Novel Otolaryngology Simulation for the Management of Emergent Oropharyngeal Hemorrhage

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Archives of Otorhinolaryngology-Head & Neck Surgery. 2018;2(1):3 DOI: 10.24983/scitemed.aohns.2018.00068 1 of 6
Archives of Otorhinolaryngology-Head & Neck Surgery
IDEA AND INNOVATION
Novel Otolaryngology Simulation for the
Management of Emergent Oropharyngeal
Hemorrhage
Joshua Feintuch, BA1; Jeremy Feintuch, BA1; Emily Kaplan MPA, EMTP2;
Merona Hollingsworth, BS3; Christina Yang, MD4; Marc J. Gibber, MD4*
1New York University School of Medicine, New York, New York, USA
2Monteore-Einstein Center for Innovation in Simulation, Bronx, New York, USA
3Mary and Michael Jaharis Simulation Center, College of Physicians and Surgeons, Columbia University, New York, New York, USA
4Department of Otorhinolaryngology - Head & Neck Surgery, Albert Einstein College of Medicine, Bronx, New York, USA
Introduction
Oropharyngeal hemorrhage is a rare but life-threatening complication of
oropharyngeal tumors [1]. They can occur quickly, and with or without
stimulation of the tumor. Bleeding episodes such as these can quickly
lead to airway obstruction, aspiration and can result in asphyxiation [1].
Oropharyngeal bleeds are associated with these dangerous outcomes
and also have a high mortality rate because safe management of these
cases can be rather complex [1]. Nascent otolaryngology residents who
have recently graduated medical school are “expected to triage and man-
age airway [and] bleeding with little prior experience [2].” Further, due
to the emergent nature of these bleeds, the approach to rapid patient
stabilization likely involves providers from dierent specialties working
side by side to manage this life-threatening condition. This can make
for a stressful setting in which conicting medical opinions pertaining
to management may arise. With all of this in mind, we created a sim-
ulation scenario in which our junior residents learned to properly and
safely manage a patient with an oropharyngeal bleed while also learning
to properly interact and communicate with fellow healthcare providers in
a tense, emergent situation. The goals of the study were to apply airway
management and leadership skills in the context of a clinical team as well
as to identify and adapt to clinical changes in real time.
Methods
This scenario was designed for the training of rst year residents (in-
terns), however it can be used for residents at any level of training. In
order to benet most from this scenario, the participating intern/resident
should have a background of the basic anatomy of the oropharynx pri-
Abstract
Introduction: Oropharyngeal hemorrhage is a rare but life-threatening complication of oropharyngeal tumors. Bleeding episodes such as these
can quickly lead to airway obstruction, aspiration and can result in asphyxiation. Nascent otolaryngology residents who have recently graduated
medical school are expected to manage this situation with scant amount of prior experience. Simulation oers the unique opportunity to learn
procedural skills to a resident/trainee in a safe, controlled environment designed to have specic, obtainable educational goals without any risk
to the patient.
Methods: In this study, we created a simulation scenario in which junior otolaryngology residents learned to properly and safely manage a patient
with an oropharyngeal bleed while also learning to properly interact and communicate with fellow healthcare providers in a tense, emergent
situation.
Results: A 5-point Likert scale survey was utilized to assess realism and benet from the simulation. An average score of 4.7 points was obtained
for this simulation.
Conclusion: We developed an eective and realistic oropharyngeal bleeding mass scenario that was well received by participants in preparing
them for real life scenarios.
Table 1. Materials/Equipment Required for Mannequin Setup and
Scenario Management
Mannequin Setup Scenario Management
Laerdal ALS Mannequin® Mouth guards
Simulated patient monitor Mac blade, laryngoscope
handle, extra batteries
Instructor computer Fiberoptic scope
Link box Camera and tower
External compressor for chest rise
and fall
Portable light source
3L bag of pre-Mixed blood per learner Trachestomy tray
Administrator extension set 10 gtt/ml Tracheostomy tubes
30” IV extension tubing Scalpels
Absorbent disposable u underpads
(chucks)
Headlight
6.5 ETT tube
HY-tape®
60cc syringe
3-way stopcock
Magill forceps
or to running through the simulation. Table 1 shows a list of equipment
needed for both the mannequin setup and for the oropharyngeal bleed
simulation.

