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Technical Reports

Endoscopic Skills Training in a Simulated Clinical Setting


Leon Fisher, BMBS, FRACP;
Donald G. Ormonde, MBBS, FRACP,
PhD;
Richard H. Riley, MBBS, FANZCA,
FACA;
Bernard H. Laurence,
BMedSci(Hons), MBBS, FRACP

Background/Aim: We describe a simulation and scenario-based model of training


in gastrointestinal endoscopic hemostasis, which combines acquisition of procedural
and problem-solving skills in a close to reality simulated clinical setting.
Methods: Two day courses in endoscopic hemostasis were conducted at the Clinical
Training and Education Centre, the University of Western Australia, Perth, Australia. In
total, 23 trainees were enrolled. The Erlangen Endo-Trainer simulator, porcine specimens of esophagus, stomach, and duodenum with a range of simulated bleeding
sources, a separate catheter and a pump to simulate massive bleeding, and a full arm
model with injectable veins were used. The SimMan monitor and software package
were used to simulate hemodynamic parameters and electrocardiogram. Faculty
members adjusted the rate of bleeding and vital parameters. The exercise was video
recorded. On the first day, the group underwent simulator training in techniques of
endoscopic hemostasis. On the second day, participants were scenario-based trained
in full management of a bleeding patient, which included resuscitation, sedation,
endoscopy, and hemostasis, acting as leaders in teams of three. The course was
evaluated by participants using a standardized questionnaire.
Results: A complex clinical setting of acute gastrointestinal bleeding was recreated
with a high degree of realism. All participants reported that the simulated clinical
scenario was a positive learning experience, helpful in managing complications and
performing complex problem-solving tasks in a dynamic environment.
Conclusions: Scenario and simulation-based training in endoscopic hemostasis may
provide an opportunity to improve procedural skills and acquire practical experience
in managing this medical emergency, which requires the ability to process, integrate,
and adequately and quickly respond to complex information in unexpected conditions
working as a team leader.
(Sim Healthcare 5:232237, 2010)

Key Words: GI training, Endoscopy, Gastroscopy, Clinical simulation, Scenario training.

he value of simulation-based training in acquiring endoscopic skills is increasingly recognized. The use of isolated
animal gut allows endoscopic procedural training with sufficient realism and difficulty to promote operator competence
and confidence.13 Modification of this model by creating
simulated pathology such as ulcers, varices, and arterial
bleeding widens its applications and its value in learning
complex hemostatic techniques by repeated supervised practice. However, procedural skill is not the only determinant of
a successful clinical outcome, as many endoscopists have
learnt, often to the patients peril, when faced with control-

From the Department of Gastroenterology, Sir Charles Gairdner Hospital (L.F.,


D.G.O., B.H.L.); the University of Western Australia (L.F., D.G.O., R.H.R., B.H.L.);
and Royal Perth Hospital (R.H.R.), Perth, Australia.
Author contributions: Leon Fisher, BMBS, FRACP: analysis and interpretation of the
data, drafting of the article, critical revision of the article for important intellectual
content, and final approval of the article; Donald G. Ormonde, MBBS, FRACP, PhD:
conception and design and final approval of the article; Richard H. Riley, MBBS,
FANZCA, FACA: conception and design and final approval of the article; and
Bernard H. Laurence, BMedSci(Hons), MBBS, FRACP: analysis and interpretation of
the data, conception and design, critical revision of the article for important
intellectual content, and final approval of the article.
Reprints: Dr. Leon Fisher, Department of Gastroenterology, Sir Charles Gairdner Hospital,
Nedlands, Western Australia 6009, Australia (e-mail: leonfisher@optusnet.com.au).
Copyright 2010 Society for Simulation in Healthcare
DOI: 10.1097/SIH.0b013e3181d2a7af

