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Current Anaesthesia & Critical Care 19 (2008) 354–360

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Current Anaesthesia & Critical Care

journal homepage: www.elsevier .com/locate/cacc

EDUCATION

Anaesthetic simulators: Making the most of your purchase

Tim Meek*

James Cook University Hospital, Marton Road, Middlesbrough TS4 3BW, UK

Keywords:Anesthesiology, educationPatient simulationClinical competenceEducation, medicalManikins

* Tel.: þ44 1642 854600.E-mail address: tim.meek@stees.nhs.uk

0953-7112/$ – see front matter � 2008 Elsevier Ltd.doi:10.1016/j.cacc.2008.07.010

s u m m a r y

This article covers the topic of medium to high fidelity anaesthesia simulation. Specifically, it refers tosimulation of anaesthesia scenarios using a whole body manikin with physiological modelling, based ina simulated operating theatre setting. It draws on the author’s own experiences in this area to offerpractical answers to common questions, including: What is an anaesthesia simulator good for? Who islikely to buy one? What else will I have to buy? Who is going to pay? What are the physical requirementsfor a simulator room? What can I use the simulator for? and Who should take charge?

� 2008 Elsevier Ltd. All rights reserved.

This article is aimed at the growing number of anaesthetists andanaesthetic departments who have, or have access to, an anaes-thetic simulator, as well as at those out there who might beconsidering such a purchase. It provides ideas for how they mightuse their new acquisition.

There are anecdotal reports of departments of anaesthesia orequivalent bodies having purchased expensive anaesthetic simu-lators, only for them to sit gathering dust, with no one quite surehow to exploit this potentially valuable resource (an apocryphaltale tells of one institute that currently has several unboxedsimulator systems gracing its shelves, purchased with some unusedfunds, their purchase now sitting equally unused). Clearly a degreeof thought and planning can prevent the simulator becoming anexpensive white elephant. Why are simulators bought and thenunder-used? Firstly, there is a general feeling that simulation mustbe useful, even though for many the thought is no more formedthan that. Some see their simulator as a vehicle to improve training,some as a vehicle to generate income. The relative affordability ofwhole body simulators has also contributed: £30 000 will buya very comprehensive state-of-the-art system.

1. What are we talking about?

This article excludes simple ‘part-task’ trainers such as intuba-tion heads or venous cannulation hands and specifically relates towhole body simulators with physiological modelling. The com-monest such simulators are the Laerdal SimMan� (Laerdal MedicalLimited, Orpington, BR6 0HX, UK) and the METI� Human PatientSimulator (HPS�) (Medical Education Technologies, Inc., 1016 PG

All rights reserved.

Amsterdam, Netherlands). Both can be used to simulate manydiverse clinical situations. From the anaesthetist’s point of view,their usefulness lies in the ability to recreate realistic scenarios inanaesthesia and intensive care. Both are full size human manikins,with physiological characteristics variously capable of beingexamined, measured and monitored, and also altered according tothe requirements of the simulated scenario. Both can be subjectedto a variety of practical procedures relating to airway, breathing andcirculation such as venous cannulation, intubation, tracheostomy,thoracocentesis and so on. They differ in the way changes inphysiological variables are controlled. With SimMan, such changesrequire real time intervention by the simulator operator, either byaltering individual variables (e.g. blood pressure) or by triggeringa pre-programmed complex response (e.g. malignant hyper-thermia). With the HPS, such changes are model-controlled, i.e. nointerventions are required by the simulator operator. For example,the model senses administration of a simulated drug, by detectinga coded syringe and makes the appropriate changes to the physi-ological variables. Both approaches have advantages and disad-vantages. With SimMan, the operator can easily make changes tothe scenario ‘on the hoof’ by adjusting individual or group variablesas desired; this does of course reduce the opportunity for theoperator to participate in the running of the scenario. With the HPS,the operator can more easily devote attention to the scenario, but itis much less easy to make changes to the model’s pre-ordainedresponse to any action if desired. Perhaps the most importantdifference though is the cost: a basic Laerdal SimMan set up costsaround £30 000; a METI HPS costs over £100 000. For this reason,the Laerdal SimMan is the most commonly encountered anaes-thetic simulator in the UK. SimMan comprises a manikin, a monitorscreen, a compressor to drive the mechanics of the manikin anda laptop PC with the control software. All the components connectvia a control box that also houses infrared detectors for the remotecontrols that can be used to control the unit. Examples of a typical

