Rarely used skills need practice
There are a number of very rarely used skills that some consider to be core to the emergency physician: those that are life, limb and sight saving. These are the skills that we should be able to whip out at the drop of a hat in the heat of battle, the ones that can't wait for anyone else to arrive, but are ones that we will likely never have the opportunity to practice beforehand:
- Thoracotomy for penetrating traumatic arrest
- Hysterotomy for maternal cardiac arrest
- Surgical airway for a can’t intubate, can’t oxygenate situation
- Limb amputation for the entrapped casualty with life-threatening injuries
- Escharotomy for a burns patient with compromised ventilation or limb perfusion
- Lateral canthotomy for retrobulbar haemorrhage with orbital compartment syndrome
Knowing what to do and when to do it is vital. These procedures are so rare, yet when the situation arises, the knowledge and action needs to be at your fingertips ready to roll. Running through these scenarios in your mind is important, but knowing how to do the actual actions are a vital part too.
We are never going to "practice" these procedures on real patients. When we do it, we do it for real. So simulation is the only way we can learn and practice these skills, but custom simulation models for these procedures are also rare (and very expensive).
Before I get to my latex models, I thought I'd summarise what I've seen as DIY skills trainers for these procedures.
Down at MedSTAR, we've used the "shig" to practice thoracostomy and thoracotomy - a sheep carcass covered in pig skin to give a realistic feel. It gets a bit messy once the Gigli saw starts humming.
This was one of the SimWars challenges at ACEM ASM 2014, but before that, Tim Leeuwenburg created his very own trainer using his favourite mannequin (and I mean favourite), a laundry basket, beach ball and condom full of fluid.
So, of course, Tim got out his favourite mannequin once more:
Burr Hole Trainer
And as a bonus - the craniostomy burr hole trainer made of a coconut and papier mache, also from Sydney HEMS:
And that brings us to my project:
There are, of course, professionally made trainers available, but these are beyond my resources, even the recently lauded trainer developed out of the Uni of Adelaide. In addition, there are a number of other cheap options that have been proposed, such as the edible model, or the simple tape roll and tube model.
I was looking for something with a little more realism, and the same shoestring budget (and less temptation to eat it), and came across Oogoo, a homemade mouldable silicone. It's pretty basic - mix cheap silicone caulking (cheap acetic cure) with corn starch and maybe a touch of solvent (such as white spirits) to make it softer, and you can cast or mould it, and it will set in less than an hour.
So it was then onto moulding a larynx. First attempt was a little rough and ready, but then Tim pulled out his own model larynx, and phase 2 was casting copies of this. Once set up, limitless larynxes can be poured from the same mould. A bit of leftover ventilator tubing slides in the middle to provide a trachea that can be cut and replaced.
For practice, the model is mounted on some cardboard and covered in a sheet of the same silicone as a multi-use disposable skin layer. The mount I made from an old box also had a chin to make it a little more difficult.
Altogether I spent less than $10 and have made 4 larynxes with casting moulds and have silicone leftover. I think this could be done for less than $1 per model once set up.
Make it a difficult airway! I plan to try mixing up some ballistic gel (also known as very thick jelly - gelatine and water) to make a thick subcutaneous layer that will obscure landmarks and make the cut down more difficult. Maybe it should bleed too?
What else can I use mouldable silicone for?
It is very easy to make disposable skin for trainers - maybe even for some of those more expensive trainers around the place. Skin could also be added to a homemade gel "phantom" for ultrasound vascular access practice. It might also be practical to make some impressive and reusable moulage effects for simulation.
Of course, we can also cast other body parts... maybe a hand for digital blocks? Yes, I know where your mind was going, but let's keep it medical.
Actually, most people don't use this stuff for medical purposes. You can also fix cables, stick things together or make your own phone case.
What skills trainers do you use?
Simulation is becoming increasingly recognised as a vital learning tool, and good resources will become more important as we look to add this to our education schedules (often on a limited budget).
Has anyone seen any other good, homemade (or at least cheap) skills trainers? What other potentials can you see for making our own trainers?