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E-letters: Electronic letters published:
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Need of further investigation in simulation
- York A. Zausig et al. (29 February 2008)
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Expansion of standard operating procedures
- York A. Zausig et al. (22 January 2008)
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Are Simulators an effective tool for teaching and training?
- Dr. Oswald D'Mello; DA, FRCA (20 November 2007)
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Universal Patient-Protection Algorithm
- John George George Cherian, Need for Universal Patient-Protection Algorithm against Deliterious Effects of Hyper-Pressured ETT cuffs (6 November 2007)
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York A. Zausig et al., Department of Anaesthesiology, Emergency and Intensive Care Medicine University of Goettingen, Germany
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Re: Are Simulators an effective tool for teaching and training? Sir, Dr. D’Mello has underlined the important role of simulation in aviation and medicine. The diversity of this teaching tool in simulating a “realistic” world with a “low to high fidelity” has offered a new dimension of safe learning and training of technical and non-technical skills.[1 2] In general, trainees in anaesthesia evaluate the simulated world as very realistic.[3 4] Additionally, training of technical skills and especially of non technical skills are rated very educational and useful[2 5], and participants even show an increase in self-reported non technical skills, e.g. crisis resource management (CRM) behaviours.[3] Due to this favourable rating by the participants, simulator training has become very popular and successful in the last years. Unfortunately, as Dr. D’Mello mentioned “cost effectiveness of simulator-training is still pending”. Furthermore, most of these reported and measured improvements after simulator training are only based on a subjective impression/perception. In general, an absolute objective proof of the effectiveness of simulator training improving of technical or non technical performance in simulated and clinical critical incidents is still missing. Moreover, some studies even showed a failure of simulation training in improving performance.[6] Superiority of simulation for teaching or training compared to other established traditional (simple) teaching tools is also absent. But these facts should not disappoint the trainers and the participants and they should not question the application or the effect of simulation in general. Simulation has demonstrated to be a qualified, valide and reliable assessment tool to describe technical [1 4 7] and non-technical performance.[3] But, where simulation fails to show an improvement of participants’ behaviour, one could question if the applied training and of course its evaluation were adequate? Forrest et al. (2002) showed using a high-fidelity simulator increases novice anaesthetists technical performance of rapid sequence induction.[1] And Yee et al. (2005) showed after even a single exposure to CRM-session an improvement of anaesthesia residents in non-technical skills.[2] Both studies failed to show an additional improvement when training was continued. So should the content of simulator training be more adapted to the increased and modified requirements of already well trained participants? Yes of course, since novice and expert anaesthetists have different knowledge and experience, their needs of training is also unequal. And so it is not surprising, that non-technical and technical performance do correlate with clinical experience of participants. [1 4] Additionally, it has to be kept in mind that trained novice participants are certainly becoming more expert in the field of training. But if the training is adapted to the need of the participants, then of course statistical methods for evaluation of improved participants’ behaviour also have to be adjusted for an accurate presentation of the improved skills. For planning further investigations on effectiveness of simulation training it is necessary to accurately define the participants’ needs of training and the goals of the training in advance. Here, studies presenting their limitations and their proposals for accurate inclusion criteria for studying participants’ performance provide valuable assistance by designing a study.[1-3 6] Clearly proved evidence of the benefit of simulation in medical training will help to increase the funding of simulation. With more financial support, more anaesthesiologists will be frequently more trained to be prepared to quickly diagnose and treat critical life- threatening incidents, and so to increase safety, as it is common today in aviation. References 1. Forrest FC, Taylor MA, Postlethwaite K, Aspinall R. Use of a high- fidelity simulator to develop testing of the technical performance of novice anaesthetists. Br J Anaesth 2002; 88 :338-44. 2. Yee B, Naik VN, Joo HS, Savoldelli GL, Chung DY, Houston PL, et al. Nontechnical skills in anesthesia crisis management with repeated exposure to simulation-based education. Anesthesiology 2005; 103:241-8. 