Fig. 1. A typical small to medium size simulator room. The laptop computer thatcontrols the simulator manikin and patient monitor is in the rear corner of the room.The infrared remote control receiver and simulated patient monitor are on top of theanaesthetic machine. The air compressor that powers the manikin’s movements is outof view. The air cylinder to the left of the photo supplies the anaesthetic machine flowmeters and powers its ventilator.

T. Meek / Current Anaesthesia & Critical Care 19 (2008) 354–360 355

SimMan set up are shown in Figs. 1–3. Only the larger simulationcentres will have the HPS.

In summary, both the Laerdal SimMan and the METI HPS can beused to mimic a wide range of real-world clinical scenarios,

Fig. 2. Screenshot from laptop computer showing the graphical user interface of the latestmanikin and controls for basic manikin functions. Top right: reproduction of patient monit(courtesy Laerdal).

providing a reasonable level of real interaction and a realisticreplication of common monitoring modalities.

2. What is an anaesthesia simulator good for?

Much of anaesthesia training is about learning how to deal withthe unexpected. This ranges from the common and simple (e.g.unexpected bradycardia) to the rare, complex and life-threatening(e.g. cannot ventilate, cannot intubate). Evidently, learning theskills to deal with the former is likely to be gained much sooner inroutine practice than for the latter, and with a lesser magnitude ofrisk to the patient. Therein lies the usefulness of the simulator; itenables trainees to experience and learn how to respond to criseswith potentially adverse outcomes without exposing a real patientto risk. This has been described as closing the gap between ‘slow’and ‘accelerated’ learning. Consider the two examples above.Unexpected bradycardia is relatively common and relatively easilydealt with: a trainee who learns this ‘treatment reflex’ in real-lifepractice is likely to do so very early in his/her career and patientharm is very unlikely. There is little role for simulator training here.However, ‘can’t ventilate, can’t intubate’ (CVCI) is very uncommon.If a trainee waits until they encounter this in real life, they are onthe ‘slow’ learning path. By practicing a failed intubation drill onthe simulator, a trainee can perfect the drill over five, 10, 50 or as

software version used to control Laerdal SimMan. Top left: graphical representation ofor display. Bottom: control and display area for pre-programmed scenarios and trends

Fig. 3. Screenshot from Laerdal SimMan patient monitor. This is one of many permutations possible. Monitor can be configured to represent a simple ward bedside monitor,anaesthetic machine monitor or complex intensive care monitor (courtesy Laerdal).

T. Meek / Current Anaesthesia & Critical Care 19 (2008) 354–360356

many repetitions as they wish. It seems self-evident that a traineewho has practiced dealing with such a critical incident many timeson a simulator will be better equipped to deal with it when ithappens in real life; this is of course virtually impossible to testscientifically. It will also be self-evident that any benefit derivedfrom simulator practice of rare events will diminish over time.There is a strong argument for established practitioners undergoingregular refresher sessions. This is one area that is currently under-exploited. This is one area where the aviation-anaesthesia analogyholds up: commercial pilots do not just use simulation to learn how

Fig. 4. With the addition of the right personnel and modest props, a very realisticclinical environment can be created (courtesy Laerdal).

to fly and deal with critical incidents; they are required to undergoperiodic re-certification. Anaesthesia simulators can be used tosimulate an almost infinite number of scenarios. It has been saidthat in fact it is not the performing of the scenario that is the mostimportant part of the experience, but the reflection that follows:the simulation allows the debriefing that makes sense of theevents.