232

Endoscopic Skills Training

ling massive ulcer bleeding in a high-risk patient with unskilled support in the early hours of the morning. The proceduralist also needs to be skilled in resuscitation and sedation
and must have the communication and leadership abilities to
manage the endoscopy support team effectively. However,
current simulator training in endoscopic hemostasis is primarily concentrated on endoscopic skills. Such training significantly improves the procedural skills,13 but it does not
address other important in a clinical setting goals.
Kneebone et al4 has highlighted the significant deterioration of simulator acquired sigmoidoscopy skills when the
operator is required to carry out the procedure in a simulated
clinical setting. The distracting effects of anxiety, the need to
make complex logistical decisions, and identify and treat intraprocedure complications while attempting endoscopic
treatment are likely to be much more significant in the management of a patient with gastrointestinal (GI) bleeding.
To be beneficial, the experimental simulator-based teaching should focus on acquisition of both multiple skills and
knowledge needed to solve complex problems and ability to
perform promptly and efficiently during critical clinical
events. The likelihood of personnel making mistakes increases as critical events evolve indicating the need for team
training.57 It has been documented that individuals thought
processes, attention spans, and proficiency are compromised
Simulation in Healthcare

when stress levels increase and error reduction could be


achieved through team training and team leadership. From a
cognitive perspective, emergency situations involve a starting
condition (eg, GI bleed but unknown precise diagnosis), a
goal condition (in our case arrest of the bleeding to avoid
surgery and/or fatal outcome), a possible and unpredictable
condition (eg, development of complications and unstable
patient at any stage of the procedure requiring prompt intervention), and available (may be limited) resources to achieve
the goal.
Therefore, the ability to practice the acquisition of critical
thinking to create an appropriate strategy, error management, and team work in a simulated critical care environment simultaneously with improving the procedural skills
seems to be a unique learning opportunity. According to
cognitive theory, as students gain experience in problemsolving paths of strategy development emerge, and improvement in performance is usually accompanied by increase in
speed and reduction in the data processing.8 10
In an effort to enhance the scope of simulator-based training in the endoscopic treatment of GI bleeding, we have designed a course to improve clinical decision making and acquire principles of crisis resource management in a realistic
clinical context.

MATERIALS AND METHODS


Participants
The participants were doctors, majority in the 1st or 2nd
year of GI or surgical training programs, and included a number of endoscopy nurses. All participants had at least 6
months prior experience in upper GI endoscopy and had
done cardiopulmonary resuscitation courses prior. All doctors had at least 4 years postgraduate experience and some
previous clinical exposure to managing acutely sick and
bleeding patients. The level of endoscopic training ranged
from just 6 months of GI fellowship to 3 years of endoscopic
experience. Although all had some exposure as above, none
were dedicated anesthetic or intensive care trained. Overall,
23 doctors took part in the training. Eleven trainees took part
in the first course and 12 in the second.
Experts who conducted the training were volunteers; each
had at least 5 years experience in therapeutic endoscopy.
They met before training to standardize teaching methods
and review the scenarios and evaluation criteria. These included each particular hemostasis technique and the main
components of the scenario-related performances such as
correct diagnosis, proper management strategy, correct instructions to the assistants, recognition of complications, application of proper hemostasis, and successful leadership behavior. Each of three experts expressed their opinion judged
on the afore-mentioned steps of trainees performance.
Laboratory Setup
The management of GI bleeding course was conducted at
the Clinical Training and Education Centre (CTEC), The
University of Western Australia, Perth, Australia twice during 2004 2005 and annually since. CTEC is a purpose-built,
simulation-based medical skills teaching facility with three
suites each comprising a training room with simulator, a
Vol. 5, No. 4, August 2010

