Lori Ponoroff, MEdSim Staff Writer, provides insights on the fielding of do-it-yourself simulators as instructional devices.   

Budget cuts, time constraints and the peace of mind that comes with practicing by simulation instead of on patients is driving surgeons, students and instructors alike to make their own simulators. From the simplest applications – like citrus fruits and soda cans – to more involved devices like a vascular simulator made from a laundry basket, wood and copper tubing, DIY (do-it-yourself) simulators are popping up on You Tube, in medical journals and at surgical conferences.

The cost of commercial simulation equipment often presents financial barriers to institutions interested in holding procedural or examination skills workshops, according to Ted Warren, Manager of Education and Career Development at the American College of Physicians (ACP) in Philadelphia, Pennsylvania and at the ACP's Herbert S. Waxman Clinical Skills Center that takes place at the ACP's annual scientific meeting. “Depending on the skill being taught, homemade or do-it-yourself simulation can remove those barriers and allow participants to get the valuable hands-on practice proven to change behavior – at a fraction of the cost,” Warren said. “A program can then make these skills workshops available to more participants, broadening the reach of the educational experience.”

Take, for example, the ACP center’s simulated abscess model developed by ACP from an idea by Thomas Rebbecchi, M.D., an associate professor of emergency medicine at Cooper University Hospital in Camden, New Jersey. Using a suturing pad, a balloon, toothpaste, rubber cement and some clamps, the mock abscess model is easy and inexpensive to make – and provides a realistic model that helps teach the motor skills and steps necessary to properly incise, drain and dress an abscess, Warren explained. “At the annual ACP Internal Medicine scientific meeting, we can cycle over a hundred individuals through our Incision and Drainage of Abscesses workshops, while saving thousands of dollars by using a homemade simulation – rather than a commercial option.”

Equally simple to make is the vascular surgery simulator designed by general surgery Resident Kevin Sexton, M.D., at Vanderbilt University in Nashville, Tennessee. In one weekend trip to the hardware store, Sexton and his wife designed a $5 vascular simulator that is now being used by residents to easily and effectively practice intricate vascular surgical techniques and vessel repair. Using nothing more than copper tubing, plastic bird guards (often used to block dryer vents), a drain and some miscellaneous items such as wood screws and two-by-fours, Sexton produced 18 vascular simulators for a residency workshop.

In the first two-hour workshop, 24 first-year surgery residents practiced multiple vascular techniques at various anatomically challenging positions and were then asked for their feedback. The results were overwhelmingly positive – all of the respondents said they would like to have the simulator for personal use.

“It’s not uncommon to come up with non-traditional solutions to medical training. Residents do this all the time,” said Sexton. “I practiced vascular anastomoses in a coffee can because that is what my chief resident said worked. What makes our design useful is we can share it with other residents and institutions who want cost-effective simulation. That’s the win.”

Sharing Simulation Ideas

On-line journals, papers and videos make sharing low-cost alternatives simple and sweeping, as do education conferences like Surgery Education Week, where Sexton presented his invention. Surgery Education Week is sponsored by the Association of Program Directors in Surgery and the Association for Surgical Education. The meeting provides a forum for those involved in surgical education to seek new approaches and creative solutions to medical education issues.

Similarly, SimGHOSTS – The Gathering Of Healthcare Simulation Technology Specialists, is an independent training meeting dedicated to supporting healthcare simulation technicians by developing online resources and hands-on training events. At SimGHOSTS 2012, Laerdal sponsored a DIY Video contest where simulation techs could share DIY tips and tricks for increasing efficiency or realism in their medical simulation labs. Fritz Sticht from the Behling Simulation Center at the State University of New York at Buffalo won an iPad for his video that demonstrates an affordable and easy-to-build Cervix/Uterus Model, and Brian Florek from Northwestern University’s Feinberg School of Medicine Simulation Technology & Immersive Learning (STIL) program won a GoPro2 for his video on Increasing Mechanical Ventilation Fidelity on the Laerdal Simman 3G.

