Simulators have long been a mainstay of education and training in non-medical industries such as the airlines and NASA. Patient simulation in anesthesia training however has been utilized only in the last several years. These simulators have become increasingly sophisticated: they now include mannequins with eyes that respond to light, airways that become difficult to intubate, and chests that move with respiration. The human patient simulators provide appropriate heart and lung sounds, and simulate pathologic conditions (e.g. pneumothorax). Mannequins have palpable pulses, respond to nerve stimulators, and can even be subjected to various procedures (e.g., needle pericardiocentesis). The simulators furthermore incorporate sophisticated physiologic models to determine the effects of various user interventions. And, most importantly, they interact with the user in a setting very similar to a real anesthetic practice, using the same anesthesia machines and monitors that are being used in the operating room. Indeed, in the last several years, simulators have been refined to closely approximate modern anesthesia practice.

As anesthesia simulators have become more realistic, a strong interest has also developed to try to incorporate their use into traditional medical education. Realistic simulation allows users to practice responses to dangerous but rare complications without putting patients at risk. The question, however, remains: how do we best go about doing this? How much faculty time should be devoted to simulator use? Who are the appropriate candidates for use? What type of simulations should be used? How often? We have devoted much time and effort at the University of North Carolina at Chapel Hill to answer these questions in order to optimize this available and worthwhile educational opportunity. We think our findings can serve as a model for incorporating simulator training into an academic department’s teaching efforts.

The Department of Anesthesiology at UNC is strongly committed to incorporating our anesthesia simulator into medical education. We have three faculty members who have designated clinical time allotted for the simulator only. These attendings are responsible for the medical student and resident sessions as well as the general upkeep and maintenance of the simulator. We are currently running simulated sessions with both medical students and anesthesiology residents.

All medical students at our institution are required to go through a weeklong Life Support Skills (LSS-1) course. This serves as an introduction to some basic clinical concepts and skills, including intravenous line placement, blood gas sampling, basic airway management, and ACLS protocols. Some students elect to follow up with another weeklong course (LSS-2) that supplements LSS-1. LSS-2 goes into greater depth, including discussions of shock and pulmonary disease, and the management of these states. We are using our simulator in selected portions of both courses. The simulator has preprogrammed scenarios that cover all the arrhythmias in the ACLS algorithms. It can also model shock from various etiologies and can model many respiratory events. We take small groups of medical students (usually three to five) through scenarios in random order, with each student having the chance to lead the team. We discuss the important teaching points about each pathophysiologic condition, as well as the students’ responses in evaluating and treating the simulated patient. Almost all the students going through this course have felt that there was an appropriate level of realism and stress and have found it to be a very educational experience.

A more formalized simulator course for residents is currently in place at UNC. Residents have been using the simulator for approximately five years, but in the busy clinical setting at UNC, we initially found it quite difficult to insure that residents were obtaining good and reliable simulated training. Over the past two years, however, we have developed a well-structured course for the residents to follow. Each week on a Wednesday afternoon, two residents are relieved from afternoon duties in the operating room. Available residents, nurse anesthetists, or attendings covering those residents for the day provide relief. It requires a concerted effort to reliably and promptly relieve these two residents. These residents then spend approximately two hours in simulated training with one of our three designated attendings. Therefore eight residents a month undergo simulator training; this usually provides approximately six sessions a year for each of our residents.

The residents are scheduled for the simulator approximately six weeks prior to each session. We provide a Simulator Coursebook, which includes predetermined cases for each month of the year. The residents are therefore expected to review and prepare for each session. After one year we will have reviewed a variety of anesthetic problems including the difficult airway, obesity, trauma, coronary artery disease, heart failure, shock, preeclampsia, and malignant hyperthermia. Each session outlined in the Simulator Coursebook includes a brief case presentation from the Problem Based Learning Discussion book from ASA and selected readings. This format encourages preparation by our residents and allows for a useful discussion of the topic in conjunction with use of the simulator to help develop psychomotor skills and critical (and timely) thinking. During each two hour session, we also typically simulate random situations to test recall of material covered in previous months as well as other specific problems not in the coursebook (e.g., ACLS protocols). The residents’ experience has generally been very positive, similar to that of our medical students.

In summary, we are currently running simulations with both medical students and anesthesia residents. We cover basic medical concepts as well as specific anesthetic problems. For the residents, we have coupled simulation with problem-based learning scenarios, which are commonly available and adaptable. The simulator experience has been educational and rewarding for everyone involved. In the future we hope to expand use of simulations by increasing medical student and resident exposure. Ultimately the simulator may also be useful in educating personnel throughout the hospital. For example, nurses and physicians in pulmonary medicine, critical care, and emergency department may all benefit, as well as nurses who are now providing sedation in clinics and procedure rooms in remote locations. We will need to develop specific case scenarios and simulations, as well as a reliable way to evaluate performance, in each of these areas.