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Technical Reports

Endoscopic Skills Training in a Simulated Clinical Setting

Leon Fisher, BMBS, FRACP;

Donald G. Ormonde, MBBS, FRACP,PhD;

Richard H. Riley, MBBS, FANZCA,FACA;

Bernard H. Laurence,BMedSci(Hons), MBBS, FRACP

Background/Aim: We describe a simulation and scenario-based model of trainingin gastrointestinal endoscopic hemostasis, which combines acquisition of proceduraland problem-solving skills in a close to reality simulated clinical setting.Methods: Two day courses in endoscopic hemostasis were conducted at the ClinicalTraining and Education Centre, the University of Western Australia, Perth, Australia. Intotal, 23 trainees were enrolled. The Erlangen Endo-Trainer simulator, porcine speci-mens of esophagus, stomach, and duodenum with a range of simulated bleedingsources, a separate catheter and a pump to simulate massive bleeding, and a full armmodel with injectable veins were used. The SimMan monitor and software packagewere used to simulate hemodynamic parameters and electrocardiogram. Facultymembers adjusted the rate of bleeding and vital parameters. The exercise was videorecorded. On the first day, the group underwent simulator training in techniques of endoscopic hemostasis. On the second day, participants were scenario-based trainedin full management of a “bleeding patient,” which included resuscitation, sedation,endoscopy, and hemostasis, acting as leaders in teams of three. The course wasevaluated by participants using a standardized questionnaire.

Results: A complex clinical setting of acute gastrointestinal bleeding was recreatedwith a high degree of realism. All participants reported that the simulated clinicalscenario was a positive learning experience, helpful in managing complications andperforming complex problem-solving tasks in a dynamic environment.Conclusions: Scenario and simulation-based training in endoscopic hemostasis mayprovide an opportunity to improve procedural skills and acquire practical experiencein managing this medical emergency, which requires the ability to process, integrate,and adequately and quickly respond to complex information in unexpected conditionsworking as a team leader.(Sim Healthcare 5:232–237, 2010)

Key Words: GI training, Endoscopy, Gastroscopy, Clinical simulation, Scenario training.

The value of simulation-based training in acquiring endo-

scopic skills is increasingly recognized. The use of isolated

animal gut allows endoscopic procedural training with suffi-

cient realism and difficulty to promote operator competence

and confidence.1–3 Modification of this model by creating

simulated pathology such as ulcers, varices, and arterial

bleeding widens its applications and its value in learning

complex hemostatic techniques by repeated supervised prac-

tice. However, procedural skill is not the only determinant of

a successful clinical outcome, as many endoscopists have

learnt, often to the patient’s peril, when faced with control-

ling massive ulcer bleeding in a high-risk patient with un-skilled support in the early hours of the morning. The proce-

duralist also needs to be skilled in resuscitation and sedation

and must have the communication and leadership abilities to

manage the endoscopy support team effectively. However,

current simulator training in endoscopic hemostasis is pri-

marily concentrated on endoscopic skills. Such training sig-

nificantly improves the procedural skills,1–3 but it does not

address other important in a clinical setting goals.

Kneebone et al4 has highlighted the significant deteriora-

tion of simulator acquired sigmoidoscopy skills when the

operator is required to carry out the procedure in a simulated

clinical setting. The distracting effects of anxiety, the need tomake complex logistical decisions, and identify and treat in-

traprocedure complications while attempting endoscopic

treatment are likely to be much more significant in the man-

agement of a patient with gastrointestinal (GI) bleeding.

To be beneficial, the experimental simulator-based teach-

ing should focus on acquisition of both multiple skills and

knowledge needed to solve complex problems and ability to

perform promptly and efficiently during critical clinical

events. The likelihood of personnel making mistakes in-

creases as critical events evolve indicating the need for team

training.5–7 It has been documented that individuals’ thought

processes, attention spans, and proficiency are compromised

From the Department of Gastroenterology, Sir Charles Gairdner Hospital (L.F.,

D.G.O., B.H.L.); the University of Western Australia (L.F., D.G.O., R.H.R., B.H.L.);

and Royal Perth Hospital (R.H.R.), Perth, Australia.

Author contributions: Leon Fisher, BMBS, FRACP: analysis and interpretation of the

data, drafting of the article, critical revision of the article for important intellectual

content, and final approval of the article; Donald G. Ormonde, MBBS, FRACP, PhD:

conception and design and final approval of the article; Richard H. Riley, MBBS,

FANZCA, FACA: conception and design and final approval of the article; and

Bernard H. Laurence, BMedSci(Hons), MBBS, FRACP: analysis and interpretation of

the data, conception and design, critical revision of the article for important

intellectual content, and final approval of the article.

