VIRTUAL PATIENTS

Teaching through simulation comes of age at UMMC

The eyes are open, he’s wheezing and coughing, his fingernails turn blue, he gasps for breath, says he can’t breathe, his airways constrict, and he dies.

This high fidelity patient simulator – going through the cascade of symptoms of anaphylactic shock – is about as real as it gets without flesh and bones. It responds to whatever students do or don’t do in the attempt to save him.

“A real patient near death in the hospital may not be the best teaching moment,” said Dr. Anna Lerant, associate professor of anesthesiology and co-director UMMC’s Medical Advanced Skill and Simulation Education Center.

Simulation is the next big advance in health-care education, but it’s expensive. With a recent $1.9 million grant from the Hearin Foundation, the simulation center is poised to accrue more funding from other sources for better space and more equipment.

Dr. Claude Brunson, chair of anesthesiology, is principal investigator of the Hearin Foundation grant that provides salary support for physicians who form the core teaching team.

Students in teaching hospitals have traditionally learned medical procedures from textbooks, discussion, practice on static mannequins and bedside instruction. Those methods are time-tested and valuable, but have limitations.

Few patients would volunteer enthusiastically for the student’s first IV, first catheter placement, first lumbar puncture or first anything.

“The first time you do a procedure on a real patient can be gut-wrenching,” Lerant said. “One of the main goals of the center is to train students to do the procedures before they touch a live patient.”

Flight training for pilots was among the earliest use of simulators. Since then, video game-makers have been the innovators of the computer technology that makes virtual patient care such a robust tool for educators, according to Dr. Ken Vick, assistant professor of surgery and director of the surgical simulation center.

Now simulation devices can mimic patient encounters for a wide range of caregivers – EMTs and paramedics, nurses, dentists, medical students and residents. Last year (ending June 30), the simulation center instructors spent 312 hours training both present and future health professionals.

“It’s more than just learning how to do the procedure. Simulation teaches cognitive skills, pattern recognition, communication and team organization,” said Dr. Jim Phillips, associate professor of emergency medicine. Phillips wrote the original grant proposal for $275,000 from the Department of Homeland Security that purchased the first three patient simulators to use in disaster life-support training.

These teaching attributes are especially important when a team has to form suddenly and act quickly. Dr. John Bethea, assistant professor of anesthesiology and director of the center, said the Hearin Foundation grant has allowed us “to move simulation to the floors and special units to improve safety and care throughout the hospital.”

The center’s staff now take one of the simulators to patient floors and call a surprise code. They set up the simulator, controlling computer and recording equipment in an unoccupied room. When a code is called – when a patient is in cardiac arrest – the team assembles (nurse, respiratory therapist and physician) and does what they’ve been trained to do on the simulator.

“We can discuss the results with the team and discover the deficiencies,” Lerant said. “Was the crash cart accessible? Who had the pagers which responded to the code? Who was in charge?”

“We can learn very quickly where the deficiencies are,” Lerant said, a crucial piece in the hospital’s accreditation process.

Dr. Jeff Orledge, assistant professor of emergency medicine, is the center’s co-director. He creates scenarios for the simulators based on real-life emergencies, and on Sept. 1 developed a way to teach residents how to place an intravenous pacing catheter on the simulator.

A set of wires, which does the same job as a heart pacemaker, goes into a patient who is critically ill to correct irregular heart rhythms. It is not a routine procedure, but could be a lifesaving one. One week later, an emergency medicine resident had to place such a pacer in a real patient. He told Orledge, “I felt like this was my 50th time doing this instead of my first because I had trained on the simulator.”

Senior medical student Alan Torrey, who took simulation training during his rotation in anesthesia, said “the experience of recalling information while the clock is ticking really gives you confidence.” And it was not uncommon for the students to forget some essential piece of information.

“I’m glad I did forget, because when you forget something while people are watching, you will never forget it. You learn from each mistake so you know what to do when it really counts.”

UMMC’s original whole-body simulators have been upgraded at a cost of $80,000 each. The center also includes other task-training models, the newest of which is the ultrasound-guided placement of central lines.

In addition to Bethea, Brunson, Lerant and Phillips, the center’s instructors include nursing educator Michelle Schweinfurth; Dr. Thom Allingham, associate professor of anesthesiology; Dr. Stephen Commiskey, assistant professor of anesthesiology; and Dr. Andrew Anderson, Dr. Jonathan Jones and Dr. James Thomas, assistant professors of emergency medicine.

Such simulation centers are not standard in health professional education now, but they will be, Lerant says. The existing center occupies 1,023 square feet in the classroom addition in repurposed space. The high-fidelity simulators are used in a room that was meant for storage. “As the demand for simulation increases, we will need more space, and our goal is a state-of-the-art facility.”

The surgical simulation center that opened in 2003 allows medical students and surgery residents to learn laparoscopic and endoscopic surgery techniques.

“Five years ago, surgical simulation in medical schools was uncommon. Now many schools have them, and in another five years, I think it will be standard,” said Dr. Marc Mitchell, chairman of the Department of Surgery.

For the last three years, Department of Surgery residents have placed first, second and third in the national Top Gun competition of the Society of Gastrointestinal and Endoscopic Surgeons. The “shootout” awards recognize skill, speed and accuracy in laparoscopic and endoscopic surgical simulators. And three residents in the Department of Emergency Medicine will represent the Medical Center in the American College of Emergency Physicians’ Sim Wars competition in October. Only six institutions were selected to compete.

The Department of Obstetrics and Gynecology and the School of Nursing jointly use a high fidelity simulator to train students in vaginal delivery.  The School of Dentistry also has a state-of-the-art simulation center for students.

Today’s technology makes the simulation of many procedures possible. And according to Bethea, the documented enhancement of student skills and the need for patient safety make simulation imperative.

-Janis Quinn

2009-09-17 00:00:00 3535