EDITORIAL – Should humans be used as a teaching tool? ….Simulation in Anaesthesia

Author: Dr Shahab Naqvi

HOD, Department of Cardiac Anaesthesia
AFIC/NIHD, Rawalpindi (Pakistan)

On 13th of April 1970 the Apollo XIII astronauts notified their mission control that a devastating explosion in one of the oxygen tanks had taken place. At that time they were thousands of miles away from the earth moving very fast in an unknown direction. Lives of all three of them i.e. Fred Haise, John Swigret and James Lovell were in great danger. They never gave up but continued their voyage after giving up the command module and performed necessary repairs, completed the mission and landed safely on 17th April 1970 (1). This is a story of shear commitment, great courage and application of knowledge and training at the time of absolute need and extreme danger. None of them had had any ‘practical experience’ of a similar situation before. Behind their success was years of exhausting training on ground of coping up with worst case scenarios on simulators. Simulators have been in use for years now; starting from their use in aviation and space exploration, military trainers have been quick to grasp their benefits. Advanced computer technology has firmly secured its place in the modern armament and present day guns, tanks, fighter-bombers and even missiles, bombs and alike, all are heavily dependant upon the chip. The increased complexities in the defense arsenal has led to development of training simulators, in which computers simulate real looking (virtual) scenes of different situations; normal as well as abnormal or usual and unusual. Trainees practice with these simulators and get prepared for the real life experience.

The purpose is not to downplay the importance of experience in the fields of aviation, astronomy or anesthesia, where there is no second chance to rectify the mistakes, but, is it necessary to learn or get trained only after passing through a devastating experience? The wisdom dictates us to learn from the mistakes of the others. Human life is too precious to be used for experimenting or imparting training, be it our own or anybody else’s. After all patients are not the guinea pigs. With modern developments in bioengineering it has become possible to simulate almost all body actions, biochemical reactions included. Simulators are available in the market with huge number of worst case scenarios already fed in the software with multiple options to change and improve according to our need.

By convention, we all have been getting and imparting training on patients. In an emergency department, where the life of the patient is in grave danger, how ethical it will be to train e.g. endotracheal intubation. Anaesthesia is a specialty that requires quick reflexes with prompt application of knowledge and skills with zero chance of error. This all is only possible with continuous training on scenarios, which you might come across only once in your life. Medical literature is rich with case reports of such incidences. Theoretical knowledge is important but to be able to confront with the disasters quickly and efficiently will come only through simulators. The past two decades have seen rapidly growing interest in using simulation for purposes of improving patient safety and patient care through a variety of applications. The reason for this expanding interest is multifactorial. Many simulation professionals would cite the Institute of Medicine publications To Err Is Human(2) and Crossing the Quality Chasm(3) as the primary catalyst of this change. Others might say the power of experiential learning better fits the needs of a 21st century health care learner.(4) Regardless of what you believe, simulation training has arrived in health care education. The Society for Simulation in Healthcare <ssih.org> was formed in January 2004. The first issue of Simulation in Healthcare (a peer-reviewed, multidisciplinary journal) was published in January 2006 <www.simulationinhealthcare.com>.

Simulation is a technique, not a technology, to replace or amplify real experiences with guided experiences, often immersive in nature, that evoke or replicate substantial aspects of the real world in a fully interactive fashion.(5)

Training on simulators offers the obvious advantage of repeated practice to acquire a skill while allowing the performers to err. In addition, it provides a chance to get training of uncommon and very rare scenarios with provision of repetition of training so that skills could be maintained. Possibility of stopping the scenario in the middle with a question answer session and restarting the same scenario is also a great help in training a skill (6). Simulation also teaches leadership, ability to work in groups, task assignment and communication skills (7). This all is done in presence of an experienced clinician trainer equipped with computer based assessment tools available inside the same room or sitting in other room not visible to the trainee. This gives a high authenticity to the whole process. The best example of the success of simulation training is perhaps the success of BLS and ACLS programs throughout the world in which training is imparted on mannequins with simulated conditions.