control room, and an adjacent viewing/debriefing room.11


The simulator room incorporates two-pan tilt zoom video
cameras and a scan converter connected to the simulators
vital signs monitor; the adjoining control room, separated
from the training room by a one-way mirror, allows the trainers to observe the participants, control the scenario, and
communicate to the trainee supervisor through wireless
headset. The patients voice was simulated by the controller
talking through a speaker in the mannequin. The pump used
to simulate ulcer bleeding was controlled by the supervisor.
For the scenario-based teaching exercise, the training room
was furnished with standard endoscopic equipment (gastroscope, processor, diathermy, and hemostatic accessories),
and vital signs monitoring (including oximeter and electrocardiogram).
All courses were conducted and approved by the University of Western Australia. An approval for this project and the
report were obtained from the local institutional ethics committee. Videotaping was used for provision of feedback and
with written participants permission only.
The Model
The Erlangen Endo-Trainer simulator (Erlangen, Germany) was used to simulate upper GI bleeding. This model
and its role in teaching techniques of endoscopic hemostasis
are well described.2,3,12 Frozen preparations of adult pig
esophagus, stomach, and duodenum were thawed and
opened along the greater gastric curve; simulated pathology
(gastric and duodenal ulcers, esophageal mucosal tears, and
Dieulafoy lesions) were created by incising appropriately
shaped discs of mucosa over submucosal saline cushions.
The lesions were placed at random sites, including the high
lesser curve and posterior duodenal wall. Both visible and
nonvisible arteries were simulated by positioning 1 and 2
mm diameter Silastic tubes in the base or edge of ulcers
using a transmural hypodermic needle and secured with a
serosal stitch; the individual tubes were marked to identify
their position in the preparation and connected to a roller
pump to simulate pulsatile, arterial bleeding of a look-alike
blood substitute.
The porcine specimens of esophagus, stomach, and duodenum were mounted in an anatomic position within the
plastic torso of the model. A wide-bore duodenal tube was
inserted to drain or flood the preparation with blood during the procedure to improve endoscopic visibility or mimic
massive hemorrhage; the duodenal stump and greater gastric
curve were closed with continuous sutures and tested for air
leaks.
Additionally, a full arm and hand model (Multi-Venous
IV Training Arm, Laerdal Medical (AS, Norway) with injectable veins to enable simulated intravenous injection and
blood transfusion was arranged on a standard endoscopy
trolley adjacent to the Endo-Trainer and both were draped,
leaving the head, forearm, and hand exposed (Fig. 1).
A SimMan (Laerdal Medical AS, Norway) monitor and
software package were used to reproduce simulated pulse
oximeter data, blood pressure, pulse and respiratory rates,
and an electrocardiogram trace for the patient. SimMan is
a sophisticated patient-simulator mannequin designed for
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233

Figure 1. The Erlangen Endo-Trainer model complete with a roller pump and intravenous training arm (A) and simulated en-

doscopy room (B).

training in advanced life-support skills; its software allows


multiple physiological trends to be run simultaneously with
additive effect. Preprogrammed clinical scenarios are available or as in this training exercise, can be custom designed for
a particular clinical situation and progressively rolled out by a
teaching faculty observer in the control room.

MATERIALS
All equipment used was either disposable or for dedicated
animal use only. The following equipment and accessories
were used.
Real Olympus GIF-140 video endoscopes.
Erbe (Erbe Elektromedizin, Ltd., Tubingen, Germany)
and Valleylab (Valleylab, Inc., Boulder, CO) electrosurgical generators.
Argon plasma coagulation probe (Erbe Elektromedizin,
Ltd., Tubingen, Germany), Gold Probe (Boston Scientific Corporation, Natick, MA), Hemoclip applicator
(Olympus Corporation, Japan), Six-Shooter ligator
(Wilson-Cook Medical, Inc., Winston-Salem, NC).
Intravenous catheters and connection lines.
Evaluation of the Course by Participants
To assess participants satisfaction with the course, a standardized structural questionnaire regarding the course outcome and organization was used. Each participant was asked
to answer anonymously 12 questions on a 5-point scale (from
strongly disagree to strongly agree). Each question also
included four to eight reasons to explain the rating. Suggestions for further improvement of the course and any other
comments were also asked to be expressed.

RESULTS
Conduct of the Course
The course consisted of 2 days of theoretical and practical
sessions. The first day of the course covered both the basic
theoretical background and practical approach to endoscopic
hemostasis using epinephrine injections, endoclips, coagulation probes, and variceal banding devices. Participants were
shown the techniques (initial didactic demonstration) and
then practiced their skills under expert supervision on the
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Endoscopic Skills Training

