July 1, 2000- June 30, 2002

During the final years of the 1990s, the reputation of the simulation center at the UPMC Montefiore Hospital in Pitt's Department of Anesthesiology/CCM spread rapidly. An increasing number of faculty members in the Departments of Anesthesiology/CCM and Emergency Medicine, and to some degree the School of Nursing designed and implemented several training programs for senior medical students, residents in Anesthesiology and Emergency Medicine, fellows in CCM, nurses and student nurses of various categories, and paramedics. Equally, if not more important, have been the scientific reports, lectures and workshops by faculty members at various national and international meetings and congresses. Dr. Schaefer's experience and skill in providing such presentations have resulted in significant international popularity, as indicated by the attached list of his world-wide involvement.

Dr. Grenvik, serving on the Board of the Laerdal Research Foundation for over twenty years, repeatedly advised the Laerdal Corporation to consider developing an advanced computerized simulator for training in invasive procedures. In August 2000, together with Mr. Tore Laerdal, President of the Laerdal Corporation, Dr. Grenvik attended an annual meeting of the Swedish Society of Anesthesiology and Intensive care at the University of Uppsala in Sweden, among other things, watching Dr. Schaefer conduct one of his excellent training courses in difficult airway management. Impressed by Dr. Schaefer's outstanding performance, Mr. Laerdal suggested to Drs. Schaefer and Grenvik that an application be submitted to the Laerdal Research Foundation for funding of an expanded simulation center at UPMC.

Upon his return to Pittsburgh, with input from his peers, Dr. Schaefer wrote a detailed grant application which was co-signed by Dr. Leonard Firestone (current Chairman of the Department of Anesthesiology/CCM) and Dr. Patrick Kochanek (Director of the Safar Center for Resuscitation Research -- SCRR). Mr. Laerdal's experience from collaboration with Dr. Peter Safar over the past four decades inspired him to request a significant collaboration between the simulation center and SCRR. A preliminary report from the Laerdal Foundation indicated that the application was favorably considered for funding.

An informational meeting dealing with Laerdal's intention to provide a major grant for expansion and further development of the simulation center took place on November 14, 2000, in the Cathedral of Learning in Pittsburgh. It was hosted by University of Pittsburgh's Chancellor Nordenberg, in the presence of Dean Levine, Senior Vice Chancellor of the Health Sciences, Drs. Firestone, Safar, Winter, Kochanek, Simmons (representing UPMC as its Medical Director), Grenvik and Schaefer. Mr. Tore Laerdal participated in this meeting as well. Dr. Grenvik was asked to give brief background information on the simulation center, its accomplishments and importance in modern medical education to improve skills of various health care professionals and improve patient safety. Mr. Laerdal provided his viewpoints on potential funding, indicating the need for institutional matching of funds, collaboration with SCRR, provision of a suitable facility and continued involvement of Dr. John Schaefer as the center's leader. Chancellor Nordenberg provided the University's appreciation and indication of commitment as did Dean Levine. Following written confirmation of the above by Chancellor Nordenberg, Vice Chancellor Levine and Dr. Simmons for UPMC, the US Laerdal Foundation decided to provide funding over a three-year period in the total amount of $998,000.

Dr. Grenvik, who had been appointed Chairman of the Anesthesia Department's Fundraising Committee by Dr. Firestone with the charge to raise funds for a potential endowed chair to honor Dr. Peter Winter, suggested and the Committee agreed that a most suitable way to honor Dr. Winter would be to name the new simulation center after him. Thus, the Peter M. Winter Institute for Simulation, Education and Research (WISER) was established, following approval by Dr. Firestone and Dean Levine as well as acceptance by Dr. Winter.

With the nearly $1 million grant from the Laerdal Foundation secured in January 2001 and a commitment from the Department of Anesthesiology/CCM to more than match that amount, plus contributions from the Schools of Medicine and Nursing, UPMC made serious efforts to find a suitable location for WISER. The first alternative identified was the second floor of the Murdoch Building on Forbes Avenue. However, both the electrical and air conditioning system in the 75 year old building were found to be unacceptable without costly renovation. As neither the University nor UPMC is the owner of that building, which belongs to the Murdoch Foundation, both considered it unwise to pay for such expensive renovation of rented space and this possibility for a future WISER location was aborted. In the spring of 2002, the third and fourth floors of the Medical Arts Building on Fifth Avenue were identified as a suitable location. However, this too became an impractical solution, and the vacant third floor of the McKee Building was found to be a more attractive possibility with negotiations started late in calendar year 2002.

