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124-547: Modern-day simulation for training was first utilized by anesthesia physicians to reduce accidents. When simulation skyrocketed in popularity during the 1930s due to the invention of the Trainer Building Link Trainer for flight and military applications, many field experts attempted to adapt simulation to their own needs. Medical simulation was not immediately accepted as a useful training technique, both because of technological limitations and because of

248-557: A hazard ratio of 2.12 (95% confidence interval, 1.26–3.54). The immediate time after anesthesia is called emergence . Emergence from general anesthesia or sedation requires careful monitoring because there is still a risk of complication. Nausea and vomiting are reported at 9.8% but will vary with the type of anesthetic and procedure. There is a need for airway support in 6.8%, there can be urinary retention (more common in those over 50 years of age) and hypotension in 2.7%. Hypothermia , shivering and confusion are also common in

372-428: A "theory of experience", Experiential Learning Theory states that experience plays a central role in human learning and development. The six principles of Experiential Learning Theory align with educational simulation. The six principles are: Simulation also aligns with Guided Discovery learning . Developed by Jerome Bruner in the 1960s, discovery learning also stems from the work of Jean Piaget and can be described as

496-597: A "uniform mechanism to educate, evaluate, and certify simulation instructors for the health care profession" was recognized by McGaghie et al. in their critical review of simulation-based medical education research. In 2012 the SSH piloted two new certifications to provide recognition to educators to meet this need. The American Board of Emergency Medicine employs the use of medical simulation technology in order to accurately judge students by using "patient scenarios" during oral board examinations. However, these forms of simulation are

620-512: A Public Safety Communication warning that "repeated or lengthy use of general anesthetic and sedation drugs during surgeries or procedures in children younger than 3 years or in pregnant women during their third trimester may affect the development of children's brains." The warning was criticized by the American College of Obstetricians and Gynecologists, which pointed out the absence of direct evidence regarding use in pregnant women and

744-498: A difficult airway ) and any coexisting diseases (especially cardiac and respiratory diseases ) that might impact the anesthetic. The physical examination helps quantify the impact of anything found in the medical history in addition to lab tests. Aside from the generalities of the patient's health assessment, an evaluation of specific factors as they relate to the surgery also need to be considered for anesthesia. For instance, anesthesia during childbirth must consider not only

868-426: A drop in blood pressure is common. This drop is largely dictated by the venous side of the circulatory system which holds 75% of the circulating blood volume . The physiologic effects are much greater when the block is placed above the 5th thoracic vertebra . An ineffective block is most often due to inadequate anxiolysis or sedation rather than a failure of the block itself. Nociception (pain sensation)

992-521: A facilitator during this phase include: Participant performance is a key component during the analysis phase. However, performance can often be a difficult topic to broach with participants, as criticism or constructive feedback often incur negative feelings. There exists a framework for questioning named "Advocacy-Inquiry," or the "debriefing with good judgment" approach, which aims to reduce negative experiences in medical simulation debriefing. Advocacy Inquiry. The use of advocacy-inquiry (AI) questioning

1116-499: A far cry from high- fidelity models that have surfaced since the 1990s. Due to the fact that computer simulation technology is still relatively new with regard to flight and military simulators, there is still much research to be done about the best way to approach medical training through simulation, which remains un-standardized despite having been embraced generally by the medical community. That said, successful strides are being made in terms of medical education and training, although

1240-548: A formula which he named tsūsensan (also known as mafutsu-san), which combined Korean morning glory and other herbs. Hanaoka's success in performing this painless operation soon became widely known, and patients began to arrive from all parts of Japan. Hanaoka went on to perform many operations using tsūsensan, including resection of malignant tumors , extraction of bladder stones , and extremity amputations. Before his death in 1835, Hanaoka performed more than 150 operations for breast cancer. However, this finding did not benefit

1364-423: A learning environment where there is little to no instructor-guidance. Guided discovery learning, on the other hand, continues to place learners in a discovery environment, but where an instructor is available to help guide learning via coaching, feedback, hints, or modeling. Both Experiential and Discovery Learning are based on constructivist philosophy. Broadly, Constructivism is based on the belief that learning

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1488-462: A learning opportunity for other members of the team who were not present at the events being debriefed. In the field of psychology , debriefing is used in the processing of traumatic events. Here, the emphasis is on the narrative; in a facilitator-led environment, participants reconstruct what happened and review facts, share reactions, and develop a shared meaning of the events. The aim is to reduce stress, accelerate normal recovery, and assist in both

1612-410: A medical school dedicates 27 rooms of its CSSC to training with simulations. A medical simulation centre is an educational centre in a clinical setting. The key elements in the design of a simulation center are building form, room usage, and technology. For learners to suspend disbelief during simulation scenarios, it is important to create a realistic environment. It may include incorporating aspects of

1736-660: A number of studies have shown that students engaged in medical simulation training have overall higher scores and retention rates than those trained through traditional means. The Council of Residency Directors (CORD) has established the following recommendations for simulation: The Association of Surgeons in Training has produced recommendations for the introduction, availability, and role of simulation in surgical training. The two main types of medical institutions that train people through medical simulations are medical schools and teaching hospitals. According to survey results from

1860-601: A painless operation. However, Long did not announce his discovery until 1849. Horace Wells conducted the first public demonstration of the inhalational anesthetic at the Massachusetts General Hospital in Boston in 1845. However, the nitrous oxide was improperly administered and the person cried out in pain . On 16 October 1846, Boston dentist William Thomas Green Morton gave a successful demonstration using diethyl ether to medical students at

1984-626: A paucity of quantitative data regarding the effectiveness of debriefing in medical simulation, despite Lederman's 1992 seminal Model for the Systematic Assessment of Debriefing. Nearly every article reviewed had a cry for objective studies regarding the effectiveness of debriefing, whether it be comparing: the myriad options of conversational structures, debriefing models, or the comprehensive 5 W's of Who – debriefer, What – content and methods, When – timing, Where – environment, and Why – theory. Currently, there are critical limitations in

