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Simulation-based education (SBE) has become pervasive in health care training and medical education, and is even more important in subspecialty training whereby providers such as otolaryngologists and anesthesiologists share overlapping patient concerns because of the proximity of the surgical airway. Both these subspecialties work in a fast-paced environment involving high-stakes situations and life-changing events that necessitate critical thinking and timely action, and have an exceedingly small bandwidth for error. Team training in the form of interprofessional education and learning involving surgeons, anesthesiologists, and nursing is critical for patient safety in the operating room in general, but more so in otolaryngology surgery.

Background We sought to determine whether mannequin-based simulation can reliably characterize how board-certified anesthesiologists manage simulated medical emergencies. Our primary focus was to identify gaps in performance and to establish psychometric properties of the assessment methods. Methods A total of 263 consenting board-certified anesthesiologists participating in existing simulation-based maintenance of certification courses at one of eight simulation centers were video recorded performing simulated emergency scenarios. Each participated in two 20-min, standardized, high-fidelity simulated medical crisis scenarios, once each as primary anesthesiologist and first responder. Via a Delphi technique, an independent panel of expert anesthesiologists identified critical performance elements for each scenario. Trained, blinded anesthesiologists rated video recordings using standardized rating tools. Measures included the percentage of critical performance elements observed and holistic (one to nine ordinal scale) ratings of participant’s technical and nontechnical performance. Raters also judged whether the performance was at a level expected of a board-certified anesthesiologist. Results Rater reliability for most measures was good. In 284 simulated emergencies, participants were rated as successfully completing 81% (interquartile range, 75 to 90%) of the critical performance elements. The median rating of both technical and nontechnical holistic performance was five, distributed across the nine-point scale. Approximately one-quarter of participants received low holistic ratings (i.e., three or less). Higher-rated performances were associated with younger age but not with previous simulation experience or other individual characteristics. Calling for help was associated with better individual and team performance. Conclusions Standardized simulation-based assessment identified performance gaps informing opportunities for improvement. If a substantial proportion of experienced anesthesiologists struggle with managing medical emergencies, continuing medical education activities should be reevaluated.

Hospitalized patients outside of the operating room frequently require emergency airway management. This study investigates complications of emergency airway management in critically ill adults, including: (1) the incidence of difficult and failed intubation; (2) the frequency of esophageal intubation; (3) the incidence of pneumothorax and pulmonary aspiration; (4) the hemodynamic consequences of emergent intubation, including death, during and immediately following intubation; and (5) the relationship, if any, between the occurrence of complications and supervision of the intubation by an attending physician.Data were collected on consecutive tracheal intubations carried out by the intensive care unit team over a 10-month period. Non-anesthesia residents were supervised by anesthesia residents, critical care attending physicians, or anesthesia attending physicians.Two hundred ninety-seven consecutive intubations were carried out in 238 adult patients. Translaryngeal tracheal intubation was accomplished in all patients. Intubation was difficult in 8% of cases (requiring more than two attempts at laryngoscopy by a physician skilled in airway management). Esophageal intubation occurred in 25 (8%) of the attempts but all were recognized before any adverse sequelae resulted. New infiltrates suggestive of pulmonary aspiration were present on chest radiography after 4% of intubations. Seven patients (3%) died during or within 30 min of the procedure. Five of the seven patients had systemic hypotension (systolic blood pressureor = 90 mmHg), and four of the five were receiving vasopressors to support systolic blood pressure. Patients with systolic hypotension were more likely to die after intubation than were normotensive patients (P0.001). There was no relationship between supervision by an attending physician and the occurrence of complications.In critically ill patients, emergency tracheal intubation is associated with a significant frequency of major complications. In this study, complications were not increased when intubations were accomplished without the supervision of an attending physician as long as the intubation was carried out or supervised by an individual skilled in airway management. Mortality associated with emergent tracheal intubation is highest in patients who are hemodynamically unstable and receiving vasopressor therapy before intubation.

Background Anaesthetists may fail to recognize and manage certain rare intraoperative events. Simulation has been shown to be an effective educational adjunct to typical operating room-based education to train for these events. It is yet unclear, however, why simulation has any benefit. We hypothesize that learners who are allowed to manage a scenario independently and allowed to fail, thus causing simulated morbidity, will consequently perform better when re-exposed to a similar scenario. Methods Using a randomized, controlled, observer-blinded design, 24 first-year residents were exposed to an oxygen pipeline contamination scenario, either where patient harm occurred (independent group, n=12) or where a simulated attending anaesthetist intervened to prevent harm (supervised group, n=12). Residents were brought back 6 months later and exposed to a different scenario (pipeline contamination) with the same end point. Participants’ proper treatment, time to diagnosis, and non-technical skills (measured using the Anaesthetists’ Non-Technical Skills Checklist, ANTS) were measured. Results No participants provided proper treatment in the initial exposure. In the repeat encounter 6 months later, 67% in the independent group vs 17% in the supervised group resumed adequate oxygen delivery (P=0.013). The independent group also had better ANTS scores [median (interquartile range): 42.3 (31.5–53.1) vs 31.3 (21.6–41), P=0.015]. There was no difference in time to treatment if proper management was provided [602 (490–820) vs 610 (420–800) s, P=0.79]. Conclusions Allowing residents to practise independently in the simulation laboratory, and subsequently, allowing them to fail, can be an important part of simulation-based learning. This is not feasible in real clinical practice but appears to have improved resident performance in this study. The purposeful use of independent practice and its potentially negative outcomes thus sets simulation-based learning apart from traditional operating room learning.

