Typical Simulator Applications Physiology and Clinical Medicine Classroom lectures on cardiovascular and respiratory physiology, clinical pharmacology and basic physical diagnosis can be enhanced by using a patient simulator, often replacing sessions in animal laboratories. Depending on medical student level, instructional goals can vary from simple to complex. Students can learn the basic interaction between spontaneous breathing, hypo- and hyperventilation and blood gases, or simulate disease states such as asthma, ARDS, and pneumothorax and investigate the physiological disturbances. Similarly, the teaching of cardiovascular compensatory mechanisms becomes much more dynamic when parameters such as vascular resistance, contractility, venous return and blood volume can be manipulated easily. Acute Care Medicine & Invasive Monitoring The simulator can be used to teach the insertion of pulmonary artery catheters and how to interpret the data obtained. The role and rationale of fluid / inotrope administration can be tested and re-examined under differing scenarios, with full simulation of the ICU setting. Complete cardiac arrest codes can be simulated. Harvard, for instance, moves its simulator to a hospital ward and runs full code simulation with videotaping for immediate feedback to participants. Airway Management The teaching of airway skills to all levels of health care workers can be done with a realistic simulator. Basic skills such as head tilt, jaw thrust and mask ventilation can be acquired by non-anesthetists. Anesthetic residents early in their training can be taught not only conventional laryngoscopy and intubation but more advanced skills such as use of lighted stylet, transtracheal jet ventilation and retrograde wire intubation. The simulator can also add realism with appropriate cardiovascular and oxygen saturation changes during staged airway scenarios. Clinical Anesthesia Skills The realistic simulator can be used at all levels of anesthesia training. For residents in the early stages, practice can range from gas machine checkout to induction of general anesthesia under emergency situations. As they gain experience, the scenarios can be more specific such as the patient with pheochromocytoma or coming off cardiopulmonary bypass. Unusual problems which may never arise during a residency can be practiced, such as malignant hyperthermia or complete loss of electrical power or an operating room fire. Team Skills In the same way that the airline industry has developed programs to teach, practice and test crews' ability to handle crisis events, the realistic simulator has been extended to include Anesthesia Crisis Resource Management (ACRM). The group at Veteran Affairs / Stanford in Palo Alto, California has been a leader and their book Crisis Management in Anesthesiology is highly recommended. A network of simulation centres now exists to promote this program. The principles of ACRM include "definition of the roles leaders and followers, good communication, obtaining help as needed, utilizing all forms or resources and avoiding fixation by repeated reassessment of the whole picture." Simulation is taken a step further by having a control room separate from the mannequin with operator altering the scenario on the fly remotely, speaking for the patient by microphone and directing other members of the "surgical team" by wireless intercom. The experience is often called "theatre simulation" and trainees who have been through it attest to its realism. One important aspect is videotaping and the debriefing session that follows where performance is evaluated in terms of ACRM principles. Service to Industry The industrial community has become aware of the potential to use the simulator. Engineers of monitors and gas machines can learn how anesthetists interact with equipment and how modifications will be received by the anesthetic community. Drug manufacturers can have their salespeople exposed to the anesthetic working milieu and learn from first hand simulator experience how the new drug being promoted can be used effectively and safely. The development of pharmacokinetic and dynamic profiles for new drugs is still a major challenge for manufacturers of simulators. Research Biomedical engineering research into further refinement of the realistic simulator is ongoing. The role of simulation as an teaching tool is the subject of much educational research. Whether the performance of anesthetists under simulated situations can be objectively evaluated is the topic of recent research by Dr Gaba' s group at Stanford. Whether simulators can be useful and valid in testing and certifying clinical competence is also an area of research.