Through the end of academic year 2001-2002, the Human Simulation Center occupied only 1800 square feet on the third floor of Montefiore Hospital including 7 seven small rooms. The main simulation theater is separated from an adjacent control room by a large one-way mirror for observation. This theater can be configured as an operating room, patient room, ICU or emergency department bay. The control room houses audio-visual equipment. The conference room includes an area for debriefing trainees through directed review of video-taped performances and didactic presentations on relevant medical topics. Teaching aids such as an audio-visual projector for powerpoint or internet based curriculum, a slide projector, and posters are used to facilitate learning in this room. Another room, adjacent to the control room with its own one-way mirror, is utilized for advanced cardiac life support courses. An airway skills laboratory is located in a room across the hall from the control room. The Laerdal AirMan Simulator is particularly beneficial in supporting training efforts in this room as it allows high level, difficult airway management simulation training.

Throughout academic year 2001-2002, the Anesthesia Department's Simulation Center remained in the above relatively small facility using two types of Laerdal simulators and a variety of partial-task trainers.

1. The Laerdal SimMan is a full-scale patient simulator. The key features of this simulator include: 1) affordability (one-tenth the price of the original simulator), 2) simplicity of operation, 3) portability and 4) high degree of realism. One can either talk through the simulator itself via a remote microphone or activate pre-recorded sounds. Carotid, radial and femoral pulses are palpable. The simulator breathes and exhales carbon dioxide for qualitative measurement. The anatomy of the airway and lung compliance can be varied dynamically to facilitate difficult airway management training. The simulator supports all major airway devices, cricothyrotomy and needle decompression of an induced pneumothorax. The bronchial tree is accurate down to the segmental level to facilitate fiberoptic bronchoscopy training. Breath, heart and bowel sounds can be auscultated and a variety of abnormalities can be activated. Blood pressure can be measured either manually or automatically. The simulator permits both external defibrillation and external pacing.
2. The Laerdal AirMan is a simulator which provides high quality difficult airway management training on a simplified, portable and low cost platform. AirMan allows the instructor to simulate the following conditions:
   • Restricted mouth opening, rigid neck, tongue swelling, pharyngeal edema, laryngospasm and, poor unilateral or bilateral pulmonary compliance
• Cricothyrotomy through correct neck cricothyroid membrane made of replacement polymer tape which can be punctured and cannulated.
• Inflatable lungs which can be ventilated by conventional means or by transtracheal jet.
• Pneumothorax which can be treated by needle decompression.
• A realistic tracheal bronchial tree to allow training in fiberoptic endoscopy, insertion of double lumen tubes and bronchial blockers.
• Pulse oximetry directly controlled by the instructor.
• Detection of exhaled carbon dioxide from a provided gas source
• Subcutaneous silicone rubber veins to allow intravenous cannulation and administration of drugs.
• A concealed speaker which allows the simulated patient to speak or cough.

Education

Training Courses Taught

1. Medical Students (Approximately 450 in 2001-2002)
   Year 1 - Summer Preceptorship - Preceptorship in Anesthesiology is offered to a few students each year. Basic simulator training involves setting up an OR, technical aspects of monitoring, basic airway management and performance of a basic general anesthesia induction.
   
   Year 2 - Clinical Procedures - This includes all 150 students in the second year. The objectives are to train the students in performing technical procedures related to the practice of medicine, e.g., placing central venous lines, using invasive monitoring and providing basic life support.
   
   Year 3 - Anesthesia and Perioperative Medicine - This clerkship includes all 150 students in the third year. The overall objectives are to train the medical students in basic anesthesiology and perioperative medicine.
   
   Year 3 - Acute Inpatient Medicine - Includes all 150 students in the third year class. This provides the fundamentals of managing the acutely ill patient.
   
   Year 4 - Electives in Anesthesiology - This includes approximately 65 fourth-year students. involving such elective clinical rotations as general, cardiac, thoracic and neurologic anesthesia
   
   Year 4 - Critical Care Medicine - This includes approximately 65 fourth-year students, reinforcing the elective ICU rotations.
   
   
2. Anesthesia Resident Training (Approximately 120 in 2001 - 2002)
   1. Introduction to anesthesiology
      
   2. Difficult airway management
      
   3. Fiberoptic bronchoscopy
      
   4. Anesthesia crisis leadership
      
   5. Pediatric crisis management
      
   6. Management of critical events in obstetrics
      
   7. Introduction to thoracic Anesthesiology
      
   
   
3. Critical Care Medicine Fellowship Courses (Approximately 30 in 2001 - 2002)
   
   
4. Continuing Medical Education Program (Approximately 40 in 2001 - 2002)
   

Total number of trainees 640 in academic year 2001 - 2002

Winter Institute for Simulation, Education and Research (WISER)

Faculty

John Schaefer, MD Director, WISER Assistant Professor Department of Anesthesiology Charles Brindis, MD, MS Assistant Director, WISER Assistant Professor Department of Anesthesiology Ake Grenvik, MD, PhD Distinguished Service Professor Critical Care Medicine Department of Critical Care Medicine Director of Research, WISER Department of Anesthesiology