There is also the question of simulator use in assessment.There is now general agreement that simulators are not suitablefor stand-alone assessment of competence. There is no evidenceto link success or failure in any given simulator scenario withcompetence in the real world of patients. Any use of simulatorsin assessment has to be taken in a broader context of multimodaltesting. A good example is the use of simulation in the Primaryexamination of the Royal College of Anaesthetists. Candidates canexpect to encounter a simulator station in the Objective Struc-tured Clinical Examination (OSCE), and can expect to be requiredto deal with a simulated critical incident such as anaphylaxis ortension pneumothorax. However, this will be one 5-min stationout of 16, in addition to the same-day Structured Oral Examina-tion (formerly the ‘viva’) and the Multiple Choice Questionnairethat the candidate has already passed. In this context, the use ofthe simulator is complementary to the other means of assess-ment. Likewise, the Royal College of Anaesthetists’ Initial Tests ofCompetence for new starter anaesthetists1 allow for the practiceof failed intubation drills to be manikin based. Again, this iscomplemented by real-world assessments of competence in otherdomains.

In summary, anaesthesia simulators are useful for teaching andpracticing responses to potentially dangerous critical incidentswithout risking harm to patients and can be a useful tool inmultimodal assessment of trainees’ competence.

T. Meek / Current Anaesthesia & Critical Care 19 (2008) 354–360 357

3. Who is likely to buy one?

Given the cost of even the cheaper option, very small depart-ments are perhaps unlikely to buy a simulator on their own, at leastin the current climate. It is possible that a consortium of smallerdepartments may join together to make a joint purchase. Schools ofAnaesthesia are likely to want to have a simulator for their traineesand so a centralised purchase may make more sense. There may begood reason for course directors to buy a simulator in order to givean added dimension to their particular course, such as MOET(Managing Obstetric Emergencies and Trauma)

4. What else will I have to buy?

Beside the purchase cost of the simulator itself, there are otherassociated costs. The largest of these is likely to be the cost ofbuilding or modifying the home for the simulator. (The desirableelements of the set up are covered later.) Clearly, the former is likelyto cost more than the latter. The room will then need furnishing:storage cupboards, working surfaces, an operating table (orequivalent) and items such as drip stands all have to be factored in.Besides this, there are ongoing costs. At the very least, the simulatorroom will need hardware and those more resilient items which willlast a reasonable time before needing to be replaced. This includesitems such as laryngoscopes, bougies, and oropharyngeal airways.In addition to this there are those items which have a finite lifespanand will need to be replaced more frequently. This includes itemssuch as tracheal tubes, laryngeal masks, syringes, cricothyrotomykits and thoracotomy sets. There are the consumable parts for andinevitable repairs to the simulator itself. Finally, the simulator willultimately need to be replaced itself.

5. Who is going to pay?

The initial capital outlay can come from a number of sources,including existing departmental funds, training budgets or dona-tions from charity. It may be necessary to share the cost with otherdepartments. This may be departments of anaesthesia from otherhospitals, but it is also worth considering joining with otherdepartments within the same hospital whose simulation require-ments may be complementary. Emergency medicine, surgery andobstetrics and gynaecology are just three examples. It may bepossible to reduce the financial burden by sourcing some itemsfrom theatre stock. This applies both to the initial set up and theongoing consumables. However, in the current financial climate,theatre managers have every reason to be unwilling to let thesimulator be a free drain on theatre’s resources. However, thesimulator room is a good place to use up non-serviceable and out-of-date items that would otherwise go to waste. For this reasonalone, it is worth cultivating a good relationship with the theatremanager, so he or she knows not simply to discard such itemswithout thought! It may be possible to identify a continuing sourceof funds for simulator related expenditure. In reality though, theremay be only one way of effectively covering the recurring costs ofthe simulator and that is to charge for its use. This includesdesigning and running courses to exploit the simulator, whetherthey be for anaesthetists or other groups of health workers andallowing other departments to use the simulator for their owneducational purposes. In any case, it is prudent to charge anappropriate rate. A going rate can be estimated by comparingsimilar level courses elsewhere. A more technical solution is toassume a replacement date for the simulator and base a charge onthat. For instance, if one wishes to have £30 000 to replace thesimulator after a minimum of 5 years use, and the simulator is inchargeable use one day per week, the necessary charge to generate

