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Richard Downs


Video ping-pong, role-playing Dungeons and Dragons, and Betsy Wetsy, the doll so “lifelike” she pees. Each was once at the cutting edge of its particular genre of simulation.

But time, tide and technology wait for no man — or mannequin — as illustrated by the current state of simulation education in medicine. The Center for Advanced Pediatric Education at Lucile Packard Children’s Hospital, for example, uses mannequins that simulate the sounds of beating hearts and breathing lungs, with chests that rise and fall. In an emergency, they can be intubated, ventilated and injected. Through wireless speakers, they can voice words an instructor speaks on their behalf. The mannequins include infants, young children and a mannequin mom who delivers her mannequin neonate. Some of the mannequin newborns even have congenital malformations. Poor old Betsy seems about as lifelike as a prehistoric cave painting by comparison and just that up to date.

The advances in mannequin capabilities reflect both the flowering of technology and proliferating interest in simulation training. Stanford anesthesiologist David Gaba, MD, is one of medical simulation’s pioneers. In 1986 he created the first modern hands-on anesthesia simulator and in 1995 founded the Simulations Center at the Veterans Affairs Palo Alto Health Care System. Gaba is also the father of medical simulation training at Stanford, where he is the medical school’s associate dean for immersive and simulation-based learning. He says the number of simulation groups has been snowballing since 1990, when only Stanford and the University of Florida had major efforts. According to a tally kept by England’s Bristol Medical Simulation Centre, over 100 centers are operating in Europe and more than 300 in the United States.

One obvious advantage: Trainees can attempt procedures they haven’t done before without risk to the patient. Gaba thinks simulation training is so valuable that medical personnel should train periodically throughout their careers on simulators and undergo evaluations, much as airline pilots do today. “What really is needed is a whole reorganization of the culture of training and assessment in health care,” says Gaba.

Over the last 10 years, the simulations at CAPE have grown to involve entire teams of medical personnel in simulated settings complete with hospital beds and all the equipment and supplies used in actual pediatric care. Instructors in a control room look onto the simulation room through a one-way mirror, behind which they can change a scenario on the fly. After a session, the trainees debrief with an instructor as they view a video made of their session.

Whole delivery-room teams do training courses such as neonatal resuscitation and maternal cardiac life support. The goal is to help doctors and nurses sharpen communication skills as well as medical skills, because often it’s communication that makes or breaks the effort to save a life. As Lou Halamek, MD, associate professor of pediatrics and head of CAPE, puts it, “If you look at what we’ve done in medicine, nursing and allied health-care profession training, we’ve essentially trained people in isolation. And then we throw them together, often in times of crisis, and expect them to function well together. It just doesn’t happen.”

If you’re looking to get virtual…

Places to play doctor at Stanford

Center for Advanced Pediatric Education
CAPE offers simulation training in neonatal, pediatric and obstetric medical emergencies using mannequins, with some actor role-playing, in replicated hospital settings in dynamically changing scenarios.

Veterans Affairs Palo Alto Health Care System Simulation Center
The center boasts replicas of an operating room and an emergency department/intensive care unit, four patient simulators and complete audiovisual recording capabilities.

Coming soon:
The Goodman Simulation Center
Overseen by the Department of Surgery, GSC will give students hands-on experience — without touching a human being — using mannequin simulators and specialty simulators for practicing placement of catheters, stents, endoscopes and laparoscopes. Surgical teams could rehearse before an actual surgery. The center will be adjacent to Stanford Hospital’s operating rooms and near the ICU. Opening in November.

Immersive Learning Center
ILC classrooms will be equipped with part-task trainers such as “IV arms” or mannequins for practicing physical examinations or invasive procedures; a mock clinic with patient actors; replicas of an operating room, emergency department, ICU and hospital room; and a virtual reality and visualization center. It will be in the Learning and Knowledge Center. Opening in late 2009

CAPE uses actors in some simulations, such as the scenario of delivering bad news to a parent of a baby that didn’t survive. Only a living person can respond as a distraught parent might. But, mannequins certainly have advantages. “With an actor you can’t stick them with needles or put tubes in them, you can’t ask them to have diseases that are serious or lethal,” says Gaba. “They don’t like to die, whereas the mannequins don’t really care.”

Both Halamek and Gaba agree that it’s crucial to select the appropriate simulation for the lesson being taught. Halamek says a pricey, high-tech mannequin is the last item one should buy in setting up simulation training. And for some types of training, mannequins aren’t needed at all; a virtual world on a computer screen is just fine.

One of the leaders in computer simulations is the Stanford University Medical Media & Information Technologies research and development lab. At SUMMIT, director Parvati Dev, PhD, and associate director LeRoy Heinrichs, MD, PhD, have been working on computer programs ranging from simulations that allow the user to feel resistance when using a specially rigged scalpel to operate on virtual patients, to multi-player medical emergency simulations that are available over the Internet. The latter they’ve been developing with Forterra Systems, a leading simulation maker.

Making computer simulations medically accurate is critical, but they also have to be technologically functional, and that’s where Kevin Montgomery, PhD, technical director of the National Biocomputation Center at Stanford, is involved.

“I’m a geek,” he says. “A geek who’s an MD wannabe.”

Montgomery is also an evangelist for simulation training. One project he’s part of seeks to gain converts by developing an open-source surgical simulation program. The program, called Spring, is a starter kit to help academics and researchers develop their own simulations. In the first seven months it was available on the Internet, starting in December 2006, Spring was downloaded more than 600 times.

The planned widespread availability of computer simulations meshes well with Gaba’s hopes for the future. He envisions a virtual hospital, with students playing their future professional roles. Medical students would play interns and residents, interns would play attending physicians, nursing students could be the floor nurses and charge nurses and so on. In their last years of medical school, students spend time working in various specialties and Julie Parsonnet, MD, senior associate dean for medical education, sees a place for simulations there. “We’re encouraging all of those programs to develop simulations, especially for things that medical students might have missed,” she says.

The early obstacles faced by simulation medical training — technological and attitudinal — have largely been overcome. But hurdles remain, notably time, money and personnel.

Time for training has to come from somewhere. Even schools that value simulation training must decide what part of their curriculum to sacrifice to make time for simulations and where to find money to buy and run them, Gaba notes.

Although some simulators can be costly, instructors are the biggest expense, he says. When a staff doctor is off running a simulation instead of treating patients, a hospital loses revenue. But you can’t just simulate a qualified instructor, nor can you create a mannequin to fill in on rounds.

Current obstacles aside, Gaba and Halamek think simulation training will keep growing, in part due to increased demand by a public becoming more aware of its availability.

Just as no one wants to be on a plane with a pilot who’s never flown, no one wants a surgeon who’s never performed surgery. Most would prefer their rookie — pilot or surgeon — to have trained on a simulator, says Thomas Krummel, MD, chair of surgery and head of the soon-to-be-completed Goodman Simulation Center.

Asked if he would rather have one of his children operated on by a surgeon who has never done surgery, but has done 50 simulated surgeries, or one with just a single real surgery and no simulation experience, Krummel replies: “I would say that someone who has rehearsed 50 times is probably more broadly able to do and deal with unusual nuances than someone who has done actual surgery one time.”

Admittedly, it’s about as answerable a question as whether Batman would beat Superman in a fight. But Krummel makes the point that simulations can expose surgeons to a far wider range of the anatomical variations, and in a much more time- and cost-efficient manner than real surgery. “I think simulations for complex surgery may be an even bigger bang for the buck than basic training of medical students and surgery residents,” he says.


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