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By

Edward S. Kosik, DO
Department of Anesthesia, Case Western Reserve University, Metrohealth, Cleveland, OH

MENTOR: Paul Barach, MD, MPH


Department of Anesthesia, Utrecht Medical Center, Utrecht, Netherlands, and
College of Medicine and Public Health
University of South Florida, Miami, FL

University of Southern California, 1969.

International Anesthesia Research Society, March 27, 2007.


Four Decades of Suspending Disbelief:
Milestones in Anesthesia Simulation

. The value of history lies in the fact that we learn by it from the mistakes of others, as
opposed to learning from our own which is a slow process.

W. Stanley Sykes (1894-1961)

Introduction

Anesthesia full scale simulation has evolved for forty years. Anesthesia simulation has
experienced inconsistent but exponential growth ever since the founding fathers of anesthesia
simulation, Dr. Denson and Dr.Abrahamson, brought Sim One to life in the late 1960s.
No single innovation can be credited for the current status of anesthesia simulation. It has taken
many. This manuscript attempts to illustrate the major innovations responsible for
metamorphosing anesthesia full scale simulation to its current status.

Patient Safety: The Driving Force

The current climate of simulation and medical education has been altered tremendously by an
initiative for patient safety. In fact, patient safety has been the most important driving force
behind anesthesia simulation. A multidisciplinary approach has been taken to address patient
safety in medicine. The issue of patient safety was fueled by input from the Institute of Medicine,
Accreditation Council for Graduate Medical Education, healthcare experts, aviation experts and
others.

In 1994, Leape explained why adverse incidents in healthcare were not perceived as an issue at
that time. He noticed that adverse events are scattered, most errors do not lead to serious injury,
and the culture of health care leads clinicians to deny or conceal errors.1

In 1999, the Institute of Medicine reported that up to 98,000 patients die yearly secondary to
medical errors in the United States.2 In a follow-up work the IOM stressed the importance of
simulation in training of novice practitioners, problem solving and crisis management especially
when new and potentially hazardous procedures and equipment are introduced.3

David Leach, MD, pointed out that patient safety relates in some way to the six ACGME
competencies that guide residency training programs.4

It was realized that the six competencies cannot be accomplished entirely by the use of real
patients. Logistical, ethical and economic issues often preclude systematic, contextual, learner-
focused deliberate practice with rich immediate feedback the well-known critical components
of attainment of expertise.5 In other words, it was understood that simulation could be used to
teach essential principles in medicine and sometimes better than using a real patient.

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There were also medico-legal constraints of medical education which provided a chance for
simulation to flourish. With the recent implementation of the Health Insurance Portability and
Accountability Act of 1996 (HIPAA), medical students have less opportunity to come in contact
with real patients. The litigious society in the United States has also left less opportunity for
medical students and residents to perform dangerous procedures on patients. Lastly, limited
resident work hours have left less time and experience for residents to train. Simulation is a
possible solution to these deficits in training. 6

Before Anesthesia Simulation: From Go to the Early 1900s

Anesthesia full scale simulation grew as an indirect result from simulation efforts in different
industries. The history of mans use of simulation is rich. The game of Go originated in the
orient three to four thousand years ago and was mentioned in the analects of Confucius.7 Legend
states that Go was a theocratic means to simulate the interaction of universe with the
individual. Though a far distance from what simulation has become today this example
exemplifies mans yearning to simulate human behavior in one form or another.
The earliest use of simulation is debatable. Using simulators for war has been a reoccurring
theme. The quintain emerged in the Middle Ages to train warriors for the battlefield. It is
rumored that the first quintains began as a mere tree trunk which later developed into more
sophisticated designs. The quintain simulated a combat situation without the risk of serious
injury or loss of life while simultaneously improving the skill of a warrior.8

Application of man-made simulators to medical situations did not occur until approximately the
mid 16th century. The Gregoires obstetric simulator could replicate the birth of child and
accompanying problems. This simulator consisted of a human skeletal pelvis contained in a
wire basket with oil skin to simulate the genitalia and coarse cloth to simulate the reaming skill.
Real fetuses, likely preserved by some means, were used in conjunction with the manikin.
Additional obstetrics simulators would be developed after the Gregoires but widespread
adoption would be limited secondary to skepticism and cost. 9

In 1930, the Link flight simulator was successfully designed and patented. The Link Trainer,
became a flight training standard before World War II and beyond.10 Nuclear reactors also used
simulation to train personnel for everyday operations and crisis situations.

