Gaumard's S.M.A.S.H. Advanced Patient IV Training arm was first introduced in 1986 to help train, teach, and practice IV administration. The latest improvement to this "world-class" standard offers realism in a sleek design. A micropump mounted within the simulator's shoulder delivers automatically generated arterial pulses at the radial and brachial sites and controls arterial blood flow by allowing variable heart rate and pulse strength. Interchangeable arterial and venous inserts within the forearm allow creation of arteriovenous (AV) fistulas and placement of AV grafts, while a simulated healed fistula insert provides a platform on which hemodialysis exercises can be performed. An additional multi-layer insert in the bicep area can be used for incision and suture training exercises.