Simulation Equipment

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CHAPTER 3 Simulation Equipment

“I’m afraid I can’t let you do that, Dave.”

HAL’s refusal to open the space hatch to an astronaut.

—2001, A Space Odyssey

Dave ran into a little trouble with his equipment on 2001, A Space Odyssey. First, the equipment shut off life support for his fellow space travelers; then it snipped the air hose to Dave’s partner; and then the darn thing wouldn’t let Dave back into the ship. And Dave had forgotten to bring along the helmet to his space suit.

Some equipment malfunctions are more vexing than others.

Fortunately, Dave knew his equipment inside and out and found a way to blast back into the ship and shut down the decidedly antisocial HAL.

To date, no simulation equipment has committed mass astronaut-o-cide. But we are wise to take 2001’s lessons to heart.

1. Know thy equipment as thyself.

2. It’s the astronaut (the simulator instructor), not HAL (the simulator mannequin) that keeps the ship running.

So this chapter focuses on lesson 1: knowing the simulation equipment. In the back of our minds, though, we’ll be ever mindful of lesson 2—that the simulator instructor is the key element to any simulation scenario.

What’s out there in simulation equipment land? This chapter focuses on the Big Kahunas in anesthesia training—full-service computerized anesthesia mannequins, but it’s worth mentioning all the other “toys” out there that are used to train medical personnel.

PARTIAL TASK TRAINERS

The devices known as partial task trainers let people train for one specific task—some easy, some quite complicated.

ANESTHESIA-RELATED TASKS

Intravenous catheter insertion

Intubating dummies

Bronchoscopy (tailored for pulmonologists but good for us too)

Central line insertion

Epidural (works either upright or on the side)

Surgical airway (you can perform a cric and place a cricothyrotomy kit)

SURGERY–RELATED TASKS

Hollow organ closure

Total hip replacement

Ophthalmic surgery, including laser photocoagulation

AAA endovascular repair

Surgical suturing

Shoulder arthroscopy

INTERNAL MEDICINE AND ITS SPECIALTIES

IVC filter placement

Upper GI endoscopy

Interventional cardiology simulator (this is a PC-based application)

So there’s no shortage of gizmos and gadgets to train doctors in doing specific tasks. As noted in the last item—interventional cardiology simulator—there are also a host of “flat screen computer simulators.” You can interview a patient, order tests, run codes, examine lab tests. What can’t you do on a computer?

FIGURE 3-1 Partial task trainers add to the simulation experience. You can focus on one thing (the airway). You can demonstrate, up close and personal, how the various blades “handle” the epiglottis. The curved blade goes into the vallecula and lifts the epiglottis indirectly. The straight blade lifts the epiglottis directly. The model also helps demonstrate how the LMA fights in the airway. Practice it first on the partial model and then on the intubating dummy.

In surgery, more and more detailed “haptic” trainers are coming into use. “Haptic” means that the trainer gives you the actual “feel” of the tissue and the procedure. Quite realistic and a great way to train surgeons.

In obstetrics, they have a vaginal delivery mannequin capable of generating all kinds of problems—occiput anterior, shoulder dystocia.

In a perfect world and in a perfect simulation center, you could imagine a kind of “amusement park” where every partial task and flat screen computer simulator is present.

You go into room 1, practice placing IVs.

Room 2, put in a central line.

Room 3, place an epidural.

Room 4, perform intubation.

Room 5, perform fiberoptic intubation.

Room 6, run through the difficult airway algorithm, ending with placement of a surgical airway.

Room 7, what’s this? A real live human being. What’s going on here?

Room 7 opens up another consideration in the “perfect simulation center”—standardized patients.

FIGURE 3-2 A great addition to the simulation experience is the standardized patient—an actor with a script. That standardized patient can portray a psychotic patient, a grieving widow, a litigious parent, or a patient with a “mystery disease” (say, MH, and the resident has to “uncover” this in a history). You name it. Here, the patient has a clear case of “IQ deficit disorder.”

