Clinical Simulation in Medicine Poonam Malhotra Kapoor, Navin C Nanda, Yatin Mehta, HK Chopra, KK Kapur
INDEX
Page numbers followed by f refer to figure and t refer to table.
A
Abdominal scanning probes 82, 370
Adult learning, circle of 327
Afibrinogenemia, case of 217f
Airway 282, 290f
anatomy of upper 13f
assessment 314
care 314, 315f
diagnosed difficult 300
difficult 297
evaluation, basic 298
intubator 304
management 292
simulation for 314
manual breathing unit 288
open 283
scenarios 366
simulation learning, upper 14f
upper 303
workshop, components of 317f
Alveolar concentration, minimum 359
Alveolar ventilation 357
American Board of Emergency Medicine 7
American Heart Association 67, 273, 278
American Society of Anesthesiologists 297, 314, 315
American Society of Echocardiography 86
Amyloidosis, case of 218f
Anaphylaxis 366
Anesthesia 211, 314
crisis resource management 238
depth of 240
low flow 356
simulation environment 238
Anesthetic concentration 360f
Anesthetizing airway 301, 302t
Aneurysm 180
Ankle jerk 349
Annular dilation 140
Anoxic brain injury 280
Anteflex 87, 89
Anticardiolipin antibodies 222
Antifibrinolytics, role of 212
Antiphospholipid antibodies 221, 222
syndrome 221
Aorta 96, 177
anatomy of 157f
arch of 34f
ascending 22f
descending 22f
evaluation of 156
pathology
ascending 93, 94, 98, 99, 180
descending 96, 97
Aortic aneurysms 161
Aortic annulus 180f
Aortic antegrade velocity 168
Aortic arch 156
Aortic dissection 131f, 161, 162
complications of 165
Aortic insufficiency 187f
severe 164f
Aortic lumen 131f
Aortic pathology, diagnosis of 131
Aortic position 176f
Aortic regurgitation 60, 62, 174, 179
severity of 63t, 168
Aortic root 61, 180f, 192
pathology 174
Aortic sclerosis 185
Aortic stenosis 60, 61, 64, 66, 171, 181, 186, 262
calcific 171, 182, 183, 185
etiology of 61
mild 172t
moderate 172t
planimetry 179
severe 172t
calcific 184f
severity, quantification of 62t
valvular 183f
Aortic valve 61f, 64, 9294, 99, 100, 108, 130, 130f, 167, 172, 173, 173f, 177, 182f, 183f, 186189f
anatomy of 167
apparatus 167, 178f
area 168
continuity equation 188
estimation 191f
calcification of 179f, 185f
complex 181
disease 180, 180f
doming of 189f
echocardiography of 183, 184t
endocarditis 175f
evaluation of 93, 167
implantation 63
infective endocarditis 186f
lumen, calcific 179f
mechanical 64, 65, 65f
normal 178f, 180f
outflow tract 180, 181
regurgitation, quantification of 176t
replacement, surgical 60
section of 173f
severity 171, 177
stenosis 61
systole of 179f
treat diseases of 177
vegetation 64
Aortic velocity, changes in 190f
Apoptosis 281
Artefact, extension of 165
Arterial blood 357
Arterial pressure, mean 240
Artery, large 177
Arytenoid cartilage 303
Asthma, severe 366
Atherosclerosis 180
of ascending aorta 156, 160
Athlete's heart 49t
Atlanto-occipital angle, measurement of 299, 299f
Atrial appendage 91
left 91, 99
thrombus, left 265
Atrial area, left 55
Atrial fibrillation 266
Atrial masses 9193, 101
left 95
right 95
Atrial myxoma 258f
left 257
Atrial pressure 251
assessment of left 40
estimation of right 252t
left 266
right 129t
Atrial septal defect 30
Atrial septum 35f
Atrium 91
dilated right 141f
left 57, 89, 91, 95, 128f
right 128f
Automated external defibrillator 282, 287
B
Bag volume 203
Bag-mask ventilation 284f
Basic life support 287, 290, 291f
Bernard-Soulier syndrome 221
Bernoulli equation 172
Bicuspid aortic valve 62, 171, 181, 184, 184f
Bicuspid value 62, 168
Bioprosthetic valve 176f
Biphasic defibrillators 284
Bleeding patient, management of 225
Blood 299
cells, packed rate 205, 248
component, type of 203
cylinder of 130
flow 151
simulation of 118, 118f
oxygen 291
pressure 289, 327
product 248
management of 196, 227
transfusion of 205
transfusion, whole 248
Blood-brain barrier, disruption of 281
Blue phantom simulator 83
advantages of 83
disadvantages of 83
Blue phantom simulation system 84
Body simulation, whole 366
Brachiocephalic artery 157
Bradycardia 292, 350
Brain
injury, irreversible 281
protection 273t
Breathing 282, 290f, 308
circuit 357, 360f
Bronchial
anatomy 307
sampling 310
wall 310
Bronchoalveolar lavage 310
Bronchoscope 301, 302f, 304f
Bronchoscopic competence 307
Bronchoscopic intubation 303, 304
Bronchoscopic simulation 306
Bronchoscopic skills 311
Bronchoscopy 30612, 322, 366
competence assessment 311t
simulation 310t, 311
training 309t, 311
Bronchospasm 303
Bundle branch block, left 147
C
Calcific degeneration 168
Capnography 300
qualitative role of 275f
Carcinoid syndrome 140
Cardiac arrest 273, 280, 293
treatment 294
Cardiac arrhythmias 310, 338
