Sim­u­la­tors de­liver an edge

The Weekend Australian - Travel - - Health -

tice­ship model of learn­ing by ran­dom ex­am­ple, in which sur­geons have no con­trol over the cases pa­tients present with, and which limit ex­po­sure to rare con­di­tions that re­quire im­me­di­ate and de­ci­sive ac­tion.

For ex­am­ple, Cre­gan notes that even tiny amounts of cer­tain anaes­thetic agents in ge­net­i­cally sus­cep­ti­ble in­di­vid­u­als can trig­ger a con­di­tion called ma­lig­nant hy­per­ther­mia, or ex­ces­sive heat, where the body lit­er­ally cooks it­self.

‘‘ An anaes­thetist might en­counter it once in a life­time,’’ he ex­plains. ‘‘ If (the doc­tor) is pre­pared, then the per­son will live — if not pre­pared, then the per­son will die.’’

And with­out prac­tis­ing on a sim­u­la­tor first, that sur­gi­cal trainee per­form­ing his or her first ap­pen­dec­tomy is likely to be wholly fo­cused on the tech­ni­cal as­pects of the op­er­a­tion, to the ex­clu­sion of other con­cerns.

‘‘ With less sit­u­a­tional aware­ness you might not re­alise that the pa­tient has turned bright blue be­cause the anaes­thetist has gone off to have a cup of cof­fee,’’ Cre­gan ex­plains.

But do skills learned in a vir­tual world trans­late to the op­er­at­ing theatre? And is there any ev­i­dence that the emerg­ing role of sim­u­la­tor labs in sur­gi­cal train­ing can ac­tu­ally im­prove pa­tient out­comes? The jury re­mains out on these ques­tions. Ac­cord­ing to Wind­sor, there are only about a dozen stud­ies in the lit­er­a­ture to date and most of them re­late to the laparoscopic (key­hole surgery) re­moval of gall blad­ders.

How­ever, he says what ev­i­dence ex­ists is ‘‘ en­cour­ag­ing’’.

Mean­while, re­search into how well the Mediseus epidu­ral sim­u­la­tor pre­dicts re­al­world per­for­mance is yet to be pub­licly re­leased but ‘‘ pre­lim­i­nary re­sults are that doc­tors (trained on the sim­u­la­tor) have less stress and fewer com­pli­ca­tions,’’ says Wat­ter­son.

De­spite their po­ten­tial, how­ever, Wind­sor warns that sim­u­la­tors should not be em­braced as a panacea for all the is­sues cur­rently plagu­ing sur­gi­cal train­ing.

One of his key con­cerns is that the sim­u­la­tor de­vel­op­ments are driven by in­for­ma­tion tech­nol­ogy spe­cial­ists rather than ed­u­ca­tion­al­ists.

‘‘ We’re not ask­ing the fun­da­men­tal ques­tion: What are we try­ing to achieve?’’ he asks. ‘‘ Sim­u­la­tors have a place but (that place) has to be de­fined by ed­u­ca­tion­al­ists, not the IT guys.’’

Wind­sor says he, like oth­ers, is also both­ered by the ‘‘ short course men­tal­ity’’ that sur­rounds sim­u­la­tor tech­nol­ogy ‘‘ with no pre-learn­ing or post-learn­ing for re­in­force­ment’’.

An ar­ti­cle in Sur­gi­cal En­doscopy (2007;21:357-366) noted that sur­gi­cal res­i­dents needed time to prac­tise their tech­ni­cal skills ‘‘ and will of­ten find this time to be in the mid­dle of the night when on call’’.

‘‘ A sim­u­la­tion lab that truly serves the res­i­dents will thus pro­vide a se­cure en­vi­ron­ment that is op­ti­mally lo­cated in a main hospi­tal with ac­cess af­ter hours.’’

But the avail­abil­ity of this tech­nol­ogy is lim­ited by its costs. Ac­cord­ing to Cre­gan, sim­u­la­tors de­signed to repli­cate colono­scopic, en­do­scopic and laparoscopic pro­ce­dures cost $250,000 each. ‘‘ These are big in­vest­ments — they’re not the sort of thing we can have on ev­ery street cor­ner.’’

Sound­ing a fur­ther note of cau­tion is urol­o­gist Don­ald Murphy, who be­lieves that sim­u­la­tors are use­ful, but only as one part of the staged learn­ing process: ‘‘ You can­not learn to be a sur­geon by do­ing vir­tual real­ity com­puter games.’’

As med­i­cal di­rec­tor of the skills lab­o­ra­tory at the Royal Aus­tralasian Col­lege of Sur­geons in Mel­bourne, Murphy has de­vel­oped a ‘‘ bio­re­al­ity model’’ for sur­gi­cal train­ing which he be­lieves is one step closer to the real thing.

This in­volves us­ing a piece of meat — even some­thing ed­i­ble, ob­tained from a su­per­mar­ket or abat­toir — and re-es­tab­lish­ing a blood flow to cre­ate a more re­al­is­tic model for sur­gi­cal train­ing.

For ex­am­ple, a chicken mary­land — the leg with both thigh and drum­stick at­tached — when per­fused with blood can be adapted to pro­vide a model for repli­cat­ing pyeloplasty, the sur­gi­cal re­con­struc­tion of the pelvis to take pres­sure off the kid­ney.

‘‘ When I show these mod­els to my fel­low sur­geons they think they are see­ing live tis­sue,’’ says Murphy.

While re-an­i­mat­ing dead an­i­mal tis­sue can sound a bit grue­some for the lay per­son, Murphy points out that the model he’s cre­ated is a more pub­licly ac­cept­able al­ter­na­tive to vivi­sec­tion, or cut­ting up live an­i­mals, which also com­monly oc­curs in sur­gi­cal train­ing.

One thing sur­geons do agree on is that any form of sim­u­la­tion takes trainees only as far as the table­top.

‘‘ At some stage you have to trans­late your skills into a real life per­son,’’ says Cre­gan. ‘‘ Ev­ery­one can train like mad on a sim­u­la­tor — but at some stage you must fly the aero­plane with an in­struc­tor, and even­tu­ally go solo.’’

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