Tag Archive | "patient safety"

The rubber doll bleeds and talks

On a November afternoon, a third year student at New York College of Osteopathic Medicine, showed up at St. Barnabas Hospital in her blue scrubs. Her mission was to treat the first trauma case in her career. The man on the stretcher had been shot in the jaw with a handgun and needed a surgical airway so he would not choke.

Marisa Wolff put on a pair of latex gloves, found the small hollow space that marks the airway on the patient’s neck and inserted a needle into the patient’s throat. A doctor instructed the 25-year-old to adjust the angle of her needle. Once corrected, she inserted a guide wire into the puncture hole and cut a horizontal incision on the man’s neck with a scalpel. Then she inserted a trachea into the incision until it reached the patient’s airway.

Success. The blockage inside his airway spurted out. Now the doctor-in-training had more time to deal with the man’s injuries without worrying about him suffocating. A second medical student attached an airbag to the new airway and kept pumping in even beats.

“Beautiful!” said Ann Marie McDonald, the trauma program coordinator at St. Barnabas Hospital.

Suddenly, a lab technician pulled the surgical airway out of the patient’s neck and tore off part of his skin. The patient’s red flesh and detailed anatomy was exposed. The technician calmly put another piece of skin on the patient’s neck and asked another student to start the process all over again.

The students were able to tear off his skin as many times as they wanted. They could even flip his skin up during the process to see whether the needle was in the right place. The man in trauma was a high-tech, ultra-realistic mannequin, an indispensable element in the evolving medical simulation education.

For years, the military and aviation industries have used simulation to select and train their personnel. Medicine, on the other hand, has adhered to the age-old practice of observing experienced doctors and learning from real patients, a practice that limits training possibilities.

In the past 10 years, as mannequin costs have fallen, and as a patient safety movement has emerged, simulation education has begun to take root in medical schools and hospitals across the country. According to the Society for Simulation in Healthcare, 120 hospitals in the U.S. currently have simulation labs. That estimate may be low, because some hospitals have small labs with one or two mannequins, and these did not become a member of the society.

At St. Barnabas Hospital in the East Tremont section of the Bronx, mannequins help doctors-in-training avoid causing unnecessary harm to patients, and help end some of the cruel practices used by some hospitals on animas in labs.

For medical educators, the mannequins provide a great opportunity for students to “practice the skills before seeing the patients,” said Dr. Anthony Errichetti, chief of virtual medicine at New York College of Osteopathic Medicine. “Medical education shifted from knowledge-based practice to competency-based practice.”

Skeptics point out that the mannequins are only rubber dolls, and they cannot simulate real situations. As of yet, there is no longitudinal study that examines whether students can recall the simulated scene and when faced with real life trauma.

This leads to the most debated question in simulation education to date: Do simulations actually produce better doctors? Simulation may provide a good indication of a student’s current skills. But does the training have lasting results later?

So far, the medical students at St. Barnabas Hospital are optimistic: “The simulation lab is effective in building confidence and skills that will be useful for when I’m a first year resident and actually performing those procedures on patients,” said Wolff.

Dr. Errichetti said he has seen a complete turn around in the acceptance of simulation in the past 10 years. He pointed out the problems in the health care system today are shorter hospital stays and inadequate insurance, so patients may not be around when a doctor wants to teach a particular class. Mannequins can give educators more opportunities to teach.

That is why McDonald was able to cram as many types of classes as she could into her tight teaching schedule. She did not need to check with the clinic to see what kinds of patient were available.

McDonald put “TraumaMan” on the gurney, and let Wolff try her best. The “TraumaMan” was made by the SimuLab Corporation, a major medical simulator producer based in Seattle, WA. The mannequin only resembles a man’s torso with replaceable skin. An air compressor is connected to the mannequin and a plastic lung inside breathes in and out. Wolff could practice trauma life support skills such as chest tube and diagnostic peritoneal lavage (DPL) on the mannequin.

Dr. Owen Kieran, a surgical resident at St. Barnabas Hospital, demonstrated DPL to the students. It is a common procedure in trauma care to treat intra-abdominal bleeding. When he cut a midline incision on the mannequin’s lower belly, it started to bleed. In fact, the blood came from a tube of red ink buried inside the mannequin.

The bleeding showed that the procedure was done correctly. Dr. Kieran then drained the blood through a tube connected to the incision.

Wolff was satisfied with her first trauma class. “It is not likely that I’d ever get the chance to place a chest tube or a trachea in a real patient as a third year student,” said Wolff, 25. “It is exciting to be in the simulation lab because as a student you are able to actually use the equipment and do the procedure on your own. The hands-on learning is much more effective and exciting than just watching.”

The lesson was videotaped by a lab manager, so doctors and students could critique her performance.

Sometimes if the curriculum allows, hired professional actors are hired to play distraught family members of the patient. Students practice as a team saving a person’s life and consoling loved ones. In this case, it is a hybrid simulation.

“It’s like driving a car,” said Lynn Kemp, the assistant vice president of surgical services at St. Barnabas Hospital who started the simulation lab with only one mannequin in 2006. “You could read a manual about driving a car, you could sit in a car, but when you actually drive a car, you don’t really know how to do things.”

But her inspiration came nearly 15 years ago, when she attended an air medical conference that trains flight nurses and paramedics in Salt Lake City, Ut. There a mobile simulation truck from the Alberta Shock Trauma Air Rescue Society (STARS) in Canada was on display, the first mobile simulation program in North America.

