Marjorie Lee White, Anne Ades, Allan Evan Shefrin and Susanne Kost
© Springer International Publishing Switzerland 2016
V. J. Grant, A. Cheng (eds.), Comprehensive Healthcare Simulation: Pediatrics, Comprehensive Healthcare Simulation, DOI 10.1007/978-3-319-24187-6_11 M. L. White ()
Department of Pediatrics, Office of Interprofessional Simulation, Pediatric Simulation Center, University of Alabama at Birmingham, Children’s of Alabama, Birmingham, AL, USA
e-mail: [email protected] A. Ades
Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
e-mail: [email protected]
Department of Pediatrics, Neonatology Division, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
A. E. Shefrin
Department of Pediatrics, Division of Pediatric Emergency Medicine, University of Ottawa, Children’s Hospital of Eastern Ontario, Ottawa, ON, Canada
e-mail: [email protected] S. Kost
Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
e-mail: [email protected]
Simulation Pearls
1. Task trainers are available commercially for most major pediatric procedures
2. Multiple recipes for homemade task trainers are available 3. Curricular development is an important component for
pediatric procedural skills training
4. Simulation enables the learner to practice potentially life- saving but rarely performed emergency procedures
Introduction
Procedures are a fundamental part of healthcare delivery.
Learning procedures on task trainers has been a practice for centuries. Task trainers are devices that replicate a portion of a complete process or system [1]. They may take many forms, ranging from foods (e.g., using oranges to practice injection techniques or pig’s feet to practice suturing) to more developed plastic molds, which allow for repetitive
use. In addition, virtual reality trainers are now being devel- oped and used with increasing frequency and effectiveness.
In pediatrics, there are added challenges for development of procedural competency, which include the limited op- portunities in clinical practice and the technical complexity inherent in the variability of patient size and physiology. As such, learning procedures on a partial task trainer, particu- larly those that are uncommon and high risk, is a preferred learning modality.
The use of simulation for psychomotor skills acquisition has received significant attention in the literature [2, 3]. Its use is advocated by major medical accrediting bodies includ- ing the Accreditation Council for Graduate Medical Educa- tion (ACGME) and the Royal College of Physicians and Surgeons of Canada [4, 5]. Table 11.1 lists the specific pro- cedures required of pediatric medical trainees. Several meta- analyses have shown that simulation-based procedural skills training results in improved skill acquisition [6–10].
Review of Procedural Task Trainers Airway
Successful completion of a procedural task is a function of knowledge, skill, and judgment. The learner requires knowl- edge and judgment as to when an airway maneuver is neces- sary and skills practice to perform the action competently and with consistency. Airway task trainers were among the first devices to become available for simulated medical skills training [11]. A variety of devices are currently marketed to assist the learner in understanding the anatomy of the pedi- atric airway and to facilitate learning and practice of physi- cal airway-related skills. Airway task trainers may comprise partial- or whole-task training and may include both virtual and/or physical components. Live animals (e.g., cats, ferrets) have traditionally served as pediatric airway task trainers, but cost and ethical considerations limit the practicality of
this approach. The remainder of this section will focus on inert physical airway task trainers.
Airway-related tasks in pediatric medical training gener- ally consist of techniques that enable maintenance of a patent airway and ventilation when anesthesia, illness, or trauma hinder the patient’s ability to do so independently. Insertion of airway adjuncts, such as nasopharyngeal and oral pha- ryngeal airways, and artificial airways, such as laryngeal mask airways and endotracheal tubes, are techniques well suited for skills training on physical task trainers. Some air- way task trainers also have simulated lungs that allow the learner to practice ventilation skills, either via a bag-mask device placed directly on the simulated face or via an artifi- cial airway.
The most basic physical airway task trainer consists of a simulated head with a realistic face, nose, and mouth. The simplest models have an externally anatomically correct nose and mouth with a simple opening in the mouth con- nected to rudimentary simulated lungs that will inflate with appropriate positive-pressure ventilation. The lungs may be as simple as a pair or balloons attached to a simulated tra- chea, or may be embedded within a whole torso or whole- body mannequin, where ventilation is assessed by chest rise. When provided in a variety of sizes (neonate, infant, child, adolescent), even the most basic airway task train- ers allow practice in the selection of an appropriately sized
facial mask, proper technique for holding the mask, and an approximation of ventilation volume required for patients of various sizes.
