HISTORICAL SELECTION: Rosenberg MB. Simulation technology in anesthesiology. Anesth Prog. 2000;47(1):8-11.

Abstract

It is indeed an honor to be asked to select a landmark article in dental anesthesiology from the archives of Anesthesia Progress and to provide commentary on its continued relevance and historical importance 21 years after its publication. Normally, this honor is bestowed upon the yearly Heidbrink Award recipient of the American Dental Society of Anesthesiology (ADSA). However, due to the ongoing pandemic and subsequent postponement of an in-person Heidbrink presentation, your editor asked me to provide this year's selection, an historic article authored by Morton B. Rosenberg, DMD concerning the past, present, and future of anesthesia simulation technology.Mort is certainly no stranger to the readership of Anesthesia Progress nor to any dentist interested in dental sedation or general anesthesia. He graduated from Boston University with a BA in biology in 1970 and from Tufts University School of Dental Medicine in 1974. He was selected for Omicron Kappa Upsilon honors, documenting his excellence in clinical dental skills and superior academic performance. Rather than pursue an almost assured successful private practice of general dentistry, he opted to complete a 3-year medical anesthesiology residency at Tufts-New England Medical Center where he earned the unique honor of being selected from among their physician anesthesia residents as chief-resident in his final year. It was obvious to the entire faculty of his medical center's department of anesthesiology that Mort had become such an extraordinary anesthesiologist that they felt compelled to create an anesthesiology faculty position for him, which he just could not refuse. Over the next 4 decades, Mort rose to the rank of full professor, including a remarkable 14-year stint as medical director of the operating rooms (ORs). Among the broad areas of his clinical expertise including cardiac and neuro-anesthesia, he was entrusted to head their pediatric liver transplantation anesthesia team. He has been a superb educator and mentor of anesthesia residents, including one of his “peeps” who eventually ascended to the presidency of the 54,000-member American Society of Anesthesiologists.However, despite his exceptional hospital anesthesia training and experience, Mort never abandoned the dental profession. He also remained on the faculty at Tufts School of Dental Medicine and taught pharmacology, sedation, and management of medical emergencies to dental students and residents. He encouraged numerous dental students to enter anesthesia residency programs to become dentist anesthesiologists. Mort has taught scores of continuing education courses, authored dozens of peer-reviewed published articles, and has been a common-sense leader and stabilizing influence in the ADSA as well as in the specialty of dental anesthesiology. His dental anesthesia mentor was Dr Tom Quinn, a Boston-area Heidbrink award winner (1987) and oral surgeon, who introduced us in 1979 at the annual ADSA meeting at the Hyatt Regency Hotel in Chicago. Since that moment, we have become not only colleagues but also the closest of friends.At that time, high-fidelity anesthesia simulation technology did not exist. It was preceded by gradual advances in low-fidelity simulation that arose from Dr Peter Safar's description of mouth-to-mouth artificial ventilation.1,2 In order to expand the teaching and practice of Dr Safar's new form of resuscitation, anesthesiologist Dr Bjorn Lind requested Asmund Laerdal, a Norwegian toy and doll-maker, to design and manufacture a pliable human-like torso that made it possible to practice Safar's head-tilt/chin-lift maneuver to relieve upper airway obstruction during his mouth-to-mouth ventilation procedure.3 Dr Safar later suggested that a spring be added to the mannequin's chest so that compressions for closed chest cardiac message could complement the artificial ventilations3–5 we now call cardiopulmonary resuscitation (CPR).Thus, Resusci-Anne was born in 1960 and contributed greatly to low-tech CPR simulation training. Then in the mid-1970s, the American Heart Association developed their Advanced Cardiac Life Support (ACLS) course, which combined an intubating mannequin that could be defibrillated and an attached primitive computer that could generate and display a variety of cardiac rhythms on a monitor to simulate medical emergency situations. Over the past 5 decades, thousands of health care practitioners utilizing this slightly higher-tech simulation technology have enhanced their advanced resuscitation skills to the benefit of countless patients.In the decades to follow, computer hardware and software continued to improve so that high-tech simulation became possible, beginning at Stanford University with Dr David Gaba's development of the Comprehensive Anesthesia Simulation Environment (CASE). Its computer system could produce all of the monitoring parameters of a patient in the OR, creating a life-like environment for the practitioner to apply their knowledge and skills in diagnosing and managing common and uncommon anesthesia urgencies and emergencies.6,7 With its extraordinarily realistic recreation of the OR environment, this high-tech equipment was soon used for teaching anesthesia crisis resource management (ACRM).7,8 Since then, tremendous improvements in simulation technology have continued to advance the realism and popularity of high-fidelity simulation in a variety of medically related fields.Dr Rosenberg's article explains that anesthesia simulation is “designed to reproduce or represent effects simulating phenomena likely to occur in reality” and compares it to flight simulation in aviation. He points out that anesthesiology “has been the driving force in the medical community in introducing realistic, complex simulation concepts.” He predicts that dental sedation and general anesthesia practice may greatly benefit from simulation