Cardiac critical care
medicine 365, 367
simulation for 251
Cardiac index 151
Cardiac life support, advanced 274f, 286, 287f, 314, 366
Cardiac output 149, 151, 152, 240, 276, 357
estimation of 129
Cardiac surgery 195, 198
Cardiac surgical patient bleeds 224f
Cardiac tamponade 254
Cardiogenic shock 366
Cardiopulmonary
arrest 287
bypass 224
anticoagulation for 198
resuscitation 272, 273, 274f, 282284, 286, 286f, 287, 287f, 292, 293, 295, 368
adult 282
basic 287, 289f
Cardiothoracic surgery scenarios 366
Cardiovascular intensive care unit 337
Cardiovascular life support, advanced 287, 291, 292
Central nervous system 202
Central venous
catheter insertion 366
oxygen saturation 292
pressure 276
Cerebral
blood flow 280
function, depressed 281
oximetry 273
oxygen delivery 273
performance category 281
thermopooling 281
Chest
compress 282
compression
before airway 286
before breath 286
types of 287
tube insertion 271
Child-Pugh score 204, 207, 209
Chordae tendineae 53
Chronic liver
disease 201, 207, 209
failure 204
Circulation simulator 340, 341f
Circumferential strain 44f, 47
Cleft lip repair 322
Clot rate 199
Clot retraction 176, 196, 197, 227
phase 197f, 227f
Clot viscoelastic test 213
Clotting time
activated 196, 199, 213, 224, 339
measurements, activated 226f
Coagulation abnormalities 281
Coagulation dysfunction, simulations for 201
Coagulation testing in perioperative period 225
Coagulation tests 213
Coaptation of aortic valve 185f
Cockpit resource management 328
Collapsed left lung 126f
Colloids 248
Color flow Doppler 141, 174
propagation velocity 39f
Commissural fusion 171, 171f
thickening 179f
Complete sonoclot signature 227f
Congenital
abnormalities 174
bicuspid valves 62
cardiac pathologies 36
Coronary arteries 69f, 71t, 178f
disease 68f, 72
right 53, 145
Coronary cusp-left coronary cusp, right 134
Coronary heart disease 67, 72
Coronary perfusion pressure 289
Coronary sinus 22f, 30, 91
Coronary syndrome, acute 277
Crawford classification 161, 161f
Cricoid pressure 304
Cricothyroidotomy 271
Crisis resource management 323, 326, 327, 368
Crisis simulation 350
Critical care units 126
Cryoprecipitate dose 204
Crystalloids 248
Cutaneous vasculitis, case of 220f
D
Deep transgastric long-axis 111f
Desflurane 356
Diastolic
coaptation defect 168
dysfunction 37
grading 50
function assessment 37
heart failure 37
pressure 289
Dilute Russell's viper venom time 222
Disc summation method 151
Disseminated intravascular coagulation 221
Distal lad tract 70
Dobutamine stress ECHO 190
Dopamine 240
Doppler assessment of aortic stenosis 186
Doppler echocardiography 136
Doppler spectral data 36
Drug delivery 292
Dyssynchronous left ventricular 45f
E
Ebstein's anomaly 140, 260, 260f, 261f
diagnosis of 260
Echocardiographic evaluation 38, 157
Echocardiographic sign 171
Echocardiography
for aortic valve 60
of mitral valve 53
usefulness of 125t
Echocom simulator 81
Ejection fraction, surrogates of 145
Emergency cardiovascular care 273
Emergency medical services 273, 293, 295
Emergency medicine 4
Emergency situation simulation 350
Emergency trauma training course 269
End diastolic area 148
Endobronchial ultrasound 313
Endocardial excursion 145
Endocarditis 129, 140
infective 64, 129, 177
Endocrine 298
Endoscopic ultrasound 312
Endotracheal intubation 315
Endotracheal tube 301, 302, 302f
tip 304f
Enflurane 356
Epiglottis 299, 303
Epistaxis 303
Esophageal
aortic arch, upper 109, 112f, 135, 135f, 158, 160
ascending aorta, upper 135
coronary, lower 101
Esophagus 88f
European Association of Echocardiography 85
Extracorporeal membrane oxygenation 322, 335, 367
mannequin's chest cavity 368f
simulation for 335
simulation systems 340
simulator 341, 341f
training 335
challenges of 336t
Eye balling 149
F
Facial trauma 299, 300
Fentanyl 276
Fiberoptic bronchoscope, size of 301t
Fiberoptic bronchoscopy of difficult airway 297
Fiberoptics 307
Fiberscope 302
Fibrin formation 196
Fibrin gel formation 196, 226
rate of 196
stage 226f
Fibrin interaction 197f
Fibrinogen 203, 204, 209, 212
converts into fibrin gel 196
levels 208
Fibrinolytic proteins 201
Fibrous annulus 178f
Fibtem 228
Fidelity bronchoscopy simulation, low 307
Fish mouth appearance 184
Flexible bronchoscope 306, 309
Flexible fiberoptic bronchoscope 303
complications of 303
Flexi-tip tubes 304
Fluid deficit replacement 248
Foreign body 298
Fresh frozen plasma 203, 208, 248
Functioning ultrasound system 84f
G
Gamma-aminobutyric acid 280
Garden hose 342f
Gargling lidocaine liquid 301
Gastrointestinal mentor 17f
Gentle puffs 284
Gerbode defect 252
Global cerebral ischemia 274