A standardized patient is an actor who plays out a role from a script. This script can detail any aspect you want a resident to learn about:

Manipulative patient demanding to see his or her records and wants to sue

Patient with a history of malignant hyperthermia that you must “uncover” in the course of your preop visit

Psychotic patient

Distraught parents of a child in the ICU

Relatives who need to hear of a patient’s death

Because you want your residents to be able to handle “anything,” you can make use of standardized patients to handle, well, “anything.” Let your imagination run wild and come up with any possible interpersonal interaction your resident might ever encounter. Then, using the standardized patient, you “simulate” this interpersonal interaction.

Simulation centers do not live on mannequins alone.

BOX 3-1 Standardized Patient

• Real human being

• Scripted conversation

BOX 3-2 Big Simulator Players

• METI (Sarasota, FL, USA)

• Laerdal (Denmark)

But there’s no getting around it, the centerpiece of the simulation center is the anesthesia mannequin, so here goes.

What’s out there?

There are three big players: one lame duck company and two that are still very much part of the action.

The lame duck—MEDSIM Eagle

You will still see some of these sturdy players out there.

These anesthesia simulators are no longer made or serviced; they are (dab your eyes here) “orphan simulators.” MEDSIM Eagle doesn’t even exist anymore; the company is now just MEDSIM, and they only make ultrasound simulators. (You can try contacting the company (www.medsim.com), but don’t be surprised if no one knows what you are talking about when you mention their simulator.)

However, these simulators are built like brick houses, so they last and last. “Why throw it out?” its owners say, “I’ll service it myself and keep this baby going and going!” The MEDSIM Eagle simulator has a drug recognition system, like the METI simulator.

Harvard’s simulation center has one of these simulators, and you sense that they love keeping it going. Picture some diehard Volkswagen beetle owner keeping his 1965 bug alive, engine rehaul after engine rehaul, never giving up on the old car.

The two players: METI (Sarasota, FL; www.meti.com) and Laerdal (Denmark; www.Laerdal.com).

Each has its pluses and minuses, each has its champions and detractors, so we’ll just go down the line and see how they add up. Your best bet if you’re considering laying down cash for these simulators (it’s serious bread) is to take them for test runs and see which fits your style better.

OVERARCHING PRINCIPLE

If you remember one thing, remember this, the Laerdal is like flying a plane in which you have direct control over the stick, rudder, and ailerons. The METI is like flying a plane where the computer actually controls the plane, and you input what you want done. You don’t have direct control over the stick, rudder, or ailerons. This analogy is less than perfect but serves to illustrate the main difference between the two.

DRUG RECOGNITION SYSTEM

METI—Has a library of drugs it can recognize and respond to physiologically.

Laerdal—Lacks a library of drugs, though you can program in a canned response to a given drug.

Example: You inject 40 mEq of potassium.

Real life—Patient arrests.

METI—Recognizes the drug, patient arrests.

Laerdal—Nothing happens unless you program this in as a response, then you have to note that they gave the 40 mEq of K in the field, then you institute the response, then the patient arrests. Alternatively, you could just, “on the fly,” program in a fibrillation response when you see that K was given.

Example: Anaphylaxis occurs; resident gives phenylephrine instead of epinephrine.

Real life—Pressure would rise for a bit, but you really need epi to resuscitate

METI—Recognizes the neo, allows a small increase in blood pressure, but patient continues to deteriorate unless epi is given.

Laerdal—No response from neo unless you have programmed this information in as a canned response and you note that it’s given. Alternatively, you could just manually raise the blood pressure for a little while, then let it go down again.

One Step Removed from Direct Vital Sign Changes

METI—Everything runs on a physiologic model, so you have to program in, say, a shunt, and let the shunt occur before the saturation can go down.

Laerdal—You just punch in a lower saturation.

Example: You want the saturation to drop to 85% after aspiration occurs.

METI—You punch in a shunt, then wait; with time the sat drifts down to 85%.

Laerdal—Press 85% on the O₂ sat, and 85% appears.

One Button Pushed and the Scenario Runs

METI—A preprogrammed scenario can run with just a touch of a single button. Over 10 minutes, the entire scenario plays out and you don’t have to do anything. The drug recognition system runs on its own.