2108-506: A performance are explored and analysed with the aim of gaining insights that impact the quality of future clinical practice". Or another regarding debriefing in gaming, by Steinwachs (1992), "...a time to reflect on and discover together what happened during game play and what it all means." Medical simulation is often defined as, "a technique (not a technology) to replace and amplify real life experiences with guided ones, often "immersive" in nature, that evoke or replicate substantial aspects of

2232-575: A physician's understanding and use of best practices, management of patient complications, appropriate use of instruments and tools, and overall competence in performing procedures." The main purpose of medical simulation is to properly educate students in various fields through the use of high technology simulators. According to the Institute of Medicine, 44,000 to 98,000 deaths annually are recorded due primarily to medical mistakes during treatment. Other statistics include: If 44,000 to 98,000 deaths are

2356-601: A quicker recovery. A combination of drugs was later shown to result in lower odds of dying in the first seven days after anesthetic. For instance, propofol (injection) might be used to start the anesthetic, fentanyl (injection) used to blunt the stress response, midazolam (injection) given to ensure amnesia and sevoflurane (inhaled) during the procedure to maintain the effects. More recently, several intravenous drugs have been developed which, if desired, allow inhaled general anesthetics to be avoided completely. The core instrument in an inhalational anesthetic delivery system

2480-515: A regional or national anesthesiologist-led framework. The same minimum standards for patient safety apply regardless of the provider, including continuous clinical and biometric monitoring of tissue oxygenation, perfusion and blood pressure; confirmation of correct placement of airway management devices by auscultation and carbon dioxide detection; use of the WHO Surgical Safety Checklist ; and safe onward transfer of

2604-465: A sedative, the effect is a feeling of general relaxation, amnesia (loss of memory) and time passing quickly. Many drugs can produce a sedative effect including benzodiazepines , propofol , thiopental , ketamine and inhaled general anesthetics. The advantage of sedation over a general anesthetic is that it generally does not require support of the airway or breathing (no tracheal intubation or mechanical ventilation ) and can have less of an effect on

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2728-407: A series of activity clusters, or "hubs" on its way back to consciousness. Andrew Hudson, an assistant professor in anesthesiology states, "Recovery from anesthesia is not simply the result of the anesthetic 'wearing off,' but also of the brain finding its way back through a maze of possible activity states to those that allow conscious experience. Put simply, the brain reboots itself." Long-term POCD

2852-555: A study conducted by Bjorn Hoffman, to find the level of efficiency of simulation based medical training in a hi-tech health care setting, "simulation's ability to address skillful device handling as well as purposive aspects of technology provides a potential for effective and efficient learning." More positive information is found in the article entitled, "The role of medical simulation: an overview," by Kevin Kunkler. Kunkler states that, "medical simulators can be useful tools in determining

2976-519: Is a "one-shot" injection that provides rapid onset and profound sensory anesthesia with lower doses of anesthetic, and is usually associated with neuromuscular blockade (loss of muscle control). Epidural anesthesia uses larger doses of anesthetic infused through an indwelling catheter which allows the anesthetic to be augmented should the effects begin to dissipate. Epidural anesthesia does not typically affect muscle control. Because central neuraxial blockade causes arterial and venous vasodilation ,

3100-445: Is a subtle deterioration in cognitive function, that can last for weeks, months, or longer. Most commonly, relatives of the person report a lack of attention, memory and loss of interest in activities previously dear to the person (such as crosswords). In a similar way, people in the workforce may report an inability to complete tasks at the same speed they could previously. There is good evidence that POCD occurs after cardiac surgery and

3224-420: Is an anesthetic machine . It has vaporizers , ventilators , an anesthetic breathing circuit, waste gas scavenging system and pressure gauges. The purpose of the anesthetic machine is to provide anesthetic gas at a constant pressure, oxygen for breathing and to remove carbon dioxide or other waste anesthetic gases. Since inhalational anesthetics are flammable, various checklists have been developed to confirm that

3348-531: Is an active process whereby learners make sense of new knowledge by building upon their prior experiences; each person has a unique set of experiences which frame their interpretation of information. While many models for debriefing exist, they all follow, at a minimum, a three-phase format. Debriefing models can be divided into two categories: the "Three-Phase Debriefing Structure," and the "Multiphase Debriefing Structure". A benchmark in all forms of facilitator-guided, post-event debriefing conversational structures,

3472-408: Is highly encouraged by nearly all authors of debriefing models. Advocacy-inquiry consists of pairing "an assertion, observation, or statement" (advocacy), together with a question (inquiry), in order to elicit the mental frameworks – or schema – of both the facilitator and the participants. In phrasing questions this way, participants are made aware of the facilitator's own point of view in relation to

3596-399: Is not hard-wired into the body. Instead, it is a dynamic process wherein persistent painful stimuli can sensitize the system and either make pain management difficult or promote the development of chronic pain. For this reason, preemptive acute pain management may reduce both acute and chronic pain and is tailored to the surgery, the environment in which it is given (in-patient/out-patient) and

3720-445: Is recommended that these types of debriefings occur in a separate room from where the simulation scenario took place. This allows for a release of tension as participants move from one place to another and encounter new surroundings. Note, however, that it is important to remind participants not to begin debriefing during the walk to the new room. The momentum of the simulation leads participants to begin debriefing with one another as soon

3844-409: Is recommended that, during the debriefing, the facilitator(s) or participants be seated in a circle. This is done so that everyone can see each other and increase group cohesion. Furthermore, the use of a circle implies equality among the group, and decreases any sense of hierarchy which may be present. Establishing psychological safety and a safe learning environment is of utmost importance within both