experiences in training programs and continuing education programs for dentist anesthesiologists and oral and maxillofacial surgeons.In his article, Dr Rosenberg explains that in all levels of simulation technology, 2 important concepts must be closely followed for the experience to be valid and relevant—the fidelity and the representation of the simulation. Fidelity is how closely the simulation reproduces an actual clinical event, whereas representation is the summation of all the simulator's outputs and is what actually constitutes the critical event. Representation can be done via computer-based simulator with information viewed on a computer screen or with more realism by recreating an office or an OR environment that is fully equipped with interactive mannequins, monitors, and anesthesia equipment, including the confusion, pressure, and stress created by alarms, misleading signs and symptoms, equipment failure, obnoxious surgeons, distracted nurses, etc. The greatest advantage of simulation is that common and uncommon events can all be managed without risk to actual patients. Computer-based simulators certainly cannot reproduce the same fidelity and representation that the realistic high-fidelity anesthesia simulators can produce, but they are considerably less expensive and much more easily accessible. Students can proceed at their own pace and use this technology as a first step in their education and training.Dr Rosenberg points out that high-fidelity anesthesia simulators can also be used to teach basic manual skills in airway management, as well as management of shock trauma, cardiac dysrhythmias, and ACLS. Over the past 21 years, there has been increasing interest in determining whether high-fidelity simulation actually improves educational outcomes compared with traditional teaching. For example, Manton et al9 demonstrated the superior value of high-fidelity simulation training for teaching the management of medical emergencies compared with traditional lecture discussion education for general practice dental residents.Most importantly, Dr Rosenberg's article discusses an even more unique advantage of high-fidelity simulation training beyond the mastering of specific critical events, namely the area of interpersonal performance training for any crisis. Similar to aviation's cockpit resource management training, ACRM stresses improved communication skills among the team, appropriate roles and emergency responses of team members, and the continuous reassessment of an evolving critical event. Although simulation experiences can cover many common and uncommon anesthesia events, one cannot practice every possible anesthetic crisis and all their variations. However, high-fidelity simulation utilizing the principles of ACRM does provide valuable experience in the universal skills of keeping calm and communicating clearly while problem solving during any crisis, not just those previously practiced.Finally, Dr Rosenberg peers into the future, stating that “Simulation may prove to be an excellent educational tool to update and recertify practicing healthcare professionals and could become an important adjunct to office inspection and evaluation conducted under the auspices of dental professional societies…”. The beauty of his article is that Mort's look into the future has now come true. As an example, the American Association of Oral and Maxillofacial Surgeons (AAOMS) announced on May 19, 2021, that their House of Delegates would soon vote on a proposed resolution mandating that members who provide office-based moderate or deep sedation or general anesthesia must complete an association-approved anesthesia simulation training course every 5 years effective 2026 and, starting in 2022, all members must attest to conducting quarterly team mock emergency drills. Ideally, this would involve high-fidelity simulation. At their annual 2021 fall meeting, the AAOMS House of Delegates passed those mandates.Furthermore, the development of high-fidelity simulation centers and their incorporation into training curricula is increasingly more common, especially in major universities and large hospital systems. As accredited residencies in oral and maxillofacial surgery and dental anesthesiology must have substantial rotations with a hospital anesthesia department (5 months and 1 year, respectively), there is ample time for the inclusion of high-fidelity anesthesia simulation following initial computer simulation teaching courses. Hopefully in the future, as hardware and software costs moderate and as universal interest in high-fidelity simulation increases, all dentists will have the opportunity to practice medical emergency management within the scope of their training and practice.Clearly, as predicted in Mort's timely article, anesthesia simulation has already progressed remarkably in this century and will continue to increase the safety margin of sedation and general anesthesia within dentistry.Respectfully submitted,Joel M. Weaver, DDS, PhDDentist Anesthesiologist SpecialistProfessor EmeritusCollege of Dentistry and Department of AnesthesiologyWexner Medical CenterThe Ohio State UniversityADSA Jay A. Heidbrink Award (1998)ASDA Leonard M. Monheim Award (2003)IFDAS Horace Wells Award (2006)This continuing education (CE) program is designed for dentists who desire to advance their understanding of pain and anxiety control in clinical practice. After reading the designated article, the participant should be able to evaluate and utilize the information appropriately in providing patient care.The American Dental Society of Anesthesiology (ADSA) is accredited by the American Dental Association and Academy of General Dentistry to sponsor CE for dentists and will award CE credit for each article completed. You must answer 3 of the 4 questions correctly to receive credit. Submit your answers online at www.adsahome.org. Click on ‘‘On Demand CE.''CE questions must be completed within 3 months and prior to the next issue.