CUT­TING EDGE

Grow­ing pub­lic re­sis­tance to pa­tients be­ing used as teach­ing ma­te­rial is fu­elling the rise of sur­gi­cal sim­u­la­tors, re­ports Denise Cullen

The Weekend Australian - Travel - - Health -

WHEN it comes to surgery, ev­ery­one agrees ex­pe­ri­ence is the great­est teacher. Ev­ery­one, that is, ex­cept the pa­tient upon whom a trainee in­tends to per­form his or her first ap­pen­dec­tomy. Sur­gi­cal trainees have tra­di­tion­ally ac­quired their tech­ni­cal skills Grey’sA­natomy - style — in the op­er­at­ing room, work­ing along­side more se­nior sur­geons in an ap­pren­tice­ship model.

But pa­tients th­ese days aren’t so keen on a real-life ver­sion of am­bi­tious sur­gi­cal in­tern Cristina Yang do­ing a run­ning whip stitch on their still-beat­ing heart. ‘‘ Pub­lic opin­ion is in­creas­ingly re­sis­tant to hav­ing pa­tients used as teach­ing ma­te­rial,’’ ex­plained pro­fes­sor Os­car Traynor, of the Royal Col­lege of Sur­geons in Ire­land, at the Royal Aus­tralasian Col­lege of Sur­geons’ an­nual sci­en­tific congress in Christchurch, New Zealand, last month. ‘‘ We need to de­velop a new model of tech­ni­cal skills ac­qui­si­tion.’’

En­ter vir­tual-re­al­ity sim­u­la­tors, which mimic the look, and even the feel, of per­form­ing ac­tual sur­gi­cal pro­ce­dures. They pro­vide for trainee sur­geons what flight sim­u­la­tors pro­vide for prospec­tive pi­lots — the op­por­tu­nity to hone their skills with­out killing any­one.

That is not so flip­pant as it sounds. An ar­ti­cle in the Bri­tish Med­i­cal Jour­nal (2000;320:774-777) re­vealed that all forms of med­i­cal er­ror re­sults in as many as 18,000 un­nec­es­sary deaths in Aus­tralia each year, and more than 50,000 pa­tients be­com­ing dis­abled.

Th­ese fig­ures are con­tentious; Bryce Cassin, man­ager of clin­i­cal safety and qual­ity projects with the Aus­tralian Com­mis­sion on Safety and Qual­ity in Health­care, ar­gues they are an ‘‘ over­es­ti­ma­tion’’, and that it’s ‘‘ not clear how many sur­gi­cal deaths are pre­ventable, as the con­tribut­ing fac­tors are com­plex and not well un­der­stood’’.

How­ever, Monash Univer­sity re­searchers have noted that the num­ber of er­rors com­mit­ted is in­versely pro­por­tional to a sur­geon’s ex­pe­ri­ence; and that there is a big­ger chance of sur­geons mak­ing mis­takes in up to a dozen sur­gi­cal pro­ce­dures un­der­taken im­me­di­ately af­ter train­ing.

Sim­u­la­tors — used in sur­gi­cal train­ing only for the last two to three years — re­duce the risk of trainee sur­geons in­jur­ing hu­mans and give them per­mis­sion to safely make mis­takes, one of the nec­es­sary pre-con­di­tions to learn­ing, ex­plains Pa­trick Cre­gan, as­so­ci­ate pro­fes­sor of surgery at the Univer­sity of West­ern Syd­ney.

Their use re­mains ‘‘ patchy’’ be­cause of their com­plex­ity and high cost — around $250,000 for some ma­chines — and the prac­ti­cal is­sues of de­vel­op­ing cur­ric­ula with sim­u­la­tion train­ing as an in­te­grated part, says John Wind­sor, pro­fes­sor of surgery at the Univer­sity of Auck­land and found­ing di­rec­tor of the Ad­vanced Clin­i­cal Skills Cen­tre in New Zealand.

Wind­sor points to the avi­a­tion in­dus­try, where sim­u­la­tion has pro­gressed to a so­phis­ti­cated tool even for ex­pe­ri­enced pi­lots.

‘‘ We have avi­a­tion at 100 per cent and surgery lag­ging way be­hind,’’ says Wind­sor. ‘‘ It’s dif­fi­cult to know whether gov­ern­ments are go­ing to man­date it, or whether train­ing in­sti­tutes (like the RACS) will do this first.

‘‘ Un­til then it is go­ing to be ad­vanced in cen­tres with a par­tic­u­lar in­ter­est and (as) dif­fuse as funds al­low, un­til we get leg­is­la­tion that re­quires this approach.’’

To­day’s high-tech sim­u­la­tors can repli­cate com­plete pro­ce­dures, in­clud­ing keyhole gall blad­der re­moval, si­nus surgery and in­ves­tiga­tive pro­ce­dures to ex­am­ine the in­sides of the colon and womb.

They force trainees to make judg­ment calls and com­plete com­plex tasks us­ing their vis­ual per­cep­tion. The most so­phis­ti­cated sim­u­la­tors have ‘‘ force feed­back’’ tech­nol­ogy, where trainees can feel re­sis­tance against the in­stru­ment when it presses or pulls, ac­cord­ing to the tis­sue that they are sup­pos­edly ‘‘ cut­ting’’ or mov­ing through at the time.

This can be cru­cial when it comes to prac­tis­ing pro­ce­dures that rely mostly on touch — such as epidu­rals, which pro­vide pain re­lief dur­ing labour. The pro­ce­dure in­volves in­sert­ing a large hollow nee­dle into the pa­tient’s spine and ad­vanc­ing it un­til the epidu­ral space — iden­ti­fied by a sud­den loss of re­sis­tance — is reached. Slid­ing the nee­dle even a cou­ple of mil­lime­tres too far can cause com­pli­ca­tions rang­ing from headaches to spinal cord dam­age, ex­plains anaes­thetist Leonie Wat­ter­son, chair of the Aus­tralian So­ci­ety for Sim­u­la­tion in Health­care. The Di­vi­sion of Anaes­the­si­ol­ogy and In­ten­sive Care at the Univer­sity of Queens­land re­ported that such headache-pro­vok­ing punc­tures oc­curred in about 1.7 per cent of cases in teach­ing hos­pi­tals.

Th­ese high stakes, cou­pled with the dif­fi­cul­ties as­so­ci­ated with deal­ing with labour­ing women suf­fer­ing se­vere pain, make it ‘‘ ex­tremely stress­ful’’ for ju­nior doc­tors try­ing to learn on real pa­tients.

Ac­cord­ingly, Wat­ter­son was in­volved in the de­vel­op­ment of the Mediseus epidu­ral sim­u­la­tor, launched less than two years agoSim­u­la­tor labs also pre­pare sur­geons for a wide variety of dif­fi­cult sit­u­a­tions.

This dif­fers from the tra­di­tional ap­pren­tCon­tin­ued inside, page 19

Pic­ture: Michael Pot­ter

Trial run: Sur­geon Don­ald Mur­phy, left, and Matt Jack­son sim­u­late keyhole surgery at the Royal Aus­tralasian Col­lege of Sur­geons

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