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3968-478: Is the injection of local anesthetic around the spinal cord to provide analgesia in the abdomen , pelvis or lower extremities . It is divided into either spinal (injection into the subarachnoid space ), epidural (injection outside of the subarachnoid space into the epidural space) and caudal (injection into the cauda equina or tail end of the spinal cord). Spinal and epidural are the most commonly used forms of central neuraxial blockade. Spinal anesthesia

4092-686: Is the journal of the SSH. The journal was first published in January 2006 with Dr. David Gaba as the founding Editor in Chief. The journal is published by Lippincott Williams & Wilkins. The SSH was envisioned as an umbrella organization and the journal also serves as the official publication for other groups such as the Australian Society for Simulation in Healthcare. The journal is indexed by National Library of Medicine . In 2010

4216-404: Is the phase in which the bulk of the time of debriefing is spent, with a focus on participant performance, rationales, and frames. It is meant to be a time of reflective practice on what actually occurred during the scenario, and the reasons why events unfolded as they did. The analysis phase uncovers the decision-making process behind observed actions. Common questions posed, or statements made, by

4340-425: Is unique in that it is not a direct means of treatment; rather, it allows the clinician to do things that may treat, diagnose, or cure an ailment which would otherwise be painful or complicated. The best anesthetic, therefore, is the one with the lowest risk to the patient that still achieves the endpoints required to complete the procedure. The first stage in anesthesia is the pre-operative risk assessment consisting of

4464-459: Is usually overlap in the contributing factors that lead to morbidity and mortality between the health of the patients, the type of surgery being performed and the anesthetic. To understand the relative risk of each contributing factor, consider that the rate of deaths totally attributed to the patient's health is 1:870. Compare that to the rate of deaths totally attributed to surgical factors (1:2860) or anesthesia alone (1:185,056) illustrating that

4588-465: The Salerno school of medicine in the late 12th century and by Ugo Borgognoni (1180–1258) in the 13th century. The sponge was promoted and described by Ugo's son and fellow surgeon, Theodoric Borgognoni (1205–1298). In this anesthetic method, a sponge was soaked in a dissolved solution of opium, mandragora , hemlock juice, and other substances. The sponge was then dried and stored; just before surgery

4712-505: The cardiovascular system which may add to a greater margin of safety in some patients. When pain is blocked from a part of the body using local anesthetics , it is generally referred to as regional anesthesia. There are many types of regional anesthesia either by injecting into the tissue itself, a vein that feeds the area or around a nerve trunk that supplies sensation to the area. The latter are called nerve blocks and are divided into peripheral or central nerve blocks. The following are

4836-507: The medical history , physical examination and lab tests . Diagnosing the patient's pre-operative physical status allows the clinician to minimize anesthetic risks. A well completed medical history will arrive at the correct diagnosis 56% of the time which increases to 73% with a physical examination. Lab tests help in diagnosis but only in 3% of cases, underscoring the need for a full history and physical examination prior to anesthetics. Incorrect pre-operative assessments or preparations are

4960-476: The opium poppy ( Papaver somniferum ) in lower Mesopotamia as early as 3400 BCE . The ancient Egyptians had some surgical instruments, as well as crude analgesics and sedatives, including possibly an extract prepared from the mandrake fruit. In China, Bian Que ( Chinese : 扁鹊, Wade–Giles : Pien Ch'iao , c.  300 BCE ) was a legendary Chinese internist and surgeon who reportedly used general anesthesia for surgical procedures. Despite this, it

5084-445: The surgical stress response. Anesthesia is a combination of the endpoints (discussed above) that are reached by drugs acting on different but overlapping sites in the central nervous system . General anesthesia (as opposed to sedation or regional anesthesia) has three main goals: lack of movement ( paralysis ), unconsciousness , and blunting of the stress response . In the early days of anesthesia, anesthetics could reliably achieve

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5208-473: The Association of American Medical Colleges (AAMC), simulation content taught at American medical schools spans all four years of study, while hospitals utilize simulations during the residency and subspecialty period. Internal medicine, emergency medicine, obstetrics/gynecology, pediatrics, surgery, and anesthesiology are the most common areas taught in medical schools and hospitals. The AAMC reported that

5332-471: The MAC, generally, the less potent the anesthetic. The ideal anesthetic drug would provide hypnosis, amnesia, analgesia, and muscle relaxation without undesirable changes in blood pressure, pulse or breathing. In the 1930s, physicians started to augment inhaled general anesthetics with intravenous general anesthetics. The drugs used in combination offered a better risk profile to the subject under anesthesia and

5456-559: The SSH Council for Accreditation of Healthcare Simulation Programs began an accreditation process for simulation centers to show that they are performing at the high standards recommended by the organization. In addition to university or hospital based education programs, the Clinical Simulation Program for the American College of Chest Physicians (ACCP) became the first medical association to become accredited by

5580-499: The SSH in 2013. As of 2015, there have been fifty-four programs in six countries have passed the accreditation process. The SSH has also partnered with groups such as the Association of Standardized Patient Educators (ASPE) in conducting these surveys. The need for a “uniform mechanism to educate, evaluate, and certify simulation instructors for the health care profession” was recognized by McGaghie et al. in their critical review of simulation-based medical education research. In 2012

5704-520: The SSH piloted two new certifications to provide recognition to educators in an effort to meet this need. By the end of 2012 the final programs were in place. The SSH Certified Healthcare Simulation Educator (CHSE) program was established to provide “formal professional recognition of your specialized knowledge, skills, abilities and accomplishments in simulation education.” The CHSE had been issued to 600 simulationists in 17 countries by 2015. The National Council of State Boards of Nursing cited CHSE as

5828-524: The above-mentioned forms of debriefing, but the emphasis here is on education. Debriefing in education can be described as a "facilitator-led participant discussion of events, reflection, and assimilation of activities into [participants'] cognitions [which] produce long-lasting learning". More specific descriptions of debriefing can be found, such as the following in relation to debriefing in healthcare simulations, described by Cheng et al. (2014): "...a discussion between two or more individuals in which aspects of

