High-fidelity mannequins essential in hospital simulation training

Arkansas Democrat-Gazette/Melissa Sue Gerrits - 07/19/2014 - Mark Shlomovich pretends to apply an ice packet on a mannequin during Standardized Patient/ Mannequin bootcamp July 19, 2014 at the PULSE Center at Arkansas Children's Hospital where the doctors are able to practice operating on mannequins and giving bad news to mock "parents."
Arkansas Democrat-Gazette/Melissa Sue Gerrits - 07/19/2014 - Mark Shlomovich pretends to apply an ice packet on a mannequin during Standardized Patient/ Mannequin bootcamp July 19, 2014 at the PULSE Center at Arkansas Children's Hospital where the doctors are able to practice operating on mannequins and giving bad news to mock "parents."

Bobby Hughes, 14, was at baseball practice when he took a line drive to the chest and collapsed. Now at Arkansas Children's Hospital, he is surrounded by beeping machines and determined voices, as a handful of doctors crowd around his bed administering CPR and pharmaceuticals. Darrell Hughes, 49, hovers over his son.

"He's been out for a long time," Hughes says, his tone rising with panic. "Is he going to have brain damage?"

Bobby isn't responding to CPR, so a doctor places defibrillation paddles on his chest.

Hughes steps back, terrified, as the procedure is administered. "How many times can you shock him?" he asks.

One of the doctors moves toward Hughes, addressing his questions while guiding him away from the bed.

About a minute later, it's done. Everyone files soberly out of the trauma room.

It's not that Bobby died. It's more that Bobby never lived.

The doctors, mostly first-year pediatric intensive care unit and emergency room fellows, seat themselves at a long table in a debriefing room.

"How did it go?" asks Dr. Jonathan Orsborn, an emergency doctor at Children's Hospital.

"Not good," said team leader Dr. Leigh-Ann Washer, a Children's Hospital fellow.

"I feel like we didn't have enough hands," says Dr. Jagila Minso, a fellow at Children's Hospital at Montefiore in New York.

"We waited way too long to start CPR," Washer said.

"We didn't give him fluids in time," said Dr. Camille Immanuel, a fellow at Le Bonheur Children's Hospital in Memphis.

But no one seems especially concerned, not even the patient's father, who listens at the end of the table.

Darrell Hughes is really Darrell Grant, a Little Rock man retired from the grocery business. He has a 14-year-old son who

plays baseball. But his son wasn't in the trauma room just now.

Although Bobby sweats, breathes, bleeds, urinates and has a pulse and pupils that respond to light, he isn't a boy at all. He's a high-fidelity mannequin, used by Children's Hospital's PULSE (Pediatric Understanding and Learning through Simulation Education) Center for training exercises.

And this three-day Pediatric Critical Care and Emergency Medicine Bootcamp, attended by nine physicians from Little Rock, Memphis and the Bronx, is one of two in the country. It's designed to improve response time and teamwork in emergencies and improve communication between doctors and the families of patients.

...

"Doctors have a hard time saying the 'D-word,'" says Grace Gephart, director of the PULSE Center. "That's a conversation you're going to have with someone that is going to change their world ... why would you not want to practice?"

Attending physicians give advice: If possible, take the family bedside so they can witness efforts at resuscitation. (According to research, when a loved one dies, having been a witness in the room helps survivors process their grief.) Also, remember to turn the monitor off so that a blip caused by the bed being bumped won't send a conflicting message.

Dr. Steve Schexnayder, chief of Critical Care Medicine at Children's Hospital, reminds the fellows that information gathering -- trying to figure out what happened to the patient before coming to the hospital -- has to happen early.

"Once you say 'die,' you lose them. What you say after is almost never heard and certainly never remembered," he says.

But this boot camp is also about cheating the D-word, through responding quickly and effectively. The fellows, who have already completed medical school and four years of residency, use mannequins to practice inserting tubes into veins and airways (processes that historically were practiced on live animals) and go through scenarios in which they handle pediatric seizures, shock and severe allergic reactions.

...

The first medical mannequins were used in the early '60s to teach CPR. Sim 1, the first computerized mannequin, was created in the mid-'60s via a collaboration between the University of Southern California and military engineering companies. The U.S. Office of Education funded the project with a $272,000 grant.

For hospitals, Sim 1 was too expensive to be a useful training tool. Another early prototype, Harvey, created in 1968, simulated 27 cardiac conditions.