Global hemostasis test 213
Global pericardial effusion 131f
Glottic edema 300
Gorlin formula 173
H
Halothane 356
Head tilt lifting 283
Headache 348
Health
care simulation 6
record, electronic 13
Healthcare 6
decision makers 13
education 364
processes 15
simulation challenges 16
Healthy mitral valve 118, 118f
Heart
block 365
chambers of 31f
disease, ischemic 67
pumping chamber of 177
rate 276
various tomographic planes of 22f
Heartbeat 269, 291
Heartworks
advantages of 83
disadvantages of 83
simulation system 84
simulator 83
Hematoma 269
Hemodynamic
computer simulation of 241f
monitoring, simulation in 237, 367
parameter, teaching management of 240
Hemophilia A 218f
Hemostatic bleeders 227
Hepatic vein, transgastric modified 102, 103f
Hepatic venous flow 142
Hepatitis B reactivation 204
Hereditary disorders 315
High fidelity bronchoscopy simulation 308
Human patient simulator 17, 269, 270f
Hypercoagulation detection in liver disease 214f
Hyperfibrinolysis 197, 213
Hyperglycemia 275, 276
Hyperlipoproteinemia 182
Hypertension 244, 338
Hypertensive crisis 366
Hyperthermia 275, 277, 365
Hypertrophic cardiomyopathy 49t, 262, 265
Hypertrophic obstructive cardiomyopathy evaluation 93
Hypertrophy cardiomyopathy 263f
Hypervolemia 365
Hypocapnia 277
Hypoglycemia 277
Hypokalemia 275, 276
Hypomagnesemia 275
Hypotension 276, 277, 338, 365
Hypotension in critical care unit 127, 128t
Hypothermia 273, 274, 275, 295
suppresses inflammation 274
Hypovolemia 149f, 276
Hypoxia 277
I
Inflammatory disease 298
Instructor-driven simulators 243
Intensive care unit 124, 125t, 202, 245, 326, 365, 366
Interatrial septum 30, 90
International normalized ratio 212
International Pediatric Simulation Society 363
Interventricular septum 27
Intimal flap towards false lumen, systolic movement of 164f
Intra-aortic balloon pump 246
Intracardiac chamber masses 90
Intracranial hypertension 281
Intramural hematoma 165
Intraoperative echocardiography, role of 259
Intubation 322
causes of 298f
elective 300
Isoflurane 356
Isovolumic contraction time 153
J
Jaw thrusting 304
John Burns School of Medicine 343
K
Kidney injury, acute 367
Kissing papillaries 148, 149
Kolb's experiential learning cycle 327f
L
Laparoscopy 322
Laryngeal axes 315
Laryngeal mask 284f
airway 304
Laryngeal visualization 299
Laryngoscopy 297, 315
direct 297
Laryngospasm 303
Laryngotracheal airway 308
Laryngotracheobronchitis 300
Larynx injury 300
Larynx tumors 300
Leaflet
closure line 168
morphology 121f, 179
pathology 174
prolapse 180
stress distribution 121
thickening 174
Lidocaine spray 301
Liver
disease 201, 202t
chronic 210
plays 201
surgery 211
Lorazepam 276
Low molecular weight heparin monitoring 217f
Lungs 357
Lupus anticoagulant 221, 222
Lymph node stations 310
M
Macroglossia 299, 300
Macro-level simulation 12
Mallampati classification 299
classes of 299f
Manikin simulator package 115
Mannequin's chest cavity 339f
Mannequin-based computer simulators, advantages of 7
Mature clot process 214f
Medical record, electronic 13, 270, 270f
Medical simulation 4, 156
stages of 328
types of 237
Mentice aortic valve 63
Mercedes Benz sign 178f
Metabolic acidosis, severe 366
Micro-level simulation 12
Midazolam 276
Midesophageal aortic valve 71f, 93, 94, 181f, 182f
long axis 71, 79f, 93f, 94f, 157, 179, 180
short axis 71, 94f, 180
Midesophageal ascending aorta
long axis 97, 98f
short axis 98, 99f
Midesophageal descending 96, 158
Aorta
long-axis 96f
short-axis 97f
Midesophageal five chamber 168, 171
Midesophageal four chamber 79f, 89, 89f
Midesophageal right ventricular inflow outflow 100, 102f
Midesophageal short axis 183
Midesophageal two chamber 79f, 90, 90f
Mitral annular
dilatation 56f
motion 152
plane systolic excursion 152, 153f
velocity 154f
Mitral cusps 26
Mitral leaflet 53
Mitral pulmonic plane 22
Mitral regurgitation 54, 55, 80f
Mitral stenosis 54, 65f, 80f
Doppler 66
Mitral transannular velocity 153
Mitral valve 53, 57, 57f, 90, 91, 93, 99, 102, 104, 105, 114116, 117f, 118, 118f, 255f
anatomy 53, 54f
dynamics 119, 122
evaluation 90
leaflet
anterior 105
zona coapta of 54f
prolapse 55, 56, 258, 259f
Model-driven simulators 243, 243f
Modern medical simulation 7
Modern pediatric emergency trainees 321
Modified Simpson's biplane method 150, 151f
Modular simulation environment 344
Morbid obesity 300
Mortality rates 370
Mucocutaneous bleeds, diffuse 204f
Mucosal bleeds 203
Multifocal leukoencephalopathy 54
Multiplane angle range 9098, 179181
Multiplane probe angle 89
Muscle 356
relaxants 276
Myocardial contractility 365
Myocardial fiber arrangements 43f
Myocardial infarction 245, 256f