Reprints:Dr. LeonFisher,Department of Gastroenterology,SirCharles GairdnerHospital,

Nedlands,Western Australia 6009, Australia (e-mail: [email protected]).

Copyright © 2010 Society for Simulation in HealthcareDOI: 10.1097/SIH.0b013e3181d2a7af

232 Endoscopic Skills Training Simulation in Healthcare


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training in advanced life-support skills; its software allows

multiple physiological trends to be run simultaneously withadditive effect. Preprogrammed clinical scenarios are avail-

able or as in this training exercise, can be custom designed fora particular clinical situation and progressively rolled out by a

teaching faculty observer in the control room.

MATERIALSAll equipment used was either disposable or for dedicated

animal use only. The following equipment and accessories

were used.

• Real Olympus GIF-140 video endoscopes.• Erbe (Erbe Elektromedizin, Ltd., Tubingen, Germany)

and Valleylab (Valleylab, Inc., Boulder, CO) electrosur-gical generators.

• Argon plasma coagulation probe (Erbe Elektromedizin,Ltd., Tubingen, Germany), Gold Probe (Boston Scien-

tific Corporation, Natick, MA), Hemoclip applicator(Olympus Corporation, Japan), Six-Shooter ligator

(Wilson-Cook Medical, Inc., Winston-Salem, NC).• Intravenous catheters and connection lines.

Evaluation of the Course by ParticipantsTo assess participants’ satisfaction with the course, a stan-

dardized structural questionnaire regarding the course out-

come and organization was used. Each participant was askedto answer anonymously 12 questions on a 5-point scale (from

“strongly disagree” to “strongly agree”). Each question also

included four to eight reasons to explain the rating. Sugges-tions for further improvement of the course and any othercomments were also asked to be expressed.

RESULTSConduct of the Course

The course consisted of 2 days of theoretical and practicalsessions. The first day of the course covered both the basic

theoretical background and practical approach to endoscopichemostasis using epinephrine injections, endoclips, coagula-

tion probes, and variceal banding devices. Participants wereshown the techniques (initial didactic demonstration) and

then practiced their skills under expert supervision on the

Erlangen EASIE model, plastic models, and GI-Mentor II

computer simulator (Simbionix Corp, Cleveland, Ohio) forapproximately 4 hours. One tutor trained two to three doc-

tors and evaluated all steps of their performance of the pro-cedure, including manual skills in setting up the device, test-

ing the equipment, localizing the bleeding site andapplication of specific hemostatic techniques—injection,

electrocoagulation, hemoclip application, and variceal liga-tion. This training endoscopic hemostatic skill station was

organized following previously published recommenda-tions,3 but the trainees were not exposed to the full resuscita-

tion and endoscopic simulator until day 2.On the second day, the class was divided into four “endos-

copy teams” each consisting of three people for simulatedclinical setting exercises. Each team consisted of three doctors

or two doctors and a nurse (because the majority of partici-pants were doctors). The team decided on the endoscopist

before the beginning of exercise, whereas the other two wereresponsible for support. In each session, the endoscopy teams

were given a brief clinical scenario (Appendix) and were re-quired to assume full management of the simulated patient.

Four different clinical scenarios were used simulating ulcerhemorrhage and Diulefoy lesion. Trainees had to explain the

procedure to the “patient,” assess their hemodynamic status,initiate resuscitation if indicated, administer sedation, per-

form an endoscopy, and identify and treat the bleeding le-sion. The choice of hemostatic method, the preparation of

the equipment (endoscopes, generators, and power settings),and the appropriate accessories (injection needles, Gold

Probe, Hemoclip, or argon plasma coagulation probe) wereentirely the responsibility of the trainees. Thirty minutes

maximum was allowed to complete the exercise. Traineeswere aware of the time limit, and they knew that they had to

resuscitate the patient and apply endoscopic treatment. The

details of clinical history and other parameters were only revealedonce the exercise started. Each exercise was observed

by at least three faculty members—one was in the room incontrol of the “bleeding pump,” and two were in the control

room and could adjust the hemodynamic parameters. Thefaculty members adjusted the rate of bleeding and hemody-

namic parameters depending on whether the treatment was

Figure 1. The Erlangen Endo-Trainer model complete with a roller pump and intravenous training arm (A) and simulated en-doscopy room (B).