5952-536: The application of medical simulation in healthcare. It serves as a resource for young professionals in their growth in medical education and administration. The society was formed was founded as a nonprofit organization in 2004. The society formally changed its name in February 2006 to the Society for Simulation in Healthcare (SSH) in an attempt to increase appeal to non-physician healthcare providers. By

6076-714: The blood (pulse oximetry), and temperature. In the UK the Association of Anaesthetists (AAGBI) have set minimum monitoring guidelines for general and regional anesthesia. For minor surgery, this generally includes monitoring of heart rate , oxygen saturation , blood pressure , and inspired and expired concentrations for oxygen , carbon dioxide , and inhalational anesthetic agents. For more invasive surgery, monitoring may also include temperature, urine output, blood pressure, central venous pressure , pulmonary artery pressure and pulmonary artery occlusion pressure , cardiac output , cerebral activity , and neuromuscular function. In addition,

6200-673: The burden of feeling that they will be shamed, humiliated, or belittled". It is recommended that establishing safety begin in the pre-brief phase by alerting participants to the "basic assumption." The basic assumption, derived from the Centre for Medical Simulation at Harvard University (n.d.), is an agreed upon, predetermined mental model whereby everyone involved in the simulation & debrief believe that all participants are intelligent, well-trained, want to do their best, and are participating to learn and promote development. Additionally, Rudolph et al. (2014) have identified four principles to guide

6324-435: The central nervous system. For instance, the immobilizing effect of inhaled anesthetics results from an effect on the spinal cord whereas sedation, hypnosis and amnesia involve sites in the brain. The potency of an inhalational anesthetic is quantified by its minimum alveolar concentration (MAC). The MAC is the percentage dose of anesthetic that will prevent a response to painful stimulus in 50% of subjects. The higher

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6448-403: The cognitive and emotional processing of the experience. In all instances, debriefing is the process by which people who have gone through an experience are intentionally and thoughtfully led through a discussion of that experience. Debriefing in simulation is a critical component of learning in simulation and is necessary to facilitate change "on an individual and systematic level". It draws from

6572-465: The combined alkaloids proved a mainstay of anesthesia until the 19th century. Local anesthetics were used in Inca civilization where shamans chewed coca leaves and performed operations on the skull while spitting into the wounds they had inflicted to anesthetize. Cocaine was later isolated and became the first effective local anesthetic. It was first used in eye surgery in 1884 by Karl Koller , at

6696-558: The day-to-day operations of simulation centers, typically in addition to other responsibilities. However, the technology that has emerged within medical simulation has become complex and can benefit from the utilization of specialists. In 2014, Society for Simulation in Healthcare introduced the Certified Healthcare Simulation Operations Specialist (CHSOS) certification. The CHSOS certification endeavors to standardize and authenticate

6820-425: The development of a simulation scenario, or they may be emergent as the scenario unfolds. It can be challenging for the novice facilitator to adapt to emergent learning objectives, as the subsequent discussion may be purely exploratory in nature with no defined outcome. Conversely, the discussion may lead to a specific area of expertise which neither the facilitator nor participants are familiar with. In such situations,

6944-561: The direct result of medical mistakes, and the CDC reported in 1999 that roughly 2.4 million people died in the United States, the medical mistakes estimate represents 1.8% to 4.0% of all deaths, respectively. A near 5% representation of deaths primarily related to medical mistakes is simply unacceptable in the world of medicine. Anything that can assist in bringing this number down is highly recommended and medical simulation has proven to be

7068-527: The early 19th century, ether was being used by humans, but only as a recreational drug . Meanwhile, in 1772, English scientist Joseph Priestley discovered the gas nitrous oxide . Initially, people thought this gas to be lethal, even in small doses, like some other nitrogen oxides . However, in 1799, British chemist and inventor Humphry Davy decided to find out by experimenting on himself. To his astonishment he found that nitrous oxide made him laugh, so he nicknamed it "laughing gas". In 1800 Davy wrote about

7192-410: The effects of anesthetic drugs is referred to as being anesthetized. Anesthesia enables the painless performance of procedures that would otherwise require physical restraint in a non-anesthetized individual, or would otherwise be technically unfeasible. Three broad categories of anesthesia exist: In preparing for a medical or veterinary procedure, the clinician chooses one or more drugs to achieve

7316-481: The end of 2006, membership in the organization was just over 1,500 people. Membership continued to steadily grow to be over 3,000 people by 2012. The first annual International Meeting on Medical Simulation (IMMS) was held in 1995. The SSH has wholly supported the meeting since 2006. In 2007, the IMMS meeting was renamed to become International Meeting for Simulation in Healthcare (IMSH). Simulation in Healthcare

7440-457: The endpoints differently. Regional anesthesia , for instance, affects analgesia; benzodiazepine -type sedatives (used for sedation, or " twilight anesthesia ") favor amnesia ; and general anesthetics can affect all of the endpoints. The goal of anesthesia is to achieve the endpoints required for the given surgical procedure with the least risk to the subject. To achieve the goals of anesthesia, drugs act on different but interconnected parts of

7564-427: The environment not essential in simulation activities, but that play a big role in patient safety. For instance, many reports show that patient falls and injuries occur in the hospital bathroom, so the simulation rooms were designed with bathroom spaces. A successful simulation center must be within walking distance of the medical professionals who will be using it. Often, clinical and medical faculty are responsible for

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7688-417: The exception of minimal sedation or superficial procedures performed under local anesthesia. A trained, vigilant anesthesia provider should continually care for the patient; where the provider is not an anesthesiologist, they should be locally directed and supervised by an anesthesiologist, and in countries or settings where this is not feasible, care should be led by the most qualified local individual within