Myocardial ischemia 155
detection of 129
Myocardial performance index 153, 154f, 155f
Myocardial strain 45
N
Narcotics 276
Neck
cannula 339f, 368f
mobility 298, 299, 299f
Needle decompression 271
Neonatal resuscitation 284f
Program 284
learning 284
Nerve blocks 322
Neuronal death 281
Nitrogen 356
Nitrous oxide 356
Nonalcoholic steatohepatitis 202, 204
Nontechnical skills 328
Norepinephrine 245
Normal pulsed wave Doppler 140f
Normothermia 275, 280
O
Obstructive pulmonary disease, chronic 246
Occlusive portal vein thrombus 209f
Occult cardiac tamponade 254
Ochronosis 182
Oxygen
rich blood 282
via mouth-to-mouth resuscitation 288
P
Pain
medicine 348
simulation in 347
neuropathic 348
Pancreatitis 275
Papillary muscles 27f, 53, 117
Parallel three-dimensional models 4
Parasternal
long axis 22
short-axis 185
Partial pressure of end-tidal CO2 292
Patent foramen ovale 128, 257
Peak transvalvular velocity 186
Pediatric
acute care 323
airways 310
and neonatal intensive care 322
anesthesia and surgery 322
cardiopulmonary resuscitation 281
emergency medicine 321
intensive care unit 323
simulation 319
Percutaneous tracheostomy 271
Pericardial effusion 256, 256t
Pericardial tamponade, diagnosis of 131
Pericardiocentesis 271
Perioperative coagulation dysfunction, simulation for 195, 211
Peritoneal lavage, diagnostic 271
Persistent hypoxia
cause of 127
diagnosis of 127
Pharynx 300
Platelet 197f
count 202, 204, 209
function 197, 199, 212
rich plasma 213
Pneumothorax 350
Point-of-care testing 223
Positive pressure ventilation 295
Postcardiac arrest
brain injury 280
care 277
syndrome, management of 277t
therapy 295
Postcardiopulmonary bypass 195
Posterior descending coronary artery 70, 70f
Posterior mitral
leaflet, prolapse of 258f
valve leaflet 105
Postresuscitation care 277
Precocious defibrillation 287
Pressurization, simulation of 58
Propofol 276
Protease inhibitors 280
Prothrombin time 213, 214, 224
international normalized ratio 201
Proximal descending aorta 35f
Psychomotor skills 271
Pulmonary arterial hypertension 40, 251
Pulmonary artery 111
hypertension 251, 255f
transesophageal echo of 251
left 134
main 135
pressure 40, 252
right 33, 97, 98, 134
Pulmonary embolism
acute 132t
diagnosis of 132
dilation in 132f
Pulmonary hypertension 214, 252, 253
severity of 252
Pulmonary regurgitation 137
severity of 137t
Pulmonary stenosis 135
mild 136f
severity of 136t
Pulmonary valve 134136, 143
presence of 252
thickened 136f
Pulmonary vascular resistance 40, 254
Pulmonary vein
left upper 99, 266
right 95
Pulmonary venous
Doppler velocities 40f
flow 39
Pulmonic valve 99100, 111
Pulse oximetry 300
Pulsed wave 71, 136f
Doppler 142
across pulmonary valve 136f
Pulseless
electrical activity 292
rhythms 366
ventricular tachycardia 274, 293, 295
R
Radial strain 43, 44f, 47
Random donor platelet concentrate 204
Realistic simulation experience 285
Regional left ventricular function 145
Regional wall motion abnormalities 68, 145
Regular technical skills, development of 239
Regurgitation
fraction 176
volume 176
Renal replacement therapy 322
Rescue breaths 291, 291f
Respiratory
arrest 281
distress syndrome, acute 290, 367
therapists 335
Restrictive transmitral filling pattern 39f
Resuscitation training, simulation in 367
Retroflex 87, 89
Rheumatic
aortic stenosis 171, 185
disease 140
heart disease 54
stenosis 185f
Rheumatology 348
Rigid bronchoscopy 313
Ristocetin-induced platelet aggregation 221
Rotating tube 302f
Rotational thromboelastometry 223, 227, 229f, 230f
S
Septic shock 366
Shaken baby syndrome 221
Shock
stages of 247t
types of 246
Shockable rhythms ventricular fibrillation 295
Simman simulator 273f
Simpson's biplane method 150
Simpson's rule 151
Simulated transesophageal echocardiography 156, 167
Simulation 3, 11, 270, 326, 364
application of 239, 367
based advanced cardiac life support 286
based education, types of 322
based medical education 114
based TEE curriculum 166
based tools, types of 322t
computer-based 322, 366
in bronchoscopy 307
in medicine, role of 11
in paediatrics, role of 321, 368
in pain medicine 350
in transesophageal echocardiography 77
in trauma 269
learning, advantages of 5, 269
levels of 12
mannequin 4f
need of 355
of mitral valve repair 58
procedure 4
promotes training 11f
surgical 364
system, qualities of 340
techniques of 348
training 9, 337
significance of 9
types of 327
true benefit of 12
works for tee 115
Sinotubular junction 157, 174, 180
Sinuses of Valsalva 60, 168
Smarter simulation modes 12
Society of Cardiovascular Anesthesiologists 8, 86
Sodium nitroprusside 240
Sonoclot
