Medical trainers and simulators customised to meet specific skill gaps in medical colleges seems like an ask resonating strongly in the minds of the faculty, administrators and students. Responding to this Accreate Labs, has conceptualised and developed skill specific customisable skill trainers and simulators.
The uniqueness of the trainers and simulators is richer functionality customised to specific skill gaps, superior haptic & tactile experience and cost effectiveness. Our offerings are completely tailor-made for the new syllabus and revised MCI guidelines applicable for skill labs to be setup by medical colleges for the initial two years of their course.
Accreate Labs works with universities and colleges to setup complete Skill Labs or provide skill specific mannequins or trainers.
An unique enhancement in our simulators is the ability to acquire data from sensors in trainers such as CPR or Basic Life Support, to measure chest compression rate, depth of compression, Chest Compression Fractions(CCF) and store this data is a database. From this database, our software would present performance data by student or batch thereby analysing skill gaps.
Setting up medical skill labs and equipping them with Standard Operating Procedures/Protocols so that faculty could train students effectively requires Systems know how, experts trained on the simulators and access to technical support for ease of maintenance.
Product Design highlights
Accreate Labs would provide the skills lab related equipment, while the space, lighting, consumables, medical items such as Surgical tools, tables, beds, Oxygen, Scrub suits, Utilities, Air-conditioning and supporting infrastructure would come from the hosting college.
Accreate Labs proposes a comprehensive Basic Skills Lab consisting of these skill stations.
This project uses best in class technology from Materialise for 3D modelling and image processing, 3D Printing technology from Stratasys. The functionality and facilities associated with each station are provided below. The skill stations have been classified into THREE categories namely:-
Revised MCI guidelines issued in August 2019
Original guidelines covering the entire scope
Advanced skill stations as required for Post Graduate studies
Skill stations as per the revised MCI guidelines
Injectables: Thisskill station supports variants to suit different clinical requirements.
The variants are
Venipuncture, IV injection, Blood transfusion - An anatomically accurate hand model would be designed using either Basilic or Cephalic vein. This skill station would allow students to puncture, inject fluids and do a blood transfusion. An electronic control system will manage the fluid flow and drainage system. The fluid management system will have an easy to replace piping system after it is punctured.
Intramuscular injection - The hand model would mimic the typical hardness, penetration depth for intramuscular injectables. The injectable would be drained off after every usage by the students
Subcutaneous injection - typical inserted at 450 to 900 angles with a 5/8" needle and 3/8" needle respectively. The 900 injection angle is supported as adequate mass has been designed. The injectable drainage would allow students to actually perfuse the tissue with the medicine
Intradermal injection – this is a shallow injection into the dermis, which is located between the epidermis and the hypodermis.
Urinary catheter: This station allows a student to catheterize a male or female subject. The model will allow a student to slip in a catheter while advancing it into the urinary tract. On entering the urinary bladder, a sensor will detect the entry and notify through an alert. The student would then empty the bladder to complete the procedure. The system would automatically fill up the bladder with urine like fluid for the next student to do the procedure. This can be practiced on a male or female model, which are swappable on the same base.
Ryle’s tube/GI Tract: The station is a model of the upper body until the abdomen of the nasogastric anatomy with surrounding tissue material in order to ensure the precise insertion of the tube without hurting the soft tissue, with a part visual check for preventing coiling near epiglottis. Hollow pathway for passage of the tube and collection of fluid from the stomach with drainage facilities. It consists of feedback set with an audio indicator to ensure the correct length of the tube.
Basic Life support: The skill station supports four BASIC procedures and has scope for adding a few more procedures subject to technical feasibility. The procedures supported include:-
Chest compression – Chest compressions to revive a patient can be performed on this. Data would be acquired for the key parameters of the number of compressions, depth of compression and the same would be converted into form/datasheet for every session. A report would be available for the entire batch.
Airway management – The student would be presented with a simulated blockage from a foreign object. The supported procedure would be to position the head in the correct procedure, remove the foreign object and clear the airway as quickly as possible
Breathing – Simulated breathing for a student to measure the rate and classify as normal or abnormal.