Introduction Training in transesophageal echocardiography (TEE) requires a significant commitment of time and resources on behalf of the trainees and the instructors. Training opportunities may be limited in the busy clinical environment. Medical simulation has emerged as a complementary means by which to develop clinical skills. Transesophageal echocardiography simulators have been commercially available for several years, yet their ability to distinguish experts from novices has not been demonstrated. We used a standardized assessment tool to distinguish experts from novices using a commercially available TEE simulator. Methods Anesthesiologists certified in advanced perioperative TEE and anesthesiology resident physicians were recruited into the expert and novice cohorts, respectively. The cohorts were recruited from 2 academic medical centers. The novice cohort received a structured introduction to the basic TEE examination. Both cohorts then proceeded to perform a basic TEE examination involving normal cardiac anatomy, which was evaluated by blinded raters using a standardized assessment tool. Results The expert cohort consistently demonstrated the ability to obtain standard TEE imaging views in less time and more accurately than the novice cohort during the course of a simulated TEE examination. Conclusions A simulated transesophageal examination of normal cardiac anatomy in concert with a standardized assessment tool permits ample discrimination between expert and novice echocardiographers as defined for this investigation. Future research will examine in detail the role echocardiography simulators should play during echocardiography training including assessment of training level.

Background:Established models for assessment and maintenance of competency in anesthesiology may not be adequate for anesthesiologists wishing to reenter practice. The authors describe a program developed in their institution incorporating simulator-based education, to help determine competency in licensed and previously licensed anesthesiologists before return to practice.Methods:The authors have used simulation for assessment and retraining at their institution since 2002. Physicians evaluated by the authors’ center undergo an adaptable 2-day simulation-based assessment conducted by two board-certified anesthesiologists. A minimum of three cases are presented on each day, with specific core competencies assessed, and participants complete a standard Clinical Anesthesia Year 3 level anesthesia knowledge test. Participants are debriefed extensively and retraining regimens are designed, where indicated, consisting of a combination of simulation and operating-room observership.Results:Twenty anesthesiologists were referred to the authors’ institution between 2002 and 2012. Fourteen participants (70%) were in active clinical practice 1 yr after participation in the authors’ program, five (25%) were in supervised positions, and nine (45%) had resumed independent clinical practice. The reasons of participants not in practice were personal (1 participant) and medico-legal (3 participants); two participants were lost to follow-up. Two of 14 physicians, who were formally assessed in the authors’ program, were deemed likely unfit for safe return to practice, irrespective of further training. These physicians were unavailable for contact 1 yr after assessment.Conclusion:Anesthesiologists seeking to return to active clinical status are a heterogeneous group. The simulated environment provides an effective means by which to assess baseline competency and also a way to retrain physicians.

Patient simulation has been widely incorporated into the educational programs of many anesthesiology residencies. These educational tools have been validated by a number of studies and have been recognized by the Accreditation Council for Graduate Medical Education (ACGME) as effective means of teaching domains of competency. The ACGME and the American Board of Medical Specialties (ABMS) have also recognized that these tools are effective devices for competency evaluation of resident and attending physicians. The use of simulation for both retraining and evaluation of a physician for medical licensure is presented.

Patient simulation is now considered to be a valid method for the education and evaluation of providers of sedation. Using full-scale human simulators to provide a realistic setting, participants can acquire skills for patient monitoring, administration of sedation medications, and the recognition and management of critical events. Although obstacles to its implementation exist, it appears likely that simulation training will become an integral part of training for providers of procedural sedation.

Study Objective There is a high rate of relapse among anesthesia residents attempting to re-enter clinical anesthesia training programs after completing treatment for opioid addiction. Individuals may return to clinical practice after a short period of treatment only to relapse into active addiction, and for the opioid addicted anesthesia resident, this often results in death. The objective of this study was to determine weather or not a period of time away from clinical practice after treatment would reduce the rate of relapse by allowing the individual to concentrate on recovery in the critical first year after treatment, during which the majority of relapses occur. Design 5 residents identified as being addicted to a controlled substance were removed from residency training and offered treatment. Prior to returning to residency training they were required to complete a post-treatment program involving no less than 12 months of work in the anesthesia simulator, followed by a graded re-introduction into the clinical practice of anesthesia. Setting Academic anesthesia practice in a large teaching hospital. Results Of the 5 residents who participated in the program, 3 (60%) successfully completed their residency program and their 5 year monitoring contract, and entered the anesthesia workforce as attending anesthesiologists. Conclusions The treatment of addicted physicians can be successful, and return of the highly motivated individual to the clinical practice of Anesthesiology is a realistic goal, but this reintroduction must be undertaken in a careful, stepwise fashion. A full understanding of the disease process, the potential for relapse, and the implications of too rapid a return to practice must be taken into careful consideration.

