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
Laparoscopy
Hollow organ closure
Total hip replacement
Ophthalmic surgery, including laser photocoagulation
Otolaryngology
AAA endovascular repair
Surgical suturing
Shoulder arthroscopy
TURP
Breast biopsy
Hysteroscopy
INTERNAL MEDICINE AND ITS SPECIALTIES
ERCP
Colonoscopy
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?

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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.

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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
You name it

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.

Gas Analyzer

METI—Has one.
Laerdal—Lacks one.
Example: You crank up the halothane (Isoforane, ISF) to 5%.
Real life—Eventual cardiovascular collapse.
METI—Gas analyzer recognizes the ISF, and the pressure eventually comes down.
Laerdal—Unless you program in a response and note that the ISF is high, there is no response.

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FIGURE 3-3 METI simulator—all the bells and whistles. Pricey.

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FIGURE 3-4 METI kid.

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FIGURE 3-5 A. METI baby. B. Coochy coo. C. Dentition optional.

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FIGURE 3-6 Laerdal SIM MAN. Somewhat simpler to work with. Less pricey. Fewer bells and whistles.

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.

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

BOX 3-3 The Two Biggies

METI

• Pricey
• Bells and whistles

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