The use of Simulation is now not only established in the teaching of basic and advanced skills but also for assessment and evaluation. It is particularly important for the retention of skills that may be important in a crisis situation, but are only occasionally used in an emergency setting. So, Simulation is now used for both training and assessment. In addition, there is also “personal” simulation, often using a computer whereby an individual spends as long as needed practicing a particular technique or skill.
THE SIMULATION CENTER AT NEW YORK PRESBYTERIAN
The Simulation Center at New York Presbyterian Hospital (NYPH) strives to improve quality and safety of patient care through realistic experiental simulation-based medical education (SBME). The Center draws on the combined expertise of the entire NYPH community to promote the acquisition and assessment of clinical knowledge, skills, and attitudes that are needed for the highest quality and safest patient care.
Simulation is a powerful tool for teaching for individuals and teams because it allows for deliberate practice and reflective review and discussion of procedures and scenarios. For example, multidisciplinary teams from pediatrics and adult care units at NYP routinely practice skills for managing the care of a patient in cardiac arrest.
Drs. Margaret Wood and Vivek Moitra serve on the Executive Steering Committee of the NYPH Simulation Center. In collaboration with the Center, the Department of Anesthesiology has developed scenarios for faculty, residents, nurses and other staff. Two examples include (1) airway and fetal management in the obstetrical suite and (2) cardiac arrest in the intensive care unit. The learning objectives of these scenarios focus on medical management and crisis resource management during a cardiac arrest and/or rapid response situation. Teaching sessions emphasize that preventing a “failure to rescue” from a cardiac arrest requires both comprehension that an arrest or near arrest situation is occurring and effective action. Several faculty members have been trained as expert debriefers to enhance the simulation experience.
SIMULATION IN THE DEPARTMENT OF ANESTHESIOLOGY
- 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 and transthoracic 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 the 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.
- The Ultra Sound Experience
a. Ultrasound orientation
At the beginning of your residency you will spend one whole day receiving an introduction to ultrasound as a diagnostic and procedural tool in the medical field of Anesthesiology. 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 being followed by an extensive practical session during which you will perform 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 an oral board style multiple-choice exam, which is being held once before the seminar and once after conclusion of the seminar, which covers all topics taught during the seminar. This allows us to monitor individual progress and to constantly adjust and improve our teaching skills.
b. Ultrasound IT Program
Before the start of residency and continuing throughout the residency the participants will complete a web based ultrasound course, which 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.
- 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.
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. In addition, our department offers an annual Cadaveric Airway Workshop that provides residents and fellows the 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.