that sum is £30 000/(52 days� 5 years)¼ £30 000/260 days¼ £115per day.

6. What are the requirements for an anaesthesiasimulator room?

The scale and scope of the simulator room is limited only by thefunds available and the imagination of the individual! However,a surprisingly realistic environment can be created with relativelymodest efforts (Fig. 4). It is likely that at the very least, anaestheticusers will wish to have a mock up of a theatre environment. Theideal is to have a new purpose-built or converted space to house thesimulator. In any case, it is vital that an interested end-user isinvolved in the design from the earliest stage. It can be expensive oreven impossible to make retrospective changes once the work iscomplete. The essential and desirable characteristics of the simu-lator room are presented in Table 1 and discussed below.

6.1. Size

The bare minimum useful set up is manikin (with its associatedhardware), an anaesthetic machine, a trainee and a trainer. Evenwith this bare set up, a space of 3 m� 3 m should be viewed as anabsolute minimum. However, one only has to remember howcrowded a conventional anaesthetic room can become to see thata substantially larger space is desirable. Expanding to 5 m� 5 mmore than doubles the area and makes the space much moreusable. It becomes possible to accommodate all the accoutrementsthat will make the scenarios more realistic and will permit a largernumber of players into the room at any given time.

6.2. Location

It is essential to have a ‘break out’ area of some sort. This is thearea where briefings and debriefings can take place and wheretraditional ‘chalk and talk’ teaching can be done. These elements ofthe simulator-based teaching cannot easily be done in the simu-lator room itself. At its most basic, this need be nothing more thanan appropriately sized side room, equipped with seating anda whiteboard. If it is possible to have changing facilities with a readysupply of theatre clothing, having participants change into uniformcan aid create a more realistic simulator environment and can helplearners suspend their disbelief.

Where exactly the simulator is housed will depend upon users’anticipated uses for their simulator. It could be useful to have thesimulator room close to other teaching, simulation or educationalareas. This opens up opportunities for cross-specialty or mixed-group teaching and may reduce overheads as it enables shared useof associated facilities (see below). At the most developed end ofthis spectrum is the simulator housed within a simulator centre oreducation centre, which might also house simulated ward areas,emergency resuscitation rooms and even intensive care beds. Withthis level of complexity, one can simulate a patient’s entire journeyfrom pre-operative to post-operative. Alternately, some might takethe opposite view and prefer to have their simulator based in ornext to theatres.

6.3. Equipment

An anaesthetic machine is an essential component of thesimulator room. As a starting point, any machine will do, even onethat would not be used in current clinical practice, such as a Boyle’smachine. However, trainees understandably prefer to train usingmachines that accurately reflect those they are encountering in thereal world. The logical end-point is that the best anaestheticmachine for your simulator is the same machine that you have in

Table 1Ideal characteristics of an anaesthetic simulator room

Domain Essential Desirable

Size 3 m� 3 m Larger space, e.g. 5 m� 5 m

Location Area for:

- ‘Chalk and talk’- Sit down teaching- Brief and debrief

Adjacent to other teaching,simulation and/or educationalareas?Accessible for multi-disciplinaryuse?Close to theatres?Changing facilities

Equipment Anaestheticmachine – any

Anaesthetic machine:

- Modern- Same as rest of hospital

Table for manikin Functioning operating table ortrolley

Airwayequipment – basic:

- Laryngoscopes,airways, facemasks,laryngeal masks, etc.