Laerdal—Either you have to do everything on the fly, responding to each drug given or the maneuver performed, or you have to program in a canned response. But you have to note what’s given, as there is no drug recognition system.

Example: Malignant hyperthermia.

METI—Press the button, and the sequence rolls, with increasing heart rate, increasing end-tidal CO₂, and eventually increasing temperature. If, when tachycardia first occurs, the resident gives esmolol, you don’t have to do anything, as the drug recognition system recognizes it and decreases the heart rate for a while. Of note, the library does not yet recognize dantrolene, so you’d have to note when it’s given and make the adjustment.

Laerdal—As in earlier scenarios, you can do this all on the fly: entering tachycardia yourself, entering higher end-tidal CO₂ yourself, entering higher temperature yourself. Alternatively, you can program the system to roll, but you still need to respond individually as things occur. For example, if the resident gives esmolol when the tachycardia occurs, you must note this and respond either manually or by a canned response to esmolol that you yourself programmed in.

Eyeballs

METI—Blinks, has pupils that respond, can “blow” a pupil, which is very handy in a cerebral herniation scenario, a response to atropine, or a brain death situation.

Laerdal—No such thing.

Monitors

METI—Can hook up to your anesthesia machine monitors.

Laerdal—Hooks up to its own proprietary monitors.

Technical Glitches

METI—more complicated, so, guess what, more chances for things to go wrong.

Laerdal—less complicated, so, guess what, fewer chances for things to go wrong.

Cost

METI—About 200,000 smackers, with a yearly service agreement that can run $12,000 more. (METI, not blind to this high cost relative to the Laerdal, has come out with a stripped-down, less expensive version, the ECS, for about $45,000.)

Laerdal—About 30,000 smackers, with a yearly service agreement of $3200

Once you have the simulator mannequin, you need a “place” to make it all happen. The Simulator is theater, and theater needs props. We need both medical props to create the medical “feel” as well as stage props to help achieve the “suspension of disbelief” so crucial to the Simulator experience.

FIGURE 3-7 Times are tough, and budgets are tight. There are cheaper alternatives to computerized mannequins.

BOX 3-3 The Two Biggies

METI

• Bells and whistles

Laerdal

• Less pricey

• Fewer bells and whistles

Theater Props

Outfits for various “players” (cop, parents)

Water spritzer (for “sweat”)

Anything else that adds zing to the experience

Great, where do we get this stuff?

Scour the hospital for outdated or broken stuff.

eBay actually has some of these things (broken stuff from other hospitals).

Ask vendors for outdated or flawed articles, shipments that lost sterility.

You’ll need permanent stuff as well as disposables (for disposables, get things with the seals broken so the hospital can’t use them).

Fake bags of blood.

Where do you get all the “characters” to play parts? One handy trick is to just leave the room, change one thing in your appearance, then come back as a different person.

There, now that we’ve laid out the equipment, let’s see the actors do their thing. Let’s put some meat on all this theory and see the METI and Laerdal in action.

FIGURE 3-8 The simulator lab is the “place of final repose” for broken down, unsterile, or outdated equipment. This pacemaker is broken and is missing a knob, but you can still use it to teach.

FIGURE 3-9 A. You don’t need the entire cast of Ben Hur to play the various characters in your scenarios. B. Just step out of the room, change one little thing, and you’re someone else! C. See? Just put on a lab coat, and I become utterly unrecognizable. D. Who could this man possibly be? International diamond thief? Superspy? Rock star? E. The truly dedicated instructor agrees to minor plastic surgery to change “the look” ever so slightly. F. And here again, another character entirely.

How do you actually punch things into the simulator to make all this stuff happen? How do you “make the blood pressure go down” and “elevate the ST segments” and “fibrillate” the patient?

The short answer is—you get trained by the METI or Laerdal people.

The long answer is—METI or Laerdal reps come to your place, in-service you, and help you get started. You do best, when starting, to use one of their “canned scenarios” (for example, an allergic reaction). You start out with simple cases; then, as you get more comfortable, you add complexity. Time passes, you become more facile, you start hunting around in the virtual world of simulation, and you discover more scenarios you can use. Then you attend meetings, run through simulations, and start programming your own scenarios.