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Kneebone et al4,18 pioneered the use of medical simulators

in a realistic environment by positioning a surrogate patient

adjacent to the computer generated endoscopic image. Inte-

grating skills training in sigmoidoscopy within a clinical con-

text improved the perceived realism of the procedure and

enhanced the learning experience by allowing interaction

with the patient but increased the anxiety of the participants

with a corresponding reduction in dexterity.4,18,21

Successful management of acute GI bleeding requires a

team approach and the endoscopist because team leadermust not only be competent in resuscitation but must also

possess strong communication and leadership skills. The

value of teaching the team approach to managing life support

and multiple trauma has been recognized for over a decade

but has so far received little attention in endoscopy teaching

programs. Experience of medical emergency team training

shows that despite appropriate levels of individual skill, the

team often functions poorly because of lack of organization

and leadership.22 Moreover, it has been demonstrated that

performance can be improved significantly by training on

simulated patients using realistic clinical scenarios and pro-

viding extensive feedback and analysis.22,23

To provide simulator training and practice in both psy-

chomotor and cognitive skills in emergency situations (under

pressure), we used a two-stage approach. To our knowledge,

this is the first course in endoscopic management of GI bleed-

ing to incorporate the acquisition of technical skills with a

team approach to the resuscitation and overall management

of a bleeding patient.

On the first stage, the trainees practice mainly procedural

skills, whereas the second stage integrates technical proce-

dures with unexpected changes in “patient’s” status requiring

immediate responses from the trainee as the team leader.

Such training not only improves the endoscopic hemostatic

skills of the trainees but also gives them an opportunity to

experience the complexity and danger in a dynamic environ-

ment and to practice in problem solving, leadership, and

teamwork. Such realistic (but safe) setting should increase

their knowledge of the procedure and its potential pitfalls.

The 2-day CTEC course in the endoscopic control of GI

bleeding provides realistic clinical scenario-based simulation

which the trainee is likely to encounter in daily practice. The

training and debriefing sessions were focused on a structured

team approach to a patient with GI bleeding, highlighting the

importance of monitoring, early and adequate resuscitation,

effective endoscopic treatment, and the recognition of the

limitations of both the treatment modality and personal

skills. Importantly, the majority of participants expressed

high satisfaction with the training course.They noticed that it

was helpful in adapting to and overcoming the difficulties in

managing unexpected complications and performing com-

plex problem-solving tasks in a dynamic environment.

Issenberg et al24 have conducted an extensive review of the

published literature concerning the use of high-fidelity med-

ical stimulators. This study emphasized the key importance

of feedback, repetitive practice, curriculum integration, vari-

ation in task difficulty, and clinical setting in facilitating

learning; it stressed the value of providing a controlled envi-

ronment where trainees can learn from mistakes without risk to patients.24

The CTEC course satisfies all these criteria, particularly feedback based on faculty and peer review of video recorded

performance, and is an important addition to our GI Fellow-ship teaching program. Once setup, the training model out-

lined can be used many times and provides an opportunity

for repetitive practice to reinforce newly acquired skills. It isanticipated that in future courses, the number of simulated

scenarios will be increased with the degree of difficulty tai-lored to the training and experience of endoscopists and sup-

port staff. Communication skills training is an essential partof the course,and the scenarios could be expanded to include

clinical history taking, obtaining informed consent, consult-ing colleagues, and informing patient or kin of treatment

outcomes.Although the presented pilot 2-day intensive simulator

endoscopic training was enthusiastically accepted by traineesand can potentially improve patients’ safety, only further

long-term assessment and prospective randomized con-trolled trials will determine whether the skills learned in the

course translate into the ability to perform such proceduressafely in clinical practice.

CONCLUSIONThere is growing evidence that endoscopic training can be

improved by the use of simulation. A number of publications

have reporteda positive training effect whenusing simulatorsin the early phase of endoscopic training. Management of GI

bleeding is arguably one of the most challenging and stressfulendoscopic procedures. It requires a high degree of technical

and cognitive skills and knowledge and is also one of the mostdifficult techniques to teach trainees because of limited expo-

sure, time constraints, stress of the situation, and high risk tothe patient. In this article, we report on the application of a

biomechanical GI bleeding model in a close to reality simu-

lated clinical setting to teach principles of endoscopic man-agement of GI bleeding. The 2-day intensive course allows

trainees not only to improve their endoscopic hemostaticskills but also to gain practical experience in clinical judg-

ment and to develop better leadership and teamwork abilitiesin emergency situations. Future randomized trials are needed

to evaluate the patient-relevant effectiveness of the modelobjectively.

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simulator for interventional endoscopy training is superior to solely clinical education in endoscopic hemostasis—the French trainingproject: a prospective trial. Eur J Gastroenterol Hepatol 2006;18:1217–1225.

2. Maiss J, Wiesnet J, Proeschel A, et al. Objective benefit of a 1-day training course in endoscopic hemostasis using the “compactEASIE”endoscopy simulator. Endoscopy 2005;37:552–558.

3. Matthes K, Cohen J, Kochman ML, Cerulli MA, Vora KC, HochbergerJ. Efficacy and costs of a one-day hands-on EASIE endoscopy simulator train-the-trainer workshop. Gastrointest Endosc 2005;62:921–927.