Airway equipment –advanced:

- Kits for cricothyrotomy,fibrescope, intubatinglaryngeal mask, McCoyblade, etc.

Other equipment:

- i.v. fluids, giving sets,drip stands, etc.

Other equipment:

- X-ray viewing box, defi-brillator, etc.

Piped gases

Interpretablemedia

X-ray films, blood test results, ECGs,etc.

Control Separate control area

People Sufficient numbers to playout scenario

Dedicated staff to play roles:

- Health care professionals- Actors

Communication Working telephoneRadio frequency headsets

Video Facility to:

- Video scenarios- Review recordings

Live video link to ‘viewing suite’,lecture theatre or seminar room

Simulation‘extras’

Accessories for simulator:

- Fractures and other trauma- Pregnancy bump

Paediatric and/or baby manikinPart-task trainers:

- i.v. cannulation- airway- epidural, etc.

T. Meek / Current Anaesthesia & Critical Care 19 (2008) 354–360358

your theatres. For some, it may be possible to source an unusedmachine from somewhere. Given the cost of even a basic newanaesthetic machine, this is an attractive option. However, as moredepartments move to lease hire arrangements for their anaestheticmachines, this may become less of an option and for many, it will benecessary to buy a machine. Whichever option is chosen, theprocess is likely to be expensive and/or difficult and so it isimportant to consider this aspect of the set up early on in theprocess. An additional problem, which may not be self-evident, isthat of provision of gases to the machine. Depending on where thesimulator is set up, piped gases may not be available. Installingthem is an expensive business and equipping a clinical area withpiped gases under pressure has health and safety implications. An

alternative option is to rely on cylinder supply. However, cylindersare bulky and require storage room. In addition, even a size Gcylinder does not last for long if used at standard flows. Whetherfrom a pipeline, gases also have to be paid for – another cost tofactor in. Depending on which gases are used, scavenging may berequired. One way to avoid this is to run the machine on medical airalone. This obviates the need for scavenging and reduces thecombustion risk from oxidant gases. It is possible for the medicalengineering department to modify the anaesthetic machine so thatmedical air supplies all the flow meters as well as any internal gas-driven ventilator. Thus reality is not sacrificed to safety andconvenience.

A table will be needed for the manikin to lie on. Any table willsuffice, but ideally it should possess some realism, particularly theability to tip and adjust attitude. A simple anaesthetic trolley isa basic option, although even these are not cheap and so using anobsolete one from theatre may be a preferred option. The ideal is ofcourse a genuine theatre table. Again, these are not cheap and ex-theatre stock is a likely source.

Basic airway tools are a must: airways, laryngoscopes, trachealtubes, laryngeal airway devices and so on. Expanding the airwaytoolbox to include the various difficult airway management optionsincreases the range of scenarios that can be simulated. Practicingmanagement of failed intubation is a key use for anaestheticsimulators. The simulators referred to in this article permit invasivemanagement of failed intubation, including cricothyrotomy. Aswith the basic airway tools, other equipment such as drip standsand i.v. fluids and giving sets are essential for realism. Although notessential, the other hardware found in and around theatres canprovide a more realistic atmosphere and bring valuable addedrealism if incorporated into scenarios: X-ray viewing boxes anddefibrillators are but two examples.

6.4. Interpretable media

In order to make scenarios even more realistic, it is useful tohave a ‘bank’ of tests and test results to incorporate into scenarios.As is the convention in College examinations, it is best practice touse real results from real cases.

6.5. Control

Commissioning users should seriously consider specifyinga separate control room for the simulator, separated by a one-waymirror. This gives the ability to allow a scenario to play out withoutthe obvious and sometimes distracting presence of the personcontrolling events.