Study Objective: To determine the current status and future plans of residency programs to train residents in office-based anesthesiology (OBA), which is rapidly emerging as an important specialty within the field of anesthesiology. Design: Survey questionnaire. Setting: University hospital. Measurements: A 14-question survey was sent to the 134 listed members of the Society of Academic Anesthesia Chairs/Association of Anesthesiology Program Directors to elicit the current status of educational endeavors and clinical exposure of anesthesiology residents to this type of practice. Main Results: There were 95 respondents (72%). Fifteen (15.8%) academic anesthesiology programs provide OBA services in the community and two (2.1%) of the academic programs provide clinical exposure to their residents. Conclusions: Residents are receiving minimal, if any, exposure to OBA during their training.

The development of medical students' perceptions of different medical specialties is based on many factors and influences their career choices and appreciation of other practitioners' knowledge and skills. The goal of this study was to determine if participation in a series of anesthesiologist-run, simulation-based physiology labs changed first year medical students' perceptions of anesthesiologists.One hundred first-year medical students were surveyed at random three months before completion of a simulation-based physiology lab run by anesthesiologists. All participants received the same survey instrument, which employed a 5-point Rating Scale to rate the appropriateness of several descriptive terms as they apply to a particular specialist or specialty. A post-simulation survey was performed to track changes in attitudes.Response rates to the survey before and after the simulation labs were 75% and 97% (ofthe initial cohort responding), respectively. All students who filled out the post-simulation surveys had been exposed to anesthesiologists in the prior three months whereas none had interacted with surgeons in the interim. Nearly all had interacted with internal medicine specialists in that time period. No changes in the medical students' perceptions of surgeons or internal medicine specialists were evident. Statistically significant changes were found for most descriptors of anesthesiologists, with a trend towards a more favorable perception after the simulation program.Using a survey instrument containing descriptors of different medical specialists and specialties, we found an improved attitude towards anesthesiology after medical students participated in an anesthesiologist-run simulation-based physiology lab series. Given the importance of providing high quality medical education and attracting quality applicants to the field, integrati-on of anesthesiology staff into medical student courses at the non-clinical level appears useful.

In 2010, the American Board of Anesthesiology instituted a new Maintenance of Certification in Anesthesiology (MOCA) Part IV activity requiring diplomates to attend and self-reflect on a simulation-based course in an American Society of Anesthesiologists-endorsed program. Although there are certain course requirements, much of the curriculum and structure of these MOCA activities is left to the discretion of the participating endorsed program. The ideal course would emphasize multimodality simulation-based activities that optimize diplomate education and satisfaction, while economizing faculty requirements. We describe of our course structure and content as a potentially useful template.

Remifentanil is a potent micro-opioid receptor agonist that produces intense analgesia. This anilidopiperidine analog of fentanyl was approved by the United States Food and Drug Administration and became commercially available in the United States in 1997. Because of its unique chemical structure, remifentanil must be reconstituted; it has a rapid onset, and because of ester hydrolysis, it has a rapid rate of degradation. Although remifentanil's package insert warns against the potential for addiction, because of its rapid rate of degradation there was little concern that health care workers would abuse this drug. Herein, we report a case of intranasal remifentanil abuse by an anesthesiology resident.

The increasing role of simulation in medical education has paralleled advancement of this technology. Full environment simulation (FES) can be employed to effectively replicate rare medical catastrophes with exacting realism. It has been suggested that emotion can significantly enhance learning by producing memories that are processed and stored via the amygdaloid complex which is relatively impervious to extinction and thus forgetting. Theoretically the addition of emotional content to simulated crises during FES can be used to affect such changes in the participants and thus facilitate learning. We discuss the theoretic benefit and the use of FES with emotional enhancement as it relates to improved memory and learning.

Although rarely thought of as simulations by anesthesia educators, the use of standardized patients to simulate clinical encounters spans 4 decades (Mt Sinai J Med. 1996;63:241-249; J Am Med Assoc. 1997;278:790-791; Int J Dermatol. 1999;38:893-894). Although its efficacy for education and evaluation in the medical community has been well established through extensive research, there is a distinct dearth in the literature in its use for anesthesia trainee education and evaluation. In this article, we discuss this simulation modality via a historic review, its current application in competency assessment, and its use in anesthesiology education and evaluation. We conclude with a "how to guide" to facilitate those considering including standardized patient simulations into their anesthesia training or simulation curriculum.

The increasing role of simulation in medical education has paralleled the advancement of this technology. Full environment simulation (FES) can be used to effectively replicate rare medical catastrophes with exacting realism. It has been suggested that emotion can significantly enhance learning by producing memories that are processed and stored via the amygdaloid complex, which are relatively impervious to extinction and thus forgetting. Theoretically, the addition of emotional content to simulated crises during FES can be used to affect emotional changes in the participants and thus facilitate learning. Here, we discuss the theoretical benefit and the use of FES with emotional enhancement as it relates to improved memory and learning.