4. Kneebone RL, Nestel D, Moorthy K, et al.Learning the skillsof flexible

sigmoidoscopy—the wider perspective. Med Educ 2003;37(suppl 1):50–58.



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5. Barker J. Error reduction through team leadership: what surgeons canlearn from the airline industry. Clin Neurosurg 2007;54:195–199.

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7. Schwid HA, O’Donnell D. Anesthesiologists’ management of simulated critical incidents. Anesthesiology 1992;76:495–501.

8. VanLehn K. Cognitive skill acquisition. Annu Rev Psychol 1996;47:513–539.

9. Haider H, Frensch PA. Why aggregated learning follows the power law of practice when individual learning does not: comment on Rickard

(1997, 1999), Delaney et al. (1998), and Palmeri (1999). J Exp Psychol Learn Mem Cogn 2002;28:392–406.

10. Schunn CD, Lovett MC, Reder LM. Awareness and working memory in strategy adaptivity. Mem Cogn 2001;29:254–266.

11. Riley RH, Grauze AM, Chinnery C, Horley RA, Trewhella NH. Three years of “CASMS”: the world’s busiest medical simulation centre. Med J Aust 2003;179:626– 630.

12. Hochberger J, Euler K, Naegel A, Hahn EG, Maiss J. The compactErlangen Active Simulator for Interventional Endoscopy: a prospectivecomparison in structured team-training courses on “endoscopichemostasis” for doctors and nurses to the “Endo-Trainer” model.Scand J Gastroenterol 2004;39:895–902.

13. Gerson LB, Van Dam J. Technology review: the use of simulators fortraining in GI endoscopy. Gastrointest Endosc 2004;60:992–1001.

14. Hochberger J, Maiss J, Hahn EG. The use of simulators for training inGI endoscopy. Endoscopy 2002;34:727–729.

15. DiGiulio E, Fregonese D, Casetti T, et al.Training with a computer-basedsimulator achieves basic manual skills required for upper endoscopy: arandomized controlled trial. Gastrointest Endosc 2004;60:196–200.

16. Ferlitsch A, Glauninger P, Gupper A, et al. Evaluation of a virtualendoscopy simulator for training in gastrointestinal endoscopy.Endoscopy 2002;34:698–702.

17. Hochberger J, Matthes K, Maiss J, Koebnick C, Hahn EG, Cohen J.Training with the compactEASIE biologic endoscopy simulatorsignificantly improves hemostatic technical skill of gastroenterology fellows: a randomized controlled comparison with clinical endoscopy training alone. Gastrointest Endosc 2005;61:204–215.

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APPENDIX: TWO SAMPLE SCENARIOS USED IN THEMANAGEMENT OF GI BLEEDING COURSESample Scenario 1

Background information given to trainees:

An 85-year-old female patient is admitted via the emer-gency department with a 3-day history of melena. She

has a history of noninsulin-dependant diabetes andischemic heart disease and had a previous myocardial

infarct. She takes Aspirin, Celecoxib and Ramipril.While in emergency department, she has an episode of

hypotension. Her admission blood count shows he-

moglobin of 105 g/L, and her coagulation profile isnormal.

Initial setup:The patient has been transferred to the endoscopy unit for

urgent gastroscopy. She is awake on a trolley and con-sented for the procedure. Her heart rate is 108 beats/

minute, blood pressure 105/48 mm Hg supine, and oxygen saturation 94% on room air.

Progress:Once sedated, the patient becomes rapidly hypoxic, oxygen

saturation falling to 78%.Actions required:

Increase oxygen, attempt to rouse the patient, reverse seda-tion, check oxymeter probe, insert airway, bag, and

mask.

Sample Scenario 2

Background information given to trainees:

A 27-year-old fit male admitted via emergency departmentwith hematemesis and melena. His history is remarkable

only for a recent leg injury, and he has been taking high-dose non-steroidal anti-inflammatory drug for pain

control in the last 2 weeks. On admission, his hemoglo-bin is 89 g/L. He is transferred to the endoscopy unit for

urgent gastroscopy.Initial setup:

The patient is awake on a trolley and consented for the pro-cedure. He has a small intravenous cannula in his left

arm. His pulse rate is 110 beats per minute, his supineblood pressure is 105/60 mm Hg, and his oxygen satura-

tion is 99% on room air.Progress:

After sedation, patient’s blood pressure begins to fall. As thescope is inserted, his blood pressure falls to 88/52 and

then to 74/40 mm Hg.Actions required:

Insert a large-bore intravenous cannula, increase intravenousfluids, administer blood products, and treat the bleeding

lesion.

Vol. 5, No. 4, August 2010 © 2010 Society for Simulation in Healthcare 237

endoscopic skills training in a simulated clinical.8

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