6.6. People

Most often, the other ‘characters’ in the scenario are played bythe other trainees on the day and/or the scenario controller.However, for more serious users, and certainly those entertainingcommercial exploitation of their simulator, it is worthwhileconsidering other ways of filling these roles. In some centres,educational fellows or other interested senior trainees are draftedin, although this of course can impact on service delivery and ontheir hours of work. Other health care professionals may be inter-ested in becoming involved, whether they be medical or otherwise.Finally, in some circumstances, non-medical volunteers or paidactors may be used.

6.7. Communication

Realism can be further improved by providing a working tele-phone in the simulated operating theatre. Thus, scenarios can

Table 2Possible uses for an anaesthetic simulator

Anaesthesia specific

New starters’ course

- Introduction to specialty- Basic skills practice

Specific skills for juniors

- Training and practice- e.g. obstetric on call, difficult airway management

Critical incident training and refreshment

- Broad vs specific (e.g. difficult airway)

‘Crew Resource Management’

Run throughs

- Anticipated difficult cases- Post-event analysis

Other specialties

Integration into formal courses

- e.g. MOET

‘Inter-professional education’:

- Anaesthetists, anaesthetic and theatre nurses, midwives, surgeons

‘Taster days’

- Postgraduate: Foundation Year doctors- Undergraduate: medical and nursing students- Other: ‘open days’

T. Meek / Current Anaesthesia & Critical Care 19 (2008) 354–360 359

incorporate telephone calls to get senior help, to the laboratory torequest tests and results, to X-ray to request investigations, to ITUto organise a bed space. Clearly, these have to be calls to ‘simulated’people, not the real departments! A simple way to achieve this is tohave another telephone in the control room (if present) and allowthe controller to play the various roles. This is also efficient in use ofpersonnel. Alternately, if there is no control room, another playercan be sequestered elsewhere and field the calls. This has thedisadvantage of requiring another person (or taking another personaway from the scenario). For the ultimate in control, it is possible touse radio frequency headsets to relay instructions from the scenariocontroller to the role-players in the scenario. Thus instructions canbe given about key moments in the scenario.

6.8. Video

It is useful to have the facility to video scenarios as they play outand replay them later for the debriefing session. Ideally, this willinclude single or multiple camera angles and an overlay of thepatient’s physiological variables. Laerdal has just introduced sucha feature for SimMan (‘Integrated Video Debriefing System’) witha single camera, although custom made systems can be locallycreated to the same end.

6.9. Simulation extras

There are a number of accessories that can be added to expandthe repertoire of the simulator: items such as pregnancy bumps,trauma limbs, simulated wounds and so on. Some departmentsmay wish to consider buying a paediatric and/or baby simulatormanikin depending on their intended scope. Finally, the simulatorroom could also house a variety of associated part-task trainers,such as those for i.v. cannulation of cricothyrotomy. There isvirtually no limit to the accessories that one could add in order toimprove the simulator experience.

7. What can I use the simulator for?

Once a simulator facility has been established, there are manyways in which it can be used, some of which have already beenmentioned. A summary is provided in Table 2.

7.1. New starters’ course

The simulated theatre is an excellent environment for brandnew anaesthetists to learn and practice key skills with no risk toreal patients. At the author’s hospital, this course takes all the newstarters in the locality at each intake, and holds six one day sessions,covering: equipment; problems on induction; post-operativeproblems; rapid sequence induction; failed intubation; medicalproblems; emergency anaesthesia; regional anaesthesia and crit-ical incidents. The course combines lectures and hands-on simu-lated experience and is simultaneous with the trainees’introduction to clinical practice, i.e. they attend one day per week,whilst spending the rest of the week in real theatres. Other modelscould be easily adopted for local needs.

7.2. Specific skills for juniors

The simulator can be used to prepare junior anaesthetists forparticular ‘hurdles’ in clinical practice. A good example isprogression to the obstetric on call rota. The author’s hospital hassuccessfully run courses for junior anaesthetists approaching thismilestone, enabling them to train for and practice responses tocommon critical incidents, such as severe hypotension, massivehaemorrhage, total spinal anaesthesia and failed intubation. There

are undoubtedly many other clinical ‘hurdles’ that could benefitfrom such treatment.

