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From a Garage Across the Ocean to our Operating Rooms: How Collaboration and 3D Printing Is Transforming and Expanding Emergency Airway Training at the University of Minnesotaby Anna Budde, MD and W. Kirke Rogers, MD Cricothyrotomy has the potential to be life-saving in the event of a failed intubation, but it is a procedure that few anesthesia providers have the opportunity to practice. And in a specialty like anesthesiology, procedural confidence in an emergency can mean the difference between hesitation and a life saved. Cadaver or veterinary models to practice cricothyrotomy are sometimes available at academic centers, but these options and commercially-available high-fidelity simulation models are often prohibitively expensive or difficult to come by. Here at the University of Minnesota, Dr. Megan Kakela, a CRNA and DNP leader of our SRNA training program, worked with Tori Kotz, an SRNA, on a cricothyrotomy “Check off” project to ensure that all anesthesia providers at our institution - providers with both physician and nursing backgrounds - could have adequate hands-on experience to report feeling comfortable with the procedure. In order to provide adequate opportunities for over a hundred trainee and staff providers to get intensive, high-volume practice on high-fidelity simulation equipment, Dr. Kakela and Ms. Kotz utilized 3D printing to cheaply create a large number of airway manikins. 3D Printing as a cost-effective way to scale training Informal polling suggests that every anesthesia provider at the University of Minnesota is at least vaguely familiar with the potential of 3D printing (and that’s probably true for most people these days) but no one had significant personal experience in creating materials. So it was eye-opening for all of us to learn more about what was necessary to obtain 3D-printed training equipment for Megan and Tori’s project. We are sharing our experience as it may be inspirational to other programs. The models Dr. Kakela selected (https://www.thingiverse.com/thing:6047559) were originated by Dr. Archie Port, an anesthetist at a moderate-sized regional acute-care community hospital in Hawke’s Bay, New Zealand. Dr. Port has been creating 3D printed training material for many years now, and freely shares his creations on open-access websites with hospitals across New Zealand and the world. He reports that he began designing and printing medical trainers in his garage using open-source tools like TinkerCAD and a personal Prusa XL printer. “I have no formal training in design or tech,” he says. “I just make them for fun.” Dr. Port says he gets no reimbursement for his work, but the cost per trainer is minimal (he pays $40 NZD for 1kg of printing filament, and each model weighs only a few hundred grams), although he does note that developing and testing models can be a significant time investment. The current iteration of his cricothyrotomy trainers that the University of Minnesota printed and uses include an articulated “head/face” to encourage the motion of lifting a chin to expose the cricothyroid membrane, the ability to attach a test lung to the “trachea,” and a means to securely attach simulated “skin” material. One of the academic medical labs at the University of Minnesota had a pre-existing collaboration with Stratasys (https://www.stratasys.com/en/, a Minnesota-based global provider of industrial 3D printers and printing materials), so we were able to harness that relationship to print multiple models at no cost. However, even if we would have had to pay for materials and equipment, the estimated cost to produce our models would have been about $50-$100 per model, significantly below the cost of commercially-produced training manikins, which can be many hundreds of dollars each. Interested in creating your own training tools? Access to some sort of 3D printer is likely available to anyone interested in obtaining training equipment, regardless of practice location. For example, many moderately-sized community hospital systems have access to so-called “innovation hubs” intended to generate bespoke patient care equipment. Even in smaller communities, it is now common for places such as public libraries or community colleges to have “Maker Spaces” with 3D printers available to the general public for free or at a nominal cost. Further, a number of companies, like Treatstock (www.treatstock.com) and Xometry (www.xometry.com) offer low-volume 3D-printing and manufacturing services directly, and websites like www.makexyz.com let you upload a design and connect with local printers. You can find free, medically oriented models to print through repositories like the NIH 3D Print Exchange (https://3d.nih.gov/) and Thingiverse (www.thingiverse.com) - simply search for terms like “airway” or “larynx” and “anatomical models” (besides cricothyroidotomy trainers, things like tracheal models to practice double-lumen intubation are available). Reaching out to the broader maker-medical community may also be productive: many clinicians and designers, like Dr. Port, are happy to share their STL files and may even walk you through adapting them for your own requirements. Indeed, many of Dr. Port’s original designs have been tweaked and edited and re-shared by users on Thingiverse to either make generic improvements or create products more bespoke to a specific institution’s needs. Having access to someone experienced in 3D printing may be necessary to help select what components and material to use (although often the designers of models will include recommendations for material in their plans). Dr. Port used standard PLA material when he created his original models for ease in printing, but based on recommendations from technicians managing our project, our models combined a more durable ABS and more flexible TPU materials to help replicate the tactile experience of a real procedure and provide appropriate functionality for heavy use. Dr. Kakela added sheets of tattoo practice skin ($25 for 30 pieces) and durable packing tape to mimic cartilage, to increase the tactile realism of our models. A thorough review describing the various types of material used in 3D printing and other considerations for building medical models is available from BMJ Simul Technol Enhanc Learn. 2017 Dec 9;4(1):27–40. (doi: 10.1136/bmjstel-2017-000234) if you do not otherwise have access to advice about choosing materials. One of the biggest surprises for those of us not familiar with 3D printing was just how long the process can take. Each individual model took approximately 80 hours to print, and after printing, the parts were washed at 70°C to dissolve QSR support material, then rinsed and dried. Printers often break and require maintenance, or may require cleaning between prints, which can also slow down the printing process - especially when making multiple versions of a product, as we did. Conclusion: The biggest learning point for us in the Department of Anesthesiology at the University of Minnesota was that 3D printing of medical training equipment isn’t just about technology—it’s about accessibility, collaboration, and creativity. Options for easily acquiring low-cost 3D-printed training materials proved remarkably abundant once we learned how to access them. Based on our experience, we believe that whether you’re at a major academic center or a rural hospital, with a gumption and initiative, you can readily find a way to bring high-quality procedural manikins to your learners. Article contributors include: W. Kirke Rogers, MD Madeline A. Wethington, MBS Rachel Larson BA, RDCS Megan Kakela, DNP Tori Kotz, BS Anna Budde, MD
With special thanks to Paul Iaizzo, PhD, the Visible Heart® Laboratories at the University of Minnesota, and Stratasys®. Authors
Anna Budde, MD W. Kirke Rogers, MD
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