Erlangen EASIE model, plastic models, and GI-Mentor II


computer simulator (Simbionix Corp, Cleveland, Ohio) for
approximately 4 hours. One tutor trained two to three doctors and evaluated all steps of their performance of the procedure, including manual skills in setting up the device, testing the equipment, localizing the bleeding site and
application of specific hemostatic techniquesinjection,
electrocoagulation, hemoclip application, and variceal ligation. This training endoscopic hemostatic skill station was
organized following previously published recommendations,3 but the trainees were not exposed to the full resuscitation and endoscopic simulator until day 2.
On the second day, the class was divided into four endoscopy teams each consisting of three people for simulated
clinical setting exercises. Each team consisted of three doctors
or two doctors and a nurse (because the majority of participants were doctors). The team decided on the endoscopist
before the beginning of exercise, whereas the other two were
responsible for support. In each session, the endoscopy teams
were given a brief clinical scenario (Appendix) and were required to assume full management of the simulated patient.
Four different clinical scenarios were used simulating ulcer
hemorrhage and Diulefoy lesion. Trainees had to explain the
procedure to the patient, assess their hemodynamic status,
initiate resuscitation if indicated, administer sedation, perform an endoscopy, and identify and treat the bleeding lesion. The choice of hemostatic method, the preparation of
the equipment (endoscopes, generators, and power settings),
and the appropriate accessories (injection needles, Gold
Probe, Hemoclip, or argon plasma coagulation probe) were
entirely the responsibility of the trainees. Thirty minutes
maximum was allowed to complete the exercise. Trainees
were aware of the time limit, and they knew that they had to
resuscitate the patient and apply endoscopic treatment. The
details of clinical history and other parameters were only
revealed once the exercise started. Each exercise was observed
by at least three faculty members one was in the room in
control of the bleeding pump, and two were in the control
room and could adjust the hemodynamic parameters. The
faculty members adjusted the rate of bleeding and hemodynamic parameters depending on whether the treatment was
Simulation in Healthcare

appropriate. The exercise was video recorded, and all steps of


the performance were timed. The rest of the faculty and trainees who finished their exercise could observe on the video
monitor from the conference room. Each team was judged by
three faculty members and was given detailed feedback of
their overall performance and of the individual components
of each strategic decision and each technique, endoscopic,
and resuscitation. Diagnostic errors such as condition present
but not detected, delayed diagnosis or misdiagnosis, and errors
and incompetence in management strategies were addressed.
Feedback was provided by the faculty conducting the course
immediately after all groups finished the exercise with all participants present. Debriefing focused on reinforcing team approach to management of an unstable patient with GI bleeding.
Participants Response
At the end of the first day of simulator training, an improvement in endoscopic techniques with decrease in performance time was reported by all trainees. The tutors confirmed that at this stage, all trainees achieved successful
hemostasis using injection and coagulation, and about 34
were successful with clip application and variceal ligation.
This objective evaluation by the experts indicates that trainees self-assessment reflects real improvement. The main results of the self-administered questionnaire used to assess
participants satisfaction with the course are shown in Table
1. The response rate to the questionnaire was 100%. All 23
doctor-trainees found the course worthwhile and reported
that their practical ability to manage GI bleeding improved as
a result of the course. All of them also found the scenarios
with hands-on practice useful. Ninety-five percentage of participants reported that their understanding of principles of
endoscopic management of GI bleeding improved. Increased
awareness of managing an acutely ill patient in relationship to
the resuscitation was reported by 82.6% of trainees and in
relationship to effective leadership and communication by
83.3%. The trainees also reported a high level of anxiety when
performing procedures in this high-fidelity simulated setting.
However, they recognized the usefulness of such experience

to adapt to unpredictable changes in dynamic and complex


situations.

DISCUSSION
Simulator training in endoscopic hemostasis, an important gastroenterological procedure possessing the main skills
needed for most urgent endoscopic operations, represents a
new paradigm in postgraduate interventional education.
Although an earlier review of the published literature by
Gerson and Van Dam13 concluded that there was insufficient
evidence to recommend that endoscopy simulators replace
traditional teaching, there is growing evidence that simulatorbased courses can accelerate training particularly at an early
stage.2,3,13,14 Di Giulio et al15 used the GI mentor to teach
basic manual skills of upper endoscopy and demonstrated
that computer-based training is an efficient and effective
teaching tool. Using the same simulator, Ferlitsch et al16 have
shown a significant improvement in endoscopic skills after
only 3 weeks of training. Hochberger et al17 have used the
Erlangen EASIE animal-based model extensively in training
and in a recent prospective study have shown objective clinical improvement in the trainees performance after intensive
hands on experience with this model. There is also emerging
evidence that even 1-day intensive courses in endoscopic hemostasis using Erlangen EASIE simulator can have a positive
impact on trainees performance.2
For endoscopic hemostasis as for other complex interventional procedures equally important are technical skills and
knowledge of the procedure and the ability to process, integrate, and respond correctly and quickly to complex information in a dynamic team setting. Experience in clinical
judgment, leadership, teamwork, and communication are
becoming recognized as key determinants of outcome and
patient safety, especially in emergency situations and when
dealing with unexpected.18 20 However, currently, the nontechnical skills in simulator training are taught to a limited
degree only if at all.