Archives of Otorhinolaryngology-Head & Neck Surgery. 2018;2(1):3 DOI: 10.24983/scitemed.aohns.2018.00068
IDEA AND INNOVATION
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Mannequin Setup
Our oropharyngeal tumor simulator was created to train our Otolaryn-
gology junior residents on management of oropharyngeal bleeding. Re-
alism is enhanced through the specic, novel, selection of the manikin
for modication. We used the electronic simulator Laerdal ALS Manne-
quin. The mannequin breathes, has lung sounds, heart sounds, talks and
has the capacity to display vital signs. To set up for this simulation, the
abdominal bag was removed and padded with absorbent disposable
u underpads (chucks) to absorb any residual uids that ran along the
pharynx into the mannequin (Figure 1). The chest skin was also removed,
and the internal mechanics were covered with a towel and chucks (ab-
sorbable side up) to capture any residual uids. We then disconnected
the esophagus from the mannequin’s abdomen (Figure 2) and placed the
bottom of the esophagus into a plastic bag to prevent uid from damag-
ing the innards of the mannequin. IV tubing, attached to a pre-mixed 3L
bag of articial blood, and extension tubing, was then threaded through
the esophagus into the oropharynx (Figure 3). The cu of a 6.5 ET tube
was inated, and the ET tube tip was cut o. A portion of the proximal
end of the ETT tube was also removed with a scissor. The inated balloon
was then covered with HY-Tape®to make the mass look more realis-
tic (Figure 4). The IV tubing from the oropharynx (that was threaded up
the esophagus) was then pulled up using Magill forceps and threaded
through the inverted ET tube (Figure 5), letting the opening of IV tubing
to sit right at the inated balloon of the ET tube. The inverted tube, with
the IV tubing still inside was then placed into the oropharynx using Magill
forceps, allowing the balloon to sit in the oropharynx (Figure 6), and the
superior part of the tube to go down the pharynx.
Bleeding
In order to facilitate bleeding (Figure 7), we used two dierent, but equal-
ly eective techniques.
Figure 1. Preparation of the mannequin for simulation step 1.
Figure 2. Preparation of the mannequin for simulation step 2.
Version 1
An Alaris 8015 pump tubing is connected to the extension tubing with a
3L bag of pre-mixed articial blood. To express minimal continual blood-
ow, the pump was set to express 500 ml in 10 minutes. Greater blood
ow is achieved by increasing the rate of the pump. Up to 1 liter of blood
should be aimed to be expressed per learner. The pump is positioned
behind the mannequin. This version requires manual changes of pump
setting to increase blood ow.
Figure 3. Intravenous tube placement.

Archives of Otorhinolaryngology-Head & Neck Surgery. 2018;2(1):3 DOI: 10.24983/scitemed.aohns.2018.00068 3 of 6
IDEA AND INNOVATION
Figure 4. Construction of the oropharyngeal mass.
Figure 5. Preparation of the oropharyngeal mass for bleeding.
Figure 7. Bleeding from the oropharyngeal mass.
Figure 6. Placement of the oropharyngeal mass.

Archives of Otorhinolaryngology-Head & Neck Surgery. 2018;2(1):3 DOI: 10.24983/scitemed.aohns.2018.00068
IDEA AND INNOVATION
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Version 2
To express greater blood volume and force associated with emergent
bleeding cases, a manual hand pump is utilized. A three-way stop-cock
is attached to the extension IV tubing. A 60 CC syringe is connected to
one port. The remaining port is attached to a pre-mixed 3L bag of blood
via an Administrator Extension set and IV tubing (Figure 8). The Simula-
tion Technician is positioned behind the bed, out of the learner’s line of
sight. Using the 60 CC syringe and three way stop cock, blood is drawn up
into the syringe from the 3-liter reservoir bag. After the syringe is com-
pletely full, the stopcock is then switched to allow blood to be expressed
from the syringe into the patient’s oropharynx. Blood is then expressed
from the syringe, at the desired rate, to cause oropharyngeal bleeding.
The process is repeated continuously throughout the scenario. After the
mannequin setup is complete, the learner can then manage the oropha-
ryngeal bleeding as directed by the instructor/scenario.
Scenario
The intern/learner is paged to the intensive care unit (ICU) for a 69-year-old
male with history of oropharyngeal cancer complaining of oral bleeding.
The ICU attending is at the bedside. Table 2 shows the vital sign setting.
