A simple epidural simulator

Editor, I read with interest the recent article by Raj et al.1 and the accompanying Commentary by Columb2 on the use of several fruits as a simulator for epidural anaesthetic puncture. Raj et al.1 should be congratulated for their work. The topic remains popular as witnessed by a number of recent publications on diverse mechanical simulators.3,4 In the study by Raj et al.1, bananas seemed to be the best choice as a teaching tool for training novices in epidural puncture. However, I have some doubts concerning this model. First, fruits and other vegetables have been previously proposed as an inexpensive and reproducible model for this indication, but apart from the first publications, there were no subsequent ones reinforcing or supporting their effectiveness. Bananas in complex assemblies,5,6 and potatoes, raw or slightly boiled,7,8 have been used with this aim, the latter being the simplest and most economic solution. Second, there are several types of bananas and its ‘tissue’ consistencies are quite different from one to another. As a general rule, there are two main vegetal genus of bananas (Family Musaceae, genus Musa and Ensete,http://en.wikipedia.org/wiki/Banana) that used to be named banana or plaintain (plátano in Spanish). From a culinary point of view, these are used as a dessert or for cooking. But even pertaining to the same genus or species, bananas might be different; one may think, for instance, about unripe fruits. Thus, although the vegetable proposal seems inexpensive and easily accessible worldwide, one should remain sceptic about its value as a teaching tool. Mechanical devices are not universally available and are expensive. Therefore, I wonder whether it would be better to closely supervise the residents in training during their first epidural attempts (and other manual and nontechnical skills), with previous theoretical instruction and watching how experts perform the procedure.9 In addition, obstetric patients would not be the best ones to start the experience with this technique, because accidental dural puncture is the most frequent complication and postdural puncture headache is frequent as well.10 Acknowledgements relating to this article Assistance with the letter: none. Financial support and sponsorship: none. Conflicts of interest: none. Presentation: none.