This chapter alone cannot teach you all the steps and intricacies of running the simulator computer. But if we run through some real examples, you can get a feel for it.

So let’s get a feel for it!

Two simulators, the METI and the Laerdal, are mentioned (more on both of them in the next chapter).

METI SIMULATOR, CANNED SCENARIO, ALLERGIC REACTION, SIMPLEST POSSIBLE

The residents get a preop and operative record that shows a routine patient. You tell the residents that the patient has no known allergies. (Tee-hee, we know that an unpleasant surprise awaits.)

They get instructions to hang Ancef and (surprise, surprise), the patient develops an allergic reaction to this antibiotic.

Built into the machine is the “allergic reaction scenario.”

You let the residents come into the room, set up, induce the patient, get going; then you press the button that says “Allergic reaction.”

Everything is programmed in, including drug recognition via bar code, so you can sit back and watch the event unfold.

What does the computer have and what does it do?

On the computer screen, you see the steps of the reaction, and the computer will be “looking out” for the one thing that can save the day—in this case epinephrine.

Start scenario.

Allergic reaction starts.

Allergic reaction worsens.

Allergic reaction becomes severe.

Allergic reaction resolves.

At each stage, the computer has built into it certain responses that mimic an allergic reaction. In this case, we pretend that we only focus on the blood pressure (ignoring the many other things that happen during an allergic reaction).

Allergic reaction starts. The SVR (systemic vascular resistance) decreases, which makes the blood pressure go down to, say, 90/60.

After 2 minutes the computer goes to the next step—allergic reaction worsens. The SVR decreases again, and the blood pressure goes to, say, 80/50.

After 2 minutes, the computer goes to the next step—allergic reaction becomes severe. The SVR decreases again, and the blood pressure goes to 70/40.

FIGURE 3-10 A. Here’s how it actually happens. These views are from the control room. Through the window you see the residents in “mid-scenario” (here, a bioweapon has gone off and one person is in a Haz-mat suit—in real life, of course, everyone would have such a suit on). You look through the one-way mirror to observe them, and you work the controls. B. Cameras catch and record the action. C. Hunched over the controls, you change things, react to what they are doing, and try to make the whole thing as educational as possible. D. Microphones allow you to “speak” as the patient (“I can’t breathe!”) or make overhead announcements (“X-ray on the way.”) Work those students, work them, work them. If they figure out one thing, then throw them another curve ball.

Allergic reaction resolves. If at any point, the student gives epinephrine 10 μg (1 cc of a dilute mixture; in reality, water in a syringe that has the bar code for “epinephrine, 10 μg/cc), everything goes back to normal.

Everything proceeds on automatic pilot. Of course you, as simulator runner, have to do a lot more work than just press the button and stand back. You have to deck out the operating room to make it look real, act the part of the surgeon, for example, or the circulator. Keep up the normal OR chatter, and overall try your best to “make the whole thing as real as possible.”

But as far as actual computer work goes, you can press the button and stand back and let the little morality play unfold.

What Might the Residents Do?

• They might tumble to the allergic reaction right away, give the appropriate dose of epinephrine right away, and then everything resolves right away. That is a real bummer, because they’ve “short-circuited” all the fun, and now you’re back to ground zero.

• They might flounder around for a while, giving fluids, phenylephrine, or ephedrine. (To “give fluid,” they have to tell you they did so, and you then have to enter “fluid given” with the amount in the computer. So in that respect, the scenario is not completely a “hands-off-after-you-push-the-start-button” affair.) When they give fluid, the computer responds by increasing the blood pressure for a while, as it is programmed to increase the blood pressure after phenylephrine or ephedrine. The computer recognition system always responds to a drug given so long as the computer sees the bar code correctly and so long as the drug is in the computer’s “library” of drugs. But complete resolution of the problem does not occur until epinephrine is given.

• The residents might over-react and give a code dose of epinephrine (1 mg). The computer then responds with a huge overshoot of blood pressure, severe tachycardia, and ectopy.