Consultants

Peter M. Winter, MD Professor Emeritus Coordinator for Faculty Development Department of Anesthesiology Rita Patel, MD Associate Professor Vice Chair, Education Department of Anesthesiology Associate Dean for Medical Education University of Pittsburgh - School of Medicine Peter Safar, MD, Dr h.c. Distinguished Service Professor Resuscitation Medicine Safar Center for Resuscitation Research

Course Directors

Lawrence Borland, MD Department of Anesthesiology Ajay Chalasani, MD Assistant Professor Department of Anesthesiology Michael DeVita, MD Associate Professor Department of Critical Care Medicine Tom Dongilli Director, Operations WISER, Department of Anesthesiology Susan Dunmire, MD Associate Professor Department of Emergency Medicine Theresa Gelzinis, MD Assistant Professor Department of Anesthesiology William McIvor, MD Assistant Professor Department of Anesthesiology Michael Mohr, MD Assistant Professor Department of Anesthesiology John O'Donnell, RN, MS Director, Nurse Anesthesia Program School of Nursing Steven Orebaugh, MD Assistant Professor Department of Anesthesiology Paul Rogers, MD Professor Department of Critical Care Medicine Ryan Romeo, MD Assistant Professor Department of Anesthesiology John Schaefer, MD Assistant Professor Department of Anesthesiology Mohamed Soliman, MD Department of Anesthesiology Erin Sullivan, MD Associate Professor Department of Anesthesiology Samuel Tisherman, MD Associate Professor Department of Critical Care Medicine Ramesh Venkataraman, MD Assistant Professor Department of Critical Care Medicine

Course Instructors

Omer Bajwa, MD Patrick Forte, MD Theresa Gelzinis, MD Robert Krohner, MD Bob Lawler, MD Gordon Mandell, MD David Metro, MD Andrew Murray, MD Joseph Quinlan, MD Sara Shekar, MD Joseph Talarico, MD Steven Whitehurst, MD

WISER Committees

Steering Committee

John J. Schaefer III, MD, Chairperson Director, Peter M. Winter Institute for Simulation Education and Research Assistant Professor, Anesthesiology Steven L. Kanter, MD Vice Dean University of Pittsburgh School of Medicine William McIvor, MD Associate Professor Department of Anesthesiology Director, Medical Student Simulation Studies John O'Donnell, CRNA, MSN Director, Nurse Anesthesia Program University of Pittsburgh, School of Nursing Rita M. Patel, MD Associate Professor Vice Chairman of Education Department of Anesthesiology Andrew B. Peitzman, MD Professor Department of Surgery Paul Rogers, MD Professor Department of Critical Care Medicine

Research Committee

Ake Grenvik, MD, PhD (Chair) Distinguished Service Professor of Critical Care Medicine Michael DeVita, MD Associate Professor Department of Critical Care Medicine Alan M. Lesgold, PhD Professor and Dean University of Pittsburgh School of Education William McIvor, MD Associate Professor Department of Anesthesiology Director, Medical Student Simulation Studies University of Pittsburgh School of Medicine John O'Donnell, CRNA, MSN Instructor Program Director, Nurse Anesthesia Program University of Pittsburgh School of Nursing Paul Paris, MD Professor and Chairman Department of Emergency Medicine Rita M. Patel, MD Associate Professor Department of Anesthesiology Vice Chairman of Education University of Pittsburgh School of Medicine Michael Pinsky, MD Dr h.c. Professor Department of Critical Care Medicine P. Rogers, MD Professor Department of Critical Care Medicine John Schaefer, III, MD Director, Peter M. Winter Institute for Simulation Education and Research Assistant Professor, Anesthesiology Walt Stoy, MD Assistant Professor Department of Emergency Samuel Tisherman, MD Associate Professor Department of Critical Care Medicine Henry Wang, MD Assistant Professor Department of Surgery Peter M. Winter, MD Professor Emeritus Department of Anesthesiology

Advisory Committee

Chairman: Ake Grenvik, MD, PhD Distinguished Service Professor of Critical Care Medicine Consultant: Peter Safar, MD Distinguished Service Professor of Resuscitation Medicine Safar Center for Resuscitation Research Mitchell P. Fink, MD Watson Professor of Surgery Chairman Department of Critical Care Medicine Steven Kanter, MD Vice Dean University of Pittsburgh School of Medicine Alan M. Lesgold, PhD Professor and Dean University of Pittsburgh School of Education Ellen Rudy, RN, PhD Dean and Professor University of Pittsburgh School of Nursing William Shaffner, JD Associate Council, Legal Department University of Pittsburgh Medical Center Richard L. Simmons, MD Distinguished Service Professor Department of Surgery Medical Director University of Pittsburgh Medical Center Peter M. Winter, MD Professor Emeritus Department of Anesthesiology/CCM Ex-Officio Members: Patrick Kochanek, MD, Director Safar Center for Resuscitation Research Professor Department of Critical Care Medicine John Schaefer, MD Assistant Professor, Anesthesiology/CCM Director, Human Simulation Center Department of Anesthesiology/CCM Leonard Firestone, MD Safar Professor & Chair Department of Anesthesiology/CCM