3. Blum RH, Raemer DB, Carroll JS, Sunder N, Felstein DM, Cooper JB. Crisis resource management training for an anaesthesia faculty: a new approach to continuing education. Med Educ 2004; 38 :45-55. 4. Devitt JH, Kurrek MM, Cohen MM, Cleave Hogg D. The validity of performance assessments using simulation. Anesthesiology 2001; 95:36-42. 5. Berkenstadt H, Kantor GS, Yusim Y, Gafni N, Perel A, Ezri T, et al. The feasibility of sharing simulation-based evaluation scenarios in anesthesiology. Anesth Analg 2005; 101 :1068-74. 6. Olympio MA, Whelan R, Ford RP, Saunders IC. Failure of simulation training to change residents' management of oesophageal intubation. Br J Anaesth 2003; 91:312-8. 7. Zausig YA, Bayer Y, Hacke N, Sinner B, Zink W, Grube C, et al. Simulation as an additional tool for investigating the performance of standard operating procedures in anaesthesia. Br J Anaesth 2007; 99: 673- 678. Conflict of Interest:None declared |
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York A. Zausig et al., Department of Anaesthesiology, Emergency and Intensive Care Medicine University of Goettingen, Germany
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Re: Universal Patient-Protection Algorithm Sir, I really support this very important issue raised by the author. It is in the responsibility of every physician to prevent any harm from the patients while treating them. The implementation of algorithms into medical practice has been very successful in the past, and standard operating procedures have shown to be reliable and helpful tools. Additionally, following these procedures, for example in basic or advance life support or in airway management, has led to a reduced morbidity and mortality.[1,2] The precautions to prevent aspiration during the rapid sequence induction described and evaluated in our study present a proper basis to formulate a safe and successful standard operation procedure in anaesthesia. For sure, an expansion with other precautions like, the measurement and documentation of intra-cuff pressures of endotracheal tubes is desirable. This might reduce the incidence of tracheal trauma in tracheal intubated patients in the future. 1.Nolan JP, Deakin CD, Soar J, Böttiger BW, Smith G; European Resuscitation Council. European Resuscitation Council guidelines for resuscitation 2005. Adult advanced life support. Resuscitation. 2005 ; 67: S39-86 2.Heidegger T, Gerig HJ, Henderson JJ.Strategies and algorithms for management of the difficult airway. Best Pract Res Clin Anaesthesiol. 2005; 19: 661-74 Anaesthesiol. 2005; 19: 661-74 Conflict of Interest:None declared |
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Dr. Oswald D'Mello; DA, FRCA West Suffolk Hospital, Bury St. Edmunds
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Sir, I read with interest the paper by Y.A Zausig and colleagues (1) and wish to comment on this as well as share my personal views. . Since antiquity, simulation have been used in healthcare, representations in clay and stone were used to demonstrate clinical features of disease states and their effects on humans. Models have been found from many cultures and continents. Currently, simulators are being used extensively throughout the world, in the field of aviation. Since I am a trainee pilot myself, I have found the usefulness of simulators in mimicking hazardous situations and performing dangerous maneuvers. Simulators tend to prevent accidents by their ability to train pilots to a higher level of competence than is possible in actual airplane training(2,3). That is because many maneuvers can be performed in simulators that are just too dangerous in airplanes and they can be repeated multiple times until the pilot is honed to a very sharp edge. Similar to the aviation environment, anesthesia practice in the operating room involves multiple tasks requiring a high degree of vigilance, procedural, monitoring and decision-making skills in a dynamic, complex environment which is affected by the simultaneous interactions of the different members of the operative team. As in aviation, critical life- threatening incidents are rare, but when they do occur, they have potentially disastrous consequences unless the anesthetist is able to quickly diagnose and correct the problem. Simulation technology provides a potential way of learning and practicing all the skills involved in anesthesia, including crisis management without harm to a real patient(4) Types of medical simulators available- P (One P) Simulation (Low fidelity): A “One P” simulator includes anatomical models such as the ”Ressuci” dolls which are used for training in cardio pulmonary resuscitation. These mannequins can be passive, active, or interactive based on the level of training. Simple mouth to mouth breathing and chest compression is taught on a passive simulator (P1 p) . More advanced models may simulate wounds, or the result of wounds such as a pneumothorax. If the wound simulated bleeding, or air movement, then it would be a (P1a) simulator. PP (Two P) Simulator (Intermediate fidelity): Advanced CPR with cardiac life support is taught on a mannequin combined with a computer program which simulates the electrocardiogram. In this case, both the patient and the diagnostic test are being simulated. This is a (P1 a P2a) simulator. If the electrocardiographic portion of the simulator has been programmed to respond to the administration of medications, or electrocardioversion, then this would be a (P1 a P2 i ) simulator. PPP (Three P) Simulator (High fidelity): usually includes a mannequin and software which simulates the patient interactively. e.g. Leiden Anaesthesia stimulator PPPP ( Four P) Expert systems: Although the need for Four P simulators is rare. The analysis shows that such a machine would be an expert system, with all elements of the clinical interaction represented. From a theoretical point of view, this machine could be used to study the economic and cost-benefit aspects of the health care process(5). Currently simulators are being used for both teaching and training and their popularity is increasing. 