Photo by Dennis Walsh
Playing Doctor
At the Hannaford Center for Safety, Innovation and Simulation at Maine Medical Center high-tech mannequins, convincing actors, and committed instructors work together to prepare resident physicians for the real world.
Ethan has a lump on his leg. He’s 5 years old, and his mother has brought him to the emergency room because the lump has swollen and turned red and is causing the child considerable pain. Now he’s in a hospital bed with his mother’s calming hand on his forehead, as two young physicians talk to him and look at his leg.
“Ow, ow, it hurts,” the youngster cries, as one of the doctors examines the inflamed area.
The doctors decide to sedate Ethan with an intravenous ketamine solution and to also give him a local anesthetic before they drain the abscess. An oxygen mask hangs near Ethan’s head. One of the physicians lances the lump and releases the pus beneath the skin. The procedure is going smoothly until Ethan begins to gasp and wheeze.
“What’s happening? What’s going on?” the mother wants to know, her voice pinched with anxiety.
One of the doctors offers a quick explanation that Ethan seems to be experiencing spasms of the vocal cords, a rare side effect of ketamine. But their attention is primarily on their patient. They need to clear his airway so that he can breathe until the spasms subside. Ethan stabilizes for a moment, then goes into a set of renewed spasms. The doctors give him more oxygen. After several tense minutes, Ethan’s breathing returns to normal and he slowly returns to full consciousness. His relieved mother is at his side. “It’s all over, sweetheart,” she says.
“You did great, Ethan,” says one of the doctors.
His partner nods as a voice comes over an unseen intercom: “This ends your simulation.”
The doctors aren’t practicing physicians—not yet, anyway. Ethan’s mother is Susie Lane, an aesthesia technician and simulation specialist at the Hannaford Center for Safety, Innovation and Simulation at Maine Medical Center in Portland, where the faux procedure has just taken place. And Ethan isn’t human at all. He’s a mannequin. His voice, bodily functions, and vital signs are controlled from an adjacent room behind one-way glass. The pus that came out of the abscess on Ethan’s leg was made from a mixture of yogurt and honey.
In a classroom across the hall, some two dozen students and their instructor have just watched the procedure live on a pair of flat-screen televisions. They, like the two young physicians, are residents at the Maine Medical Center-Tufts University School of Medicine (MMC-TUSM), and such simulations are an integral part of their curriculum. After each one, the class will participate in a debriefing session to discuss what went right, what went wrong, and why.
“The debriefing rooms are the heart and soul of the place,” says the center’s director, Dr. John “Randy” Darby. “We often spend two to three times as long debriefing an event as we do running the event.”
MMC-TUSM students start doing simulations their first month as a resident, something Matt Delaney, a recent graduate, found invaluable. “Being a doctor is a new sensation. You get to make all the mistakes here,” he says. “It takes a lot of the anxiety out of seeing real patients. It’s a great safety net.”
Maine Medical Center’s simulation center opened in October 2010 at the Brighton Avenue campus in Portland. It takes up one entire floor of the building. The center contains fully-equipped operating rooms, emergency room suites, patient rooms, as well as a number of classrooms and conference rooms, plus control rooms, a skills lab, offices, and storage spaces. Amazingly, it’s run by a full-time staff of just 10 people.
You’ll see a lot more people than that on any given day, however, because the sim center is busy. The primary mission is to train future physicians attending MMC-TUSM, but it’s also used by a variety of Maine Medical Center clinical and surgical teams. Inquiries are already pouring in from hospitals and medical organizations throughout the state asking about future training opportunities.
The simulation center is on the third floor of what was once an osteopathic hospital, and still looks and functions very much like a hospital. There’s even an elaborate record-keeping system for virtual patients, though safeguards are in place to ensure that virtual records never get mixed up with real ones.
Darby describes the center as part of a “second wave” of simulation centers, built in the past decade, that benefit from the pioneering centers that opened at large university hospitals in the 1990s. He and a committee from MMC spent three years looking at simulation centers all over the country during the planning process. The center’s startup cost was $5.82 million, made possible in part by a $500,000 grant from the Hannaford Charitable Foundation. It’s an in-house operation; Maine Medical Center does not rely on government or fundraising to cover the cost of running the center.
“Maine Medical Center built the entire thing,” Darby says. “We have a very strong interest in doing medical research. We are looking at grants and funding, but we don’t have any commercial relationships or government relationships that pay for our operational costs. The faculty time is taken care of by the departments, but the support and equipment is provided by us, so they can run their courses here with no concerns about the transfer of money. It’s been a very transparent process and it makes the place work.”
