Every ENT anesthesia fellowship needs a simulation-based education program

Abstract

Anesthesiologists and otolaryngologists are specialists who share overlapping patient considerations because of the proximity of the surgical field and airway. Although many surgical environments benefit from a collegial team dynamic, the interdisciplinary otolaryngologic environment mandates collaboration from anesthesiologists and otolaryngologists for optimal patient outcomes1. Patients undergoing head and neck surgery are at high risk of potentially devastating events if the airway anatomy is distorted secondary to pathologic conditions or previous surgeries. Although many ENT Anesthesia fellowship programs provide exposure to a wide array of clinical cases and development of airway technical skills, the current simulation literature suggests that training programs focus on improvement of procedural skills in silo2–4. However, this is not optimal for prevention or management of high stress situations where crises resource management (CRM) and interdisciplinary team dynamics can affect patient outcome. We would like to encourage every ENT Anesthesia and Surgical training program to consider introducing a comprehensive simulation-based educational component to ensure proficiency in CRM, communication skills, and leadership skills to better manage the rare and critical cases. The use of simulation for interdisciplinary training amongst anesthesiologists, surgeons, and nurses offers flexibility, preserves realism, and enhances patient safety, which makes it ideal for education and assessment of practitioners, regardless of level of training. A wide variety of simulation technology exists with differing degrees of complexity and fidelity that can be used to advance technical skills. Two major classes are part-task trainers and whole-task trainers. Part-task trainers include simple models designed for a specific task. They vary from animal models and mannequins, to more advanced screen-based computer interface. Examples of airway trainers such as the Laerdal adult airway mannequin are capable of mask ventilation, supraglottic airway placement, fiberoptic intubation, as well more invasive procedures of cricothyrotomy and tracheostomy. Slightly more advanced part-task trainers include bronchoscopy devices such as GI-BRONCH Mentor (3D Systems, Littleton, CO) which provide screen-based simulation coupled with tactical psychomotor mechanics. Part-task trainers are important for clinicians to build fundamental skills that can be translated into proficiency in clinical practice. For example, studies have shown a faster acquisition of direct laryngoscopy and improved psychomotor skills on fiberoptic intubations when practiced initially on part-task trainers5,6. In contrast, whole-task trainers (Laerdal SimMan 3G, CAE HPS) are full-scale patient simulators with advanced computer-driven technology and human-modeled physiology that can be altered for desired clinical scenarios. When whole-task trainers are combined with standardized patients and part-task trainers, a hybrid learning environment can be created to incorporate high-fidelity simulation scenarios involving technical as well as nontechnical skills. Team training in the form of interprofessional education (IPE) and interprofessional learning (IPL) is critical for patient safety in the operating room in general, but more so in head and neck cases due to the shared working environment between otolaryngologists and anesthesiologists1. IPE refers to 2 or more professions learning with, from and about each other to improve collaboration and the quality of care, whereas IPL is learning that arises from interaction between members of 2 or more professions7. Rare and potentially disastrous ENT scenarios can be created and implemented, requiring interdisciplinary teamwork and communication for proper patient care. For instance, an in situ simulation course (one that uses actual clinical resources and equipment) at Boston Children’s Hospital teaches teamwork, CRM, and decision-making of high-risk, low frequency airway emergencies to a team of otolaryngology residents, anesthesia trainees, and operating room nurses8. Scenarios such as foreign body aspiration, the bleeding airway, or airway obstruction requiring a surgical airway can be simulated using a hybrid approach with mannequins and standardized patients. These complex educational modules can enhance the learning process and joint coordination of care for both specialists9,10. A rarer emergency includes the airway fire scenario, which not only tests the nontechnical skills and treatment, but also introduces the “fire triad” (oxidizer, ignition source, and fuel), and creates heightened awareness of anesthetic and surgical management to avoid such a disaster11–13. In situ simulations can also be conducted before implementation of new protocols to assess efficiency, to identify disruptions to workflow, and to evaluate various aspects of patient care such as systems-based errors and integration errors. At Johns Hopkins, an interdisciplinary difficult airway response team was created to manage hospital wide airway emergencies and incorporation of in situ simulations proved to be an invaluable tool to probe the system and to identify defects in resources14. A comprehensive, high-fidelity simulation curriculum incorporated into the ENT anesthesia fellowship allows the refinement of psychomotor skills for advanced airway as well as development of nontechnical management skills. Furthermore, when deliberate stressors are added to a fully immersive simulation involving participants in anesthesiology, otolaryngology and nursing, an opportunity is provided to enhance IPE and to facilitate multidisciplinary collaboration. A study conducted on advanced cardiac life support skills showed that adding extreme emotional stressors to a simulated scenario demonstrated an increased retention of skills and knowledge, as well as better performance of advanced cardiac life support15. Another study revealed that a negative outcome to the patient during simulated independent practice led to better retention of clinical skills upon retesting as compared with those who performed in a simulated supervised practice (where a superior helped intervene to prevent the negative outcome)16. The debriefing period that follows allowed the participants to reflect on individual practice and teamwork to identify weak links and areas of improvement for patient safety and care. Simulation has been used successfully as an assessment tool for medical students, residents, nurse anesthetists and practicing anesthesiologists17–20, as well those deemed incompetent21,22 or those retraining to reestablish competence23. Simulation is an ideal technique for fellowship training, education, and assessment of technical and nontechnical skills, especially in the subspecialty of ENT Anesthesia where unfamiliarity of rare ENT emergencies and crisis situations can have catastrophic implications. We urge that every ENT Anesthesia fellowship consider developing and incorporating simulation as part of the fellowship curriculum. Conflict of interest disclosures The authors declare that they have no financial conflict of interest with regard to the content of this report.