analysis, steps to perform 227, 228f
parameters 209
signature, abnormal 203f, 204f, 207f, 209f
tracing 214f
Speakerphones 285
Spontaneous circulation, return of 273, 292
Stanford classification systems 162
Status epilepticus 366
Stenotic aortic valve 171f
Stridor 299
Stroke volume 129
calculation of 130
Strong platelet function 227
Subpulmonic valve 101
Subvalvular aortic stenosis 185
Sudden cardiac death 273
Supravalvular aortic stenosis 185
Supraventricular arrhythmias
stable 366
unstable 366
Symptomatic arrhythmias, management of 292
Systemic vascular resistance 276
Systolic anterior motion 262
Systolic function, left ventricular 145
Systolic mitral annular velocity 153
Systolic pressure 289
Systolic pulmonary artery pressure 252, 253f
underestimation of 253f
T
Tachycardia 303
Tachycardic rhythm 294
Target cut planes 115
Task oriented simulation 328f
Tear drop calcification 171
Temporomandibular joint ankylosis 300
Tetralogy of Fallot 230
Therapeutic bronchoscopy 301
Therapeutic hypothermia 273, 275, 276f, 277
complications of 276
machine, use of 274
phases of 281f
Thickend noncoronary cusp 188f
Thoracic aorta 157
descending 131
Thoracic aortic diseases 160
Thoracoabdominal
aneurysms 161f
aorta 32
dissections 162f
Three-dimensional
heart model 71f
speckle tracking echocardiography 46
Thrombasthenia 216f
Thrombin inhibitor
effects, direct 228
monitoring, case of direct 217f
Thrombin time 214, 221
Thrombocytopenia 201, 275
Thromboelastogram 223
Thromboelastography 223
Thromboplastin time 213, 214, 221, 224
Thrombus, movement of 128
Tissue Doppler imaging 40, 41, 41f, 42t, 153
Tissue mechanics, simulation of 58
Tracheal tube 304
Tranexamic acid 230
restriction of 197
Transbronchial needle aspiration 308, 310, 313
Transcatheter aortic valve
implantation 63, 64
replacement 60, 63, 64
Transesophageal echocardiographic
dataset 81f
examination 167
Transesophageal echocardiography 7, 50f, 69, 75, 77, 80, 80f, 81, 85f, 86, 114, 119, 124, 131, 134, 137, 138, 143, 145, 162, 177, 254, 257, 258f, 259, 369
probe manipulation, terminology of 89
simulator, arts of 78f, 369
training 144
simulation for 114, 134, 156, 177
traditional training of 144
simulation 7, 8, 78, 144
Transfuse platelets 207
Transfusing blood products 208
Transfusion 208
associated circulatory overload 224
Transgastral basal valve 80f
Transgastric
aortic valve 135
basal 105, 106f
hepatic vein 139
pulmonary valve 135f
right ventricle inflow 106, 109f, 110f, 139, 139f
tricuspid valve 138, 139
two-chamber view 102, 104f
Transmitral
diastolic inflow 38f
flow Doppler 51
velocities 38
Transthoracic echocardiography 19, 22f, 57, 67, 254, 259, 369
protocol 124
simulator 58, 68f, 81
training 72
utility of 57
Transthoracic imaging in intensive care unit 125t
Transversal strain 43, 44
Trauma 298
life support
advanced 269
course 269
sonography for 369
victims 322
Tricuspid
annular plane systolic excursion 251
disease, etiology of 140
leaflet, thickened 139
regurgitation 40, 140, 141, 252, 254
jet velocity 252
peak velocity 252f
severity of 143t
stenosis 142
valve 100, 101, 106, 137, 180f
evaluation 90
inflow 255f
Tube over scope, Hamper insertion of 303f
Tuberculosis 290
Tumors 298, 299
Two-dimensional
echocardiography 37, 136, 141
speckle tracking echocardiography 42
transthoracic echocardiography 37
Tympanic membrane 275
U
Ultrasonic bronchoscopy simulator 308f
Ultrasonography 350
Ultrasound simulator package 115
Ultrasound transducer's location 166
Umbilical line insertion 322
V
Valve
area by planimetry, calculation of 168
geometrical model 117
Valvotomy 259
Vasopressors 276
Vasospasm 280
Vena cava
orifice, inferior 95
pathology, superior 95, 99
superior 95, 98
Vena contracta 168
Ventilation ratio, compression to 287
Ventricle dimensions, left 148
Ventricle function 90
left 9193
Ventricle, right 101
Ventricular apex, left 46
Ventricular diastolic evaluation 93
Ventricular ejection fraction, left 37
Ventricular fibrillation 274, 284, 287, 293, 295
Ventricular outflow tract
left 92, 93, 108, 168, 185, 188, 191, 262
right 135
Ventricular systolic
function, left 127
pressure, right 142
Ventricular tachycardia 287, 295
Ventricular volumes, left 70
Vimedix simulator mannequin 83f
system 370
Vimedix
advantages of 81
disadvantages of 81
Virtual heart model 84
Virtual procedure stations 269, 270f
Virtual simulators 340
Viscoelastic tests 195
Vocal cord injury 303
von Willebrand disease 221
von Willebrand factor 201
W
Wave Doppler 142, 171
Wet drills 336
World Simulation Society 363
Worsening abdominal distension 202
Z
Zona coapta 53
×
Chapter Notes

