Training for the Unexpected

BY MELINDA SACKS

SPRING 2003 - A team of nurses and doctors races against the clock to revive the "baby" -- a rubber doll rigged to handle respirators, injections, and CPR. The baby's "mother," another mannequin, lies with her feet in the stirrups of the delivery table in this simulated delivery room that is fully equipped with the latest hospital equipment. Microphones and cameras record the action.

On the other side of a one-way mirror, Packard neonatologist Louis Halamek, M.D., sits in the simulator control room, hand on the lever that will raise or lower the newborn's heart rate, increase or decrease her respiration, and set off emergency alarms indicating respiratory or cardiac distress.

"It's amazing how real it becomes when you're in there," says Joy Gale, R.N., a Redwood City-based Sequoia Hospital nurse, who was in the "hot seat" recently to update her neonatal resuscitation skills. "You forget it's a simulation."

The real-life tension that fills the room as events progress is exactly the point, explains Halamek, director of the training facility called the Center for Advanced Pediatric Education (CAPE). "Simulation training is a wonderful way to practice the things we do fairly often to maintain our skills, but it is also a way to practice the rare but devastating events that do occur in medical practice -- for example, the situations that may happen only once or twice in one's career."

Completed in November 2002, this unique pediatric and neonatal simulation training facility is part of the Charles B. and Ann L. Johnson Center for Pregnancy and Newborn Services at Lucile Packard Children's Hospital. It is the only dedicated pediatric and obstetric medical simulation center in the world. But simulation training has long been recognized as a valuable tool for teaching skills necessary to deal with emergencies.

"These kinds of ideas have been around a long time in industries where there is risk to human life," says Halamek, a father of two who acknowledges an affinity for technology. From the airline industry to nuclear power plants to the military, simulators have been successfully employed to give hands-on training to those who must act decisively in a crisis. But until now, their use in the field of medicine has been limited, due to cost and the complexity of duplicating medical situations, which involve sophisticated equipment and a team of role-playing peers.

"Adults don't learn particularly well sitting in a dark classroom after lunch watching slides go by," observes Halamek. "They learn best by immersing themselves in relevant, hands-on training opportunities."

The new CAPE facility was funded primarily by an anonymous gift to Lucile Packard Children's Hospital. Participants in the training also pay a fee based on the customized program they seek. CAPE offers services to both novice and experienced medical practitioners, including medical students, nurses, physicians, staff members at Packard Children's Hospital, and those from the broader community.

CAPE's simulation training gives participants a chance to maintain routine skills and to practice reacting to situations that may occur only once in a lifetime.

The training program relies on sophisticated mannequins -- a female with interchangeable abdomens to simulate different fetal positions, and eight babies who can mimic complex and rare medical conditions. Halamek and 25 volunteer colleagues role-play as necessary to act as fellow practitioners, and sometimes, distressed parents. It is a marriage of technology and humanity that allows participants the once-in-a-lifetime chance to practice skills that are life-saving.

In addition to Packard staff, physicians and nurses from around the Bay Area, across the country, and around the world already have attended the training. A Swedish group is returning for a second round of simulations because they hope to develop a similar program in their country.

"CAPE represents our effort to make education a priority," notes David K. Stevenson, M.D., director of the Johnson Center and chief of the Department of Neonatology at Packard Hospital. "It is a service to the Hospital and to the community.With the use of the latest innovative technology, we are able to give our practitioners a unique form of education that we feel is extremely effective."

In fact, CAPE staff is using research studies to determine if the training improves a participant's job performance. Halamek and his team also are working with industry to help refine the current technology so it more easily can be used for pediatric training.

Benefits of Hands-on Training

"You can really tell the difference when someone has gone through the program," says Jennifer McAuley, R.N., an interim clinical nurse specialist who has taken the training and now plays the role of a staff member in the simulations. "There is a calmness that comes over a group and you can tell which practitioners have been through the simulation and those who have not. It's really eye opening."

Glenn DeSandre, M.D., a Packard physician who has completed the training and now helps run it, knows firsthand how valuable a "practice run" can be before dealing with the real thing. After he went through the simulated birth of a baby with a rare condition in which its intestines have moved into the chest cavity, he encountered the same situation in a real delivery room.

A key aspect of the simulation training is a feedback session during which doctors and nurses get to watch and discuss their actions step by step.

"I definitely felt it had prepared me to stay calm and do the right thing," he says. "In situations you've never dealt with before, you feel more nervous and agitated. The carry-over from CAPE is great. It's almost like an immunization. You are prepared because you've been exposed to it before."

Each 10- to 30-minute simulation is developed with the participants' needs in mind. Often nurses and doctors come to CAPE to update certification or receive specialized training. During the simulation, the situation evolves depending on the team's performance. With the touch of a button or the adjustment of a lever, Halamek can alter the course of a scenario from behind the scenes, causing the baby to improve, or making things worse to test the reactions of the team. Halamek and his team observe the action on a set of closed circuit monitors that give a 360-degree view of the action.

Feedback Builds Confidence

Each CAPE session is videotaped, then reviewed in the classroom that adjoins the simulation suite. Gathered around the wide, flat-screen plasma monitor, doctors and nurses watch and discuss their actions step by step.

"What is the first thing you do when you walk into the delivery room?" poses Halamek to the semi-circle of practitioners who join him to watch the video. "What are the questions you need to ask? What do you think was going on?"

As the scenario unfolds, the discussion allows review of basics and specific details, from what is said to the mother about how her baby is doing, to when it is appropriate to call for back-up help. Even the phones are set up to connect to the control room so that participants can make calls to role-playing specialists for advice.

"Unlike in the O.R. where an anesthesiologist deals with a patient who is asleep, in the delivery room, mom is awake, and dad is there, probably with a video camera," says Alison Murphy, M.D., a staff physician in neonatal intensive care and a member of the CAPE training team.

"You've got an OB, a pediatrician, delivery room doctors and nurses. Sometimes things can get a little tense, not politically so much, but when the physician comes into the room and isn't aware of the situation.We do scenarios that involve communicating. Watching those videos can be very instructive."

Notes Halamek: "People who go through this training will have more confidence in their skills. The purpose is not to tear people down. It is to build them up."

More Than Medicine

Simulations aren't only a test of medical knowledge, say graduates. The scenarios also test one's ability to communicate with the rest of the team and parents, and to be innovative when the traditional method for something isn't working.

Murphy helps Halamek develop the scenarios, which she believes provide a highly effective learning environment for everyone from medical students to seasoned health providers. The rarest and most difficult cases can be recreated in this safe setting, where things can go terribly wrong, and the unexpected can happen without any real threat to the patient.

"You get to the point where you do what you think you should have done, and you expect the baby to get better and everyone to say, ‘Hey, good job,' says Murphy. "But the parents are standing behind you saying, ‘What's wrong? What's wrong?' The monitors are going off, and you really get sucked in, no matter who you are."

The potential to develop and expand CAPE programs is enormous, say its founders, who hope to offer programs in how to break bad news to parents, how to deal with death and dying, and other sensitive and complex pediatric and obstetric medical issues. Videotapes of simulations offer another vehicle for educating health providers, and will be made available over time. Even virtual training that is carried out over the Internet is part of the plan.

"We still train people pretty much the same way we did 100 years ago," says Halamek, "and that needs to change."