7812-404: The experience. It is the opening phase of systematic reflection, enabled by a facilitator who poses key questions such as: A facilitator is to keep asking these questions of the learners until they feel confident that all participants have voiced their understanding of the situation. The point of the description phase is to identify the impact of the experience, gain insights into what mattered to

7936-531: The facilitator and participants must be flexible and move on to the next objective, and follow-up with the debriefing of the emergent outcome at a later time. The debriefing environment consists of two main features: the physical setting, as well as the psychological environment. When choosing a space in which to debrief, one must consider whether the scenario which unfolded was a complex case. Complex cases usually involve heightened emotions, interdependent processes, and require more time spent debriefing. As such, it

8060-485: The first post-operative week). Although the three entities (delirium, early POCD and long-term POCD) are separate, the presence of delirium post-operatively predicts the presence of early POCD. There does not appear to be an association between delirium or early POCD and long-term POCD. According to a recent study conducted at the David Geffen School of Medicine at UCLA , the brain navigates its way through

8184-416: The first two, allowing surgeons to perform necessary procedures, but many patients died because the extremes of blood pressure and pulse caused by the surgical insult were ultimately harmful. Eventually, the need for blunting of the surgical stress response was identified by Harvey Cushing , who injected local anesthetic prior to hernia repairs . This led to the development of other drugs that could blunt

8308-419: The formation of long-term memories. Nevertheless, a person can dream under anesthesia or are conscious of the procedure despite giving no indication of this during it. An estimated 22% of people do dream under general anesthesia , and one or two cases in a thousand have some consciousness, termed " anesthesia awareness ". It is not known whether animals dream while under general anesthesia. Anesthesia

8432-429: The formulation of a psychologically safe environment: Included in these principles is the notion of confidentiality . Explicitly reminding participants that their individual performance and debriefing reflections are not meant to be shared outside of the simulation event can help foster participation. Confidentiality builds trust by increasing transparency and allowing participants to practice without fear. There exists

8556-554: The greatest impact of learning. The summary may be done by either the facilitator or the participants – debriefing models differ in their suggestions. In the latter, the participants summarize what was of most value for them. A summary by the facilitator consists of re-stating key learning points which occurred throughout the debrief. While all debriefing models include the phases of the three-part debriefing structure, there are several with additional phases. These additions either explicitly call out specific features which may be included in

8680-546: The help of a UCSD School of Medicine student, Computer Gaming World reported that a Surgeon (1986) for the Apple Macintosh very accurately simulated operating on an aortic aneurysm . Others followed, such as Life & Death (1988). In 2004, the Society for Simulation in Healthcare (SSH) was formed to assist in collaboration between associations interested in medical simulation in healthcare. The need for

8804-586: The immediate post-operative period because of the lack of muscle movement (and subsequent lack of heat production) during the procedure. Furthermore, the rare manifestation in the post-anesthetic period may be the occurrence of functional neurological symptom disorder (FNSD). Postoperative cognitive dysfunction (also known as POCD and post-anesthetic confusion) is a disturbance in cognition after surgery. It may also be variably used to describe emergence delirium (immediate post-operative confusion) and early cognitive dysfunction (diminished cognitive function in

8928-805: The individual. Pain management is classified into either pre-emptive or on-demand. On-demand pain medications typically include either opioid or non-steroidal anti-inflammatory drugs but can also make use of novel approaches such as inhaled nitrous oxide or ketamine . On demand drugs can be administered by a clinician ("as needed drug orders") or by the patient using patient-controlled analgesia (PCA). PCA has been shown to provide slightly better pain control and increased patient satisfaction when compared with conventional methods. Common preemptive approaches include epidural neuraxial blockade or nerve blocks. One review which looked at pain control after abdominal aortic surgery found that epidural blockade provides better pain relief (especially during movement) in

9052-423: The influence of diethyl ether. He immediately thought of its potential in surgery. Conveniently, a participant in one of those "ether frolics", a student named James Venable, had two small tumors he wanted excised. But fearing the pain of surgery, Venable kept putting the operation off. Hence, Long suggested that he have his operation while under the influence of ether. Venable agreed, and on 30 March 1842 he underwent

9176-641: The jurisdiction, and include anesthetic nurses , nurse anesthetists , anesthesiologist assistants , anaesthetic technicians , anaesthesia associates , operating department practitioners and anesthesia technologists . International standards for the safe practice of anesthesia, jointly endorsed by the World Health Organization and the World Federation of Societies of Anaesthesiologists , highly recommend that anesthesia should be provided, overseen or led by anesthesiologists, with

9300-419: The key assistant. Anesthesia Anesthesia ( American English ) or anaesthesia ( British English ) is a state of controlled, temporary loss of sensation or awareness that is induced for medical or veterinary purposes. It may include some or all of analgesia (relief from or prevention of pain ), paralysis (muscle relaxation), amnesia (loss of memory), and unconsciousness . An individual under

9424-409: The limited availability of medical expertise at the time. However, extensive military use demonstrated that medical simulation could be cost-effective. Additionally, valuable simulation hardware and software was developed, and medical standards were established. Gradually, medical simulation became affordable, although it remained un-standardized. By the 1980s software simulations became available. With

9548-424: The machine is ready for use, that the safety features are active and the electrical hazards are removed. Intravenous anesthetic is delivered either by bolus doses or an infusion pump . There are also many smaller instruments used in airway management and monitoring the patient. The common thread to modern machinery in this field is the use of fail-safe systems that decrease the odds of catastrophic misuse of

9672-534: The machine. Patients under general anesthesia must undergo continuous physiological monitoring to ensure safety. In the US, the American Society of Anesthesiologists (ASA) has established minimum monitoring guidelines for patients receiving general anesthesia, regional anesthesia, or sedation. These include electrocardiography (ECG), heart rate, blood pressure, inspired and expired gases, oxygen saturation of