Table 1. Course Evaluation (%) by Participants (n 23 Doctors-Trainees)


Course Outcomes and Characteristics
My practical ability in the endoscopic management of GI
bleeding has improved
My understanding of scientific and clinical principles underlying
the endoscopic management of GI bleeding has improved
I have an increased awareness of managing an acutely ill patient with GI bleeding in
relationship to the principles of resuscitation and fluid management
I have an increased awareness of managing an acutely ill patient with GI bleeding in
relation to the effective leadership, teamwork, and communication
I have an increased awareness of managing an acutely ill patient with GI bleeding in
relationship to sedation issues
The hands-on practice of techniques for GI bleeding was useful
The scenarios were useful
The presentations were useful
The case presentation/discussion session was useful
There was enough time to ask questions
The amount of information presented in this course was appropriate
I found the course worthwhile

Vol. 5, No. 4, August 2010

Strongly
Disagree

Disagree

4.3

8.3

Agree

Strongly
Agree

52.2

47.8

4.3

56.5

39.3

13.0

56.5

26.1

16.6

50.0

33.3

41.7

41.7

8.3

56.5
54.5
66.6
43.5
66.6
33.3
36.4

43.4
45.5
33.1
56.5
33.3
58.3
63.6

Neutral

8.3

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235

Kneebone et al4,18 pioneered the use of medical simulators


in a realistic environment by positioning a surrogate patient
adjacent to the computer generated endoscopic image. Integrating skills training in sigmoidoscopy within a clinical context improved the perceived realism of the procedure and
enhanced the learning experience by allowing interaction
with the patient but increased the anxiety of the participants
with a corresponding reduction in dexterity.4,18,21
Successful management of acute GI bleeding requires a
team approach and the endoscopist because team leader
must not only be competent in resuscitation but must also
possess strong communication and leadership skills. The
value of teaching the team approach to managing life support
and multiple trauma has been recognized for over a decade
but has so far received little attention in endoscopy teaching
programs. Experience of medical emergency team training
shows that despite appropriate levels of individual skill, the
team often functions poorly because of lack of organization
and leadership.22 Moreover, it has been demonstrated that
performance can be improved significantly by training on
simulated patients using realistic clinical scenarios and providing extensive feedback and analysis.22,23
To provide simulator training and practice in both psychomotor and cognitive skills in emergency situations (under
pressure), we used a two-stage approach. To our knowledge,
this is the first course in endoscopic management of GI bleeding to incorporate the acquisition of technical skills with a
team approach to the resuscitation and overall management
of a bleeding patient.
On the first stage, the trainees practice mainly procedural
skills, whereas the second stage integrates technical procedures with unexpected changes in patients status requiring
immediate responses from the trainee as the team leader.
Such training not only improves the endoscopic hemostatic
skills of the trainees but also gives them an opportunity to
experience the complexity and danger in a dynamic environment and to practice in problem solving, leadership, and
teamwork. Such realistic (but safe) setting should increase
their knowledge of the procedure and its potential pitfalls.
The 2-day CTEC course in the endoscopic control of GI
bleeding provides realistic clinical scenario-based simulation
which the trainee is likely to encounter in daily practice. The
training and debriefing sessions were focused on a structured
team approach to a patient with GI bleeding, highlighting the
importance of monitoring, early and adequate resuscitation,
effective endoscopic treatment, and the recognition of the
limitations of both the treatment modality and personal
skills. Importantly, the majority of participants expressed
high satisfaction with the training course. They noticed that it
was helpful in adapting to and overcoming the difficulties in
managing unexpected complications and performing complex problem-solving tasks in a dynamic environment.
Issenberg et al24 have conducted an extensive review of the
published literature concerning the use of high-fidelity medical stimulators. This study emphasized the key importance
of feedback, repetitive practice, curriculum integration, variation in task difficulty, and clinical setting in facilitating
learning; it stressed the value of providing a controlled envi236