No matter how you slice it or dice it, the scenario always misses reality in certain ways.

No skin change occurs, so you don’t see the red, flushed face you might expect with a bad allergic reaction.

Is 10 μg always the exact amount of epinephrine that miraculously and definitively “cures” the allergic reaction? Of course not. An allergic reaction may require several drugs (diphenhydramine, steroids, vasoactive infusions). But the computer has to have some “key element” to recognize to restore the vital signs to normal. This is where the binary nature of computers collides with the multiply complex, fuzzy nature of medical reality.

METI SIMULATOR, IMPROVISED SCENARIO, BLEEDING

Give the students chart work that sets the stage for a big bleed, say a gunshot wound to the abdomen.

Instead of pressing the “start scenario” button, like you did on the allergic reaction scenario, you “ride the keys” on this one.

The residents go into the room and relieve the persons in charge of a case. The patient has already been intubated and is on the ventilator.

You go on the computer to the “Fluids” tab.

You press the “blood loss” button and enter “1000 cc” to be lost over 1 minute.

Over the next minute, the computer “reacts” to this blood loss with a decrease in blood pressure and an increase in heart rate.

You watch the residents like a hawk to see if they notice the drop in blood pressure and react appropriately.

If they do the right thing (turn down anesthetic vapors, ask the surgeons if they’re losing blood, send a sample for blood gas analysis, call for blood from the blood bank and give it), then you go to the “Fluids” tab and enter “1000 cc blood infused.”

The computer responds by restoring the blood pressure and lowering the heart rate, just as a patient (ideally) would respond.

So things aren’t quite on “automatic pilot.” You yourself introduced the bleed and entered the transfusion. But the METI computer did do a lot by itself—it “responded” to the blood loss and to the blood transfusion.

The drug recognition system continues to work throughout the scenario, without you having to do anything. For example, the residents may “buy time” with phenylephrine or calcium before they “hang the blood”—as sometimes happens in real life.

Can you program in a bleed? Yes! You could set up a preprogrammed scenario, just like the first one.

Bleed starts (automatically bleed 500 cc over 2 minutes)

Bleed worsens (automatically bleed 500 more cc over 2 minutes)

Bleed corrects (all goes back to normal if they transfuse 1000 cc)

METI SIMULATOR, CANNED SCENARIO—BLEEDING—WITH COMPLICATING FACTORS

You can insert an array of variables into your METI mannequin to complicate things. Say you did the simple bleed scenario as described above, but now you make the patient a little sicker.

Decrease LV contractility.

Increase pulmonary resistance

Decrease the ischemic threshold (making ischemia more likely to appear)

All of these maneuvers have now made the patient that much “sicker,” so he is harder to ventilate, harder to resuscitate, and more likely to develop ST changes indicative of ischemia. Now, you can go through the same bleeding scenario but get in more trouble earlier.

Inspiratory pressures are now higher, which can distract the resident.

With that bleed and lower LV contractility, the blood pressure falls faster and farther.

With that decreased ischemic threshold, the resident has problems with ischemia in addition to problems with hypotension.

What about the less technically adept but more affordable Laerdal?

LAERDAL SIMULATOR, CANNED SCENARIO—VENTRICULAR FIBRILLATION

You call students into a code.

You have set the cardiac rhythm directly for ventricular fibrillation. You have a programmed response: After three shocks the rhythm returns to sinus tachycardia. (The mannequin senses the shocks when the paddles are placed on the metal tabs on its chest.)

FIGURE 3-11 Aah. Toasting another successful scenario. Instructor and simulator technician Shekhter raise a glass of bubbly after putting the residents through their paces one more time. Teaching in the Simulator is a blast. The residents generally like the experience, and you are limited only by your imagination. You can put different spins on the scenarios depending on resident level, resident interest, and, best of all, depending on your own whims and caprice!

What Do the Students Do?

• They may spoil all the fun by getting it right the first time, remembering that you shock, shock, shock first. Then everything gets back to normal, and you wonder what you’ll do for lunch.

• They may forget the prime dictum of fibrillation (shock first) and go with intubation, a round of drugs, and chest compressions. The computer continues to spit out ventricular fibrillation until it sees the three shocks.