Publications

   Peer Review Articles

1. Rogers PL, Grenvik A, Willenkin R: Teaching medical students complex cognitive skills in the Intensive Care Unit. Crit Care Med 23:575-581, 1995
   

2. Patel R, Crombleholme W: Using Simulation to Train Residents in Critical Events. Academic Medicine 73:5; 1998
   

3. Rogers P: Developing a curriculum for medical students in critical care medicine. New Horizons 6:248-259, 1998
   

4. Murray M, Rogers P: Education in critical care medicine for medical students. New Horizons 6:244-246, 1998
   

5. Powner D, Rogers PL: The process of educational change. Crit Care Med 27:2289-2290, 1999
   

6. Schaefer JJ, Gonzalez R: Dynamic Simulation: A New Tool for Difficult Airway Training of Professional Healthcare Providers. Invited article in the American Journal of Clinical Anesthesiology 27(3) pp 232-242; May 2000
   

7. Rogers PL, Jacobs H, Thomas E, Willenkin R: Medical students can learn the basic application, analytic, evaluative, and psychomotor skills of Critical Care Medicine. Crit Care Med 29:1268-72; 2001
   

8. Schaefer JJ, Grenvik A: Simulation-based Training at the University of Pittsburgh. Annals Academy of Medicine 30(3): p 274; May 2001
   

9. Rogers PL, Jacobs H, Rashwan A, Pinsky MR: Quantifying learning in medical students during a critical care medicine elective: A comparison of three evaluation instruments. Crit Care Med 29:1268-73; 2001

   Published Abstracts

1. Brindis C: "LGAS: A Real-Time Anesthesia Simulator" Int'l Journal of Clinical Monitoring and Computing. October, 1992
   

2. Schaefer J, Gonzalez R, et al: A New Method for Teaching the ASA Difficult Airway Management Algorithm Using a Full-Scale Human Simulator. Anesthesiology 85:A933; 1996
   

3. Schaefer JJ, Gonzales R, Dongilli T: Results of Systematic Psychomotor Difficult Airway Training of Residents Using the ASA Difficult Airway Algorithm. Anesthesiology 89(3): page 60; November 1998
   

4. Rogers P, Jacob H, Rashwan A, Pinsky M: Quantifying learning in medical students during a Critical Care Medicine elective. Crit Care Med 27:A82, 1999
   

5. Wax RS, Pinsky MR, Dunmire S, Cox C, Rogers PL: Experience with mock resuscitation scenarios using a human simulator improves management of respiratory distress by medical students. Am J Resp and Crit Care Med 163:A258; 2001
   

6. Frankel H. Rogers PL, Gandhi R, Freid E, Kirton O: What is taught, what is tested: Findings and competency-based recommendations of the Undergraduate Medical Education Committee of the Society of Critical Care Medicine UGMEC). Supp Crit Care Med 31:A125; 2003

Grants

1. Schaefer JJ, Kochanek P, Firestone L: Establishing a Major Simulation and Education Center to Include Research in Education. Funded in the amount of $988,000 by the Asmund S. Laerdal Foundation for Acute Medicine, Inc., New York, USA. January 2001
   

2. Schaefer J: Laerdal Foundation Grant for a development of simulator and simulator curriculum, July 1999
   

3. Schaefer J: Educational Grant From Glaxo Wellcome Pharmaceuticals Co. for development of a simulation based "Remifentanyl Preceptorship Course", September 1996
   

4. Schaefer J, Fletcher J. Gonzalez RM: Educational Grant From Glaxo Wellcome Pharmaceuticals Co. for development of a simulation-based "Anesthesiology Preceptorship Course", June 1995
   

5. Schaefer J: University of Pittsburgh Advanced Instructional Technology Grant, February 13, 1995
   

6. Schaefer J: University of Pittsburgh Specialized Instructional Lab Grant, January 6, 1995
   

Patents

Schaefer JJ: U.S. Patent #5,823,787 Awarded October 20, 1998 for difficult airway simulator

Brindis C: U.S. Patent #5,385,474 Awarded January 31, 1995 for the software concepts behind LGAS - a screen-based anesthesia training device.

Awards

Schaefer J: E.C. Pierce Award for a best patient related scientific exhibit from the Anesthesia Patient Safety Foundation, 2000 ASA Annual Meeting entitled, "Sim-Based Training in Applying the ASA Difficult Airway Algorithm"

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