Endoscopic Skills Training

ronment where trainees can learn from mistakes without risk


to patients.24
The CTEC course satisfies all these criteria, particularly
feedback based on faculty and peer review of video recorded
performance, and is an important addition to our GI Fellowship teaching program. Once setup, the training model outlined can be used many times and provides an opportunity
for repetitive practice to reinforce newly acquired skills. It is
anticipated that in future courses, the number of simulated
scenarios will be increased with the degree of difficulty tailored to the training and experience of endoscopists and support staff. Communication skills training is an essential part
of the course, and the scenarios could be expanded to include
clinical history taking, obtaining informed consent, consulting colleagues, and informing patient or kin of treatment
outcomes.
Although the presented pilot 2-day intensive simulator
endoscopic training was enthusiastically accepted by trainees
and can potentially improve patients safety, only further
long-term assessment and prospective randomized controlled trials will determine whether the skills learned in the
course translate into the ability to perform such procedures
safely in clinical practice.

CONCLUSION
There is growing evidence that endoscopic training can be
improved by the use of simulation. A number of publications
have reported a positive training effect when using simulators
in the early phase of endoscopic training. Management of GI
bleeding is arguably one of the most challenging and stressful
endoscopic procedures. It requires a high degree of technical
and cognitive skills and knowledge and is also one of the most
difficult techniques to teach trainees because of limited exposure, time constraints, stress of the situation, and high risk to
the patient. In this article, we report on the application of a
biomechanical GI bleeding model in a close to reality simulated clinical setting to teach principles of endoscopic management of GI bleeding. The 2-day intensive course allows
trainees not only to improve their endoscopic hemostatic
skills but also to gain practical experience in clinical judgment and to develop better leadership and teamwork abilities
in emergency situations. Future randomized trials are needed
to evaluate the patient-relevant effectiveness of the model
objectively.
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simulator achieves basic manual skills required for upper endoscopy: a
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16. Ferlitsch A, Glauninger P, Gupper A, et al. Evaluation of a virtual
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17. Hochberger J, Matthes K, Maiss J, Koebnick C, Hahn EG, Cohen J.
Training with the compactEASIE biologic endoscopy simulator
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Vol. 5, No. 4, August 2010

APPENDIX: TWO SAMPLE SCENARIOS USED IN THE


MANAGEMENT OF GI BLEEDING COURSE
Sample Scenario 1
Background information given to trainees:
An 85-year-old female patient is admitted via the emergency department with a 3-day history of melena. She
has a history of noninsulin-dependant diabetes and
ischemic heart disease and had a previous myocardial
infarct. She takes Aspirin, Celecoxib and Ramipril.
While in emergency department, she has an episode of
hypotension. Her admission blood count shows hemoglobin of 105 g/L, and her coagulation profile is
normal.
Initial setup:
The patient has been transferred to the endoscopy unit for
urgent gastroscopy. She is awake on a trolley and consented for the procedure. Her heart rate is 108 beats/
minute, blood pressure 105/48 mm Hg supine, and oxygen saturation 94% on room air.
Progress:
Once sedated, the patient becomes rapidly hypoxic, oxygen
saturation falling to 78%.
Actions required:
Increase oxygen, attempt to rouse the patient, reverse sedation, check oxymeter probe, insert airway, bag, and
mask.
Sample Scenario 2
Background information given to trainees:
A 27-year-old fit male admitted via emergency department
with hematemesis and melena. His history is remarkable
only for a recent leg injury, and he has been taking highdose non-steroidal anti-inflammatory drug for pain
control in the last 2 weeks. On admission, his hemoglobin is 89 g/L. He is transferred to the endoscopy unit for
urgent gastroscopy.
Initial setup:
The patient is awake on a trolley and consented for the procedure. He has a small intravenous cannula in his left
arm. His pulse rate is 110 beats per minute, his supine
blood pressure is 105/60 mm Hg, and his oxygen saturation is 99% on room air.
Progress:
After sedation, patients blood pressure begins to fall. As the
scope is inserted, his blood pressure falls to 88/52 and
then to 74/40 mm Hg.
Actions required:
Insert a large-bore intravenous cannula, increase intravenous
fluids, administer blood products, and treat the bleeding
lesion.

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