9796-500: The major reason for its occurrence is the formation of microemboli . POCD also appears to occur in non-cardiac surgery. Its causes in non-cardiac surgery are less clear but older age is a risk factor for its occurrence. The first attempts at general anesthesia were probably herbal remedies administered in prehistory . Alcohol is one of the oldest known sedatives and it was used in ancient Mesopotamia thousands of years ago. The Sumerians are said to have cultivated and harvested

9920-488: The majority of medical schools and teaching hospitals centralize their simulation activities at a single physical location, while some use decentralized facilities or mobile simulation resources. Most of the medical training institutions own their own facilities. Often, medical school CSSC locations include rooms for debriefs, training exercises, standardized exam and patient rooms, procedure rooms, offices, observation area, control rooms, classrooms, and storage rooms. On average,

10044-416: The maximum dose of local anesthetic has to be considered. Nerve blocks are also used as a continuous infusion, following major surgery such as knee, hip and shoulder replacement surgery, and may be associated with lower complications. Nerve blocks are also associated with a lower risk of neurologic complications compared to the more central epidural or spinal neuraxial blocks. Central neuraxial anesthesia

10168-419: The minimum competencies to be demonstrated by simulation center operations specialists. The origins of debriefing can be traced back to the military, whereby upon return from a mission or war game exercise, participants were asked to gather as a group and recount what had happened. These gatherings had the primary intention of developing new strategies to use in future encounters; these gatherings also provided

10292-609: The most known are the use of mannequins (referred to by the simulation company METI as Human Patient Simulators, or HPS for short) and standardized patients. As seen in the chart titled "Types of Simulation Used in Medical Education" retrieved from the AAMC article, medical schools are leading the way when it comes to the use of standardized patients, but teaching hospitals and medical schools are close when it comes to full-scale mannequins and partial task trainers. According to

10416-438: The mother but the baby. Cancers and tumors that occupy the lungs or throat create special challenges to general anesthesia . After determining the health of the patient undergoing anesthesia and the endpoints that are required to complete the procedure, the type of anesthetic can be selected. Choice of surgical method and anesthetic technique aims to reduce risk of complications, shorten time needed for recovery and minimize

10540-402: The nerve and position of the needle is localized with ultrasound or electrical stimulation. Evidence supports the use of ultrasound guidance alone, or in combination with peripheral nerve stimulation, as superior for improved sensory and motor block, a reduction in the need for supplementation and fewer complications. Because of the large amount of local anesthetic required to affect the nerve,

10664-481: The nervous system. Hypnosis , for instance, is generated through actions on the nuclei in the brain and is similar to the activation of sleep . The effect is to make people less aware and less reactive to noxious stimuli . Loss of memory ( amnesia ) is created by action of drugs on multiple (but specific) regions of the brain. Memories are created as either declarative or non-declarative memories in several stages ( short-term , long-term , long-lasting )

10788-444: The operating room environment must be monitored for ambient temperature and humidity, as well as for accumulation of exhaled inhalational anesthetic agents, which might be deleterious to the health of operating room personnel. Sedation (also referred to as dissociative anesthesia or twilight anesthesia ) creates hypnotic , sedative , anxiolytic , amnesic , anticonvulsant , and centrally produced muscle-relaxing properties. From

10912-400: The participants throughout the simulation, and to establish a shared mental model of the events which occurred. A debate in the healthcare simulation community exists regarding the exploration of feelings in the descriptive phase. One camp believes that the descriptive phase should allow an opportunity for participants to "blow off steam," and release any tension which may have accumulated during

11036-412: The patient at 2.3 times greater risk than someone less than 60 years old. Having an ASA score of 3, 4 or 5 places the person at 10.7 times greater risk than someone with an ASA score of 1 or 2. Other variables include age greater than 80 (3.3 times risk compared to those under 60), gender (females have a lower risk of 0.8), urgency of the procedure (emergencies have a 4.4 times greater risk), experience of

11160-683: The patient's care following the procedure. One part of the risk assessment is based on the patient's health. The American Society of Anesthesiologists has developed a six-tier scale that stratifies the patient's pre-operative physical state. It is called the ASA physical status classification . The scale assesses risk as the patient's general health relates to an anesthetic. The more detailed pre-operative medical history aims to discover genetic disorders (such as malignant hyperthermia or pseudocholinesterase deficiency ), habits ( tobacco , drug and alcohol use ), physical attributes (such as obesity or

11284-501: The patient's health prior to surgery and the complexity of the surgical procedure can also contribute to the risks. Prior to the introduction of anesthesia in the early 19th century, the physiologic stress from surgery caused significant complications and many deaths from shock . The faster the surgery was, the lower the rate of complications (leading to reports of very quick amputations). The advent of anesthesia allowed more complicated and life-saving surgery to be completed, decreased

11408-547: The period up to three postoperative days. It reduces the duration of postoperative tracheal intubation by roughly half. The occurrence of prolonged postoperative mechanical ventilation and myocardial infarction is also reduced by epidural analgesia. Risks and complications as they relate to anesthesia are classified as either morbidity (a disease or disorder that results from anesthesia) or mortality (death that results from anesthesia). Quantifying how anesthesia contributes to morbidity and mortality can be difficult because

11532-462: The person completing the procedure (less than 8 years experience and/or less than 600 cases have a 1.1 times greater risk) and the type of anesthetic (regional anesthetics are lower risk than general anesthetics). Obstetrical , the very young and the very old are all at greater risk of complication so extra precautions may need to be taken. On 14 December 2016, the Food and Drug Administration issued

11656-410: The perspective of the person giving the sedation, the patient appears sleepy, relaxed and forgetful, allowing unpleasant procedures to be more easily completed. Sedatives such as benzodiazepines are usually given with pain relievers (such as narcotics , or local anesthetics or both) because they do not, by themselves, provide significant pain relief . From the perspective of the subject receiving