Sim One Era-a Peacetime application

Two significant events occurred at the University of Southern California during the 1960s. In the
midst of establishing one of the first departments of Medical Education in the United States, Dr.
Barrows introduced the standardized patient in 1963.11 The second event occurred in the mid
1960s when Dr. Stephen Abrahamson and Dr. Judson Denson developed Sim One. Sim One
marked the genesis of the modern day computer controlled patient simulator. It was constructed
because of Aeorojets need to develop peacetime applications of its capabilities in the face of
diminishing military funding, before the escalation of the Vietnam conflict according to
Abrahamson.12 Funding for SimOne was hard to come by. The National Institutes of Health and
military rejected requests for funding to build Sim One. Finally, a grant of $272,000 from the
United States Office of Education provided the money for Sim One. 13,14

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Although different in many ways, Sim One had similar characteristics to those of standardized
patients. Both the Sim One and the standardized patient provided a safe environment for learner
and patient, immediate feedback was possible, faculty could control the learning objectives,
rehearsal of clinical situations, performance could be compared, limited harm to real patients,
and offered a compressed time frame.15 With the similarities, time and place of development, one
could surmise that the standardized patient provided a springboard for the development of Sim
One. Plans for a descendant, Sim Two never came to be. Sim One was clearly ahead of its time.16

Anesthesia Patient Safety Foundation (APSF)

In 1984, The Anesthesia Patient Safety Foundation (APSF) was founded as the result of the
International Symposium on Preventable Anesthesia Mortality and Morbidity (ISPAMM) held in
Boston, Massachusetts. The Foundations mission is to strive to ensure that no patient is
harmed by anesthesia. In keeping with its mission, the APSF provided funding for a portion of
earlier work in anesthesia simulation.17

Commercialization of the Anesthesia Simulators

With the highest estimates, the cost of Sim One was $272,000 back in 1968, this would carry a
price tag of more than 1.5 million dollars today.*18 Further evaluation of Sim One, with a simple
business model of supply, demand and cost allows one to see Sim Ones fate. With minimal
supply (which was one simulator) and little demand the cost was excessive. Commercialization
bred new life into anesthesia simulation and brought cost down. Gaba states,
Until the commercialization of the simulators there were only a couple of them.
Maybe each of the university sites could make a couple more for collaborators
elsewhere. Once they were made and sold ANYBODY could have one if they
paid for one. This was a huge event. It was greatly stimulated ten years later
when the manufacturers came out with medium-capability simulators that did
about 75% of what the others did for 15% of the price.19

In the mid eighties the environment was better suited for a reintroduction of anesthesia
simulators. In 1986, Comprehensive Anesthesia Simulator Environment (CASE) was a series of
simulators being developed by Gaba and DeAnda. CASE used commercially available
waveform generators to provide signals to actual clinical instruments. Other features included a
non-invasive blood pressure cuff, ability to occlude the left mainstem bronchus, insertion of
intravenous lines, CO2, mask ventilation, intubation, auscultation of breath sounds. However, the
simulator did not have palpable pulses or spontaneous ventilation.20 In 1989 CASE 2.0 was
released and featured a cardiovascular system physiologic model. 21

CAE-Link Corporation showed interest in creating an anesthesia simulator called the Virtual
Aneshesiology Training Simulator System (also known later as Eagle Patient Simulator) and
licensed technology from Drs. David Gaba and Howard Schwid. Later on CAE-Link turned the
anesthesia simulation division into Medsim-Eagle Simulation, Inc, which is no longer in
existence.

The Eagle Simulator contained complete models of cardiovascular, pulmonary, acid-base,


neuromuscular and thermal physiology. The lungs could change compliance, and were totally

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embedded in the mannequin so that it could be moved from bed to bed. Advanced airway
techniques could be performed on the simulator and CO2 could be monitored. The Eagle Patient
Simulator generated heart and breath sounds, had a changeable airway anatomy, palpable carotid
and radial pulses, and a thumb that responded to nerve stimulation. Arms were able to move in
response to light anesthesia and up to five events could run simultaneously. The CAE-Link
simulator could respond to 90 different medicines. A SmartStethoscope changed the intensity
and pitch of lung sounds based on where the stethoscope was placed. In 1999, a trans-esophageal
echocardiogram could be used with the CAE-Link simulator, although full capabilities were not
available at that time.22

The Good and Gravenstein team at the University of Florida was working on The Gainesville
Anesthesia Simulator (GAS) at about the same time CASE 1.2 was being created. 23 The
waveform generators were the same types used in the CASE series. The simulator had palpable
pulse, non-invasive blood pressure measurement devices and a thumb that moved in response to
the degree of nerve block and stimulation. GAS was capable of spontaneous ventilation, and
monitoring O2, N2O, N2 and one volatile anesthetic which were based on a mathematical model
of gas exchange, uptake, and distribution. Loral Data Systems Inc, purchased the license for
GAS. GAS was eventually intercepted by Medical Education Technologies Inc (METI). The
Human Patient Simulator was a new simulator developed by METI. This simulator had a bar-
coded drug recognition system at the stopcock. The Human Patient Simulator allowed real time
control of parameter and scenarios.