Pulse – The station would support pulse reading and measurement. The student would be able to feel, detect and establish the pulse rate. The pulse generator can simulate normal and abnormal pulse.
A. CPR Normal: This normal CPR model supports chest compression. The procedure should be continued for the period of time as specified in the standard operations procedure. The CPR model has indicators giving a green light indication whenever a compression is procedurally correct.
B. CPR Advanced: The Advanced type will consist of timing devices and linear sensors to measure the compression rate and linear displacement. Data from the sensors is transmitted to central database in Wireless(WL) mode. The data stored in the database is then used to analyse specific student’s performance with the ability to compile data batch and compare performances. The data compiled can analyse the skill gap of every student for a CPR procedure.
A. Basic Suturing:The skill station would contain a leg model with superficial injuries showing rupture of skin membrane. Basic cutting, knotting and suturing skills can be practiced here.
B. Basic Wound care: 3D printed wound with blood flow and damaged skin for wound care and bandaging. Cleaning with antiseptic and application of antibiotics if required can be applied before application of a plaster or bandage.
Per rectum and Per vaginal model:This station is a common station for both vaginal and rectum model, either of these two can be plugged in for use. The student will have to ensure a lithotomy position and initiate a vaginal inspection to asses the cervix and palpate the uterus and assess characteristics.
Similarly, per rectum examination can be simulated by swapping the female genital with the male rectum module. The male model has Piles as a feature for examination
Breast examination : This skill station features a female model designed for breast examination. A student will be able to learn clinical breast examination as a skill by plasticising on this skill station. One breast presents a normal breast and the second breast has multiple small nodes and cysts. These lymph nodes and cysts can be placed in more than one position, presenting variability for different students to examine.
Normal labour and delivery: Features to check the position of the foetus and on a simulated contraction and delivery symptoms it supports and facilitates the birth of a baby. Delivery can be practiced when the position of the baby is normal with respect to the vertex. The simulator supports a delivery system designed for normal delivery with expanding cervical orifice to support the delivery while the leg is upheld in in a stretched position with a fixture provided in the skill station.
Original guidelines covering the entire scope(excluding stations already included in revised guidelines)
Lumbar Puncture: This skill station would provide a mannequin for lumbar puncture. Vascular network modelled partially for artery supplying blood that passes through the spinal cord. Anatomical modelling of the vertebral column (from L2 to L5), intercalated disc, spinal cord, and major nerves. Threshold areas for proper insertion and drug administration would be designed. This would also be enabled with sensors and alarms. Softness and texture of bone, blood vessels, and skin as in a human body. Sensors that measure penetration depth of needle, wrong poke, proper removal of needle and flow of CSF and blood through the spine.
Pleural Aspiration: SkillStation with a lung model (distinct pleural and visceral space) of designed pleural space with accumulated fluid. The procedure performed involves inserting a needle into the pleural space and draining away the fluid into a bottle/container. The simulator would have sensors which trigger alarms if the needle moves out of the threshold area (Lung and liver puncture). This chest model will have simulated lung and rib structure with differing shore value for easy distinction.
Incision and abscess drainage: The skill station presents a hand model with multiple abscess sites. The student can cut, clean the abscess, remove damaged tissue, drain the pus and stop blood flow. Thereafter, medication can be applied, followed by suturing. Simulating pus and affected blood/fluid to escape by draining out through the incision Inserting gauze in the abscess. The model permits five procedures to be performed after which the abscess sites need to be replaced with new modules which are provided as consumables. The station simulates controlled flow of pus and blood at a volume of 7.5 ml and 10 ml respectively. A fluid system registers start and end of every procedure, before releasing additional volume of blood and pus.
Early Management of trauma and life support: This station is designed around the revised CAB sequence. The station supports the following functions:-
Chest compressions – can be simulated on the model as per the standard protocol. The data related to the performance of every session is stored in a database and analysed to provide indications for skill gaps.
Airway management – The scenario here includes foreign debris which is causing obstruction of the airway. The supported procedure involves removing the foreign object and aiding normal breathing through the now cleared airway
Breathing – The scenario supported is mouth to mouth resuscitation; in case the response is not satisfactory then an ventilator assisted device is to be connected for respiration support.