After the winners presented their ideas, an impromptu sharing session ensued, according to Lance Baily, Executive Director of SimGHOSTS.Org. “We spent another 45 minutes with other attendees sharing their own successful DIY ideas – with some incredible results,” said Baily. The winners’ DIY concepts, and those of other contestants, are available on the SimGHOSTS website at (www.simghosts.org/got-sim-2012/diy-video-contest/#entries). In October, a recording of the extemporaneous session will be posted on SimGHOSTS’ subscription-based web forum. “We have had some amazing ideas come out of our online group – it’s a great resource for folks looking to engage with a global community that is trying to create affordable solutions,” Baily said.

Objective Structured Assessment of Technical Skills (OSATS) exam. Image Credit: University of Toronto Surgical Skills Centre at Mount Sinai Hospital.
Objective Structured Assessment of Technical Skills (OSATS) exam. Image Credit: University of Toronto Surgical Skills Centre at Mount Sinai Hospital.

Snacks as Simulators

Many more DIY simulation ideas can easily be found with a simple Web search – everything from multi-component devices like homemade laparoscopic simulators to the single-piece, knot-tying tool made from an empty soda can devised by Neville Dastur, M.D., a Senior Clinical Researcher at King’s College London. Dastur’s paper published in the Annals of The Royal College of Surgeons of England, explains a simple DIY technique that allows trainee surgeons to practice knot tying while not applying too much force to the structure being sutured, something that can’t be practiced on a traditional, fixed hook simulator. How does it work? Simply place an empty soda can with the ring pull positioned upright on a piece of paper and draw a circle around the side of the can. Trainees practice tying knots on the ring pull without moving the can outside of the circle or lifting the can from the surface. Simulators don’t get much cheaper, simpler or more readily available than an empty soda can. But some are just as simple, like a box of beans or a piece of fruit.

The University of Florida College of Medicine’s Center for Simulation Education and Safety Research (CSESaR) has full laparoscopic towers and surgical simulators, but during interviews for surgical residents, the staff evaluates their manual skills with some very simple devices, according to the center’s director, Bruce Nappi. He said that without anatomical features, any delays caused by anatomical confusion are eliminated, and this is the approach used for the Fundamentals of Laparoscopic Surgery testing.

The devices are made with cardboard boxes, paper coffee cups and dried beans – and “the objective is to measure an applicant’s ability to move slippery beans from one cup to another in a set time interval,” Nappi explained. “Different box and cup placements force appropriate hand and arm positioning. The key functional elements of the system are forcing the lap tools to go through a hole cut in the rim of the box, and cutting an appropriate window in the box top to constrain vision. The cost is minimal to construct many identical units for parallel testing.”

Pamela Andreatta, EdD, Founding Director of the Simulation Center at the University of Michigan, developed a way to use a clementine to teach the skills crucial for laparoscopic surgery. Andreatta got the idea after R. Kevin Reynolds, a gynecologic oncology professor, asked her to devise a simulation to teach the delicate task of removing lymph nodes as part of surgical procedures used to minimize the spread of cancer.

Andreatta realized “a clementine has tissue variability that reflects the same variation between organs, vessels, nerves and other anatomical tissues within the pelvis,” she said, “a sturdy external cover, with spongy and delicate flesh and connective fibers on the inside.” She came up with an exercise where students insert a camera, scissors and a grasper into holes on top of an opaque box that has a clementine inside. They have to take off the peel in as few pieces as possible, remove the pith, separate the segments – and then put the segments and peel back together again.

Grapefruit – another citrus fruit – was used this summer to simulate brain tissue at a neurosurgery rookie camp. The camp brought together medical school graduates from across Canada who were starting their neurosurgery residency programs to focus on critical neurosurgery skills, according to David Clarke, M.D., interim chief of neurosurgery and medical school professor at Dalhousie University in Nova Scotia, Canada.