7.3. Critical incident training and refreshment

Established practitioners (whether trainee or senior) can benefitfrom simulated practice of managing critical incidents. With time,any learned but unused skill diminishes. Even the most experi-enced anaesthetist may benefit from periodically refreshing theirskills in managing critical incidents. The less common the criticalincident, the greater the potential benefit (a parallel with cardio-pulmonary resuscitation training).

7.4. Crew resource management

This term is borrowed from aviation training and refers to theact of appropriately and efficiently directing a team in a time ofcrisis. Training in crew resource management involves training ineffective interpersonal communication, leadership, and decisionmaking and can be adapted to the theatre environment.

7.5. Run throughs

Simulators can be used to practice anticipated difficult cases inadvance. It is possible to practice responses to any number ofoutcomes. This requires the involvement of a simulator operatorsufficiently versed in the specialty to make the necessary scriptmanoeuvres on the hoof. Similarly, it is conceivable to use a simu-lator to hold a ‘post-mortem’ run through when an adverse eventhas occurred. These are not yet common uses for simulators,although there is no reason not to use them in this way.

T. Meek / Current Anaesthesia & Critical Care 19 (2008) 354–360360

7.6. Integration into formal courses

Some courses are too rigidly prescribed to allow this, but insome, MOET for example, anaesthetic simulation has beensuccessfully integrated into courses in some centres, yet without itbeing a core or mandatory feature. However, when used, it lends anadditional layer of realism in scenarios.

7.7. Inter-professional education

It is possible to arrange simulator multi-disciplinary sessions inthe simulator. These can be useful for clarifying and defining theroles of the various medical and allied professions and can incor-porate elements of any or all of the uses mentioned above andbelow. By allowing individuals to swap simulated roles and take onroles other than their own, insight can be gained into otherprofessionals’ decision making processes.

7.8. Taster days

Finally, simulation can always be made fun. It can therefore bea great advertisement for the specialty, whether it be to those whohave already entered medicine or those who are considering theiroptions.

8. Who should take charge?

Ideally, one consultant or a small cohesive group of consultantsshould manage and develop the simulator. In some circumstances,consultants may take a regular programmed session in the simu-lator; for others, occasional sessions may suffice. Under the UKconsultant contract, a proportion of consultant time is paid sup-

porting patient activity (SPA); simulator teaching is a very valid SPAwith a demonstrable outcome.

9. A hidden benefit?

In the future, as we move to a consultant-delivered service,there will likely be many fewer trainees than there are now.Trainees will tend to converge on centres that can offer all theirtraining from start to completion. Simulation is likely to form somepart of that and so is but one element likely to attract trainees toa centre. The benefits to departments of anaesthesia of continuingto be able to attract trainees in the future are obvious.

In summary, setting up a simulator service is not as simple andstraightforward as it might initially appear. However, it isundoubtedly a worthwhile and useful enterprise. The potentialuses are almost limitless and the technology is still in an early phaseof its evolution. As time passes, the fidelity of anaesthesia simula-tion will undoubtedly improve and thus further widen its appeal. Inthe meantime it remains a useful resource to exploit and develop,with benefits from trainees, trainers and departments alike.

Reference

1. CCT in anaesthesia II: competency based basic level (ST years 1 and 2) training andassessment. A manual for trainees and trainers. London: Royal College of Anaes-thetists; January 2007.

Further reading

1. Gallagher CJ, Issenberg SB. Simulation in anesthesia. Philadelphia: SaundersElsevier; 2007 [An entertaining guide to setting up and running simulatorsessions, with a large selection of suggested scenarios].

2. For details of the Laerdal SimMan: <http://www.laerdal.com>

3. For details of the METI HPS: <http://www.meti.com>