1. They can simulate real life threatening scenarios such as anaphylaxis, failed intubation / failed ventilation as well as rare scenarios such as malignant hyperpyrexia 2. there is no risk to real patients 3. repeated assessments are possible 4. video taping for review and discussion 5. with reduction in working hours for trainee doctors, simulators can play a valuable role in both training and assessment of trainees Cost effectiveness of simulators- Definitive studies evaluating the cost effectiveness are still pending. Despite the enthusiasm and high ratings given by the participants to such training programs and the intuitive usefulness of training with a full scale simulator, the efficacy of such training compared to traditional methods of teaching is difficult to prove. The simulated setting will never fully recreate real life and the unpredictability in which real patients may respond to various interventions. Whether training on a full scale simulator makes a significant difference in patient outcome is even more difficult to ascertain. Because of its substantial cost, full scale simulators also have to answer to the question of their cost effectiveness, as compared to traditional methods of teaching in anesthesia. However Chopra et al(6) found that with the use of simulator training,there was indeed an increase in the performance by anaesthetists dealing with emergency situations and helped in better adherence to guidelines. Simulators have even been introduced into the Objective structured clinical examination scenarios for the primary FRCA In conclusion from my own personal experience with high fidelity simulators, I believe they do improve both competence and confidence with dealing with emengency situations and could indeed be used as an assessment tool of competency references: 1. Simulation as an additional tool for investigating the performance of standard operating procedures in anaesthesia Y.A. Zausig, Y. Bayer, N. Hacke, B. Sinner, W. Zink, C. Grube, and B. M. Graf Br. J. Anaesth. 2007 99: 673-678 2.What impact does the use of flight simulators have on commercial aviation? Robert J. Boser Editor-in-Chief; Airline Safety.Com 3.Use of advanced simulator technology in aviation education. S. Thatcher; International Journal of modeling and simulation 4. Full scale computer simulators in anesthesia training and evaluation, A. Wong; Canadian Journal of Anesthesia 51:455-464 (2004) 5. A Typology of Simulators for Medical Education, G.Meller Journal of Digital Imaging, August 1997 6. Chopra V, Gesink BJ, de Jong J, Bovill JG, Spierdijk J, Brand R. Does training on an anaesthesia simulator lead to improvement in performance? Br J Anaesth 1994; 73: 293–300 Conflict of Interest:None declared |
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John George George Cherian Fellow - Malaysian Institute of Medical Laboratory Sciences, Need for Universal Patient-Protection Algorithm against Deliterious Effects of Hyper-Pressured ETT cuffs
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Y. A. Zausig and colleagues' suggestion of the SIM and QUES instruments as adjuncts to advance safety during anaesthesia is commendable. One threat to safety during anaesthesia is post-intubation tracheal stenosis caused by regional ischaemic necrosis of the airway. This clinical condition is often progressive and can take up to 3 weeks to manifest - commonly misdiagnosed for asthma. Tracheal stenosis remains the most common indication for tracheal resection and reconstruction. Prognosis following these surgical procedures which yield a failure rate of 3.9% and a mortality rate of 2.4% has been reported at the Harvard Medical School [Postintubation tracheal Stenosis.Wain JC.Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA] A universal algorithm against such deliterious trauma should be instituted in the wider interest of patient safety . Each anesthesia and ICU setting must document intra-cuff pressures of endotraceal tubes against the brands used as regularly as possible and intubated tracheas examined endoscopically following extubation . When lesions are spotted they should be recorded, notified and treated appropriately. Ultimately, to offer patients their rightful widest level of protection,the provision of more information to the patient including the possible misadventures of tracheal stenosis is necessary as a benchmark for care prior to Anesthesia and ICU intubation John George Fellow - Malaysian Institute of Medical Laboratory Sciences 4 Lrg 4/48 F, 46050 , PJ, Selangor , Malaysia Conflict of Interest:None declared |
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