Clinical Editor's Corner

Stimulating Medical Simulation

morton kern, MD Clinical Editor Professor of Medicine Associate Chief Cardiology University of California Irvine Orange, California
morton kern, MD Clinical Editor Professor of Medicine Associate Chief Cardiology University of California Irvine Orange, California
My interventional cardiology recertification is due this year. To fulfill my American Board of Internal Medicine (ABIM) requirements of training, practice and didactic material, I need 100 self-evaluation points obtained from practice improvement modules or interventional cardiology simulations. At the American College of Cardiology (ACC) meeting this past March in Orlando, Florida, the Medical Simulation Corporation* offered cardiac cath simulations to help physicians acquire this 20-point unit. For those who have never worked on a cath simulator, I wanted to provide some background and share my first simulator experience. First, what is simulation? Simulation is a technique — not a technology — to replace or amplify real patient experiences with guided experiences, artificially contrived, that evoke or replicate substantial aspects of the real world in a fully interactive manner. One might immediately think of artificial environments such as flight simulators for the training of airline pilots which use computer models of “what-if” scenarios. Simulation techniques allow for interaction with almost any pre-programmed scenario on demand. Simulation techniques do not depend on hospital encounters and can be re-run, stopped or otherwise altered to enhance educational value. This field has matured to the degree that there is a Society for Simulation in Healthcare, with its own journal ( My experience began after signing up to take the simulation. I was taken into the testing area by Stephanie Collins, a clinical educator and former cath lab nurse, who was my mentor and tormentor (just kidding) for the 50- to 60-minute testing period. The patient (a dummy) is lying on a table. In front of you are computer screens, including fluoro and hemodynamic monitoring screens, while below is a foot pedal like the one in a cath lab. The catheter is already in the femoral artery (there’s a hole in the mannequin at the groin) and a guidewire is inside the catheter. The operator is now ready to take on a patient scenario. The first scenario was the practice run. Stephanie helped me understand how my orders for medications, different catheters and x-ray angulations, stent and balloon sizes, and other needs are input into the system (as if it was the nursing team). After testing the movement of the catheters (not perfect, but did the job), I was ready to go. Just like in a regular cath procedure, the operator is given the patient history and indications. Then the simulator wanted to know what pre-procedure medications were needed for the specific clinical history, physical and lab findings. Following the medications, the simulator provided the diagnostic images of the coronary arteries and then wanted to know what interventional equipment was needed. The operator also had to indicate what additional drugs he might want during the intervention. The coronary intervention was performed by moving the catheters, guidewires and stents, watching the ‘fluoro’ and keeping track of the patient’s ‘hemos’ during the procedure. After the intervention, the operator was asked to indicate the post procedure medications and activities. After the practice run, the fun starts. My first stimulation was a simple left anterior descending artery (LAD) stenosis in which the left main (LM) was dissected. “My chest hurts,” the dummy said. On seeing the dissected LM, I thought, “Ouch! I’ll take another stent.” The second case was a circumflex lesion, which needed a few different angles in order to see the lesion. Another case produced a distal guidewire perforation and I had to work through possible tamponade. I confess my heart rate picked up a bit here. It was remarkable to see how quickly you turn back to your basic training to work through these troublesome and highly instructional scenarios. I was initially feeling somewhat foolish, thinking, “What if I flunk?” but my fears were exaggerated. Fortunately, my dummy did not die and I really enjoyed the simulation process. Medical simulation was stimulating. This unique educational method has real value, not so much in the mechanical aspects of the procedure, but in the cognitive aspects, meaning knowing what and when to do things, and what medicines or steps are required to avoid or solve problems as they occur. Teaching judgment is very hard and the simulator lets trainees test and exercise their judgment without patient harm. As a historical note, medical simulation companies have been around since the mid-1990’s and provide dozens of simulations of medical problems in every specialty imaginable. Computer simulations for testing knowledge, anatomy and devices often incorporate equipment to provide tactile feedback to the operators. For example, Terumo offers simulators dedicated exclusively to transradial access, with the first dedicated simulator offered beginning in 2006. During radial artery simulator training, physicians learn how to overcome various anatomical variations such as radial loops, muscular bridges, recurrent radial arteries and vasospasm. With simulators that incorporate guidewire and catheter manipulations, operators can gain experience, learn ‘touch’ and a concept of the procedure. The simulators provide feedback and present the physician with clinical challenges that must be overcome to accomplish the task. The variety of unique three-dimensional anatomic features of both coronaries and other vascular structures enables the cath team members to gain instant understanding of coronary anatomy. Simulators can also help operators understand how each catheter shape is affected by the anatomy, and its response to torque and force. Medical simulators help to optimize procedural success and protect patient outcomes. For interventional cardiology, medical simulators can train operators on new medical devices in weeks rather than months, reducing training costs and use of experimental animal models (when possible). Medical simulations have improved physician performance, resulting in greater patient safety, and have successfully reduced or eliminated proctored cases and animal labs mandated by regulatory agencies, again resulting in significant time and cost savings. Simulators also benefit nurses and technologists by facilitating the learning of new skills, minimizing and managing risks, enhancing performance and critical thinking skills, and reducing time to proficiency with new devices or procedures. Many of our professional societies, like the ACC and Society of Cardiovascular Angiography and Interventions (SCAI) have chosen to work with simulation training to gauge the cognitive decisions that cath lab professionals make during interventional procedures. The take-home message is that simulation is educational, increases practice experience, solidifies knowledge and helps one fill in the knowledge and training gaps, and ultimately contributes to better patient care and safety. I suggest we avail ourselves of these resources whenever possible. Make sure you try the simulator at the next “Cath Lab Basics” meeting ( near you.