11780-447: The physiologic stress of the surgery, but added an element of risk. It was two years after the introduction of ether anesthetics that the first death directly related to the use of anesthesia was reported. Morbidity can be major ( myocardial infarction , pneumonia , pulmonary embolism , kidney failure / chronic kidney disease , postoperative cognitive dysfunction and allergy ) or minor (minor nausea , vomiting, readmission). There

11904-433: The possibility that "this warning could inappropriately dissuade providers from providing medically indicated care during pregnancy." Patient advocates noted that a randomized clinical trial would be unethical, that the mechanism of injury is well-established in animals, and that studies had shown exposure to multiple uses of anesthetic significantly increased the risk of developing learning disabilities in young children, with

12028-468: The potential anesthetic properties of nitrous oxide in relieving pain during surgery, but nobody at that time pursued the matter any further. On 14 November 1804, Hanaoka Seishū , a Japanese doctor, became the first person to successfully perform surgery using general anesthesia . Hanaoka learned traditional Japanese medicine as well as Dutch-imported European surgery and Chinese medicine. After years of research and experimentation, he finally developed

12152-788: The presentation of existing studies, a sparsity of research related to debriefing topics of importance, and debriefing characteristics are incompletely reported. Recommendations for future debriefing studies include: or: Current research has found that simulation training with debriefing, when compared with no intervention, had favorable, statistically significant effects for nearly all outcomes: knowledge, process skill, time skills, product skills, behavior process, behavior time, and patient effects. When compared with other forms of instruction, simulation and debriefing showed small favorable effects for knowledge, time and process outcomes, and moderate effects for satisfaction. There many different types of simulations that are used for training purposes. Some of

12276-761: The procedure for which anesthesia is being given, but in the main they are related to three factors: the health of the individual, the complexity and stress of the procedure itself, and the anaesthetic technique. Of these factors, the individual's health has the greatest impact. Major perioperative risks can include death, heart attack , and pulmonary embolism whereas minor risks can include postoperative nausea and vomiting and hospital readmission . Some conditions, like local anesthetic toxicity, airway trauma or malignant hyperthermia , can be more directly attributed to specific anesthetic drugs and techniques. The purpose of anesthesia can be distilled down to three basic goals or endpoints: Different types of anesthesia affect

12400-506: The question being posed. Note that the use of AI is most encouraged when a facilitator has a judgment about something which was observed during the simulation scenario. Using AI eliminates the tone of judgment as well as the "guess what I'm thinking" which can occur when asking questions. The third and final phase of three-phase debriefing structures is most commonly referred to as "application," or "summary". Participants are asked to move any newly acquired insights or knowledge gained throughout

12524-399: The real world in a fully interactive fashion". This definition deliberately defines simulation as a technique and not a technology, implying that simulation is greater than the technology or tools which it adopts. Also note the use of the word guided in the definition, further implying that the interactions which occur in a simulated environment are not left solely to those persons immersed in

12648-539: The response, leading to lower surgical mortality rates . The most common approach to reach the endpoints of general anesthesia is through the use of inhaled general anesthetics. Each anesthetic has its own potency, which is correlated to its solubility in oil. This relationship exists because the drugs bind directly to cavities in proteins of the central nervous system, although several theories of general anesthetic action have been described. Inhalational anesthetics are thought to exact their effects on different parts of

12772-620: The rest of the world until 1854 as the national isolation policy of the Tokugawa shogunate prevented Hanaoka's achievements from being publicized until after the isolation ended. Nearly forty years would pass before Crawford Long , who is titled as the inventor of modern anesthetics in the West , used general anesthesia in Jefferson, Georgia . Long noticed that his friends felt no pain when they injured themselves while staggering around under

12896-418: The root cause of 11% of all adverse anesthetic events. Safe anesthesia care depends greatly on well-functioning teams of highly trained healthcare workers. The medical specialty centred around anesthesia is called anesthesiology , and doctors specialised in the field are termed anesthesiologists. Additional healthcare professionals involved in anesthesia provision have varying titles and roles depending on

13020-459: The same venue. Morton, who was unaware of Long's previous work, was invited to the Massachusetts General Hospital to demonstrate his new technique for painless surgery. After Morton had induced anesthesia, surgeon John Collins Warren removed a tumor from the neck of Edward Gilbert Abbott . This occurred in the surgical amphitheater now called the Ether Dome . The previously skeptical Warren

13144-470: The scenario has finished. However, in order to establish a shared mental model with all participants, debriefing must occur in a fashion whereby all participants can hear one another and have a chance to respond. This is difficult to accomplish while walking down a hallway, or in any disorganized fashion. The location of the debriefing is ideally somewhere comfortable and conducive to conversation and reflection, where chairs can be maneuvered and manipulated. It

13268-415: The simulation and the debriefing period. As simulation participants often find the experience stressful and intimidating, worried about judgment from their peers and facilitator(s), establishing safety must be done from the outset of the simulation event. Note that psychological safety does not necessarily equate to comfort, but rather that participants "feel safe enough to embrace being uncomfortable...without

13392-433: The simulation experience forward to their daily activities or thought processes. This includes learning which may have occurred during the previous phases in the debriefing process. Common questions posed, or statements made, by a facilitator during this phase include: Note that the summary here is not always in terms of re-stating the major points which were visited throughout the simulation and debrief, but more so emphasize

13516-706: The simulation is often referred to as "Instructional simulation", "Educational simulation," or "Simulation-based learning". Favorable and statistically significant effects for nearly all knowledge and process skill outcomes when comparing simulation AND debriefing versus simulation with no intervention (in healthcare) has been shown. When applied in a capacity to further professional development, simulation and debriefing may be referred to as "Simulation-based training". Experiential learning , which draws from prominent scholars such as John Dewey , Jean Piaget , and Carl Rogers , among others, underpins simulation-based learning. Often referred to as "learning by doing", or more broadly,

