Author: Sharon Lesser, RN, Aldo Iacono, MD
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contact hours
Changes in medical practice that limit
instruction and patient availability, the expanding options for
diagnosis and management, and advances in technology are contributing to
the greater use of simulation technology in medical education.1
Training for bronchoscopy is very time
consuming, costly and involves risks. Bronchoscopy is currently taught
by hands-on training in the clinical setting including diagnostic and
therapeutic procedures. Despite the proliferation in the number of
bronchoscopic procedures currently performed, there are presently few,
if any, guidelines that ensure that basic skills and competency needed
to provide these services have been acquired.
A bronchoscopy simulator allows doctors
and other healthcare professionals to practice medical procedures
without putting patients at risk. The simulation accurately duplicates
the look and the feel of real-life situations. Doctors, nurses,
technicians and respiratory therapists can use the simulators to learn
airway anatomy and to understand the wide range of bronchoscopic
procedures. The simulator can be used to teach staffs how to better
assist the physician in the many different types bronchoscopic
procedures.
Historically, the single method used
for healthcare providers to gain realistic experience has been to
perform procedures on patients, cadavers or animals. Simulators were
created to eliminate these potentially hazardous situations by providing
a safer and more humane alternative training method.
Simulation improves the teaching
process. A healthcare professional can practice skills without the
distracting worry of causing discomfort. A clinical instructor can
direct his/her trainees to repeat any part of a procedure as many times
as necessary. This would be impossible to do while working with a
patient.
Physicians are beginning to realize the
potential benefits of simulation and are beginning to urge the medical
community to adopt simulation technology for training and certification.
The justification of patients being subjected to the "see one, do one,
teach one" training method is nearing its end. Simulators will replace
the need to practice procedures on recently deceased patients. In
addition, the use of animals for medical procedure training will become
unnecessary, and thus alleviate the associated high costs and ethical
issues.
Medical credentialing organizations,
such as the American Board of Medical Specialties (ABMS), are beginning
to investigate the use of simulation for evaluating clinical skills. A
wide variety of medical organizations are now encouraging and promoting
the use and development of medical simulators.
To begin the bronchoscopy, the user
inserts the bronchoscope into the robotic device. The bronchoscope feels
and acts like an actual flexible fiberoptic bronchoscope. The device
tracks the motions of the flexible bronchoscope and reproduces the
forces felt during an actual bronchoscopic procedure. The proximal end
of the interface device is shaped like a human face, with a nasal port
through which the flexible bronchoscope can be inserted.
The flexible bronchoscope tracks the
manipulations of the tip-control lever, the suction button and video
buttons. In addition, instruments are tracked as they are manipulated in
the working channel. This allows for biopsies and other diagnostic and
therapeutic procedures to be performed on the simulator.
A monitor displays computer-generated
images of the airway as the user navigates through the virtual anatomy.
Texture maps based on videotapes of actual bronchoscopic images are
added to the airway models to give the mucosa a realistic look. Using
different CAT scan data results in a variety of simulated cases that
reflect a range of patient anatomy and pathology.
In addition to being anatomically
correct, the virtual patient also behaves in a realistic manner. The
patient breathes, coughs, bleeds and exhibits changes in vital signs.
Complications are programmed in (such as lidocaine toxicity), causing
the patient to seize or develop a cardiac arrhythmia.
The simulation software records all the
actions of the user and stores this information in a database.
Information that is collected and displayed includes time of procedure,
number of times the bronchoscope tip collides with airway walls, the
percentage of bronchial segments entered, and the amount of lidocaine
used.
Flexible bronchoscopy simulators will
impact three major areas: training, pre-procedural planning and
bronchoscopy credentialing. Pulmonary fellows, as well as other
physicians who learn bronchoscopy, are now able to learn bronchoscopy on
a simulator, prior to patient contact. Use of the simulator rapidly
takes the fellow up the initial learning curve, so that the first time a
person performs a bronchoscopy on a patient, they will have the skills
of a physician who has performed 20 to 30 bronchoscopies.
A big hurdle, however, is that these
simulators cost hundreds of thousands of dollars. Overall, though,
simulators will allow initial training to occur in a time-efficient and
cost-effective manner.
Pulmonary fellows can be exposed to a
broad range of cases that reflect variations in patient anatomy,
pathology and physiology. This training can occur outside the endoscopy
suite, thus decreasing the amount of teaching time required during
bronchoscopy procedures performed on patients. This provides
cost-savings to the training institution and allows for a more efficient
use of the attending physician's time.
Complications such as hemorrhage,
pneumothorax and cardiorespiratory distress can be programmed to occur
during a simulated case. The trainee must then respond in a timely and
appropriate manner. Experienced bronchoscopists will also benefit from
simulators. Simulators can be used at hands-on continuing education
courses that teach new or more advanced bronchoscopic procedures such as
transbronchial biopsies, bronchoalveolar lavage, transbronchial needle
aspiration (TBNA), electrocautery, tracheobronchial stent placement, and
the use of lasers in bronchoscopy.
Reference
1. Issenberg SB, McGehie WC, Hart IR,
et al. (1999) Simulation technology for health care professional skills
training and assessment. JAMA 282,861-867.
2. Ost D, De Rosiers A, Britt EJ, et
al. Assessment of a Bronchoscopy Simulator, Am. J. Respir. Crit. Care,
Volume 164, Number 12 December 2001, 2248-2255.
Footnotes
Bushnell E, Gaba, DM. Anesthesia
Simulation and Patient Safety. Problems in Anesthesia, 2001.
Issenberg SB, McGehie WC, Hart IR, et
al. (1999) Simulation technology for health care professional skills
training and assessment. JAMA 282,861-867.
Kempainen RR, Hallstrand TS, Culver BH,
Tonelli MR. Fellows as teachers: the teacher assistant experiences
during pulmonary subspecialty training; Chest, July 2005;
128(1):401-406.
Killeen, David DO; Chin, Robert MD;
Conforti, John DO. Bronchoscopic Myths and Legends. Clinical Myths and
Evidence-Based Medicine; Clinical Pulmonary Medicine. 11(1):54-56,
January 2004.
Ost D, De Rosiers A, Britt EJ, et al.
Assessment of a Bronchoscopy Simulator, Am. J. Respir. Crit. Care,
Volume 164, Number 12, Dec. 2001, 2248-2255.