Save Clear


1Introduction to Simulation in Medicine
zoom view
Section Outline
  • What is Simulation?
  • Role of Simulation in Medicine
2

What is Simulation?Chapter 1

Kapoor Poonam Malhotra
Mehta Yatin
Chapters Outline
  • Simulation in Various Medical Fields
  • Advantages of Simulation Learning
  • Freedom to Error and Learn from Mistakes
  • Learning can be Customized
  • Simulation Provides Detailed Feedback and Evaluation
  • Simulation in Health Care
  • To Summarize about Simulation in Education
  • Objectives of Simulation
  • Activities of the Simulation Society
  • Modern Medical Simulation
  • Advantages of Mannequin-based Computer Simulators
  • Transesophageal Echocardiography Simulation
  • Importance of Transesophageal Echocardiography Simulation
 
INTRODUCTION
One of the most important steps in curriculum development is the introduction of simulation-based medical teaching and learning. Simulation is a generic term that refers to an artificial representation of a real world process to achieve educational goals through experiential learning. Simulation based medical education is defined as any educational activity that utilizes simulation aides to replicate clinical scenarios. Although medical simulation is relatively new, simulation has been used for a long time in other high risk professions such as aviation. Medical simulation allows the acquisition of clinical skills through deliberate practice rather than an apprentice style of learning. Simulation tools serve as an alternative to real patients. A trainee can make mistakes and learn from them without the fear of harming the patient. There are different types and classification of simulators and their cost vary according to the degree of their resemblance to the reality, or ‘fidelity’. Simulation-based learning is expensive. However, it is cost-effective if utilized properly. Medical simulation has been found to enhance clinical competence at the undergraduate and postgraduate levels. It has also been found to have many advantages that can improve patient safety and reduce health care costs through the improvement of the medical provider's competencies. The objective of this narrative review article is to highlight the importance of simulation as a new teaching method in undergraduate and postgraduate education.
Simulation technology (Figure 1) has been used successfully to advance medical training, especially in4 the last 10 years.1
zoom view
Figure 1: Simulation mannequin
Recently, the emphasis has been on scenarios when the skill involved is critical to patient safety and/or the number of procedures required to achieve proficiency is impractical.2,3 Simulation technology can be complemented with parallel three-dimensional (3D) models that improve the spatial perception of the procedure (reality-enhanced simulators) or with devices that allow visual feedback and kinesthetic interactions between an operator and the simulator (haptic technology).
 
DEFINITION
The dictionary meaning of simulation is “the representation of the behavior or characteristics of one system through the use of another system, especially using a computer”. One can learn in a particular zone of development by what vygotsky called the “Lure to learn” (Figure 2). Particular zones of development can be referred to as the domain where people are acting a particular scenario. For a simulation procedure (SP), it would be within the constraints of a simulated patient examining room. For a construction scene, the constraints will be at work site. Being able to successfully improvise within the particular zone of learning and engaging with the other members of the interaction will allow a fluid dynamic in interaction.
Medical simulation is a branch of simulation technology related to education and training in medical fields of various industries. It can involve simulated human patients, educational documents with detailed simulated animations, casualty assessment in homeland security and military situations, and emergency response. Its main purpose is to train medical professionals to reduce accidents during surgery, prescription, and general practice. However, it now has been extended in its use for training students in anatomy and physiology during their clinical training as allied health professionals. These professions include nursing, sonography, pharmacy assistants and physical therapy. Advances in technology are advancing geometrically and a McGraw Hill textbook, Medical Simulation, by VanCura and Bisset interfaces the simulator technology with any medically related course of study.
zoom view
Figure 2: Simulation mannequin for teaching and learning
Many medical professionals are skeptical about simulation, saying that medicine, surgery, and general healing skills are too complex to simulate accurately. But technological advances in the past two decades have made it possible to simulate practices from yearly family doctor visits to complex operations such as heart surgery.
 
SIMULATION IN VARIOUS MEDICAL FIELDS
The utility of simulation is widely recognized and becoming a greater part of medical education across fields. Each major specialty in medicine has worked to shape and optimize the use of simulation in ways that not only address common medical challenges but also specifically address competencies unique to a given specialty. To better understand simulation as a changing entity across medical fields, we briefly survey key components of the use of simulation in each of five major medical specialties outside neurosurgery: anesthesiology, emergency medicine, surgery, obstetrics and pediatrics.
The nature of certain medical fields in which spontaneous emergent intervention is required5 (e.g. anesthesiology, surgery and emergency medicine) is such that learning opportunities in critical cases may be sporadic and somewhat limited given the rapidity with which intervention must be implemented. Unacceptable consequences may occur should care be delayed or errors take place during training.
Procedural simulation has been demonstrated to improve clinical implementation of advanced cardiac life support protocols.4 Therefore, given the often high-acuity environments of anesthesiology, simulations have provided a natural supplement to clinical anesthesia training, with 70% of medical schools using some form of simulation for teaching.5
 
ADVANTAGES OF SIMULATION LEARNING
 
Simulation Learning Provides the Following Opportunities
Learning in healthcare is too frequently in an apprenticeship model. In many disciplines, as opportunities to learn and practice come along, it is hoped that learners encounter enough situations to insure that they become competent. This is ultimately a haphazard way to learn, and puts learners and patients at a disadvantage. Simulation offers scheduled, valuable learning experiences that are difficult to obtain in real life. Learners address hands-on and thinking skills, including knowledge-in-action, procedures, decision making, and effective communication. Critical team work behaviors such as managing high workload, trapping errors, and coordinating under stress can be taught and practiced (Figure 3). Training runs the gamut from preventive care to invasive surgery. Because any clinical situation can be portrayed at will, these learning opportunities can be scheduled at convenient times and locations and repeated as often as necessary.
zoom view
Figure 3: A trainee receiving instruction on anatomical correlation with echocardiographic images using a TEE simulator
 
FREEDOM TO ERROR AND LEARN FROM MISTAKES
Working in a simulated environment allows learners to make mistakes without the need for intervention by experts to stop patient harm. By seeing the outcome of their mistakes, learners gain powerful insight into the consequences of their actions and the need to “get it right”.
 