The intern/learner assesses the patient who complains of diculty
breathing as he/she is coughing up blood. The ICU attending urges the
intern/learner to help the patient. The intern/learner should rst attempt
to suction the airway and use a ber optic scope to establish the source of
the bleed. If scoped correctly, the source of the bleed should be identied
as the bleeding mass in the posterior oropharynx. As more time passes,
the patient’s oxygen saturation continues to drop, and he becomes in-
creasingly tachycardic. Seeing the dropping oxygen saturation, the ICU
attending questions the intern/learner if an orotracheal intubation could
be a good treatment option for this patient. The intern/learner should
explain to the ICU attending the risks associated with sedating a patient
with an oropharyngeal mass. As the patient’s oxygen saturation contin-
ues to drop, the intern/learner should assess the feasibility and safety
for an attempted nasotracheal intubation. If the intern/learner deems a
Table 2. Vital Signs Setup
General Patient is sitting in bed at 45 degrees, with blood
dripping from mouth. Patient is in mild distress
Head, Eyes, Ears,
Nose, Throat
Active bleeding from oropharynx
Pulmonary Clear to auscultation bilaterally
Cardiovascular Normal S1/S2. No murmurs
Extremities No cyanosis or clubbing noted
Heart Rate 118 Beats Per Minute
Blood Pressure 165/100 mmHg
Respiratory Rate 44 respirations per minute
Temperature 39.3 °C
Oxygen Saturation Starts at 93% O2 , rapidly dropping over 2 minutes
Figure 8. Bleeding equipment setup: version 2.
nasotracheal intubation safe, he/she should attempt to perform one. If
successfully placed, the patient’s oxygen saturation should increase, and
vitals should stabilize.
If the intern/learner is not able to perform a nasotracheal intubation,
or if the patient destabilizes at any point in the scenario, the intern/leaner
should perform a cricothyroidotomy. If the intern/learner is unsuccessful
in managing the scenario, the patient will continue to decompensate. If
at any point, the intern/learner sedates the patient, the patient should
decompensate. At the conclusion of the scenario, participants were then
asked to ll out a 5-point Likert score to assess realism and perceived
benet from the simulation.
To ensure benet from this scenario, a pre-training and post-training
assessment can be used as well.
Results
Over the last 2 years, 8 interns completed this simulation. A 5-point Likert
scale survey was utilized to assess resident perceived realism and benet
from this simulation. An average score of 4.7 points was obtained for this
simulation.
Discussion
The expeditious transition from a senior medical student to a junior res-
ident can be a daunting, and overwhelming experience. Coming from a
sheltered and protected environment to one that is fraught with patient
encounters, situation- based decisions and technical skills can cause
much stress for a new intern [3]. In addition to the stress put on the resi-
dent, evidence has emerged that there is more incidence of physician er-
ror causing patient harm in the beginning of residency [4]. This situation
can be made even worse when entering a surgical and a procedure-lad-
en subspecialty such as otolaryngology, where the technical skills are so
specialized that some of them are not taught in medical school [5]. To
mitigate this issue, attempts have been made, through simulation and
boot camp training, to equip these novice residents with the skills needed
to succeed in their new role.
Simulation oers the opportunity to learn procedural and inter-
viewing skills to a resident/trainee in a safe, controlled environment that
is designed to have specic educational opportunities without serious
risk to the patient [3,6-11]. Just as it applies to the military, boot camp
style learning emphasizes teaching novices the basic skills necessary to
properly function in a real-world scenario. In otolaryngology, the ulti-
mate goal is to transition “undierentiated senior medical students to
dedicated otolaryngology residents [3].” With the advent of duty hour
restrictions and resource limitations, training a resident in a shorter pe-
riod of time and in a more modiable environment is being more heavily
favored than traditional teaching of only experiencing a medical emer-
gency in a real-life situation [2,3,7,12,13]. By putting these skills into a
boot camp style course, residents are given the opportunity to partici-
pate in intense-style training while still being taught in a safe, simulated
environment.

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IDEA AND INNOVATION
Time and time again, simulation-based training has shown its eec-
tiveness in the medical eld, and specically in the eld of otolaryngol-
ogy [14-16]. A study in 2015 by Chin et al. found that “an otolaryngology
boot camp gives residents the chance to learn and practice emergency
skills before encountering the emergencies in everyday practice. Their
condence in multiple skill sets was signicantly improved after the
boot camp [7].” Other studies have also shown similar results in med-
icine and the eld of otolaryngology [17,18]. All of these studies have
consistently shown that through simulation and boot camp training,
residents began developing the appropriate knowledge, skill set and
self-condence [2,7] needed to succeed during residency and, more im-
portantly, that these skills transferred to real clinical situations/proce-
dures with real patients.