The next level of airway task trainer increases human physical resemblance with the addition of a patent nasophar- ynx and an anatomically realistic oropharynx and upper air- way, including tongue, epiglottis, larynx with vocal cords, and upper esophagus. Again, a variety of ages and sizes en- able instruction in the anatomic differences among these age groups. For example, the neonatal and infant task trainers allow emphasis on the anterior placement of the infant lar- ynx and the smaller caliber of the airway, and the child and adult task trainers include teeth.
In addition to the normal anatomically correct airway models, task trainers have also been designed to allow prac- tice with a more difficult airway. Even in the absence of elec- tronics, some models include features such as a controllable degree of mouth opening, changeable limit of neck flexibil- ity, and an inflatable tongue.
With the addition of high-fidelity electronic components, airway task trainers can mimic functional as well as anatom- ic features of the airway, and these features may be activated remotely in real time, changing the difficulty of the task. For example, the tongue can be inflated to mimic airway swelling and the vocal cords can be clamped to mimic laryngospasm.
Some simulators can produce sounds that mimic stertor or
Table 11.1 Procedures required by selected accrediting organizations for Pediatric certification
Procedure ACGME (2012)a Royal College (2008)b Royal College of Pediatrics and
Child Health (2014)c
Intravenous access/peripheral venous cannulation Y Y Y
Venipuncture Y Y
Umbilical venous cannulation Y Y Y
Umbilical arterial cannulation Y
Arterial puncture Y
Suture of a one layer laceration, simple wound closure Y Y Cardiopulmonary resuscitation (neonatal and pediatric) Y Y
Chest tube placement and thoracentesis Y (patient or model)
Intraosseous insertion Y (simulated) Y (patient or model)
Gastric tube placement (oro or nasogastric) Y
Bladder catheterization and/or suprapubic aspiration Y Y
Lumbar puncture Y Y
Bag-mask ventilation Y Y Y
Tracheal intubation Y (neonate) Y (neonatal and pediatric) Y (term and preterm 28–34 weeks)
Gastric tube placement Y
Giving immunizations Y
Incision and drainage of abscesses Y
Reduction of a simple dislocation Y
Removal of foreign body Y
Temporary splinting of a fracture Y
a ACGME 2013. https://www.acgme.org/acgmeweb/Portals/0/PFAssets/2013-PR-FAQ-PIF/320_pediatrics_07012013.pdf. Accessed 21 Oct 2014
b The Royal College of Physicians and Surgeons of Canada
c Royal College of Pediatrics and Child Health, Directly Observed Procedures (DOPS). Compulsory procedures listed. http://www.rcpch.ac.uk/
system/files/protected/page/DOPS%20Guidance%20June%202014.pdf. Accessed 21 Oct 2014
stridor, suggestive of airway obstruction. High-tech models can also be used for assessment purposes, with sensors that enable the facilitator to assess technique and success of the desired task from a remote location via computer monitor.
High-fidelity airway simulators can detect airway reposi- tioning, tracheal versus esophageal placement of an endo- tracheal tube, adequacy of ventilation, and even pressure on teeth during laryngoscopy.
Advantages of airway task trainers include the ability of learners to practice a skill in a variety of patient sizes and as many times as necessary, all without potentially causing trauma to an actual patient. Depending on the fidelity of the device, airway trainers may also provide valuable feedback to the instructor, without having to look directly over the shoulder of the learner. Direct and indirect (video) laryngos- copy and endotracheal tube placement are difficult skills to master, and studies of groups of new learners have shown that these skills can be mastered well with the aid of airway task trainers (see Fig. 11.1) [11, 12].
However, some of the features of a human airway do not lend themselves well to practice with a rigid, plastic airway task trainer. Mandibular positioning and flexibility with a jaw thrust is not replicated well with most plastic head models or mannequins. Many of the trainers and mannequins have a stiff feel compared to actual tissue. Control of secretions is also an important skill in the management of a pediatric air- way, yet simulator technology has not yet reached the point where task trainers or mannequins can produce drool, mucus, or emesis. Clever post-marketing modifications have been described, including gluing a nasal cannula inside out inside the nose of a mannequin head skin, enabling fake mucus to be pumped from an infant nose [13], and recipes for simu- lated mucus, blood, and emesis are also available [14, 15].
In addition to standard techniques for insertion of artifi- cial airways, task trainers can also facilitate surgical airway practice. The simplest of these models involves the creation
of a permanent stoma (drilling a hole) into a doll or manne- quin with a hollow neck to enable practice of tracheostomy tube replacement. Animal models, commercial head and neck task trainers, and high-fidelity mannequins are avail- able for practicing cricothyrotomy, all enabling study of the speed and efficacy of various devices and techniques as well as retention of skills [16, 17]. In addition, artificial models can be created using easily accessible medical equipment, as well as real models such as pig tracheas can also be used (See Figs. 11.2 and 11.3). Unfortunately, the majority of re- search on the topic of surgical airways focuses on the adult trauma victim, and the majority of the task trainers therefore also reflect adult anatomy. Porcine tracheas provide a close physical approximation of adult human airway anatomy.
