What does Dexter do?

Dexter trains people to drive flexible bronchoscopes. It provides a proven, self-directed, cost-effective means of developing endoscopic dexterity and allows novices to develop proficient bronchoscopic manipulation skills prior to first patient contact.

Why choose Dexter?

Dexter works. Dexter’s effectiveness was confirmed in a major review and meta-analysis of simulation based bronchoscopy training published in CHEST in 2013. Part task trainers were considered superior to far more expensive virtual reality simulators and Dexter performs its core function better than other part task trainers.

Dexter’s role and effectiveness has been proven in outcome studies published in major peer-reviewed journals. (See publications) Dexter is the unique component of a method of training for proficient manipulation of bronchoscopes, based on mastery learning principles that is highly effective for large groups of novices. (see Teaching)

Integrated self-directed education program

The integrated modular training program allows self-directed, structured practice with clearly identified educational objectives. Dexter’s maps provide the individualised feedback necessary for skill progression.

Cost effectiveness

Dexter is far less expensive than a virtual reality simulator, costing about the same as a good anatomic training head. It includes a self-directed training program. This means that trainees can progress in their own time without needing continuous expert instruction or supervision. Dexter is robust and on-going costs are negligible.

Fun, Popular and Professional. Trainees enjoy Dexter more than other part task trainers and spend significantly more time with it. This facilitates the individual practice requirements for achievement of proficiency. When set up as a skill station with video-bronchoscopy equipment, the training system with model, manual, maps and image chart looks professional and fit-for-purpose.

Dexter does not have anatomy so how can it be useful?

Despite the availability of anatomic models and appropriate knowledge, problems related to the acquisition of endoscopic dexterity have persisted. Dexter teaches psychomotor skills not anatomical knowledge. It separates psychomotor skill training from the other essential components of bronchoscopic airway management. In the development of Dexter, the removal of anatomy allowed incorporation of unique design features that systematically reconstruct the skill components in an interesting and enjoyable fashion. The modular non-anatomic components also allow the possibility of new design features as bronchoscopic technology develops.

What is the role of anatomic manikins?

Anatomic and non-anatomic manikins perform different but complimentary functions. Anatomic manikins are important for the development of anatomic awareness including familiarity with the sequence of structural landmarks that signpost navigation within a patient. The volume of the oropharynx provides an important environment to develop skill related to midline control of the unsupported bronchoscope in a larger space. An anatomic bench model is important in defining proficiency using a global rating scale (see teaching section), in a way that transfers directly to the clinical environment. Finally, anatomic manikins are useful for practicing bronchoscopic interaction with the patient e.g railroading an endotracheal tube, lung isolation techniques or bronchial tree exploration.

What about virtual bronchoscopy?

Cost, role and effectiveness

Simulators allowing virtual bronchoscopy using imitation bronchoscopes are an exciting development. They are expensive but can simulate anatomy and pathology and provide clinical case studies. An interesting gaming version controlled by an X-Box is available as is a free internet program controlled by computer keystrokes.

Outcome research is needed to define their role in bronchoscopy training and the relationship between their cost and benefits with respect to other training devices and methods. Current evidence (2013 meta-analysis in Chest) suggests that they are not as useful as part-task trainers for the development of psychomotor skills.

Dexter is of most benefit for novice to intermediate bronchoscopists who need to learn how to drive. Virtual bronchoscopy systems may be of more value to intermediate and advanced bronchoscopists interested in rehearsing management of specific clinical problems and simulating clinical exposure. While cost-effectiveness lies with part-task trainers, optimal bronchoscopy training will probably involve some combination of part-task trainers and high fidelity simulators as their role becomes better defined.

Who is Dexter for?

Dexter was initially developed for anesthesiologists / anaesthetists in response to recognised difficulty in acquiring and maintaining the endoscopic dexterity required for fibreoptic intubation in management of patients with difficult airways. However the psychomotor skills it teaches are also relevant to the specialties of respiratory medicine, intensive care, emergency medicine, and surgical sub-specialties that perform bronchoscopy. Modules for bronchoscopic biopsy and EBUS fine needle aspiration are under development.

What are the ongoing costs with Dexter?

Dexter is robust, durable, safe and cost effective. Two prototype Dexters that have had heavy use in Wellington have lasted over 10 years. The collars and necks have been replaced but they are still going strong!

Each Dexter is sold with a spare parts kit for occasional replacement of collars and neck supports. This ensures years of low cost regular use.

The polycarbonate collars that hold the Y piece halves together are sacrificial and may break after multiple cycles of the expansion and contraction that occurs each time the pieces are clicked together and separated. A full set of spare collars is included with the model to replace as required. Additional collars are available if required. A video showing how to replace a broken collar is shown here.

The neck support can fatigue and split. This is uncommon but more likely to occur if the model is transported with the Y configuration and pods attached. It is better to assemble the configurations off the neck and then attach the completed configuration as this reduces repeated stress on the neck support. Two spare neck supports are supplied with the model and additional supports are available if required. A video showing how to replace the neck support is shown here.

The polycarbonate case is designed to protect Dexter and keep all the components safely stored. To minimise stress on the hinges when closing, align the top and bottom edges at the base and close the latches from the base toward the head. Use the hand recess near the neck when removing Dexter from the case. Put a fragile label on the case when flying as the case is not designed to be dropped onto hard surfaces by baggage handlers! Replacement cases are available if needed.