53 Simulation in Pediatric Anesthesia
THE FIELD OF PEDIATRIC anesthesia has become increasingly subspecialized, with unique challenges that demand high-quality teaching and training. Pediatric anesthesia is a subspecialty that has become increasingly refined and technically advanced, with the advancement of complex surgical techniques and patients with a low tolerance for error.1 Radiologic progress and interventions have revolutionized the field to include caring for children in remote sites outside of the operating theaters. In many countries, tertiary pediatric services are becoming increasingly centralized, whereas medical working hours have been reduced, leading to a situation where there is a decline in exposure to difficult pediatric cases and emergencies for those who are not pediatric specialists. There is an inverse correlation between the level of specialization and perioperative morbidity and mortality associated with pediatric anesthesia.2 Furthermore, a significant proportion of pediatric surgical procedures will continue to be performed outside tertiary centers, at community hospitals or outpatient surgical centers where the volume-to-outcome relationship may not be favorable.3 The growth and increased sophistication of pediatric anesthesia, as well as the regionalization of specialty care, has profound implications for the ability to train anesthesiologists in the safe and effective delivery of routine and emergency pediatric anesthesia. Early portions of a trainee’s learning curve are inconsistent with the demands of safe and efficient patient care, thereby posing challenges for the medical education infrastructure. Advancements in simulation education techniques and technology have led to a new paradigm in training and assessment. These advances provide opportunities to improve diagnostic and decision-making skills for common as well as rare events.
Current medical training emphasizes basic science knowledge and leaves most of the clinical practice to an apprenticeship model. The focus has been on individual knowledge and skills rather than on performance or clinical team dynamics. Once a clinician has completed training, the required level of continued education declines, both in structure and formality. Within the past decade, there has been rapid progress in simulation in health care training for purposes of improving patient safety and quality of care. Interest in simulation in health care derived from the historical utility of simulation for training purposes in nonmedical industries, such as commercial aviation, nuclear power production, and the military.4 Similar to health care, these industries are known to be associated with hazards and complexities that benefit from simulation training. Many of the concepts in health care simulators, including systematic training, rehearsal, performance assessment, situational awareness, and team interactions, have been adopted from aviation flight simulators. Given that crises in pediatric anesthesia are rare, difficult to predict, and that trainees are expected to be able to successfully manage these situations, simulation technology can fill important gaps in many curricula. In this chapter, we review how simulation is applied in pediatric anesthesiology by describing its use for learning and practicing basic and advanced skills, and by defining key types of technologies and teaching approaches with illustrative videos.
In 1987, Gaba and colleagues identified gaps in decision making and crisis management in anesthesia training. They noted that diagnostic decisions tended to be relatively static.5–7 However, in the complex, rapidly changing, time-pressured environment of the operating room (OR), anesthesiologists are challenged beyond static decision making, especially when identifying and resolving crises and leading interdisciplinary teams. As a result, the term anesthesia crisis resource management (ACRM), modeled after the Crew Resource Management of commercial aviation,5–7 was developed. These investigators established a framework and curriculum to teach individual and team leadership skills, along with effective communication styles. ACRM provided anesthesia trainees with tools that were similar to those that made the complex dynamic world of aviation safer in the areas of decision making and crisis resource management. These skills were not systematically taught during anesthesia residency training.
ACRM was an outgrowth of the patient safety movement that began in anesthesia in the early 1980s in America. In the late 1980s, research grant funding from the Anesthesia Patient Safety Foundation (APSF) supported the early development of several forms of human patient simulators (HPS). Further publicity and advocacy from APSF propelled anesthesiology to the forefront of specialties in the application and adoption of simulators, with strong patient safety implications through education (residents attempting new skills for the first time on a manikin), training (teamwork, critical event management, and situational awareness), and research (human performance).8 Today, simulation in anesthesiology is global, with emphasis not only on medical knowledge and skills training, but also on ACRM, disaster training, debriefing, and patient safety. The American Board of Anesthesiology now requires at least one simulation-based course to satisfy its Maintenance of Certification in Anesthesia requirement.9 In some institutions, such training is required as a condition of credentialing for practice and insurance coverage.
Simulation is a technique to replace or amplify real experiences with guided experiences that evoke or replicate aspects of the real world. Simulation is enabled by a diverse set of emergent technologies.4 The application of simulation in the health care field is focused on education and training of clinicians. Education emphasizes knowledge, skills, and introduction to the actual work. Training emphasizes the actual tasks and work to be performed.4 The term “simulator” is used in the health care field to refer to a device that represents a simulated patient, and interacts appropriately in response to the actions of the simulation participant. In aviation, pilots are seated in the cockpit of a flight simulator whereas in health care, clinicians are in a simulated OR, emergency ward, or patient floor in simulated clinical scenarios, caring for a simulated “patient” experiencing a critical or otherwise challenging event.