“An important skill to teach trainees in using a bipolar (surgical instrument) is that you have to leave the bipolar on and the ends together for a fixed amount of time so that it coagulates the blood vessel; but if you leave it on too long, then the ends of the bipolar become stuck to the tissue,” he said. “If that happens and you take it out, you can rip the blood vessel and cause bleeding.”

The grapefruit is great, Clarke said, “because if you use a bipolar as you should, then the juicy part just peels away from the fibrous part that goes from the center to the outside; but if you leave it on too long, the grapefruit – just like brain tissue – will become sticky and you have to rip it out when you remove the bipolar. This is a very important skill and concept for someone operating on the brain to understand and a grapefruit does a great job of illustrating that.”

The camp teachers used a wide range of simulation techniques – from the advanced and expensive NeuroTouch simulator to other inexpensive tools like the grapefruit. For example, a simple system of tubes and beakers simulate how shunts and drains work, Clarke said.

“Another skill residents have to learn is how to manage hydrocephalus – which is a blockage of normal fluid circulation in the brain,” he explained. “Sometimes we have to drill a hole in the skull and put in a tube to drain the fluid. If a patient needs a permanent drain, we put in a tube that goes from the cavity of the brain, under the skin and into the belly. To illustrate how the different kinds of shunt systems work, we used a beaker of colored water hooked up to IV tubing – and then went through different shunt valve systems so the residents could see how the system performs when they change the position of the patient or the kind of valve used.

“Real valves cost hundreds or thousands of dollars,” Clarke said, “but this way we can put something together with left-over materials and use it to illustrate how these things work.”

A Shopping List for Supplies

Using left-over materials; home repair products and a grocery list of meat, fruits, and vegetables has been a way of life for Lisa Satterthwaite and her team at the University of Toronto Surgical Skills Centre (SSC) at Mount Sinai Hospital since it opened in 1998. “When we opened this skills lab, simulation was in its infancy and there was really no one to talk to – simulation wasn’t really popular,” said Satterthwaite, manager of the center in Toronto, Canada.

“Toronto only had one medical school with a lot of medical students and residents coming through, and not a lot of money to spend on technical skill training,” she said. “So to train the residents we started developing our own (simulation) models based on readily available materials and meats from slaughter houses and local butchers to accommodate our large number of students, but small budgets. That’s what propelled us into the DIY model making.”

They knew other schools were facing the same issues, too – all starting from scratch and struggling to substantiate their labs, so the SSC decided to share its DIY approach and created the Surgical Skills Centre’s Model Procedures webpage (http://www.utoronto.ca/ssc/procedures.htm) that lists and describes some of the lab’s DIY simulation models.

Since then, the SSC center has taken its DIY simulations to new heights – continuously developing new models in collaboration with other departments – and then sharing new developments with the medical community. Most recently, the staff went to Chicago for a colorectal objective structured assessment of technical skills examination project. It’s an exam they hosted and created the models for – all of which were tested and verified by experts in Toronto and the United States.

“We have built a culture of model creation and we’re known here at the skills lab for our low-fidelity models and creativity,” Satterthwaite said. “It’s a collective endeavor – we’re using a lot of creativity and mind-building from faculty and our staff here at the skills lab. Residents have a say in our models – and we get experts in to trial them.

“We use everything from shoe laces to wood to tennis balls to recreate technical skills training models – you name it, and we use it,” she said. They use spaghetti squash and green peppers as models for hysteroscopy and repurpose old or expired pieces of medical equipment for new uses, like using an old Jackson Pratt bulb (used as a drain in surgery) for suprapubic catheterization models.

“You really get a different vision when you go shopping now – we look at things and think, you know what, that would make a really good artery,” Satterthwaite said. “The amount of models we can make based on products from supermarkets, craft shops and hardware stores is endless.”