• They may just shock once or twice (a common mistake).

LAERDAL SIMULATOR, ON-THE-FLY SCENARIO—RIGHT MAINSTEM INTUBATION

You call in the residents to relieve on a case. Tricky you, you have placed the endotracheal tube in the right mainstem. The Laerdal has no way of “knowing this” and so to decrease the saturation, you must program that information in, which you do directly. In the saturation area on the screen, you enter 91%.

What Do the Residents Do?

• Turn up the FIO₂ to 100%, hand-ventilate, listen to the chest, and pull the endotracheal tube back. At that point you go to the screen, and in the saturation area you enter 100%. Good residents, good, good. Here, have a treat! (Throw them a doggie biscuit.)

• Flounder around, forget to listen to the chest, stand there like morons. Bad residents, bad, bad. No treat for you! (Beat them senseless, depending on how strict your department policies are.)

Wait a minute, how would I do that exact same thing with a METI simulator? Aha! Here is where you will see the real difference between these two puppies.

METI SIMULATOR, ON-THE-FLY—RIGHT MAINSTEM INTUBATION

You call in the residents to relieve on a case. Tricky you, you have placed the endotracheal tube in the right mainstem. The METI has no way of “knowing this” and so to decrease the saturation, you must program that in, which you do, but you can’t do it directly, and this is the headache. This is the big, big, big difference. You have to increase the shunt fraction or increase the O₂ consumption (or both, if you want to). What a pain in the ass! Instead of just punching in “Saturation 92%,” you have to “program the physiology to create the number.” No surprise, then, that when you do this on the fly you can easily overshoot or undershoot. All this “programming in the physiology” is great when you generate a programmed scenario well ahead of time. But when you’re sitting there and just want the damned sat to go to 92% right now, the METI can be maddening.

FIGURE 3-12 But all is not hearts and roses in the control room. Honest and caring professionals can, in the course of a scenario, arrive at substantive and meaningful differences. Although we encourage discussion and dialogue to iron out these same differences, at times our baser instincts emerge and instructors do settle things the old-fashioned way.

What Do the Residents Do?

• Turn up the FIO₂ to 100%, hand-ventilate, listen to the chest, and pull the endotracheal tube back. At that point, you go to the screen and want like crazy to just punch in 100% in the saturation area, but, alas, no. You have to “program the physiology, get rid of the shunt fraction, get rid of the excess oxygen consumption, and the saturation will then work its way back up to 100%. Fortunately, going “back to normal” is pretty easy, as you can just set everything back to normal and up you go.

• Flounder around, forget to listen to the chest, stand there like morons. Bad residents, bad, bad. No treat for you! (Beat them senseless, depending on how strict your department policies are.) So you see, when things go bad, you still get to have fun, no matter which system you are using.

To further illustrate the way the METI and the Laerdal models work, I draw on scenarios right from this book. Chapter 8 has 50 scenarios, each about four pages long. Each scenario is meant to focus on one or two main teaching points. Here I go through the first 20 scenarios and include all the “computer commands” for the simulators. Some scenarios use the METI, some the Laerdal, so you’ll be able to see each in action. You will notice a few things.

1. Some scenarios have no computer commands. All the action comes from the standardized patient, an actor with a scripted role to play.

2. The actual number of computer commands is often quite small, as most of the learning is interpersonal, ethical, or communication-related. This doesn’t lend itself easily to a computer program.

3. A lot of effort goes into the “around the mannequin” environment—partial task trainers, additional props, telling the surgeon to make the patient move. The mannequin is there and is important, but it’s not “all about the mannequin.”

4. Anyone reading these scenarios could put in a hundred more computer commands. You can always throw in more variables, more branching points, more outcomes. You can solve one problem (resolve the allergic reaction, for example) and then generate another (perhaps asthma exacerbation).

5. What is most important? The teacher, the one making it happen. The one reading the residents/students and tailoring the lesson to make sure that someone learns something—the prime directive of any simulation center.

Caution:

This is damned dreary! These are listed just to show you the “technical steps” you go through in a scenario. In Chapter 8 these will all come to life, so keep the faith!