Bigger medical institutions should have a simulation based training program. Ideally, a simulation center should be a complex of three or four rooms including a simulation room, a control room, a conference/debriefing room, a supply room, anda storage room(8). The simulation room, main area where training occurs, should ideally be flexibly converted into a range of different rooms/areas where patient care takes place e.g. operating room, ICU, ER, ward, home care etc. A well equipped library and high speed internet connection should also be available in the vicinity. The whole complex should be well equipped for education, research and development. A high resolution video camera with DVD recording and replay facility is also necessary. The curricula, techniques, and assessment tools should be meticulously researched and developed after consultation with experts in the field.

Simulation could be full-scale (high fidelity) or individual skill based according to the requirements. Mannequins of three different companies namely METI®, Laerdal® and Ambu® are available in Pakistan. While Ambu® specializes in BLS and ACLS mannequins and airway and IV trainers, METI® and Laerdal® also provide full-scale (high fidelity) mannequins. All have their advantages and disadvantages and one should carefully select the mannequin according to the requirement. Computer based learning programs mimic many adverse scenarios and their management, e.g. cardiac arrhythmias, hemorrhage, injuries etc. Anesthesiology is the leading specialty that has adapted the idea of simulation and as part of her commitment to patient safety is pioneering different new ideas in this field. Other specialties have followed the suit. Rescue and trauma teams in advanced countries routinely utilize either mannequin based or computer based training programs. Its usefulness has been proved in undergraduate as well as postgraduate medical studies and assessment of competencies.(9-11)

A simulation trainer, however, must have certain limitations in mind while imparting the training. These include, lack of accuracy of a simulator in simulating the reality, difference in feel in handling rubber or plastic as compared to live human tissue, non serious attitude of certain trainees as they may take it as a game, and lack of application of skills learnt in a simulated scenario(12).


  1. Lovell J and Kluger J. Lost Moon: The Perilous Voyage of Apollo 13. New York: Houghton Mifflin; 1994.
  2. Kohn LT, Corrigan JM, Donaldson MS, eds. To Err Is Human: Building a Safer Health System. Washington, DC: National Academies Press; 2000.
  3. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academies Press; 2001.
  4. Friedman CP. The marvelous medical education machine or how medical education can be unstuck in time. Acad Med. 2000; 75(10):137S-142S.
  5. Gaba DM. The future vision of simulation in health care. Qual Saf Health Care 2004;13(Suppl 1):i2–i10.
  6. Cooper B, Taqueti VR. A brief history of the development of mannequin simulators for clinical education and training: Qual Saf Health Care 2004; 13: i11-i18.
  7. Smart Dummies Have A New Role in Life – Reducing Medical Errors http://www.npsf.org/ October 9, 1997.
  8. Seropian MA. General Concepts in Full Scale Simulation: Getting Started. Anesth Analg 2003;97:1695-1705.
  9. Lamb D. Could simulated emergency procedures practised in a static environment improve the clinical performance of a Critical Care Air Support Team (CCAST)? A literature review. Intensive Crit Care Nurs. 2007;23(1):33-42.
  10. Youngblood P, Harter PM, Srivastava S, Moffett S, Heinrichs WL, Dev P. Design, development, and evaluation of an online virtual emergency department for training trauma teams. Simul Healthc. 2008;3(3):146-53.
  11. Wisborg T, Brattebø G, Brinchmann-Hansen A, HansenKS. Mannequin or standardized patient: participants’ assessment of two training modalities in trauma team simulation. Scand J Trauma Resusc Emerg Med. 2009;17(1):59.
  12. Nyssen AS, Larbuisson R, Janssens M, Pendeville P, Mayné A. A Comparison of the Training Value of Two Types of Anaesthesia Simulators: Computer Screen-Based and Mannequin- Based Simulators. Anesth Analg 2002; 94(6): 1560-65.