Kemp was led into the truck, and found herself inside a simulated helicopter, with a mannequin in trauma. The mobile simulation team debriefed them, telling them what they could improve. Even though Kemp was already an experienced flight nurse by that time, she was impressed. “That was a good way to teach me,” Kemp said years later. “It made an imprint on my mind.”

When Kemp arrived at St. Barnabas Hospital ten years ago as the trauma center manager, she was also involved in teaching classes for the American Heart Association at the hospital on advanced cardiac and pediatric life support, the two classes doctors need for their credentials.

“People would sit around and talk about things a lot, but they wouldn’t do it,” Kemp said about the classes. “That bothered me.”

So Kemp wrote a small grant to the Nurse’s Union and bought the first mannequin for $35,000 from Laerdal Company, a medical simulator producer based in Norway. In 2007, the New York College of Osteopathic Medicine began collaborating with St. Barnabas Hospital on the simulation lab, splitting the annual $550,000 costs.

Most hospitals cannot generate revenue from running simulation labs, but St. Barnabas Hospital is hoping to buck that trend by charging $35 for each of its cardiac and pediatric classes. Whatever is left is then spent on the lab.

Hospital employees believe the cost is well justified. “You don’t put a price tag on human life,” said Robert Scott Bostwick, the simulation lab manager with 30-year experience in emergency medicine.

More and more hospitals in the country are building new simulation labs; the New York City Health and Hospitals Corporation just built a 10,000 square-foot training facility at Jacobi Medical Center in the Bronx this year at a cost of $10 million. Banner Health, a nonprofit system, spent $12 million last year to build a 55,000-square-foot simulation training center in Arizona, the largest of its kind in the United States.

However, federal support is still lagging. A bill before the House to unlock $50 million in federal dollars for more medical simulation is still stalled in committee.

Simulation education may have its limitations, but it does help to solve some of the ethical dilemmas the medical profession faces.

In another trauma life support class at St. Barnabas Hospital, the mannequin was a 25-year-old backseat passenger who was ejected from a car in an accident. She lay on the gurney moaning, “I’m not feeling very well.” Every time she breathed there was a harsh vibrating noise. On the mannequin’s wrist and elbow there is a patch of extra soft plastic, so that students could feel the pulse or insert an intravenous drip.

McDonald explained the scenario to the students: “She wasn’t wearing the seat belt. Her heart rate is 130, and her blood pressure is 98/60.” The numerical indicators were shown on the monitor, but for the rest of the scene, the students had to use a little imagination. “She had multiple face lacerations and bruising on her abdomen. She had pain when we rocked her pelvis,” McDonald continued.

After learning the crisis, the trauma team had to decide quickly what should be done first. Remi Drozd, a visiting resident who was the team leader that day, recognized that the patient had to be intubated first.

Wolff held a laryngoscope in her hand and cracked open the patient’s jaw. She exerted a lot of force to push the laryngoscope so that she could open the patient’s throat wide enough and insert a tube.

“If you do that, you can just take out a checkbook and write a check,” Bostwick said, correcting the way Wolff was trying to intubate the patient. A laryngoscope, when used in the correct way, can open a patient’s throat for intubation without hurting him or her. But when used in the wrong way, it could damage the patient’s gum and teeth. Even though a basic procedure in emergency medicine, using the laryngoscope takes a lot of practice and muscle memory.

“If your arm doesn’t hurt from pulling the laryngoscope, you are probably not doing it right,” said Bostwick. “Your comfort is not important; your patient’s is.”

Mannequins provide an environment in which students can practice without worrying about the consequences. Once, a student broke five of the mannequin’s teeth while using the laryngoscope.

Before the mannequins came along, students learning pediatric life support had to practice surgical airways on cats, because a cat’s airway is the most similar to a baby’s.

Hospitals used to maintain animal labs to fulfill those needs. The animals were all anesthetized during the surgical procedures, but they all nonetheless suffered injuries. Now with SimBaby, a mannequin represents a newborn baby produced by Laerdal Company, hospitals no longer need cats to teach pediatric classes.

Right now mannequins range from anatomical models of a particular body part such as the brain and eyeball to full-scale SimMan that represents an adult male. When connected to computers, the doctor can adjust the SimMan’s heart rate and blood pressure to better simulate the real life situation in which the patient’s condition deteriorates.

Modern mannequin production in the world began in the 1960s, according to a paper published in the Quality and Safety in Health Care journal by Dr. Jeffrey B. Cooper, a professor of anesthesia at Harvard Medical School. But it was not until in 1999 when the Institute of Medicine, an independent group that advises the government on health issues, published a report about patient safety that hospitals began using mannequins widely.

The report, “To Err Is Human”, initiated a patient safety movement in the United States. According to the report, at least 44,000 people, and perhaps as many as 98,000 people, died in hospitals each year as a result of medical errors that could have been prevented. Even using the lower estimate, preventable medical errors in hospitals still exceed attributable deaths to such feared threats as motor vehicle accidents, breast cancer and AIDS.

According to Dr. Errichetti, the United States is now the world’s biggest mannequin user. Many of the European countries use mannequins as well. But for the rest of the world, mannequin use is sporadic. Some wealthy Middle Eastern countries may have the money to buy mannequins, but they lack the experienced faculty that could explain the scenario and teach how to tackle the unexpected.

“Every patient’s encounter is unique, you can’t recreate every single thing, because you don’t know how a patient is going to respond,” said McDonald. “But what we can do is to prepare our providers to be ready for that.”

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