13640-412: The simulation scenario in order for learners to continue the debrief and subsequent reflection without pent-up emotion. Others believe that the "venting" phase is not necessary and may explicitly make this statement in their debriefing models, or simply omit any reference to emotions or feelings at all. The second phase of debriefing is often referred to as "analysis," "description," or "discovering". This

13764-402: The simulation, but that a "guide" also be present. This guide may be virtual in nature, such as prompts from a computer program, or may be physically present, in the form of an instructor or teacher. The human guide is often referred to as a "facilitator". It is this facilitator who guides the debriefing which occurs after a simulation scenario has been completed. When these elements are present,

13888-421: The single greatest factor in anesthetic mortality is the health of the patient. These statistics can also be compared to the first such study on mortality in anesthesia from 1954, which reported a rate of death from all causes at 1:75 and a rate attributed to anesthesia alone at 1:2680. Direct comparisons between mortality statistics cannot reliably be made over time and across countries because of differences in

14012-455: The sponge was moistened and then held under the patient's nose. When all went well, the fumes rendered the individual unconscious. The most famous anesthetic, ether , may have been synthesized as early as the 8th century, but it took many centuries for its anesthetic importance to be appreciated, even though the 16th century physician and polymath Paracelsus noted that chickens made to breathe it not only fell asleep but also felt no pain. By

14136-416: The stratification of risk factors, however, there is evidence that anesthetics have made a significant improvement in safety but to what degree is uncertain. Rather than stating a flat rate of morbidity or mortality, many factors are reported as contributing to the relative risk of the procedure and anesthetic combined. For instance, an operation on a person who is between the ages of 60–79 years old places

14260-443: The strength of which is determined by the strength of connections between neurons termed synaptic plasticity . Each anesthetic produces amnesia through unique effects on memory formation at variable doses. Inhalational anesthetics will reliably produce amnesia through general suppression of the nuclei at doses below those required for loss of consciousness. Drugs like midazolam produce amnesia through different pathways by blocking

14384-684: The subsequent debriefs are aimless, disorganized, and often dysfunctional. Most debriefing models explicitly make mention of stating learning objectives. The exploration of learning objectives ought to answer at least two questions: What competencies – knowledge, skills, or attitudes – are to be learned, and what specifically should be learned about them? The method of debriefing chosen should align with learning objectives through evaluation of three points: performance domain – cognitive, technical, or behavioral; evidence for rationale – yes/no; and estimated length of time to address – short, moderate, or long. Learning objectives may be predetermined and included in

14508-454: The suggestion of Sigmund Freud . German surgeon August Bier (1861–1949) was the first to use cocaine for intrathecal anesthesia in 1898. Romanian surgeon Nicolae Racoviceanu-Piteşti (1860–1942) was the first to use opioids for intrathecal analgesia; he presented his experience in Paris in 1901. The "soporific sponge" ("sleep sponge") used by Arabic physicians was introduced to Europe by

14632-485: The surgeries and regional anesthesia techniques reviewed. When local anesthetic is injected around a larger diameter nerve that transmits sensation from an entire region it is referred to as a nerve block or regional nerve blockade. Nerve blocks are commonly used in dentistry, when the mandibular nerve is blocked for procedures on the lower teeth. With larger diameter nerves (such as the interscalene block for upper limbs or psoas compartment block for lower limbs)

14756-511: The three conventional phases of debriefing are: description, analysis, and application. Frameworks which make use of the three-phase debriefing format include Debriefing with Good Judgment, the 3D Model, the GAS model, and Diamond Debrief. Also labelled as "reaction," "defusing," "gather," and "identify what happened," the description phase of debriefing sees simulation participants describing and exploring their reactions, emotions, and overall impact of

14880-721: The three-part debriefing model, such as reviewing learning objectives, or provide additional process recommendations, such as immediately re-practicing any skills involved in the original simulation scenario. Examples of multi-phase debriefing structures include the Promoting Excellence and Reflective Learning in Simulation (PEARLS) framework, TeamGAINS, and Healthcare Simulation After-Action Review (AAR). As with any other educational initiative, learning objectives are of paramount importance in simulation and debriefing. Without learning objectives, simulations themselves and

15004-412: The types and degree of anesthesia characteristics appropriate for the type of procedure and the particular patient. The types of drugs used include general anesthetics , local anesthetics , hypnotics , dissociatives , sedatives , adjuncts , neuromuscular-blocking drugs , narcotics , and analgesics . The risks of complications during or after anesthesia are often difficult to separate from those of

15128-433: The types of regional anesthesia: A 2018 Cochrane review found moderate quality evidence that regional anesthesia may reduce the frequency of persistent postoperative pain (PPP) from 3 to 18 months following thoracotomy and 3 to 12 months following caesarean . Low quality evidence was found 3 to 12 months following breast cancer surgery. This review acknowledges certain limitations that impact its applicability beyond

15252-517: Was impressed and stated, "Gentlemen, this is no humbug." In a letter to Morton shortly thereafter, physician and writer Oliver Wendell Holmes Sr. proposed naming the state produced "anesthesia", and the procedure an "anesthetic". Society for Simulation in Healthcare The Society for Simulation in Healthcare ( SSH ), formerly known as the Society for Medical Simulation is a non-profit organization founded in 2004 to advance

15376-581: Was the Chinese physician Hua Tuo whom historians considered the first verifiable historical figure to develop a type of mixture of anesthesia, though his recipe has yet to be fully discovered. Throughout Europe, Asia, and the Americas, a variety of Solanum species containing potent tropane alkaloids was used for anesthesia. In 13th-century Italy, Theodoric Borgognoni used similar mixtures along with opiates to induce unconsciousness, and treatment with

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