Mixed simulators: Augmented physical simulators with virtual underlays

We introduce a taxonomy for mixed simulation focusing on mixed simulators with physical exteriors augmented with virtual underlays for practicing medical procedures such as central venous access (CVA). We used CT and MRI imaging and 3D printing to develop anatomically authentic mixed simulators, i.e., exact physical and/or virtual replicas of their human models. Embedded 6 DOF magnetic sensors monitor tracked instruments during simulated procedures, facilitating after action review or self-debriefing. We implemented automated scoring algorithms that include tracking and grading of near misses. After 28 anesthesia residents trained with the CVA simulator, incidence of pneumothorax and arterial puncture in the simulated environment dropped from 11 % to 7% and 13% to 7%, respectively.