Some work is being done with other animal models includ- ing rabbits, which more closely approximate the pediatric airway in size. One published study evaluated the efficacy
Fig. 11.3 Cricothyrotomy model with cannula. (Photo courtesy: Cana- dian Medical Education Journal [98])
Fig. 11.1 Pediatric airway task trainer. (Image courtesy: Laerdal
Medical) Fig. 11.2 Cricothyrotomy model showing equipment needed. (Photo
courtesy: Canadian Medical Education Journal [98])
of a commercial device for rapid percutaneous cricothyrot- omy in pediatric patients using adult rabbit cadavers [18].
All learners were successful in inserting the device and in providing adequate ventilation, with two of the ten tracheas suffering minor trauma.
Vascular Access
Vascular access is a critically important yet technically dif- ficult skill to master in the pediatric patient. The insertion of a catheter into a blood vessel is again a procedure that lends itself well to practice with a task trainer before engaging in this technique on a real patient. A variety of devices have been developed and implemented to facilitate this practice.
These trainers can be divided into three basic categories:
computerized models with haptic feedback, animal models with artificial blood vessels embedded within, and simulated plastic limbs with embedded blood vessels. Some of these trainers are geared specifically for practicing peripheral ve- nous access while others for central venous access, with or without the aid of ultrasound guidance. Trainers also exist for practicing more invasive vascular access procedures such as intraosseous access, which typically consists of either ani- mal tissue (e.g., chicken leg) or plastic bone models, with or without overlying simulated soft tissue [19].
The virtual intravenous (IV) access trainer consists of computer software that provides didactic education as well
as a stepwise approach to the entire task, from preparation through completion (see Fig. 11.4). Both adult and infant versions are marketed. The software provides feedback to the learner when steps are missed during the practice ses- sion. The computer monitor also provides visual feedback, with the ability to vary features such as skin tone, body size, and habitus. The computer is attached to a haptic device with a simulated IV catheter, which allows some level of senso- ry feedback as to features such as skin compliance, arterial pulse, and vessel depth. Incorrect insertion is met with visual feedback, such as bleeding or bruising visible on the moni- tor. The virtual trainer has some useful features, including the ability to provide didactic education and skills assess- ment in the absence of an instructor. The device is expensive, but can be used by many learners without the need to supply tissue or actual IV catheters, and the risk of needle sticks dur- ing training is eliminated. However, a realistic sensation of a needle entering tissue and the pop of puncturing the vessel are lacking in this device.
Animal tissue models typically consist of the muscle mass and overlying skin, with plastic tubing of various thick- ness and diameter inserted within the tissue to simulate ves- sels. The artificial vessels may be cannulated via traditional palpation-based localization or via ultrasound-guided tech- niques. A chicken tissue model was shown to improve com- fort levels in physician trainees learning ultrasound-guided central line placement [20]. The tubing can be filled with simulated blood under pressure to enable a flash in the hub of
Fig. 11.4 Virtual intravenous access trainer. (Photo courtesy:
Sue Kost)
the needle as feedback for proper placement of the tip of the needle before threading the catheter. Attaching the tubing to a fluid bag enables continuous flow of simulated blood from the cannulated vessel and the ability to practice flushing the catheter once it is correctly placed.
Plastic limbs with embedded blood vessels work in a manner similar to the animal tissue models described earlier, without the potential risk of infectious disease transmission and need for cold storage. Drawbacks to the plastic models include the lack of true tissue feel and the retention of per- manent holes in the plastic (needle tracks) when the same site is punctured repeatedly. Some models have replaceable simulated skin and tubing that alleviates this problem.
Commercial central venous access task trainers include torso models for subclavian, internal jugular, and femoral venous access. Simulation for central venous access training has been shown to be an effective teaching tool in numerous studies over the past decade. Training programs that have embraced vigorous, simulation-based medical education have seen patient and unit-based improvements in clinical care. Outcomes documented include improved success rates in performing procedures by novice learners in the clinical setting and decreased central line infections. The incorpo- ration of ultrasound guidance further improves the success rate of simulated central venous access, with this skill having been shown to translate to improved success in real patients [21–24]. Specific task trainers for teaching ultrasound-guid- ed access (phantoms) are readily available (See Fig. 11.5), both commercially and with homemade versions [25].