Apply basic splints and slings:This is an upper torso model. The student will be able to feel the swelling, notice the potential problem, apply a splint to keep it in alignment. Thereafter, he will be able to apply an over the shoulder sling.
Basic fracture management and Dislocation:The arm below the elbow would show all indications of a fracture, like swelling on one side, discoloration and will have a simple of the bone. The student will be able to check alignment, improve the alignment and immobilize the hand. A 3D Printed reusable cast designed for the anatomy of the hand accommodating the swelling would be used to immobilize and support the fractured hand.
Compression bandage:The model presented here is a wrist model, with signs of some damage by way of discolouration swelling as the pathology. A student can apply a compression bandage and provide the first line of support.
Visual inspection of the cervix with acetic acid: Station provides with a 3D printed pathological surface of the cervical wall with the touch and feels equivalent to that of the tissue mass. Simulated action of vinegar over the site to give it a realistic outlook. Colour would be adjusted according to the required colour of the pathology as a reference surface, though no colour change actually happens. This model would have a procedure station and a separate True positive and true negative outcome models for reference inspection.
Obstetrics examination: The station consists of the obstetrics model to provide a scope for Inspection of abdominal striations, take measurements of fundal height, check the position of the foetus along the axis with variable positioning. Lie and presentation configurations can be modified for variability or for extensive student by each student.
Episiotomy: Features modelled in a way to make a cut in the opening of the vagina during childbirth to aid delivery classified as difficult. The anatomy and structure allow the suturing of the cut region after delivery to perform a complete procedure. This skill station supports a replaceable vaginal flap after every procedure.
Neonatal resuscitation: Station consists of a baby mannequin which provides ventilation with oxygen mask and chest compression models. Timer advancements for effective compression procedure and feedback for assessing right procedure.
Paediatric IV:This skill station will provide a hand model on which peripheral IV procedures can be practiced. For this procedure, a Cannula/catheter is inserted into a small peripheral vein for therapeutic purposes such as administration of medications, fluids and/or blood products.
Intraosseous line: This station gives a model of the leg with tibial bone structure and difference in the shore value between the bone and the tissues around. Provision to collect the injected material. This skill station would provide basic skills in installing a central line for paediatric subjects. The typical key steps which would form the basis for skill evaluation include:
This station is a life-size human head model with details specific to the anterior nasal region and ear. One half is transparent to visualize the internal procedure.
Anterior nasal packing: Hollow anatomy of the anterior nasal region with a bleeding nose. In this procedure a gauze of 1 metre long dipped in antiseptic cream and a liquid would be inserted into the anterior nasal cavity. After usage of the packing material due to the pressure applied the bleeding would stop. The fluid system is based on a design which simulates bleeding in the nose. A controlled fluid(blood like) delivery system would provide real life like scenario.
Otoscopy: 3D ear model with a detail of the outer, middle and inner ear anatomy. One side with a defect for the students to identify abnormalities and the other with normal anatomy. The tympanic membrane would have a damage and tear, which is the subject of examination in one of the ears. The other ear will have a normal membrane for visual examination.
Ocular bandaging: This skill station consists of a face model with soft facial features with a slightly detailed structure of the eyes with orbit and eyeball. Discoloration of the skin around the eye would be an indication to show which needs attention.
Application of eye medication: An extensive maxilla facial design based model, with drainage in the Orbital floor area with to enable collection and drainage of the medication administered is part of the design and a feature of the simulator.
Eye irrigation: This model supports removal of a foreign body stuck on the eye surface using eye irrigation procedure. Water used for continuous cleaning of the surface means that the water drainage does not damage the model, while allowing for water drainage from behind the orbital floor.
Slit skin smear for leprosy: Station provides a 3D printed structure with leprosy like a pathology of discoloured skin with scales and a slight elevation in the area with respect to the required area to be tested. The textures are mimicked to make required slits on the surface.
Skin biopsy: This station provides you with skin anatomy with layer distinction and specific realistic tissue bio-printed in order to allow puncturing of the skin and collecting the tissue mass for biochemical analysis. This provides a realistic idea of the skin and cell composition.