LEARNING CAN BE CUSTOMIZED
Simulation can accommodate a range of learners from novices to experts. Beginners can gain confidence and “muscle memory” for tasks that then allow them to focus on the more demanding parts of care. Experts can better master the continuously growing array of new technologies from minimally invasive surgery and catheter-based therapies to robotics without putting the first groups of patients at undue risk. Some complex procedures and rare diseases simply do not present enough opportunities for practice, even to established clinicians. Examples include treating a severe allergic reaction or heart attack in an outpatient clinic setting, or handling a case of malignant hyperthermia in the operating room. This is a gap that simulation training methods can help fill (Figure 4).6
zoom view
Figure 4: Simulation teaching is easy to teach and easy to learn
 
SIMULATION PROVIDES DETAILED FEEDBACK AND EVALUATION
Real events and the pace of actual healthcare operations do not allow for the best review and learning about why things took place, or how to improve performance. Controlled simulations can be immediately followed by videotape-supported or after-action reviews that richly detail what happened. Advanced surgical and task simulators gather much data about what the learner is actually doing. These performance maps and logs provide a solid and necessary feedback mechanism to learners and help instructors target necessary improvements.
 
SIMULATION IN HEALTH CARE
Health care simulation is coming of age, and has begun to share much with established methods in aviation, spaceflight, nuclear power, shipping and the military. The rapid advance of computer science, bioengineering, and design has met demands from all stakeholders for safer, more effective and efficient ethical healthcare. When the stakes are high and real settings do not lend themselves to artificial handling for other purposes, simulation methods will find applications.
 
TO SUMMARIZE ABOUT SIMULATION IN EDUCATION
  • Simulation-based education (SBE) is a rapidly developing method of supplementing and enhancing the clinical education of medical students.
  • Clinical situations are simulated for teaching and learning purposes, creating opportunities for deliberate practice of new skills without involving real patients.
Experts can better master the continuously growing array of new technologies from minimally invasive surgery and catheter-based therapies to robotics without putting the first groups of patients at undue risk.
  • Simulation takes many forms, from simple skills training models to computerized full-body mannequins, so that the needs of learners at each stage of their education can be targeted.
  • Emerging evidence supports the value of simulation as an educational technique; to be effective it needs to be integrated into the curriculum in a way that promotes transfer of the skills learnt in clinical practice.
  • Currently, SBE initiatives in India are fragmented and depend on local enthusiasts; Health Workforce Australia is driving initiatives to develop a more coordinated national approach to optimize the benefits of simulation.
 
OBJECTIVES OF SIMULATION
  • To develop standards of practice regarding the key applications of simulation including education, research and patient care.
  • To foster a network of professionals working within the simulation field.
  • To advocate for continued development and availability of simulation-based modalities for key applications including education, research and patient care.
  • To form affiliations with societies and groups having common goals in relation to simulation and safety and quality in health care.
  • To promote the professional development of individuals working in the simulation field.
  • To advise on legislation related to the use of simulation in health care.
  • To be recognized as the official representative of these groups in the national and international scenarios.
 
ACTIVITIES OF THE SIMULATION SOCIETY
The Simulation Society (TSS) from India formulated in August 2014 by, the authors of this chapter conducts workshop on simulation regularly. Simulation in cardiac critical care is in the curriculum of medical7 education which is essential to promote technical skills in clinical practice.
  • Conducting conferences, seminars and workshops including the SimHealth conference.
  • Sponsoring student scholarships.
  • Contributing to the development of Indian and international standards of simulation.
  • Liaising with international simulation organizations.
  • Encouraging research.
  • Information dissemination via newsletters and the website.
  • Running a college and a journal to enhance simulation based education and learning in medical sciences.
  • Providing certification courses and fellowship examinations in simulation based teaching in medicine and cardiac critical care on a regular basis.
 
MODERN MEDICAL SIMULATION
The American Board of Emergency Medicine employs the use of medical simulation technology in order to accurately judge students by using “patient scenarios” during oral board examinations.6 However, these forms of simulation are a far cry from high fidelity models that have surfaced since the 1990s (Figure 5).7
Due to the fact that computer simulation technology is still relatively new relative to flight and military simulators, there is still much research to be done about the best way to approach medical training through simulation. That said, successful strides are being made in terms of medical education and training. A thorough amount of studies has shown that students engaged in medical simulation training have overall higher scores and retention rates than those trained through traditional means.
zoom view
Figure 5: High fidelity simulator for teaching and training
The Council of Residency Directors (CORD) has established the following recommendations for simulation.
Students engaged in medical simulation training have overall higher scores and retention rates than those trained through traditional means.
  • Simulation is a useful tool for training residents and in ascertaining competency. The core competencies most conducive to simulation-based training are patient care, interpersonal skills, and systems based practice.
  • It is appropriate for performance assessment but there is a scarcity of evidence that supports the validity of simulation in the use for promotion or certification.
  • There is a need for standardization and definition in using simulation to evaluate performance.
  • Scenarios and tools should also be formatted and standardized such that simulation educators can use the data and count on it for reproducibility, reliability and validity (Figures 6A and B).
 
ADVANTAGES OF MANNEQUIN-BASED COMPUTER SIMULATORS
  • Students can refine and apply their skills in realistic health care situations
  • Learning tailored to the educational needs of students
  • Allows unlimited creation of situations that might be too dangerous or expensive to perform live
  • Allows students repeated practice of procedures to reach proficiency
  • Allows adherence to standard guidelines by reinforcement
  • Allows evaluation of individual or group performance
  • Scenarios can be halted at any time to allow for discussion of management strategies
  • No issues of patient safety or confidentiality.
 