Other models of simulators would follow in different parts of the world. Some examples are the
Leiden Anesthesia Simulator, Anaethesia Simulator Sophus, PATSIM-1, and ACCESS.. 24
A surprisingly late comer, the Laerdal company, creator of Anne the resuscitation doll, did not
enter into the the high fidelity simulator until the mid-1990s . SimMan was created by Laerdal.
Affordability was the main feature of SimMan. 25

Unfortunately, because of limited resources, patient safety was not always an issue of doing what
was absolutely right for the patient but a balance between cost and benefits. But SimMan made
high fidelity simulation and patient safety more accessible to many teaching institutions by
making simulation more affordable.

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Figure 1 Sim One with Dr. Denson and Dr. Abrahamson26

Figure 2 Photogragh of CASE 0.5 (June 1986) . Note


limited mannequin and minimal audiovisual system.27

Figure 3 METIs Human Patient Simulator 28

Anesthesia Crisis Resource Management (ACRM) course unveiled: Providing Structure

The Anesthesia Crisis Resource Management Curriculum was introduced in 1990. The
foundation for this course was based on Aviation Crew Resource Management common to the
aviation industry. The main idea behind ACRM was to train crews of a single discipline to work
together as teams in the event of crisis (or even in the absence of one). In ACRM the art of
debriefing is emphasized. ACRM was classified under the Naturalistic Decision Making
thinking of helping sharp end users deal with high impact, uncertain, and potentially life
threatening events. 29 Additionally, the ACRM course helped to identify gaps in the training of
anesthesiologists and how to deal with them.
Gaba believes that the ACRM philosophy was the defining factor in establishing anesthesia
simulators as more than just toys. As a result of ACRM and other factors, anesthesia simulation
possibilities were broadened and this lead to its substantial growth and acceptance. 30 The other
factors most likely included the demand to improve patient safety and training of anesthesia
caregivers.

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Micro-simulators, a Complementary Tool

Full scale macro-simulators can be complemented by the use of micro-simulators. Micro-


simulators are also known as graphical anesthesia simulators. Micro-simulators offer
autonomous, cognitive training. The advantage to this form of simulation is that the software is
highly affordable. The programs cost anywhere from seventy to eight hundred dollars. Most of
the micro-simulation software can operate on a home personal computer without difficulty.

Micro-simulators also offer the advantage of running and debriefing scenarios autonomously.
Learning can take place at any time of the day without scheduling conflicts. Use of the more
expensive, full scale simulation training could be spent on interpersonal and team training.31
Some examples of micro-simulators are the Anesthesia Simulator Consultant (ASC), Critical
Care Simulator and ACLS Simulator by Anesoft Corporation and Body Simulation for
Anesthesia by Advanced Simulation Corporation. The APSF provided the funding for the
development of the three software titles by Anesoft.32

Simulation Education Workshops

In October 2002, the American Society of Anesthesiologists sponsored its first Full Scale
Simulation Education Workshop at its ASA Annual meeting in Orlando, Florida. On March 11,
2006 Simulation Saturday was held under the leadership of the ASA Simulation Taskforce.
Seventeen simulation centers took part in this event which was a single-day, free-to-ASA
members event that introduced new methods of skill acquisition and refinement33. At the 2006
ASA annual conference in Chicago, a simulation workshop was held via teleconference from
Boston Medical Center. In October 2007, ASA plans to hold a workshop entitled The ASA
Simulation Network: Information for Prospective Centers. The various anesthesia simulation
workshops, in addition to the ASA White paper, highlight the ASAs dedication to provide the
impetus for anesthesia simulation and improving patient safety.