SCENARIO 1.

A provocative patient acts inappropriately.

Examining room setting

No computer commands

Examining room with standard props: chart, blood pressure machine, stethoscope

Video recording equipment (as in all the scenarios, so you can review in the debriefing room)

Provocative patient, scripted to make inappropriate remarks

SCENARIO 3.

A pregnant patient is given intravascular local anesthetic through the epidural.

Laerdal mannequin with wig and pregnant belly; up in stirrups.

Epidural taped to back with epidural infusion pump.

Obstetrician with forceps.

Fetal heart rate monitor simulator (Metron makes one).

To set the FHR to 40, program it into the Metron FHR simulator.

To crash the patient, turn the Saturation monitor off.

SCENARIO 4.

Hypoxemia and myocardial ischemia in the OR.

METI mannequin in OR setting.

To set the blood pressure to 85/50, lower the SVR.

To set the HR to 130, increase the HR factor.

To get ST elevation, go to Cardiac rhythm override and enter mild ischemia.

To worsen ST elevation, go to Cardiac rhythm override and enter moderate ischemia.

SCENARIO 5.

Narcotic overdose and bradypnea.

METI simulator in a PACU setting.

Have PACU equipment (suction, oxygen).

Blood gas slip.

Normal CXR in view box.

To slow respiratory rate, enter medications given, give morphine.

To slow respiratory rate more, go to Respiratory gain factor and decrease.

Later, to increase respiratory rate, go to Respiratory gain factor and increase.

SCENARIO 6.

Inducing an aortic stenosis patient in the heart room.

METI simulator with infiltrated IV arm.

Cardiac OR (bypass machine in room, transducers, infusion pumps).

To increase the blood pressure, increase the SVR factor.

To increase the heart rate, go to Rhythm override and enter sinus tachycardia.

To cause ST depression, go to Rhythm override and enter mild ischemia; then to reverse that, go to Rhythym override and enter sinus rhythm.

SCENARIO 7.

IV phobia in a patient with placenta previa.

No computer commands.

Examining room with pregnant (or pretend-pregnant) standardized patient.

BP machine, examination room equipment.

Patient scripted to be very skittish and difficult.

SCENARIO 8.

No IV access in a bleeding patient with placenta previa.

Laerdal mannequin in an OR setting.

All vital signs you set directly: HR 130, later 140; BP 90/60, later 80/50.

FHR simulator: set for late decelerations.

Saturation, set directly for 80s, later 70s.

Cover baby with chocolate pudding (keep rest of pudding in fridge for after debriefing).

Set saturation up to 90% when LMA is placed.

SCENARIO 9.

Mediastinal mass.

METI mannequin in OR setting.

Bronchoscope, rigid.

To create high inspiratory pressures, set bronchial resistance high.

SCENARIO 10.

Triage after a disaster.

Laerdal mannequins, two.

First mannequin: all vital signs at 0.

Second mannequin: set saturation directly to 85% and HR directly to 140.

To make intubation difficult, activate swelling in the upper airway (press on X’s on a diagram in the upper airway, which inflates small air bladders).

Increase saturation once the cricothyrotomy is performed.

SCENARIO 11.

Stat C-section.

METI mannequin, pregnant.

To get BP to 80/50, decrease the SVR and LV contractility.

Set FHR to go to 60, then 50.

Mix up trauma vomit kit setup and have it in patient’s mouth (try not to gag yourself).

Turn the BP off.

SCENARIO 12.

Agitation in an ophthalmic case.

METI simulator.

Some kind of surgical microscope for the ophthalmologist.

A boom box playing Figaro from the opera Carmen.

To get the saturation to 50%, set the shunt fraction and O₂ consumption very high.

Instruct the ophthalmologist how to wiggle the patient to imitate patient movement.

To get ectopy, go to Rhythm override and put in 25% PVCs.

To get V-tach, go to Rhythm override and enter V tach.

SCENARIO 13.

Unstable atrial fibrillation.

Laerdal mannequin.

Set rhythm, atrial fibrillation.

Set initial blood pressure at 140/85.