BC1. Gram’s Stained Smear is a four step biochemistry procedure. The procedure involves using a heated applying sample from the affected area on a glass slide. Addition of iodine leads to binding of colour at a cellular level. Testing with ethanol followed by counter staining with safrannan. This complete kit is provided for Grams staining for 100 students.
BC2. Tissue Smear – the case of Pap smear has been considered. Microscopic study with a 10X enlargement is provided for FIVE concurrent studies.
BC3. Cautery chemical and electrical – This kit includes both chemical and electrical cautery. The sets provide the device and the instrument for undertaking cautery of the skin or other tissues. This kit includes only the devices and related accessories. The biological sample is expected to be sourced from the hospital.
Advanced skill stations as required for Post Graduate studies
Advanced Simulators for post-graduate studies:
Accreate Labs has the design tools for modelling various pathologies, add clinical features required for skills training as required by instructors training postgraduate study students in various specialties. Clinical requirements. Some of the key principles are: -
Clinical requirements, the simulator behaviour during the planned procedure needs to document and signed off the decision-maker for each model
SCAN based anatomy modelling and isolation of the required pathology - The BGS GIMS will need to assist in acquiring CT or MRI scans if the required pathology is not generally available and within access of Accreate Labs
The design will take maximum care on minimizing consumables, but as surgical procedures lead to puncture, incisions and excising damaged tissues – there will be considerable costs in replacing such used/damaged tissue and systems
Draft Proposal is comprehended in Annexure B. Estimated cost may vary to some extent, once the clinical requirements are fully finalized.
Intestinal anastomosis: This model supports single-layer anastomosis with a single stitch suture for an intestinal resection already done. The anatomy would be based on Scans – to be provided by BGS GIMS. From these scans, the section of the intestine would be modelled, with the material assignment of the double toned intestinal membrane where the suturing anastomosis needs to be performed. The presentation is of a sectioned intestine, where the ends have been plugged.
Two cut ends of the bowel are brought in close apposition. Stay sutures are placed between the serosa of the proximal and distal ends of the bowel at the right distance from the cut end. Sutures are tied sequentially, with care taken not to apply excessive tension to minimize the risk of cut-through of the seromuscular layer forming the posterior outer layer.
Thereafter, a Connell stitch is made in both ends. The Connell stitch is achieved by passing the suture from the outside in, then inside out, on one end. The same step is repeated on the other end in the form of a continuous U-shape. The suture is tied so that the knot is outside. The sutures are tied sequentially so that the knot lies inside the lumen.The presentation will be restricted to the sectioned area of the intestine only. The other areas would be modelled using harder material and restricted from the diaphragm to the area closer to the pelvic region
A tracheal face for insertion through the mouth would be modelled based on CT scans. The tracheal model would be done using a coloured soft material, mimicking the internal texture and softness. The model can be used for endoscopy procedures to clear airways, examine.
For the laryngoscopy, the model supports usage of gel, model mounted on a fixture for rigidity while doing the procedure. The scope, which is a thin, flexible viewing tube,
is passed through the nose and guided to the vocal folds, or larynx. A fibre optic cable permits the physician to directly inspect the nose, throat, and larynx for abnormalities performed under local anaesthesia. The simulator would be to scale, support invasive devices for examination or for excising the pathology through a laparoscopic or robotic procedure. The outer surface of the trachea would have structural strength (shore A value 35 to 40) while the inner surface would have a shore A value of around 22.
Bronchoscopy – The model supports the procedure of anaesthetic spray. The bronchoscope is then inserted through the nose or throat and descends until it reaches the airway in the lungs. This simulator is designed with pathology mimicking squamous cell carcinoma in appearance which dominates the airway limiting the passage of any device. Bronchoscopes with brushes or needles may be used to represent sample collection from the lungs.
ENT - An integrated model supporting ear, nose and throat procedures is offered with this simulator. Examinations such as paranasal sinus and ethmoid sinuses can be inspected. In the same model, the ear can be examined using an Otoscope.
This model would have the right ear to be a normal ear with no pathology, while the left ear is designed with a torn/damaged membrane. The ear model would be built into two split heads, making it possible to swap a submodule to alter pathology of the ear as an optional add on at a later stage.