Due to the proven success of simulation-based learning, we have
created a scenario in which our residents can practice how to properly
manage an oropharyngeal bleed. Vascular erosion, causing a hemorrhag-
ic episode, can occur in all patients with advanced-stage tumors, recur-
rent tumors, infection and pharyngocutaneous stulas [1,19]. Addition-
ally, when chemotherapy and radiation are used in conjunction, without
surgical intervention, secondary adverse eects can arise, including “ero-
sion of skin and mucosa…. premature atherosclerosis with stenosis and
weakening of arterial walls due to adventitial brosis, fragmentation of
elastic laments, and destruction of vasa vasorum. Following chemora-
diation, therapy, spontaneous hemorrhage can result as a consequence
of weakened arterial walls [1].” This complication, especially in tumors
arising from the oropharynx can be particularly devastating.
These emergent situations must be recognized and cared for quickly
to prevent blood loss, aspiration and/or asphyxiation. However, caution
must be used when managing a patient like this, as a wrong step can put
the patient at serious risk. A patient with a bleeding oropharyngeal mass
who loses consciousness or is anesthetized, may lose the ability to protect
his/her own airway and the bleeding may continue to ow distally, caus-
ing asphyxiation [20]. Further, endotracheal intubation can irritate and
stimulate the bleeding lesion, thus exacerbating the bleeding and making
airway management even more dicult [20]. With these complications
in mind, nasotracheal intubation is seen as the safest and most eective
way of securing an airway in these patients. Our simulation allows our
residents to systematically work through the critical decision-making pro-
cess in a safe environment, in order to acquire the knowledge as well as
the manual dexterity to properly manage these patients.
As with other medical emergencies, managing an oropharyngeal
bleed can be stressful. Working with healthcare providers of a dierent
specialty can sometimes add to the stress, as there may be diering
opinions related to patient management. Junior residents can be more
susceptible to these stressors, as they may lack the experience and con-
dence needed to make a decision in the face of conict. While the leader
of the medical team is ultimately in charge of the decision-making during
a medical emergency, there may be times when a trainee from one spe-
cialty may not agree with a treatment decision made by an attending of
a dierent specialty. In this situation, we want to foster professionalism,
collaboration, leadership and communication skills between both medi-
cal providers from dierent training backgrounds. In a study performed
by Belyansky et al., it was found that “74-78% of trainees and attend-
ings recalled an incident where the trainee spoke up and prevented an
adverse event. While all attendings in this study reported that they en-
courage residents to question their intraoperative decision making, only
55% of residents agreed [21].” By being encouraged to voice concerns
during an emergency, trainees can act as partners in the reduction of
possible medical errors. Further, in a literature review by Ignacio et al.,
it was found that “excessive stress and/or anxiety in the clinical setting
have been shown to aect performance and could compromise patient
outcomes [22].” In and out of the eld of medicine, studies have “sug-
gested that stress training showed an improving trend in performance….
[and was a] valuable strategy for enhancing… thought process and im-
proving… performance in communication skills [22].” By presenting the
junior residents with a stressful situation in which an attending suggests
a management option that might not be appropriate for the patient, the
residents learn how to properly and respectfully suggest an alternate
treatment approach, while also learning the technical skills needed to
properly care for such a patient. This provides the resident with the tools
necessary to deal with such a situation, when it is appropriate, during res-
idency and beyond. Using this simulation, the learner is encouraged to
move from comprehension and application to synthesis and evaluation.
The novelty of this scenario comes from both the setup of the man-
nequin, and the use of the mannequin with the designed scenario. By
using this simulation, the intern/learner learns how to both utilize the
treatment algorithm for a bleeding oropharyngeal mass and work with
members of medical teams composed of members from dierent spe-
cialties and experience levels. This simulation facilitates the development
of technical, knowledge-based and interpersonal skills all within a suc-
cinct and collaborative educational environment.
Conclusion
Using a safe and controlled simulation environment, we were able to
develop an eective and realistic oropharyngeal bleeding mass scenario
that was well received by participants.
Article Information
*Correspondence: Marc J. Gibber, MD
Department of Otorhinolaryngology - Head & Neck Surgery, Albert
Einstein College of Medicine, Bronx, New York, USA.
Email: Mgibber@monteore.org
Received: May 09 ,2018; Accepted: Jun. 20,2018; Published: Jul. 13, 2018
DOI: 10.24983/scitemed.aohns.2018.00068
Copyright © 2018 The Author (s). This is an open-access article distribut-
ed under the terms of the Creative Commons Attribution 4.0 Internation-
al License (CC-BY).
Funding: None
Conict of Interest: None
Keywords
Hemorrhage; oropharyngeal; otolaryngology; simulation; training.
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