Portability of Simulation

Technology has made simulators more accessible, portable and "cheaper".34


Ruben J. Azocar, MD, Director of the Boston University Simulation Program

Getting the trainee to the simulator or vice versa has been a major issue in anesthesia simulation
used in education. Having trainees travel across town to a simulation center may decrease the
probability of practicing on a simulator.
At times, anesthesia simulation workshops would either teleconference a simulation across the
country like at the American Society of Anesthesiologists annual conference 2006 or have
workshops at a permanent simulation center site. At times, this could be impractical or could
take away from the actual simulation experience. Some progress has been made regarding this
issue.
The Anesthesia In Situ Simulation Program was created at Stanford University School of
Medicine. As a result, a high fidelity fully transportable simulator on wheels has been
developed. This portable simulator allows simulation access for hospitals or training programs

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which might not have their own simulators. Its capabilities were demonstrated at the Society of
Pediatric Annual Conference simulation workshop held in Arizona, in March 2007. 35
Simulation Goes Live

In March 2007 at the International Anesthesia Research Society annual conference, a simulation
workshop involved recreating an entire hospital operating room in a commercial hotel for the
first time. Unscripted residents were challenged in front of a live audience to address cases culled
from clinical scenarios. The simulation lasted 34 minutes.36 Interestingly, this amount of time
was about the duration of one session of the anesthesia oral boards.

The IARS workshop displayed several key factors. It showed that full scale anesthesia simulation
could be moved to remote locations. Furthermore, the workshops demonstrated that residents and
trainees who did not have a lot of simulation exposure could experience a high quality simulation
when conducted by skilled and experienced facilitators. Most importantly, the essential part of
the workshop was the detailed debriefing that is the heart of all learning from simulation.
Debriefing is where the eloquent fruits of education and patient safety are harvested, said one
of the residents who participated in the workshop.

Statewide Simulation Systems

The idea of a statewide simulation system was first implemented by the state of Oregon. This
program began as one simulation center in November 2003 and had twenty-three total locations
as of March 2007. Anesthesiologists are taking a major role in collaboration and
implementation of this statewide program.37 The Oregon model has the potential to become the
model for other states. The statewide simulation system provides a means of utilizing resources
that one single simulation center might not have. Some key benefits include multiple sites,
shared audio-video infrastructure, access for smaller or non-academic programs to content
experts or administrative advice, increased training opportunities, cost-sharing, a standardized
curriculum, stronger purchasing power, greater anesthesia practice collaboration and national
significance.38 Better training with less redundancy of resources should result from statewide
systems which may lower costs. Patient care might benefit as a result.

Anesthesia Simulation for Evaluation

For the past three years, Tel Aviv University Sackler School of Medicine accepted a new way of
accepting medical students which has resulted in an 18-20% change in the make-up of the
entering class. 39 The idea of assessing potential students with simulation stations was modeled
on appraisal centers used in the psychology and aviation fields.40

In a different application of simulation, the Israeli anesthesiology board exam incorporated


simulation as a part of their certification process. Three stations out of five included full scale
simulation. This examination has been administered for the past four years and has advanced to a
prerequisite component to the Israeli anesthesia boards.41

ASA Simulation White Paper and Committee on Simulation Education

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The Workgroup on Simulation Education was formed by the American Society of
Anesthesiologists to address the details of forming high quality simulation continuing medical
education in 2004. A poll was taken to identify issues pertaining to a CME program. Both
support for and skepticism was expressed. The majority of respondents gave praise for their
efforts but others expressed concerns about credentialing and financial exploitation. Also
surprisingly troubling, was a concern for stifling anesthesia simulation progress.42

Two years later the White paper was released by the Workgroup. The White paper gave the
details of how and why simulation programs would be implemented. The White paper also
described the requirements of an ASA approved simulator program. The Workgroup also
recommended the formation of a Committee on Simulation Education. The Committee plans to
review simulation sites to make certain that the appropriate faculty, facilities and content are
available. Important assumptions are found in the White Paper.43

Virtual Reality

Virtual reality is another form of anesthesia simulation but is not currently used for full-scale
high fidelity simulation. It has been used more for task training. Since the year 2000, anesthesia
residents trained using virtual reality for regional anesthesia techniques at the Mayo Clinic.
Residents don head-mounted displays and receive haptic feedback with advancement of the
needle for different nerve blocks.44 This system was based on a model developed at Ohio State
University.45 This type of simulation is still in its infancy but holds great promise for anesthesia
simulation.

Technology, Society and Gaming

Technology and society was not a specific simulation innovation in itself but was a broad critical
component in molding simulation and its use. It is reasonable to assume, that if the technology
was not accessible to support an innovation then it would fail. Also, if society was not interested
in an innovation, then it had a high chance for failure. The Sim One situation demonstrated both.
The accessibility to and acceptance of computers and patient safety was very limited compared
to todays standards. The momentum for anesthesia full scale simulation would change with the
progress and advanced capabilities of the computer.

Put into context, in 1982 Time magazine altered its annual tradition of naming a "Man of the
Year", choosing instead to name the computer its "Machine of the Year. When introducing this
theme, a Time magazine senior writer described the computers of the past as being distant and
ominous, but becoming commonplace. In another Time article it was mentioned that a person in
Tucson figured out how a personal computer could monitor anesthesia during surgery.46 The
accessibility of the computer was increasing at this time lending to a better environment for
widespread acceptance of anesthesia simulation.

