SimHacks Thoracotomy Trainer
A Sample SimHack Production
Thoracotomy Background and Materials
The Emergency Department Thoracotomy is the Moby Dick of procedures: elusive, dangerous, and often the stuff of legend. But with physicians participating in this procedure very infrequently (if at all) over a career maintaining familiarity with all the equipment and steps involved requires deliberate, simulated practice. Cadaveric and porcine models are the primary means through which physicians can brush up on their thoracotomy skills. But access to corpses and/or hogs is subject to limitations. Even the vaunted Trauma Man is not designed to withstand this procedure. Nevertheless, the ED physician practicing at a Level 1 trauma center - and all residents in training - are required to be ready to perform this procedure on individuals who arrive in witnessed cardiac after penetrating trauma. A reusable, affordable and realistic simulator is a valuable tool for utilization in training for medical students, residents and attending providers for simple familiarity or for actual testing, certification, and CME purposes. We will detail how to build your own thoracotomy trainer with supplies easily obtained from the local hardware store, your sim center supply closet, and some boxes in your own basement.
When to use it?
To simulate ED thoracotomy. May also be utilized for chest tube insertion and intubation as well.
This model can be utilized for deliberate practice of the technique of thoracotomy with aortic cross clamping and pericardial incision/heart delivery. Model was piloted with a group of 22 Emergency Medicine residents. The activity was evaluated by all learners: 9 PGY 1, 8 PGY 2, 5 PGY 3. 16 had previously witnessed this procedure performed on a real patient. Four residents had assisted in the procedure and 1 had been the primary performer. Self-reported comfort with the procedure (on a 1-10 Likert scale) averaged a 2.5 for residents prior to simulation training. Scores universally increased for participants. There was an average comfort level of 5.1 upon completion of training.
Airway trainer. Is there a built-in board? If not you will need a board. 1-2x2-3 foot plastic cutting board preferred but wood will suffice, just get a decent grade (we’re all on a budget, but please: no balsa wood.) You will have to screw the trainer to the board so extra screws will be needed.
Power or hand drill with drill bits.
8 wire coat hangers.
8 Yankauer suction catheters (rinse if previously used.)
XL regular or Size 9 sterile glove (1 glove per procedure.)
Balloon (large and thick grade preferred - we took one from an old anesthesia machine.)
Shin Guard (rinse if previously used.)
Liquid latex or FrankenGoo (see chapter for more details) for skin (1 skin per procedure.)
Red food coloring and water.
Adjustable wrench or pliers.
Multiple chucks (at least 1 per skin and 1 for under the device.)
60 cc lurelock syringe.
Angiocath (18 gauge or larger.)
Pediatric IV catheter (1 per procedure.)
Rubber bands or zip-ties (1-2 per procedure.)
Phillips Head Screwdriver.
Screw-back hooks (4.)
An ET tube.
An Ambu Bag.
Furniture Pads or Moving Blankets.
STEP BY STEP INSTRUCTION GUIDE: See the attached Slideshow in PDF format
· Having multiple “Skins” and “pericardiums” on hand for sessions allows rapid reuse. Resetting the equipment takes 5-10 minutes, provided all materials are on hand.
· Having a proper base is valuable. A properly sized plastic bin works well. In a pinch cardboard can be modified to make a stand.
· Injecting blood into the pericardium takes a little practice. Use IV line with red water, run it through into the glove overlying the heart. Zip tie in the IV catheter and inject “blood,” withdraw air and repeat - 60 to 180 mLs should be injected. Then remove the catheter and tighten the zip tie to prevent leakage. Be prepared for a mess upon incision.
· Have an instructor dedicated to bagging throughout the procedure. Initially the fluid in the pericardium will reduce pulsations. Upon incision of the pericardium the heart should begin heart-balloon will begin inflating, creating a little gush of fluid and given the performer a good “heart” to deliver and inspect!
· Works best if there is an airway task trainer to modify (preferably an older model with “lungs” and an attached base.) Modification DOES NOT inhibit the model’s use for standard airway management.
· Requires an actual Thoracotomy set be utilized: That means autoclaving post-use, which entails a cost. Be sure to work out the details with your ED, surgery or hospital leadership prior to use.