BackgroundNICE guidelines mandates use of ultrasound guided central venous cannulation (USGCVC). This gave rise to the need for a realistic, effective and cost-effective training tool to teach this skill, as available trainers were expensive and did not survive dilation and actual cannulation. Over several years we have developed and used a simulation model that we think fulfils this function.Description of innovationWe evaluated numerous venous surrogates and found latex racing cycle inner tube to have the same dimensions, ultrasonic appearance, haptic characteristics and resealability as central veins.1 This was used initially in a gelatine substrate which was repaired after use. After developing an Ispagula husk gel based medium that was self-repairing after dilation we switched to that.2 Both these mediums suffered from desiccation and fungal colonisation, which was solved by adding a preservative to create ADAMgel (Aqueous Dietary fibre Antifreeze Mix gel). We combined the vessel and soft tissue analogue in existing manikins or food containers under a simulated skin. Also included was a pulsatile arterial simulator. The latex tubing was connected to a reservoir of coloured fluid under the correct pressure. Cost were £5–£10 per model.OutcomesThese models were then used in formal teaching on USGCVC workshops for medical students,3 junior doctors4 and Advanced Trauma and Life Support (ATLS) courses. They remained fully functional resealing after dilation and sonographically pristine without producing needletracts. Trainees scored them over 95% for realism, utility and models’ ability to remain fully functional without producing needletracts, with all participants recommending the model for teaching.4 Simulated skin analogue had to be periodically replaced and probably eventually the latex inner tubing as well.Take home messagesUSGCVC simulation based training can be effectively provided at a reasonable cost enabling trainees to fulfil requirements for specialisation training.ReferencesShaw C, Willers J, Bukunola B, et al. Searching for a superior central venous surrogate for ultrasound simulation. Anaesthesia 2013:68:43Barnes L, Willers J, Hariharan S, et al. Gauging the gel in Fybogel. AABGI Annual Congress. Anaesthesia 2014;69:s4.11–88Akrimi S, Malley T, Willers J, et al. A training day for undergraduate students using practical workshops combined with theatre sessions to teach essential skills and inspire interest in anaesthetics. Anaesthesia 2014,69:31Hall A, De Barr P, Willers J, et al. Does simulation increase the familiarity of non-anaesthetists with central venous cannula insertion? Sent to AABGI Annual Congress, 2015

BackgroundThe use of animal tissue in simulation based medical education (SBME) is an important part of teaching surgical/technical skills. Unfortunately this has logistic, cost and health and safety implications which restrict its use. We set out to organise a Regional Anaesthesia and Surgical Skills workshop that would maximise the use of our animal tissue specimens.MethodWe sourced a lamb thorax (simulating elderly patient) and a pig thorax with skin attached (simulating young well-padded patient) from a butcher. These had already passed abattoir health checks. Eight attendees were sequentially taught techniques of Seldinger chest drain insertion, intercostal blocks, interpleural catheter insertion, and paravertebral blocks. Everybody successfully carried out these procedures on both specimens with and without ultrasound. Then surgical chest drains was done, with its conversion to interpleural catheters. This was repeated by another eight on the same day by flipping the specimens. The lamb thorax was then used for a clamshell thoracotomy workshop.ResultFeedback from getting hands-on practice in these rarely needed skills were universally positive. Following a logical sequence it was possible perform multiple procedures. Using two types of meat to represent our patient spectrum meant both increased opportunity and variation in technique, as well as providing for cultural sensitivities. A combination of low cost (<£80 for meat) and hands-on training of multiple procedures to multiple clinicians meant that it was easy to obtain funding. Presentations emanating from these workshops have won several prizes at international flagship congresses and been published in peer reviewed high impact journals.1,2,3 Using food dyes to confirm successful procedure ensured that specimens could be disposed of in an ecofriendly manner by grateful canines.ConclusionsEmploying sequential use of animal specimens as a force multiplier gets more bang-for-buck. This can be useful in SMBE during these days of budgetary and regulatory restraints.ReferencesDawes T, Nicholas C, Willers J. A longitudinal, in-plane oblique approach to the ultrasound guided intercostal nerve block. Anaesthesia 2011;66(1):31Dawes T, Nicholas C, Willers J, Samuels T, Uncles D. Comparing the pressures required for pleural puncture between different types of needle and different angles of approach in a porcine model. Brit J Anaesth 2012;109(3):473P–484PGoosen L, Parker S, Willers J, Hariharan S, Bukunola B, Crossland C, Shaw C. The occasional thoracotomist – which tool is top? Anaesthesia 2012;67:78

