airway troubleshooting, and intraoperative PE management.


  Airway Fire Simulation Top


In the second simulation scenario, medical students participated in the rare intraoperative crisis of an airway fire, which was designed to test their decision-making when faced with a chaotic and unanticipated airway disaster.

Case

A 38-year-old female with a medical history of obstructive sleep apnea and morbid obesity presented with respiratory distress, requiring a tracheostomy under general anesthesia. The students were instructed to induce general anesthesia for an anticipated prolonged period of ventilator support. Before the surgeon's initiation of the tracheostomy, FiO2 of 0.75–1.0 was required to maintain adequate oxygenation during induction and maintenance of general anesthesia. Due to the patient's morbid obesity, there was a considerable amount of excess soft tissue overlying the trachea. The surgeon verbalized that electrocautery would be necessary to achieve hemostasis for the procedure. After proceeding to use the electrocautery, a fire ignited in the airway and smoke began to fill the simulation room.

Students proceeded to take team leadership positions by immediately notifying the surgeon of the airway fire and requesting discontinuation of the procedure. The majority of students disconnected the breathing circuit while decreasing the oxygen supply. Some students displayed hesitation in pulling the endotracheal tube in fear of being unable to subsequently secure the airway. With prompting, students removed the tube and applied an Ambu bag for mask ventilation. Some students performed direct saline irrigation of the airway. Overall, the students were able to make an association between the use of oxygen, airway fires and how to manage an airway emergency.

During the debriefing, a discussion of prevention of airway fires, which included the use of FiO2 of <30%, prompt communication with the OR team, cuff advancement during tracheal manipulation, cessation of ventilation on tracheal opening, and deflation of cuff during removal of the endotracheal tube. Management of an ensuing airway fire was summarized, ensuring immediate disconnection from the anesthesia machine, cessation of the gas flow, and removal of the endotracheal tube; followed by ventilation with available Ambu bag for ventilation, irrigation of the airway with saline, and securement of the airway with a new endotracheal tube. Most students felt uncertain and uncomfortable in handling an airway crisis, but felt the session improved their crisis management skills. This anesthesia emergency simulation served to increase the awareness, and hopefully the skill and confidence of the learners during this encounter.


  Malignant Hyperthermia Simulation Top


In the third simulation scenario, medical students were exposed to a case of intraoperative MH, where they were expected to recognize early signs and symptoms and proceed with prompt intraoperative management of the patient.

Case

A 19-year-old female presents acutely for an emergent laparoscopic cholecystectomy. She has no significant medical or surgical history and denies any family history of anesthesia-related complications. On arrival to the OR, the patient undergoes an intravenous induction with propofol, fentanyl, and succinylcholine followed by intubation under direct laryngoscopy using a 7.0 mm endotracheal tube. Maintenance of anesthesia is achieved with desflurane. Initially, the procedure proceeds uneventfully. After 15 min of desflurane use, the patient subsequently starts exhibiting signs of MH including hypercapnia, tachycardia, muscle rigidity, and hyperthermia.

As the simulated patient continued to deteriorate, the medical students were expected to intervene and begin treatment for suspected MH. Most students quickly noticed signs of tachycardia and progressively worsening hypercapnia and appropriately turned off the volatile anesthetic agent. With some assistance and prompting, the remainder of students turned off the anesthetic agent. Students appropriately called for the MH cart and for help with preparation of dantrolene. Once the MH cart was brought into the room, the students followed the MH Association of the United States (MHAUS) cognitive aid to assist with further management of MH. Following the protocol, students began with the placement of additional intravenous access, fluid resuscitation, charcoal absorbent on the circuit, and cooling the patient. Once all the steps in the MHAUS cognitive aid were initiated, and the dantrolene preparation started, the scenario concluded. The learners were able to notice signs of MH early and with prompting, call for the MH cart quickly.

During the debriefing, the disease process and perioperative course of MH were reviewed. In addition, the MHAUS cognitive aid protocol was discussed in depth, including detailed steps for dantrolene reconstitution and administration. The management of hemodynamic instability was outlined, which included the placement of central or large-bore intravenous access, invasive arterial pressure monitoring, correction of electrolyte derangements, and management of cardiac dysrhythmias.

The students submitted a self-assessment and feedback survey, where responses were overwhelmingly positive. Most learners realized the importance of vigilance at all stages of perioperative care and believed the scenario gave them more confidence in the OR. Exposure to the rare scenario of MH gave them the opportunity to hone their clinical decision-making skills without risk to patients.


  Conclusion Top


As an invaluable tool in high-risk fields of medicine, simulation provides enhancement of essential skills utilized in real-life crisis situations. The skills requirements include (1) technical and functional expertise training, (2) problem-solving and decision-making, and (3) interpersonal and team-based competencies.[21] These skills can be attained through simulation with no risk to actual patients. The repetitive and structured nature of simulation can enhance critical thinking and confidence. Medical students, healthcare providers, and auxiliary medical staff benefit by having a safe environment to make mistakes and hone their skills.[22]

Since the 1999 Institute of Medicine report highlighting that medical errors may cause 44,000–98,000 deaths annually, there have been increasing calls to use simulation in medical student and resident education to increase safe practices in teaching settings. Recently, some Accreditation Council for Graduate Medical Education Residency Review Committees have required simulation and participation in skills laboratory as a part of training.[23]

Most anesthesiologists may not have the luxury of time to teach and explain to medical students good patient management during real-life, real-time medical crises. SBT slows down the pace of the encountered crisis and provides immediate debriefings and reproducibility of even the rarest of patient encounters.

SBT provides an exposure of rare clinical scenarios to medical students. Instructors can identify strengths and weaknesses of trainees at all levels and provide immediate feedback. The trainees are exposed to scenarios that can address areas requiring improvement. In addition, simulation can mitigate traditional ethical dilemmas of medical training by reducing patient exposure to inexperienced trainees.[24] Perhaps with the adoption of simulation as a standard of training and certification, health-care systems will be viewed more accountable and ethical by the population they serve.[21]

For medical students rotating through the Anesthesiology Department at the College of Medicine, simulation provided an opportunity for learners to become acquainted with basic techniques in perioperative care and to become more facile. The students assessed and evaluated changes in vital signs and other important clinical findings without intimidation or intervention. Furthermore, they managed a patient without unsolicited guidance that can occur when faculty or residents are present.

Here, we have provided the readers with three scenarios given in 2 weeks intervals. The first simulation was performed at the onset of the rotation. After 2 weeks of real patient interaction, OR experience, and fundamental lectures, they were introduced to additional scenarios. At this time, they were given an opportunity to utilize their newly learned skills and knowledge, especially in airway management and interpretation of OR monitors. These scenarios were team-based, allowing the students to improve their skills at teamwork.

The SBT at the IISC afforded students the opportunity to make inquiries they felt hesitant to make in the actual OR because of time constraints or patient concerns. Armed with clarification during our debriefings, the students had developed and demonstrated enhanced confidence in their skills and abilities. Through the debriefing sessions, the students learned from their decision-making in a nonthreatening environment. Such learning models bridge simulated clinical teaching and learning to direct and safe patient care practice, and build on confidence and skill level without hazard to actual patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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Introduction
The Benefits of ...
A Single Institu...
Pulmonary Emboli...
Airway Fire Simu...
Malignant Hypert...
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