BY JIM DRYDEN
From a darkened control room, a surgeon, nurse and physical therapist peer through a one-way mirror as members of a Barnes-Jewish Hospital acute care team talk to a mannequin. Acute care teams are called in when formerly stable patients develop serious complications.
“Are you allergic to any medicines?”
“Can you hear me?”
“How long has it hurt this much?”
The mannequin answers, or at least one of the evaluators does. Speaking into a microphone located in the control room, her voice is transmitted through a speaker near the mannequin’s mouth.
“It’s hurt much worse the last few minutes. I’m really scared!”
The team — made up of residents, nurses and a respiratory therapist — orders imaging tests, starts an IV, prescribes medication and even intubates and protects the mannequin’s airway. A few minutes later, they retire to a nearby room for a debriefing and evaluation with one of the specialists who observed from the control room.
In the aircraft industry, simulators re-create the experience of flying. In modern health care, the idea has been to create the same kind of believable and accurate experience that makes it possible for students at every level to hone their physical, communications and teamwork skills without encountering actual patients. Following simulator training, these teams should be able to take their new skills back to the hospital and help real patients.
For more information on Washington University’s simulation centers, visit www.simulation.wustl.edu.
The simulators are located in Barnes-Jewish Hospital, St. Louis Children’s Hospital, the Goldfarb School of Nursing and the Farrell Learning and Teaching Center. Washington University School of Medicine uses simulation training for all levels of students in many settings, but group training of seasoned medical teams has become another key component of their use.
By teaching health care professionals — physicians, nurses, therapists and students — to work together and combine their expertise, simulator training is designed to make it more likely that they will quickly be able to diagnose and correctly treat problems.
Trainees come from pediatrics, anesthesiology, emergency medicine, obstetrics and other specialties and work through scenarios that test their abilities to recognize and diagnose medical problems. Sometimes scenarios are straightforward, such as a difficult labor, breathing problems due to a collapsed lung, or chest pain from a heart attack. But sometimes the scenarios are more complicated, as in a recent simulation that involved a trauma team of surgical and emergency medicine residents.
“In one scenario, the patient has chest injuries following a car accident,” says David J. Murray, MD, the director of the Howard and Joyce Wood Simulation Center located in the Farrell Learning and Teaching Center.
Sitting in the darkened control room observing the training session, Murray says, “This one’s more complicated than just a bruised sternum or broken ribs. The patient had a heart attack while driving. That’s what led to the accident and subsequent injuries.”
Murray, the Carol B. and Jerome T. Loeb Professor of Anesthesiology, chief of pediatric anesthesiology and anesthesiologist-in-chief at St. Louis Children’s Hospital, says this type of training, called heuristics, helps individuals learn to solve complex problems through trial and error. At the various simulation centers located throughout the medical center, heuristics training forces teams of medical professionals to confirm and continue to reconfirm their diagnosis, especially when the obvious answers turn out to be wrong.
“We want to help them move through the diagnostic process to step two or step three, to keep up the detective work that will help them determine what the problems are,” he explains. “If they do something that should make the patient better, but it doesn’t, then what?”
Murray works closely with co-principal investigators Mary E. Klingensmith, MD, the general surgery residency program director and Mary Culver Distinguished Professor of Surgery, and Bradley D. Freeman, MD, professor of trauma surgery. One of the three often can be found with Julie A. Woodhouse, RN, assistant director of the Wood Simulation Center, in the control room observing, providing a voice for the simulated patient, and evaluating how the medical teams are adapting to various training scenarios.
“These can be very difficult cases,” says Klingensmith, assistant director of the Wood Simulation Center. “In the actual practice of medicine, things don’t always go ‘by the book.’ The same thing goes for these simulated cases.”
In the case of the accident victim, the team eventually did order a blood test that detected the presence of a likely heart attack. That patient was saved, but the simulation center mannequins aren’t always so lucky.
Neither are the real patients. The Institute of Medicine estimates that medical errors are the eighth leading cause of death in the United States. Washington University is one of several centers around the country using simulators to train health professionals to communicate more effectively to improve patient care.
With funding from the federal Agency for Healthcare Research and Quality of the Department of Health and Human Services, Murray, Klingensmith and colleagues believe they are improving patient safety by training medical teams not only to be better at diagnosis, but also faster and more skilled under pressure.
“The scenarios seem simple, but you start feeling as if they are real,” says Malcolm P. MacConmara, MD, a fourth-year general surgery resident. “You have your peers around you, and you want to make good decisions.”
In another scenario, an acute care team is monitoring a patient’s breathing as the mannequin labors for breath. They order X-rays and discuss protecting the patient’s airway with intubation. Finally, one team member suggests it might be an allergic reaction to medication. It’s the right diagnosis, but unfortunately, the mannequin gets too large a dose of epinephrine, and further complications ensue.
“We aren’t trying to drill them over and over to properly treat specific problems,” Murray explains. “We don’t want to show them how to fix one condition. We need trainees to develop good judgment and diagnostic skills so that they can be ready to solve complex problems.”
The simulation centers are a cooperative venture of the School of Medicine and its Departments of Anesthesiology, Pediatrics and Surgery, and BJC HealthCare, which operates Barnes-Jewish Hospital, St. Louis Children’s Hospital and the Goldfarb School of Nursing at Barnes-Jewish College.
“Surgeons in training benefit from the opportunity to rehearse complex skill sets before they ever enter an operating room,” says Klingensmith. “In the surgical skills lab, they do hands-on exercises to teach a variety of surgical skills, from suturing to knot tying. We offer simulators where they can practice laparoscopic and endoscopic techniques.”
Community physicians and others who want to learn new skills or refresh their decision-making skills also can visit the center for training.
“It’s all about education, for medical students and the health care professionals working on the floors of our hospitals,” says Murray. “Education is more than just training. It involves teaching people to think on their feet. We want to reinforce the importance of being situationally aware, then have them take these skills back to the hospital so that when real patients are involved, they can use the skills acquired in these scenarios to prevent complications and save lives.”