MODEL PATIENTS
The operation will not go well.
But then, that's the point. The young anesthesiologist and three fellow first-year residents have gathered here to practice hands-on medicine in real-time, real-life situations.
They are surrounded by the tools of their trade: A beeping monitor displays jagged red and green lines indicating John's heart rate and blood pressure, an IV drips into his arm, the bellows of a respirator whoosh up and down in time with his breathing.
The only thing not real about the scene is John. He's a "patient simulator," a high-tech and surprisingly lifelike mannequin who tonight will also portray a healthy 32-year-old man with a bad knee, a 55-year-old man suffering from a hernia and a 70-year-old woman with rectal cancer.
Over the next three hours, John will unexpectedly come out of anesthesia during surgery, develop bronchospasms in his lungs, experience a severe allergic reaction and, in the midst of getting his prostate removed, have heart trouble requiring multiple electrical jolts from a defibrillator.
Sometimes John survives; sometimes he does not.
MEDICINE FOR DUMMIES
Traditionally, medicine has been an apprenticeship, with students and interns learning their craft at the elbows of older, working physicians. Over time, with increased experience and skills, these doctors-in-training become doctors in reality.
But there's an obvious downside to this centuries-old system: Practicing medicine means first practicing medicine, typically on people who might prefer not to be living lessons - or worse.
The situation is exacerbated by the harsh and complex realities of modern-day economics, by shifting health-care priorities and steady medical advances that have reduced both the number of senior doctors available to teach and the number of patients, diseases and medical conditions upon which would-be doctors can learn.
That's where guys such as John and Stan D. Ardman come in and lie down.
Stan D. Ardman (for "Standard Man") is also a patient simulator. Prone upon a hospital gurney, he is more mannequin than man. But beneath his vivid blue eyes and sandy brown hair, crammed within his 5-foot-11 frame, are assorted electronic, mechanical, pneumatic and hydraulic devices. Hooked up to an Apple Mac G4 loaded with the right software and algorithms, Stan comes alive, in a manner of speaking.
His eyes blink. His pupils dilate and constrict in response to light. Exposed to anesthesia, Stan will close his eyelids, then open them later when "consciousness" returns.
Stan can inhale air and exhale carbon dioxide. His airways are anatomically correct. They can be intubated using standard hospital equipment, or surgically opened for a tracheotomy. A tiny speaker in the back of his throat allows an unseen instructor to speak for him.
His chest rises and falls with every breath. Pneumatic lungs can collapse, allowing clinicians to insert a needle to re-inflate them or draw out trapped gases and liquids.
He has a pulse, which can be felt on the neck, wrists, feet, thighs, elbows and knees - all places doctors check in living humans. His heartbeat and blood pressure can rise and dip. He can suffer cardiac arrest, requiring CPR or a defibrillator.
His veins and arteries can be filled with water or fake blood. Intravenous fluids can flow into him via a drip tube inserted into his right arm.
He can be a girl, with the use of wigs, add-on padding and interchangeable genitalia. A catheter can be inserted into the urinary tract to ease the flow of fake urine.
His urethane-silicon skin is unnaturally devoid of blemishes and his limb joints look like Pinocchio's, but the skin is soft in the right places, hard and calloused in others. In some simulator models, the skin can bleed when cut. It can blister and show rashes. Future models might have skin that changes color depending upon medical conditions, temperature and blood oxygen levels.
Simulators make ideal patients. They can be perfectly sick.
"Many of the things we can do with simulators we just can't do with real people," says Dr. David Gaba, associate dean for simulation-based learning at Stanford University. "If we saw an adverse event happening with a real patient, the most senior people would have to intervene to protect the patient. Moreover, real patients don't develop all of these problems all of the time."
Not to mention the ability to die, again and again.
REAL ISSUES
The first patient simulators appeared in the 1960s, beginning with Resusci-Anne, created by Norwegian toy maker Asmund Laerdal to teach mouth-to-mouth resuscitation techniques. Resusci-Anne proved popular enough that Laerdal formed a company to make patient mannequins for medical training.
Early simulations were limited by contemporary technology. Harvey was a full-sized mannequin that simulated 27 cardiac conditions in the 1970s. The computer and support equipment needed to make him work took up more space than a dining room table.