BackgroundAfter successfully demonstrating it was possible to meld an airway manikin and a sheep’s ribcage to make a realistic resuscitative clamshell thoracotomy model1 we decided to see if an improved version could be employed in high fidelity simulations at a regional deanery simulation day for senior registrars.MethodsA trimmed lamb’s thorax with a split thoracic spine was gently splayed and mounted over the lungs of an airway manikin to resemble a human chest in form, dimension and anatomical construction. A lower torso manikin was attached. This was firstly utilised in a burns simulation with restrictive burned skin analogue on the chest wall and a custom made oedematous burnt airway. A cricothyroidotomy, escharotomies and thoracostomy were performed. Then the model was prepared for a stabbed heart simulation by returning the normal airway and replacing the burnt skin on the ribcage with chamois leather. A heart with a haemopericardium and a long bladed knife were inserted in appropriate places into thorax. This was followed by a simulation culminating in a successful resuscitative clamshell thoracotomy with release of the tamponade. Subsequent all attendees had opportunity to practise this skill.ResultsThis airway manikin clothed in lamb’s thorax visually resembled the human anatomy and providing scope for high fidelity burn and stab heart simulations allowing realistic escharotomy and clamshell thoracotomy practise. The orientation of the ribs, the feeling of the bilateral intercostal incisions and transverse sternotomy were true to life. Evaluation by ten attendees on a 5 point Likert scale rated it median 5/5 for realism and 5/5 for teaching value and 4.5/5 for having gained enough confidence to manage these conditions and 4.5/5 for skill acquisition to perform the procedures.DiscussionMorphing a sheep thorax into human dimensions creates an ideal model for high fidelity simulation involving chest procedures.ReferenceHews J, Willers J, Goosen L, Dearing J, Bisht L, Uncles D. Transforming a sheep thorax into an anatomical human shape for clamshell thoracotomy simulation. Anaesthesia 2013;68:18–18

BackgroundPerforming emergency cricothyriodotomy is an integral part of difficult airway management, and this technique is widely taught via simulation using animal, homemade surgical and commercial models. Landmarks for these procedures are usually easily palpable, but not in some of the extreme conditions where surgical airway is most urgently needed, namely burn injuries, anaphylaxis and angioneurotic oedema. Recent research showed the value of ultrasound in performing cricothyroidomies on cadavers,1 and could be even more helpful in the mentioned extreme situations. As there is currently no airway model simulating these conditions,2 or for utilising ultrasound, we sought to remedy this.MethodologyWe integrated the design of an award winning cricothyroidotomy simulator3 with a model of the neck for teaching ultrasound guided regional anaesthesia,4 and modified it to simulate neck swelling by increasing the thickness of the ADAMgel (Aqueous Dietary fibre Antifreeze Mix gel) layer representing pre-laryngeal tissue. This entailed manufacturing a larynx and airway phantom attached to a lung analogue and inserted in an airway manikin with appropriate thickness covering decorated to portray relevant pathology. Additionally a pad of ADAMgel was cast to demonstrate the effect of subcutaneous swelling on the normal ultrasound appearance of airways in neck oedema on a live model.ResultsThe neck swelling looked and felt realistic. Anatomical landmarks were visible on ultrasound allowing localising of cricothyroid membrane. Airway localisation by air aspiration or free fluid flow and imaging were possible. Needle and surgical cricothyroidotomy, with or without ultrasound, were true to life as well. Scanning the neck of a live model with and without the oedema pad illustrated landmarks for comparison. Total costs if utilising theatre discards should be <£3, and is recyclable.ConclusionThis extreme surgical airway model enable extreme surgical airway simulation, ultrasound assisted or not, in scenarios and procedural simulations.ReferencesCurtis K, Ahern M, Dawson M, Mallin M. Ultrasound-guided, Bougie-assisted cricothyroidotomy: a description of a novel technique in cadaveric models. Acad Emerg Med 2012;19:876–879Howes T, Lobo C, Kelly F, Cook TM. Rescuing the obese or burned airway: are conventional training manikins adequate? A simulation study. Br J Anaesth. 2015;114(1):136–42Akrimi S, Singh N, Willers J, Malley T, Bygrave C, Uncles D. A new cost-effective model developed for training in cricothyroidotomy. Anaesthesia 2014;69:31Willers J, Crossland C. Creating a kinetic ultrasound phantom for Interscalene Block. World Congress of Regional Anaesthesia 2014-0237