Medical simulation is an educational technique that replaces the “real world” with guided and interactive experiences. Educational research suggests that adults learn through active participation and engagement, and we believe that simulation promotes adult learning via experiential and emotional learning. Our trainees have the opportunity to practice medical techniques without risks to patient safety. Our educators have the opportunity to provide education “on demand,” standardize the curriculum, and teach concepts efficiently.
We use simulation for training and evaluation of high performance team training, technical skills training and cognitive skills training. Our scenarios include rare perioperative event and focus on crisis resource management principles.
THE ANESTHESIA CENTER FOR EDUCATION RESEARCH AND EVALUATION (ACERE)
We have established an Anesthesia Center for Education, Research and Evaluation (ACERE) in the Department of Anesthesiology at Columbia. ACERE draws on the combined expertise of our medical community to promote the acquisition and assessment of clinical knowledge, skills, and attitudes that are needed for the highest quality and safest patient care. Teaching sessions within ACERE emphasize concepts such as “failure to rescue,” establishing followership, and avoiding fixation errors. Several faculty members have been trained as expert debriefers to enhance the simulation experience.
Simulation is used for both education/training and assessment. The Center will have an OR, PACU/ICU, OSCE rooms and a conference/debriefing room. ACERE consists of 2000 square feet of space, with a patient simulator OR suite and digital A-V capture devices to allow residents and faculty to remotely view and review their training sessions.
Our equipment includes: a virtual bronchoscopy trainer, an ultrasound simulator, a central line task trainer, and a human mannequin simulator.
The new American Board Examination now has an “applied” clinical examination that includes Objective Structured Clinical Examinations (OSCEs), and the Columbia Department of Anesthesiology intends to ensure that our residents are well prepared for all aspects of the examination.
The Residency Experience
The simulation experience in the CBY training is focused on providing basic skills of ultrasonography related to anatomical image acquisition. In order to provide basic skills, the residents will spend a whole day in an ultrasound workshop during the orientation period. The one-day course consists of several lectures covering the different applications of ultrasonography such as echocardiography, abdominal and pleural ultrasound, peripheral nerve blocks under ultrasound guidance and placement of central lines under direct ultrasonographic vision. Each lecture is followed by an extensive practical session during which the resident performs ultrasonography on live models in small groups of three residents per instructor and model to apply in vivo the previously covered topics. The instructors are all members of the faculty of the Columbia University Department of Anesthesiology eager to share their ultrasonographic experience and clinical wisdom. The seminar is accompanied by a multiple-choice exam, which is being held once before the seminar and once after conclusion of the seminar, that covers all topics taught during the seminar. This allows us to monitor individual progress and to constantly adjust and improve our teaching skills.
As a way to refresh the skills gained during the workshop, when they are on rotation in OR anesthesia, pain medicine and Patient Safety, the CBY residents will be able to spend 2-3 hours per rotation in the Simulation Laboratory practicing with an ultrasound attending and then performing a focused assessment of their knowledge.
CA-1 through CA-3 Residents
During the July Orientation for our CA-1 residents, the residents will be given a refresher lecture and practice opportunities. Then in groups of 3-4 residents, the CA-1 residents will be given a focused assessment of their skills acquisition by an ultrasound attending.
CA-2 resident will be registered for a complete web-based ultrasound course that will give the residents an introduction into the theoretical basis of bedside ultrasonography. The curriculum is a comprehensive program, which covers all components of the use of bedside ultrasonography such as the focused cardiac ultrasound exam (FOCUS), abdominal ultrasonography, assessment of central and peripheral vessels, screening for deep vein thrombosis and assessment of pleural space and lung. The residents have the possibility to evaluate their progress with the help of several hundred multimedia questions and answers. Since the course is web based it will be accessible from any multimedia platform at any convenient time. During the year, several hours of the core curriculum will be devoted to the clinical applicability of ultrasonography.
Throughout the academic year, snippets on ultrasound imaging will be presented at morning report. The attendings will be encouraged to provide some upside down class experience in place of the traditional core curriculum lectures. This entails the distribution of “lecture” material one to two weeks before the scheduled session, then utilizing the “lecture-time” to provide simulation experiential learning using whole body simulators, task trainers, OSCE stations, or problem-based learning discussions.
CA-3 residents will be assigned simulation days throughout the academic year to practice and have their skills assessed.
The TEE Simulation Experience in Cardiac Anesthesia
The Department of Anesthesiology has two HeartWorks mannequin-based echocardiography simulators providing a realistic simulator experience in both transesophageal (TEE) and transthoracic (TTE) echocardiography. TEE simulation allows residents on their initial cardiothoracic anesthesiology rotation to quickly learn the basics of developing various TEE views and provides Adult Cardiothoracic Anesthesiology fellows an opportunity to hone their TEE skills in a stress free environment. The echocardiography simulators include several forms of pathology for review by the residents and fellows and are an excellent way to study the complex three-dimensional anatomy of the heart and great vessels. The echocardiography simulators are also used to demonstrate achievement of image acquisition skills by the residents and fellows.
At the conclusion of the resident’s second rotation on the adult cardiothoracic service, OSCEs are utilized to assess acquisition of knowledge and skills relevant to cardiothoracic anesthesia. This assessment will allow the resident to focus his/her efforts to improve in areas of deficiency on their third rotation on the service.
Ultrasound Regional Anesthesia
Residents use phantom models to simulate ultrasound guided peripheral nerve blockade, which improves their hand-eye coordination skills. This, in turn, improves proficiency in ultrasound probe manipulation, visualization of the needle, and increases successful placement of needles near target objects.
The Airway Workshop
Managing patients with a difficult airway is one of the most profoundly important skills that an anesthesiologist must develop. Indeed, the properly trained anesthesiologist must be ready to handle any airway related crisis--at a moment's notice--every time he or she cares for a patient. To help our residents develop these specialized skills in a thorough, relaxed, hands-on way, our department has created the Difficult Airway Management Workshop.
Over the course of a week, attendings from every division of our department provide didactic and mannequin-assisted presentations that are designed to review the intricacies of airway management, as well as share their many experiences and "clinical pearls". Sessions are limited to small groups, so residents can maximize their time improving such skills as fiberoptic intubation, LMA placement, double lumen ETT placement, retrograde intubation, cricothyrotomy and jet ventilation. The workshop concludes with a rigorous oral-board style exam that covers all aspects of elective and emergent airway management and several Objective Structured Clinical Examinations (OSCEs). In addition, our department offers an annual Cadaveric Airway Workshop that provides residents and fellows another opportunity to practice fiberoptic bronchoscopy, retrograde intubation, and cricothyrotomy on carefully selected cadavers.
Pediatric Trauma Simulation
A resident(s) and fellow on the Pediatric Anesthesia team joins Pediatric Emergency Medicine and Pediatric Surgery monthly (Sept through May) for a didactic lecture followed by a pediatric trauma simulation in the Pediatric Emergency Department. Topics covered are varied, and the wide range of scenarios allows all subspecialties to learn in real time using the mannequin. The goals of the sessions are to identify key limitations in communication, logistics and planning, and patient care. A brief debriefing session allows multidisciplinary discussions to promote continued improvement.