Richard E. Haas, PhD, CRNA, PHRN

Simulation has become more frequently used in the education of student nurse anesthetists, as well as the education of other health professionals. Though no longer in its infancy, the use of simulation as part of clinical education is still widely misunderstood, particularly by those who either a) have not experienced it at all, or b) have experienced it done poorly.

In its simplest derivation, simulation is used as a “task trainer”. Take some form of device, create a mockup of the device, insert the mockup into a simulated body part and voila’, we have simulation. While this is a very small and very simple part of one of the things simulation can do as part of a student’s education, it is by no means the most important thing. The use of high-fidelity simulation is pivotal in helping the instructor understand how the student thinks, and more importantly, how the student solves problems.

Human beings are complex, both those receiving the anesthetic, as well as those administering it. By controlling the simulated patient, the teacher can better analyze the processes by which the student approaches these complex tasks. This is particularly crucial in the novice student. A good simulation will result in a state of suspended reality: the student no longer sees a latex mannequin, he sees an actual patient in need of his expertise. In the student’s earliest learning stages, they will sometimes respond to problems which we, as experienced anesthetists, see as “normal” or “common” in ways which deviate significantly from accepted practice. Part of this is due to the stress which accompanies the simulation. This stress response does two things.

The first is it degrades executive function, or what we would call “working memory”. You may have experienced life emergencies during which you simply did not know what to do. This is what happens when the student is placed under a modicum of stress during a well thought out and executed simulation. Many of the concepts which the student had no difficulty discussing in a controlled classroom setting suddenly vanish from her armamentarium. Drug doses, indications, contraindications, biotransformation and other data points vanish like fog in the morning, leaving the student grasping for some solution to the problem at hand.

Simulation allows the instructor to take the student at this point, and walk her through a solution in a Socratic form, by asking leading questions through which the student arrives at some conclusion. The risk to the “patient” is mitigated by the instructor’s knowledge that a simple “reboot” will once again restore our “patient” to life.

The second thing a stress response does is stimulates the formation of long term memories. Some of you have experienced a stressful situation, after which you said to yourself, “I’ll never forget what happened.” The same thing will occur in simulation which is done well. Students will remember the point at which they had trouble, recall the solution to the problem, and use the solution in subsequent simulations. Done well, such simulations should increase progressively in complexity, resulting in final simulations which approximate, to the extent possible, the actual administration of anesthesia in the operating room.
The final advantage is that events which are dangerous, rare, or require specific interventions (or all three, e.g. malignant hyperthermia) can be practiced with students individually or in small groups, and done again and again leading to proficiency.

The clinical arena, while filled with fascinating cases, is very much dependent on being in the right place at the right time, having the right preceptor and the right skill set. A mismatch of any of these results in a less than optimal learning experience, yet the vagaries of clinical practice are such that the perfect combination is difficult, if not impossible, to obtain. Simulation helps bridge this gap.

Simulation is not, and will never be, a substitute for excellent hands on clinical care taught by expert clinicians. It was never intended to be so. It is, however, one tool the teacher can use to help his students progress towards competence.