TRANSESOPHAGEAL ECHOCARDIOGRAPHY SIMULATION
A perfect example of high fidelity simulation.
Transesophageal echocardiography (TEE) is a widely-used technique in the cardiovascular assessment of patients undergoing complex surgery or those that are critically ill.8
zoom view
Figures 6A and B: The teaching macrosimulation for one to one learning as “hands on experience”
It is recognized as an important element that impacts surgical technique, especially in patients undergoing mitral valve surgery (Figure 7).8,9 Image acquisition and interpretation using TEE can also be subject to variability depending on experience and skill of the operator. The National Board of Echocardiography and the Society of Cardiovascular Anesthesiologists (SCA) have therefore established training guidelines that define expectations of competency in TEE during the training period for perioperative physicians.10 Acquiring minimal proficiency in perioperative TEE can also be challenging for trainees and teaching faculty, as the number of cases required learn TEE is considerable as is the time for acquiring the cognitive skills through didactic education.10
zoom view
Figure 7: Mannequin for TEE simulation in echocardiography
zoom view
Figures 8A and B: (A) An image from the TEE simulator showing the location of the TEE probe in close proximity to the heart with the intervening structures removed to better demonstrate the relationship. (B) The panel on the right simultaneously displays the echocardiographic correlate
A TEE simulator is capable of displaying two images—one that shows a three-dimensional representation of cardiac anatomy, while the other shows the simultaneous echo correlate (Figures 8A and B). The location of the TEE probe with the esophagus removed is an added advantage that helps the user visually with anatomical relationships. The manipulation of the echocardiographic scan plane can be accomplished using a keyboard or a connected mannequin.
 
IMPORTANCE OF TRANSESOPHAGEAL ECHOCARDIOGRAPHY SIMULATION
This technology can also be used by trainees in several disciplines such as anesthesiology, cardiology, cardiac surgery and critical care to improve proficiency in basic TEE image acquisition and interpretation. At the present time, exposure to intraoperative TEE is challenging for trainees outside the operating room environment (Figure 9).9
zoom view
Figure 9: The simulation for TEE is challenging for trainee's outside the operating room environment
The development of cardiac pathology will greatly help trainees develop the interpretative skills in areas either too complex or infrequent in occurrence to permit enough time for education in the clinical environment. This technology can be used for helping physicians maintain competency in situations where clinical case volume may be insufficient to support current competency requirements.
 
Significance of Simulation Training
The availability of reality-enhanced TEE simulation is a significant departure from traditional training models that rely on a combination of didactics and real time clinical teaching. While more ‘real world’ in application, the challenges of simultaneous clinical management may place additional burden on educators in the operating room. Simulation in TEE provides a more controlled environment in which to assess the efficacy of this training methodology over conventional approaches while also providing objective data to justify its routine use.
 
Limitations of Simulation Training
Simulation technology is expensive and TEE simulators are not immune to this phenomenon. A TEE simulator can cost from US$ 22,000 up to US$100,000. Maintenance expenses add to the overall cost of a simulator. A simulator also needs to be placed in a dedicated training area and this cost should also be accounted for. Other echo modalities such as M-mode, spectral Doppler and color flow are challenging to reproduce and are not currently available. Similarly simulation of transducer functions, such as gain, compression and depth are not available. Simulation of pathologic states is the next frontier in TEE simulation when the touch of a button can produce mitral valve prolapse, aortic stenosis, or a regional wall motion abnormality.
 
CONCLUSION
Simulation patients are the issues, learning gaps, and needs that are required to improve simulation patient education. Simulation based education are requiring for the concept of virtual humans, embodied conversational agents, fundamentals of acting, clinical play, virtual humans, and future immersive technologies. A fresh look is needed into looking at standardized patient education. Improvization is essential in simulation in which there is a need to show and simulation can get us to a better level of quality when educating these essential medical role players.
REFERENCES
  1. Cooper JB, Taqueti VR. A brief history of the development of mannequin simulators for clinical education and training. Postgrad Med J. 2008;84:563-70.
  1. Ziv A, Wolpe PR, Small SD, Glick S. Simulation-based medical education: An ethical imperative. Acad Med. 2003;78:783-8.
  1. Ziv A, Wolpe PR, Small SD, Glick S. Simulation-based medical education: An ethical imperative. Simul Healthc. 2006;1:252–6.
  1. Nishisaki A, Keren R, Nadkarni V. Does simulation improve patient safety? Selfefficacy, competence, operational performance, and patient safety. Anesthesiol Clin. 2007;25(2):225–36.
  1. Morgan PJ, Cleave-Hogg D. A worldwide survey of the use of simulation in anesthesia. Can J Anaesth. 2002;49(7):659–62.
  1. Chakravarthy B. Academic resident. Medical simulation in EM training and beyond. Edited by the SAEMGME Committee.
  1. Ahmed K, Jawad M, Abboudi M, Gavazzi A, Darzi A, Athanasiou T, et al. Effectiveness of procedural simulation in urology: A systematic review. J Urol. 2011 May 13. PMID 21571338.
  1. Practice guidelines for perioperative transesophageal echocardiography. A report by the american society of anesthesiologists and the society of cardiovascular anesthesiologists task force on transesophageal echocardiography. Anesthesiology. 1996;84:986–1006.
  1. Cheitlin MD, Armstrong WF, Aurigemma GP, Beller GA, Bierman FZ, Davis JL, et al. ACC/AHA/ASE 2003 guideline update for the clinical application of echocardiography: Summary article. A report of the American College of Cardiology/American Heart Association task force on practice guidelines (ACC/AHA/ASE committee to update the 1997 guidelines for the clinical application of echocardiography). J Am Soc Echocardiogr. 2003;16:1091–110.
  1. Cahalan MK, Abel M, Goldman M, Pearlman A, Sears-Rogan P, Russell I, et al. American Society of Echocardiography and Society of Cardiovascular Anesthesiologists task force guidelines for training in perioperative echocardiography. Anesth Analg. 2002;94:1384–8.