Set next blood pressure at 75/40

Program so that at cardioversion ×2, the rhythm converts and blood pressure goes to 140/80.

SCENARIO 14.

Isolating a lung in a difficult airway.

Laerdal mannequin.

Fiberoptic tower (scope and attached camera and television, so all can see).

Univent endotracheal tube.

Saturation initially set at 100%; later set it at 75%.

SCENARIO 15.

METI mannequin.

Three blind mice and a farmer’s wife armed with a knife … Not really, I’m just seeing if you’re paying any attention. As you can see by now, a dull recitation of the computer stroke entries in a simulation scenario is as dry as being force-fed Zweiback toast. The magic is in the “entire thing playing out,” as you will see in Chapter 8. Furthermore, telling you how to work the computer converts this book into a computer manual. And no one reads computer manuals. You learn to work the computer by, well, working the computer. And so also you will learn to work the Laerdal and the METI by, well, working the Laerdal and the METI. Five minutes sitting in front of that screen and banging around will outdo five hours of reading about it. For completeness’ sake, I’ll grind all the way through the 20th scenario. Just keep in mind that this section is presented only to give you the feel of the “computer work and setup” behind the scenarios.

To drop the heart rate from 70 down to the 30s, go to Rhythm override and enter sinus bradycardia.

To make the chest rigid, go to Chest and lung compliance and decrease both.

To code the patient, go to Rhythm override and go to V tach, then V fib, then asystole.

SCENARIO 16.

Rigid bronchoscopy.

Laerdal mannequin.

Rigid bronchoscope.

To make the saturation drop, directly enter a saturation of 95, then 75, then go back up.

SCENARIO 17.

METI mannequin.

CXR showing fluid in the chest.

To increase inspiratory pressures, go to Lung compliance and decrease.

To drop the saturation, go to Shunt and O₂ consumption and decrease both.

SCENARIO 18.

Epidural hematoma.

No computer stuff.

Standardized patient coached to play out sensory and motor loss.

SCENARIO 19.

Running two rooms with problems in each.

Laerdal mannequin in one room, METI in another.

No computer work for the Laerdal.

In the METI room, drop O₂ saturation by increasing shunt and increasing oxygen consumption. Later, reverse these settings.

SCENARIO 20.

Muscular dystrophy and the need for a pacer.

METI mannequin.

To get third degree heart block, go to Rhythm override and enter (guess what?) third degree heart block.

To drop blood pressure to 70/40, decrease SVR and LV contractility.

So there it is, putting a little meat on the bones of the equipment, showing you how you actually work it. This is, as mentioned earlier, just a brush stroke on the actual workings of the Laerdal and METI. Each one has tons of options and programming capabilities (for you to insert your own scenarios). You could—for that matter, should—sit down with a company representative with the actual thing in your hands to understand better the tabs, folders, buttons, and gizmos.

My personal experience? I got in-serviced on the METI along with about another dozen faculty members. As time passed, most others “fell away”; and one other soul (Albert Varon, our education director at the University of Miami) and I became the “involuntary volunteers” in the simulator.

We found that no matter how much in-servicing you get, you don’t really know what to do until you throw yourself into it and start “doing simulation” with residents. (My personal thanks to the first residents who had to put up with some serious floundering.)

After a while, we got comfortable enough to do simple things, then branched out. Later, our department got a Laerdal, an entire floor of a building as a Safety Center, and the most important element— a technician who actually knew what he was doing! (Ilya Shekhter, who provided all the technical help on this and other chapters.) Now, when we do simulations, Ilya does the technical programming, and I do the “in-the-room-medical-stuff.” To my mind, that is the best setup—a technician who knows the stuff inside and out (and, frankly, much better than I do)—and a medical instructor who knows the lesson to be learned.

Technician, plus equipment, plus teacher—that is the magic brew.

What if you can’t afford a technician? Can you yourself (say, an anesthesia faculty member with an interest in teaching in the Simulator) do it all by yourself? Yes. It’s tough though. Things go much better with a dedicated technician to help out.

Now, HAL, I’m done here, open the hatch please. HAL?

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