Participants in a simulation are “immersed” into a task or setting to the extent necessary to achieve the learning objectives. This may be conducted in a normal classroom or in an environment that extensively replicates the real world. In the latter case, participants are asked to “suspend disbelief” and to interact and speak as they would do in their everyday jobs.4 Most importantly, it is incumbent on those who create and implement the simulation to create sufficient realism to enable the learner to feel the reality of the situation and respond accordingly. Thus the participant agrees to accept the “fiction contract” with their instructors.10,11
Participants in a simulation scenario experience realism in three distinct domains: physical, conceptual, and emotional.10 Simulations that address all three domains are more likely to instill the intended learning objectives. A high degree of realism appropriate for the specific learning objectives is central to ensure that the learners become mentally and physically engaged. The physical properties of the simulator (the patient) and the clinical environment (the simulation room, center, or OR), such as weight, flexibility, tensile strength, and color, are important for developing kinesthetic awareness and muscle memory. For example, the weight of the head and force required to effectively perform laryngoscopy are important for teaching tracheal intubation, whereas the rubbery feel of the manikin skin is not. Conceptual realism refers to the causal relationships observed in the scenario, such as a decrease in oxygen saturation during a period of apnea or the resolution of hypotension after an appropriate intravenous fluid bolus. High conceptual reality enhances clinical reasoning and decision making. Finally, emotional and experiential fidelity is achieved when participants experience familiar and authentic feelings, such as “emotional activation,” anxiety, stress, fear, or excitement. Ultimately, realism in simulation is perceived as “an exciting simulation that captures the imagination, triggering physiological responses and execution of ingrained clinical algorithms.”10 Although realism is important, investigators emphasize that, “when learning is the focus, the flawless recreation of the real world is less important.” It is necessary to find circumstances that help participants learn, rather than circumstances that exactly mimic a clinical situation.11 The degree of realism desired for a successful simulation education program is an amount sufficient to achieve the intended learning outcomes.
Partial task trainers are manikins or models (e.g., suturing board, IV arm, airway head, etc.) designed to allow participants to practice clinical skills and tasks (Fig. 53-1). They should be reliable, robust, and medically meaningful. Usually they represent a portion of a person rather than the whole. Although many are simple devices designed for learning or practicing a specific procedure (e.g., suturing, IV insertion, laryngoscopy, or intraosseous access), some are coupled with computers, robotic interphases, and digital graphics to provide sophisticated partial task simulators designed for learning or practicing more involved procedures (e.g., bronchoscopy and endoscopy, endovascular catheterization, or laparoscopic skills). These models are particularly useful for teaching invasive, risky, and rare procedures (e.g., emergency cricothyrotomy, transvenous pacing, or pericardiocentesis), complex psychomotor skills requiring repetitive training (e.g., ultrasound guided central venous catheterization or awake fiberoptic intubation), or those that are safe, but create increased anxiety for either the learner or the patient and their family (e.g., urethral catheterization, IV insertion, or arterial puncture), where coaching and deliberate practice can be done in a simulated environment.12 Curricula that use these types of training devices focus on skills training at varying levels of skill goals, rather than a particular situation. For example, cricothyrotomy training on a partial task simulator aims to teach the procedure, regardless of the indication (e.g., angioedema, burns, obstructing mass, or hemorrhage). Specific partial task trainers for simulating aspects of children include products to learn or practice lumbar puncture, peripheral IV insertion, intraosseous needle insertion, laryngoscopy and intubation, umbilical vein and artery catheterization, and cardiopulmonary resuscitation (Video 53-1).
FIGURE 53-1 Examples of partial task trainers to practice (A) intubation in neonates (Laerdal SimNewB [Laerdal Medical, Stavanger, Norway]), (B) peripheral intravenous placement (Nita Newborn Model #1800 Infant Venous Access Simulator [VATA, Canby, Ore.]), and (C) central neuraxial techniques (M43C Pediatric LP Simulator [Kyoto Kagaku, Kyoto, Japan]).
An HPS is a representation of the human body constructed on a manikin, typically made of plastic and metal, without a bony skeletal frame. Although popularized in the 1990s, the first manikin-based simulator (SimOne) was developed at University of Southern California in the 1960s and was intended to facilitate medical education and training.13 Adult HPSs became commercially available in the early 1990s; the first high-fidelity pediatric simulator was introduced in 1999. The METI PediaSIM (Medical Education Technologies, Inc., Sarasota, Fla.) represented a child between 5 and 7 years of age. Two models of integrated infant HPS became available in 2005: the METI BabySIM and the Laerdal SimBaby (Laerdal Medical, Stavanger, Norway) (Fig. 53-2). Both models exhibited standard vital signs and variable airway features (e.g., tongue swelling and laryngospasm), breathing patterns and sounds (e.g., retractions to illustrate upper airway obstruction, breath sounds [wheezing], and pneumothorax), cardiovascular features (e.g., heart sounds and peripheral pulses [diminished or absent]), and others (e.g., abdominal sounds and distension, and fontanelle bulging). Both infant simulators produce a variety of monitor signals and allow extensive treatment interventions (e.g., intubation, laryngeal mask and nasogastric tube insertion, intravenous and intraosseous cannulation, and thoracocentesis).14 Incorporated into the clinical setting or in a simulation room outfitted with biomedical equipment and teams of health care providers, the HPS can provide a high degree of clinical authenticity and realism to facilitate participants to fully engage in the care of the simulated patient. Typically, participants in simulation scenarios reflect on their performance during the simulation, for the purpose of sustaining and improving their practice with an instructor, in the process termed debriefing15 (see Video 53-1).