"High-level simulation mannequins have only been common for about a decade," says Mike Anders, medical director of the University of Arkansas for Medical Sciences Simulation Center.

About three years ago, UAMS built a new emergency facility. The old facility was transformed into the Simulation Center. Anders and his team collected mannequins from various departments around the hospital and used them to design training exercises for students, doctors and nurses.

Now the center has nine mannequins, which are sometimes transported to other hospitals for outreach training.

As at the 7-year-old PULSE Center, a mannequin's vital statistics display on monitors and can be changed while a scenario is underway to simulate reactions to medications and procedures. Pulse and respiration rates, suddenly collapsed lungs and swelling airways can be manipulated from a central computer, via wireless technology.

Each mannequin at Children's Hospital and UAMS costs between $30,000 and $60,000, depending on complexity. There's even a mannequin that "gives birth," so that UAMS students can practice complicated deliveries, such when a baby's shoulder lodges behind the mother's pubic bone.

"When that happens, it has to be quickly recognized and a few maneuvers tried, or else she needs a C-section," says Sherry Johnson, a simulation education specialist at UAMS.

...

Being in a simulation center is like being on a movie set. There are "production meetings" and scenario rehearsals, actors who play patients or family members, special effects (body fluids, stored in pouches in the mannequin's limbs or torso, that drip or squirt), set dressings and wardrobe.

In a recent PULSE Center exercise, a mannequin and a human actor were transformed into burn victims using stage makeup. The actors, called standardized patients, may be actual actors, or they may be retirees or business professionals with flexible schedules. Occasionally they're children, working in tandem with a parent to mimic a situation such as shying away from a shot.

At PULSE, the standardized patients wait in a small computer lab, dishing about local swimsuit sales, munching on fun-size candy bars and reviewing their "script" (a brief case outline).

Mary Anne Waldemayer, 65, has been a standardized patient for five years. Today she is playing a grandmother named Maybelle. In her first scenario, her 8-month-old grandson isn't breathing well and she and another actor, playing the mother, clutch each other bedside and ask questions.

Later Maybelle experiences severe chest pains, which are exacerbated by her concern over her grandson.

(According to Dr. Tonya Thompson, medical director for the PULSE Center, family members of Children's Hospital patients occasionally have their own medical emergencies, and chest pains are the most common.)

Before the scenario begins, Waldemayer spritzes herself with water so that she'll appear sweaty. Next to her, in a plastic garbage can, there's a bad-smelling, realistic-looking prop -- a mixture of lemon juice, Parmesan and oatmeal -- to show her character has been sick to her stomach.

Waldemayer, who has acted in community theater, is convincing. She gasps and wheezes as doctors help her onto a bed, ask her about her health history, feed her an aspirin (really, it's a Tic Tac) and arrange her transfer to UAMS.

In the debriefing afterward, the pediatric fellows discuss their surprise and discomfort upon encountering an adult patient when they expected a child. But the next case is even worse.

...

It's the end of a 10-hour day, and the fellows step into a trauma room to discover a 20-month-old with no pulse. He was napping, but when his mom checked on him, she found him blue and chilly. Now, an ambulance ride later, he's still not breathing.

The fellows check "vitals" and start CPR. Despite their efforts, the baby's heart won't restart. They keep working, reluctant to admit the truth: The baby was dead when he arrived at the hospital and no matter what they do, he won't be revived.

Finally, the team leader has to tell the parents.

In a "family room," Jacob LeMaster and Paige Carpenter, playing the baby's parents, cling to each other and weep real tears, sinking to a chair. Dr. T.R. McCarty sits as well. He asks if there's anything he can do. He shifts uncomfortably.

The other fellows watch solemnly via a TV screen. The scenario is pretend, but it evokes real tension and emotion. (Gephart says PULSE stocks chocolate because it's comforting.)

When McCarty rejoins the other fellows, he makes a joke: "Next time, I'm on respirator."

But he's pale and trembling with adrenaline.

In real life, McCarty, a UAMS fellow, has never been charged with this task. The scenario reminds him of delivering a grim prognosis to parents, something he has had to do more than once.

On the TV, LeMaster and Carpenter dab their eyes with tissues, shake their limbs and try to collect themselves. In a few minutes they'll have to do it again for a second team of learners.

This is boot camp. And what just happened, that's what Gephart terms "combat." But the fellows know that real combat awaits, in pediatric emergency rooms all over the world, and they're trying their best to be ready.

ActiveStyle on 08/11/2014

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