The world-wide web came into existence in 1989. Accessing and sending documents by the web
became one of the quickest and most efficient means of obtaining information.
Over time, society embraced simulation generally more and more. Many stories emerged in
newspapers, magazines and television that featured how simulation was being used in medical

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education. Simulation has even presented itself in the movies. Simulation scenarios are found
several times in the Disney movie Monsters, Inc released in 2001. Currently, simulation has
encompassed a multitude of home video games. The different types of simulation video games
include truck, train, aviation, bowling, boxing, hospital, war-games, cities, families, etc. It is
likely that this acceptance into mainstream culture will eventually have a more positive influence
towards the acceptance of anesthesia full scale simulation in future anesthesia training programs.

Most recent METI Innovations

In August 2004, METI began to develop iSTAN (see figure 2) a Stand-Alone Patient Simulator
(SAPS). It was funded by the United States Army and is used in the training of combat medics,
anesthesiologists, anesthetists, surgeons and other healthcare staff. Model iSTAN internally
houses a carbon dioxide supply and simulated blood, mucous, and saliva and has heart, breath
and bowel sounds. The iStan simulator skin was cast from an actual person and the frame built
first with the rest of the body molded around the frame. This is different from previous
simulators where a plastic mannequin was built from the outside in. 47 This is the most realistic
full scale simulator to date.

Figure 4 iSTAN Stand alone patient simulator (SAPS)48

Discussion and comments

When I selected a topic to write about, I required that the topic was revolutionary, had a defined
but still emerging history and would address patient safety. Anesthesia simulation fulfills these
criteria. This essay attempts to summarize the most salient events in full scale anesthesia
simulation in the United States, although some international references are made. It is susceptible
to incompleteness secondary to the vast amount of information available about this topic. This
work was a mental exercise to help summarize where we have been with anesthesia simulation
and to better know where we have to go. As a result of pondering about anesthesia simulation
milestones, I identified several areas that deserve further investigation.

One area deals with the need for an easily accessible anesthesia simulation scenario databank.
This databank would probably be best promoted by giving free web access to anybody wishing
to obtain scenarios that could be used in simulation training.

Another has to do with the possibility of monitoring anesthesia care to improve patient care.
Video recording, similar to that found in anesthesia simulation, should be used to identify
mistakes or system errors during real patient care. Video recording is probably the most accurate
way to record anesthesia care. Especially for quality assurance purposes because it includes sight
and sounds of anesthesia which can give more details than the current record keeping systems.
More details can help us to honestly evaluate our care to make progress in patient safety.

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Above all, patient safety is of paramount importance to me as I can remember my first tragic
experience with a patient who died after my care only three months into my anesthesia residency.
My confidence was shattered. I simply wished that my program would have had simulation
implemented into the program. Although there was no major fault, I believe that care could have
been improved upon especially after reading Dr. Gabas ACRM text. Fortunately, I had a strong
desire, an understanding family, program director and attending who all helped me through this
adversity. In retrospect, I find even the remote possibility that my learning might have occurred
at the expense of a human life, disturbing.

During the following year, I made recommendations to my anesthesia department to implement


simulation into our training program and was successful in doing so. In May 2007, I presented
Suspending Disbelief: Anesthesia Simulation 2007 for my Grand Rounds presentation to
familiarize my anesthesia department with the latest in anesthesia simulation. A seed has been
planted for patient safety. I believe that many anesthesia teaching programs without simulation
programs need just a little extra persuasion to tip the scale towards using simulation.

I conclude that the potential of anesthesia simulation is simply astounding. We have reached a
point where there is no turning back. A tipping point secondary to the great inertia of this
powerful tool and the desire to maximize patient care has been reached. But this tipping point is
not where the potential ends. We still have a long way to go. Simulation has the immense
potential to save patients lives. I simply believe that anesthesiologists have an obligation to
continue in this odyssey of familiarizing others with this powerful learning tool.

I finish my essay with a quote from Paul Barach, MD, MPH, founder, and former director of the
Miami Center for Simulation:

Simulation is the safest way to prevent harm to patients while mastering anesthesia; patients
deserve this, students deserve this.
* Inflation adjusted price using the Inflation Calculator which uses the Consumer Price Index statistics from
Historical Statistics of the United States (USGPO, 1975) for data before 1975. All data since then are from the
annual Statistical Abstracts of the United States.

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48
Image obtained from METI website http://www.meti.com/Product_istan.html accessed September 6, 2007.

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