One final vascular access technique unique to the pe- diatric setting is that of umbilical vessel catheterization in neonates. Task trainers utilized for practicing this procedure include using actual tissue (e.g., discarded umbilical cords) as well as plastic models. The plastic models are available on their own and as part of whole-body infant mannequins (See
Fig. 11.6). In addition, post-market modifications to com- mercially available models have been described [26].
Surgical Procedures
Task training in pediatric surgery has focused on laparoscop- ic surgery skills, trauma procedures, and suturing. Surgical simulators may be in the form of cadaveric or animal models, commercially produced models, or virtual reality computer simulators [27, 28]. The specific skill that is being taught will determine which trainer should be used and the environ- ment best suited for training. Trainers have been developed for circumcision, gastroschisis repair, pyloromyotomy, and thoracoscopic repair of tracheoesophageal fistulas [29–33].
Other procedures for which models exist include models to assist with extracorporeal membrane oxygenation training, endoscopy, and cardiac surgery planning [34–36]. The Soci- ety of American Gastrointestinal and Endoscopic Surgeons has developed and validated an adult-sized “fundamentals of laparoscopic surgery” simulator [37]. A pediatric version of this simulator has been developed using smaller components [27]. These simulators teach object transfer, pattern cutting, ligating loops, and suturing using laparoscopic equipment, and have become a mandatory part of surgical training across North America. For further details, please refer to Chap. 22.
Ear, Nose, and Throat Procedures
Children undergo a proportionately higher percentage of procedures on the head and neck than adults, and task train- ers have been developed for a variety of these ear, nose, and throat (ENT) procedures. Both commercially available and
Fig. 11.6 Female newborn infant reproduction designed for the prac- tice of umbilical catheterization. (Image courtesy: Laerdal Medical) Fig. 11.5 Ultrasound for venous access. (Photo courtesy: CAE
Healthcare)
homemade devices have been described for practicing tasks ranging from simple ENT procedures (e.g., removal of ceru- men from the external auditory canal) to the more complex (e.g., cleft palate repair). A comprehensive review of the use of simulators in the field of otolaryngology concluded that dozens of task trainers are available or under development in this field. Nearly 100 peer-reviewed publications were reviewed, demonstrating the burgeoning potential of simula- tion for teaching and evaluating ENT skills [38]. This section will focus on ENT procedures in children that are typically performed outside of the operating room.
A common ENT problem in the pediatric population is that of insertion of foreign material into an orifice, and the large proportion of foreign bodies ends up being inserted into the ears, nose, and respiratory tract. Foreign body removal is a procedure that is easily practiced with a task trainer.
Commercial ear simulators are marketed (with replaceable ears) that enable practice of otoscopy and cerumen removal as well as removal of foreign bodies of various shapes and sizes. Bone wax or beeswax serve as reasonable substitutes for cerumen, and beads and small toys can serve as real ex- amples of foreign bodies. One model provides both auditory and visual feedback when too much pressure is applied to the ear canal or tympanic membrane [39].
Treatment of epistaxis is another common problem ame- nable to practicing in a simulated environment. Mannequin heads and task trainers can both be modified to mimic epi- staxis [40–41]. Commercial devices are available in adult sizes, including one that enables control of the amount and speed of nasal bleeding. These devices enable the learner to practice various packing techniques for the control of hemor- rhage [42].
Procedures in the oral cavity can also be simulated; how- ever, there are currently no commercially available pediatric models. Dental procedures can be taught with a virtual real- ity device that combines graphics on-screen with a haptic device for practicing drilling and implant techniques [43].
A recent publication describes the creation of an inexpen- sive model of peritonsillar abscess with latex moulage of an oral cavity to enable practice of drainage procedures (see Fig. 11.7) [44]. Existing mannequins and airway task train- ers can be modified to allow practice of removal of foreign material from the upper airway.
Cardiovascular and Pulmonary Procedures Given that the illnesses and conditions requiring cardio- vascular and pulmonary procedures in pediatrics are rare, practitioners have limited real-life experience performing these potentially lifesaving procedures, including chest tube insertion and pericardiocentesis [45–47]. A wide variety of task trainers have been developed and used to fill these gaps.
Homemade task trainers are generally of lower cost and are simple to construct. A pediatric chest can be simulated using a rack of pork or lamb ribs (see Figs. 11.8 and 11.9) [48]. Animal models best approximate human tissue as the
Fig. 11.8 Pork rib model. (Photo courtesy: Allan Shefrin)
Fig. 11.7 Task trainer for drainage of a peritonsillar abscess. (Repro- duced with permission of SAGE publications [44])