Simulation Technology Is Gaining Traction Outside Aviation

I wish we’d had CAE Healthcare’s LapVR simulator, on which I demonstrated my atrophied appendectomy skills, when I was in surgical training. Dick Karl

I could see the cecum quite clearly and the obviously inflamed appendix sticking straight out of it. This had to be the easiest appendectomy of my surgical career. With a grasper in my left hand and a Maryland dissector in my right, I knew just where to look for the appendiceal artery. Geoff Bates held the laparoscopic camera and rooted me on.

With the appendiceal artery separated from the actual appendix, I was in a position to clip it and divide it before stapling off the appendiceal stump and curing the disease that almost killed my father in the 1920s. As I fired the vascular stapler across the artery, sickening green blobs occluded the camera. I had pulled too hard on the appendix and it had burst — a cardinal sin in surgery.

I had changed a clean contaminated case into a contaminated one and vastly increased the chances of postoperative infection. I could see a sea of pus forming in the “gutter” behind the cecum. Bates instructed me how to irrigate the area with warm saline and to aspirate the fluid through the “suction irrigator” in my left hand. I watched as the pool receded. It was hard to believe I was standing in a hotel ballroom and had just experienced medical simulation on a LapVR machine.

The occasion was CAE Healthcare’s annual Human Patient Simulation Network conference, which was fortuitously held in my hometown, Tampa, Florida. Participants got to hear from Chris Broom, American Airlines’ managing director of flight and training, and Shad Deering, an OB-GYN doctor with innovative experience in obstetrical simulation. CAE Healthcare President Robert Amyot set the tone by describing an incident he experienced as a diagnostic cardiologist.

A young woman was “found down,” pulseless and in shock, and brought to the emergency department of his hospital. The most likely cause was either a collection of fluid around the heart (which restricts the heart’s ability to fill and thereby causes shock) or a pulmonary embolism (where a massive clot breaks off from the venous system and lodges in the lung circulation, making it impossible to pump blood to the rest of the body). The former is treated with a long needle and a syringe (to draw off the fluid and allow the heart to fill and pump), the latter with thrombolytic therapy (which dissolves the clot). The trouble is if you treat pulmonary embolism with a needle, you puncture the heart, and if you treat pericardial fluid with thrombolytic therapy, you cause bleeding, which makes matters worse. Accurate and quick diagnosis is essential.

Amyot described wheeling his echo machine to the emergency department that had filled with doctors and nurses. They were waiting for him to make the diagnosis. He wondered, why didn’t everybody in the department know how to use the ultrasound machine? So he invented a simulator, started a company and now serves as CAE Healthcare’s president.

You can wear yourself out in one of CAE's simulation bays. It's sometimes surprising to step out into the light and realize it was all simulated. Dick Karl

Just eight days before my visit to the medical simulators, I was in Whippany, New Jersey, at another part of the CAE enterprise for my six-month “checkup,” which is the 297 check ride as required by Part 135 for me to serve as captain on the Cessna CJ3 for JetSuite.

Fellow captain O’Neil Smith and I have done this CAE dance before, and it is always good to be paired with this great aviator and fine man. We have an easy cadence in the simulator and a similar approach to flying and to life. Early on a Tuesday morning, we reported to that little briefing room on the second floor that we know only too well. Lou Mazzinate greeted us like long-lost friends — he’d been subjected to our slightly off-center senses of humor before. After a few pleasantries, we started in on the memory items.

Loss of engine on takeoff below V1? Use brakes as required, throttles to idle, speed breaks extend. Loss of engine on takeoff after V1? Maintain directional control, accelerate to Vr, rotate at Vr climb at V2, gear up with positive rate, wing XFLOW switch on (if anti-ice is on), flaps retract at previously briefed altitude and V2 plus 10, accelerate to Venr, flaps up, checklist. Max gear extension speed — 200 knots. Altitude limitation with yaw damper inop — 30,000 feet.

With a shrug, Mazzinate pronounced us up to speed and gave us 10 minutes to meet him in the simulator. Checklists in hand, we descended the stairs into the realistic sim, which is so much a part of professional flying. Once seated, engines started and our departure briefed, we saw only a few taxiway lights ahead of us. The RVR was set at 600 feet, our company minimum for takeoff. There was not an appendix, or much else for that matter, in sight.

Our profile was just like our proficiency check ride six months prior, only this time there was no warm-up, no days in the simulator, no time to contemplate. After takeoff we did steep turns at 200 knots and 5,000 feet, three types of stalls (clean, approach and climbing turn), and then were vectored back for an ILS at JFK.

We landed and got reset up for takeoff, knowing full well that the V1 cut was next. On the CJ3, the interval between the commit-to-fly speed (V1) and the rotation speed (Vr) is measured in seconds or fractions thereof. With the engine mounted close to the tail and good rudder authority, the V1 cut is usually pretty easy to handle.

We ran checklists, restarted engines, did engine-out procedures, returned for hand-flown ILSs, GPS approaches and, my favorite, the VOR 4L circle to land on 31R at JFK. The maneuvers and approaches race by in a blur so that, after a while, I get confused as to where we are and where we are going. Sometimes the FMS gets confused too. We had Newark, New Jersey, as our alternate, but now we were headed for La Guardia, and the box just couldn’t seem to wrap its electrons around the concept. Four hours later, we staggered out of the simulator recertified for life on the road again.

These two experiences only eight days apart gave reason for contemplation. How is it that simulators, recurrent proficiency checks, Class 1 physical exams and check airmen and crew resource management and many other things are part and parcel of aviation, yet medicine — and surgery — has been slow to adopt and use these powerful techniques?

There are estimates that between 100,000 to 400,000 patients’ lives are shortened each year due to medical error in the United States alone. Even the lower number would be the equivalent of four 747 crashes per week. My first 20 takeoffs in a CJ3 were in a simulator. My first 20 appendectomies were performed on real people, some of whom got bigger incisions than they needed due to my inexperience. CAE Healthcare is trying to do something about this. It is about time.

Dick Karl
Dick KarlAuthor
Dick Karl is a cancer surgeon who appreciates the beauty and science involved in both surgery and flying. Dick’s monthly Gear Up celebrates the human side of flying. He writes about his enthusiasm for both the machines and the people who fly and maintain them.

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