Cost was - and remains - a considerable factor. A medium-capability simulator today costs up to $50,000. A state-of-the-art Standard Man exceeds $200,000, plus another $200,000 for the related computers, software and other equipment.
Simulation is expensive in other ways. Dr. Jeffrey B. Cooper, an anesthesiologist at Massachusetts General Hospital, notes that medical residents represent a large chunk of many hospitals' revenue-generating labor force.
"Since they earn while they learn, it costs more money to take them out of the 'production line' just to learn on a simulator," Cooper says. "There are likely savings to be had in reduced adverse events, but I don't think that dollar cost itself is enough to justify simulation."
That justification, clearly, must be in improved healing and lives saved. Roughly 195,000 patients die each year in the United States due to medical errors. Only a handful of empirical studies have shown that simulation actually reduces errors or improves medical treatment, but advocates say plastic patients are a logical part of any remedy.
"There's little proof that simulation has decreased the number of accidents in aviation," observes Cooper, "but do you want pilots practicing while you're in the plane? Of course not."
OTHER BENEFITS
The obvious advantage of patient simulators is the opportunity they provide for clinicians to practice procedures and techniques until perfect. But simulation provides a perhaps more profound benefit, asserts Dr. Louis Halamek, a pediatrics researcher at Stanford University.
"Rigor in teaching technical skills, varies. The more challenging the skill, the more people practice it, though there's an old adage that says, 'See one, do one, teach one.' In medicine, you're expected to be proficient at technical skills very quickly.
"Behavioral skills, on the other hand, are minimally taught, stuff like effective communication with patients, other doctors, nurses."
Simulation's real value may be that it provides practice at teamwork, communication skills, decision-making and managing resources.
That is apparent during the simulations at UCSD. The instructors urge the residents to treat John as if he were a living person. "Tonight, he is your patient and your responsibility," says Dr. Piyush Patel, an anesthesiologist, sternly.
Dr. Ching-Rong Cheng, head of the San Diego Center for Patient Safety, operates the computer that controls John's vital signs, adjusting them to reflect the residents' actions (more oxygen, less anesthesia, another drug). Patel fires questions at them, explaining, "We want you to learn how to make decisions under stress. We want you to make good decisions when you're tired."
Sometimes the residents do; sometimes they do not. They stick with a course of action that clearly isn't working, or abandon it before it's had time to take effect. They appear panicky.
"I'm kind of freaking out about the heart rate and coronary disease," moans Ben, one resident, when John's vital signs turn south. He diligently works through standard keys in an attempt to diagnose John's apparent heart problem. Patel prods him to ask for help, but the other residents are equally flummoxed. Eventually they determine that John's shaky heart requires an electrical jolt, but struggle over how to work the defibrillator. One resident explains that nobody has taught them how to operate this particular model.
Patel is not mollified. "That's the worst excuse of all. It's like people saying they're fat because of glands. You're putting the blame on someone else. You should know how to use every piece of equipment, automatically, without thinking about it, or you shouldn't be practicing anesthesiology."
Patel calls an end to the scenario, then gathers the residents for a debriefing. He asks Ben how he thought the simulation went.
"I don't think the patient did so well," Ben replies, quietly.
Patel agrees. "(Dr. Cheng) is a nice guy; he let the patient survive. I would have killed him off."
UNREAL WORLD
Simulation is one way to provide experience and diversity without real tragedy, Patel says later. "Students get to learn by fire, practice scenarios, make decisions on the spot. These first-year residents made first-year mistakes, looked a little bit like deer in headlights. But that will change. By their last year of residency, they'll be much better at this. They'll make smart decisions, faster and with more confidence."
Twenty years ago, Gaba predicted that virtual reality simulation would eventually transcend robotic mannequins. Doctors would be able to enter holograph-like worlds that looked, sounded and felt real.
Technology has lagged behind imagination, particularly for whole-world simulations. But Gaba and others still think virtual reality will come.
In the meantime, though, simulators such as John and Stan are increasingly used to instruct future generations of doctors about the nature and vagaries of flesh-and-blood patients.
Without, of course, the flesh or blood.
Comments (0)
Greater Paramus News and Lifestyle Magazine
http://www.paramuspost.com/article.php/20060419092227865