Head and Neck – This cerebral aneurysm simulator model simulates aneurysm of the cerebral arteries, with access to the artery where the aneurysm has developed. The laparoscopic procedure can be altered to conduct clipping or gluing procedure. When integrated with an optional vascular module, a catheter procedure to install a web device in the artery would also be supported. The artery would exhibit the variation in artery wall thickness, more so where the aneurysm has developed. The wall thickness of the artery is varied based on grey scales derived from the CT/MRI scans.
Additional, pathologies are maybe taken up for design and 3D Printing as additional optional addon procedures, to be introduced on the same base.
Functional endoscopic sinus surgery – This model supports two simulations performed for inflammatory and infectious sinus disease. The balloon sinuplasty procedure could be performed by using the inflated balloon in the maxillary and sphenoid natural Ostia. Limited lesions can be endoscopically removed based on definitive controls and threshold margins. The lesions are designed in an appropriate area based on the design or from scans if made available.
Cholecystectomy – The gall bladder is modelled along with surrounding anatomy including the liver. For this laparoscopic procedure, small incisions in the abdomen area are made to allow the insertion of operating ports, through which surgical instruments are placed into the abdominal cavity. The laparoscope, with a video camera and light source at the end, illuminates the abdominal cavity and sends a magnified image from inside the abdomen to a video screen, giving a clear view of the organs and tissues. The cystic duct and cystic artery are identified and dissected, then ligated with clips and cut in order to remove the gallbladder. The gallbladder is then removed through one of the ports.
A common base model with pathologies pertaining to the pelvic area has been designed and modelled. An inguinal hernia is a weakness in the wall of the abdominal cavity that is large enough to allow the escape of soft body tissue or internal organ, especially a part of the intestine. This appears as an externally noticeable lump in the abdomen area. This procedure is about placing a synthetic mesh to strengthen the abdominal wall through a laparoscopic procedure called transabdominal preperitoneal (TAPP) repair and totally extraperitoneal (TEP) repair. In TAPP the surgeon goes into the peritoneal cavity and places a mesh through a peritoneal incision over possible hernia sites.
This design will include three to four hernia sites of mesh size 2 x 2 inches designed in the pelvic region. After these four procedures have been done, the pelvic area will which is replaceable will need to be swapped by a new module.
The laparoscopic appendectomy procedure includes making two or three small incisions in the abdomen for insertion of a port. Carbon dioxide is pumped through this port to inflate the stomach and enhance the viewability of the organs in the abdomen. A laparoscope is inserted with a lighted camera through one of the incisions. The appendix lie and position are identified, and the procedure is performed to remove the appendix, followed by procedures such as instilling sterile fluids. The carbon dioxide can escape and then the incisions are closed with sutures or bandages.
The hemicolectomy procedure is a designed pathology on the same model. The procedure is to be done on the right side due to a diseased section and attaching the small intestine to the remaining portion of the colon. The detached part of the colon is then brought out through a small incision in the abdomen.
Obstetrics and Gynaecology procedures Tubectomy; Hysterectomy and Ovarian cysts
Tubectomy procedure involves cutting the abdomen followed by insertion of the fallopian tubes, after which the tubes are cauterized using small clips. Similarly, hysterectomy is performed by a laparoscopic or robotic surgical approach — which uses long, thin instruments passed through small abdominal incisions. passes a urinary catheter through your urethra to empty your bladder. The catheter remains in place during the surgery and for a short time afterward. Your abdomen and vagina are cleaned with a sterile solution before surgery. An incision is made in the lower abdomen, using one of two approaches. A vertical incision, which starts in the middle of your abdomen and extends from just below your navel to just above your pubic bone. The abdomen is inflated with gas to enhance viewability. In this procedure, partial removal of the uterus is supported.
Ovarian cysts are modelled into the OBG simulator. A small incision will be made just below the navel to enable a laparoscope to be inserted. The cavity is inflated to enhance viewability. Once the cyst has been located, Surgical instruments will be inserted through two more incisions made to remove the cyst. Tissue may be taken up for biochemical examination. After the cyst is removed, the instruments are removed, and the incision area closed with stitches.