Darby still works as an anesthesiologist at Spectrum Medical Group in addition to running the center. He first became interested in medical simulation while serving in the U.S. Air Force. “There’s the well-worn comparison between administering anesthesia and flying,” he says. “People talk about hours and hours of boredom broken by seconds and minutes of sheer terror. When things go well it’s great, but when something goes wrong it tends to be really catastrophic.”
Susie Lane spent 20 years as a cardiovascular technician, often working beside Darby on critical cases. “In my prior job, I was his right-hand person during very critical open-heart surgery, during the placement of all the lines that go into a patient. I would monitor those lines while the patient was on the heart-lung bypass machine. Now I get to set up a lot of the same equipment, but I set it up to run on the mannequin. Props are important in creating the environment as realistically as possible.”
The “suspension of disbelief” is as important in medical simulation as it is in literature. To make the scenarios as real as possible, simulation specialists craft and rehearse what Darby characterizes as “intricate one-act plays.” These scripts become the blueprint for each teaching situation. In the control room, one specialist controls the mannequin while another manipulates the readouts on the instruments hooked up to the plastic patient. Any actors in the room have an audio feed so that controllers can whisper instructions in their ears during the scenario.
And while some of the easier roles can be played by simulation center personnel, there’s also quite a bit of work for real actors looking to broaden the range of their skills or to help train the next generation of Maine physicians. “We actually have a cadre of 70 or 80 trained actors and actresses, and a full team to train them to play patient roles,” Darby says. “These actor/patients interface with medical students, nurses, and residents for interpersonal skills, delivering bad news skills, diagnostic issues, and how you go through things like informed consent. A lot of the actors we have are very experienced, and some of them are excellent at the end of the encounter at giving real-time feedback to the medical students and the residents.”
Dr. Jeffrey Holmes is in charge of writing the scripts for some ED-related scenarios. (He also provided Ethan’s voice during the simulation.) Scripting a 15-minute procedure can take up to four hours. “We look at our monthly theme, whether it’s a cardiovascular or respiratory month, and we try to figure out what some of the core topics would be, and some rare instances or complications that might happen,” he says. In each script, it’s important to limit the number of teaching points, so that students in the debriefing can focus on a particular response to a particular situation.
“We give them a little bit of a heads-up about what topics might be covered,” Holmes says. “And then there’s no better motivation than being in front of all your peers in a scenario to study for that. They’ll read up on potential topics, do the scenario, and then right after that we’ll debrief it and go over those topics again. That repetitiveness and redundancy is really what makes it stick.”
It follows that a theater needs a prop room, and the center’s planners didn’t skimp on the backstage area, a large room where mannequins are readied and repaired. “We learned in the planning process that most sim centers underplan for storage space,” Darby says. “We always had a desire to use more of the space for clinical work. But we had to have places to repair and work on stuff and store it. It was one of the subtle, simple details that went into the planning that made a big difference.”
The room is used not only to store and service mannequins and medical equipment, but also to mix up messy concoctions used in the simulations. “My team is excellent at making vomit, blood, stool, diarrhea—you name it, they’re pretty good,” Darby says, standing in front of two large sinks and a closet full of condiments and chemicals. “They actually have odor kits that can make the oatmeal stuff smell like alcohol-laced vomit. They can make some foul-smelling colonic discharges, and all kinds of nasty human bile fluids, stuff that only adds to the realism of cases.”
In the skills center, which looks like a college science classroom, students can practice intubation on low-tech synthetic heads and throats; on the flip side, they can learn how to use a colonoscope. Again, repetition builds muscle memory, which prepares a nurse or doctor for doing the same procedure on a real patient.
Inside the simulation center’s ceilings and walls, approximately 24 miles of wiring keep all this technology humming. The center has 75 video cameras and 22 large television monitors. Anyone authorized to use the sim center’s computer system can access videos of the simulations—a boon to learning, but also a potential risk to privacy and security. For that reason, cell phones are not allowed.
“We can digitize every encounter, and we can look at it in real time, and we can digitize it for every provider in the hospital who has password access rights to our database,” Darby says. “That info is tightly controlled. Most of it auto-destructs after 30 days. What happens here stays here. This is a sensitive training area and we take our mission very seriously.”
“There’s a large demand for this type of training,” he continues. “The public’s become much more aware that we need to take novice students and residents and get their skill level up to a much higher level of proficiency before we’re cutting them loose to go to the hospital and do things to you and me and everybody else. When I was a surgical resident years ago, they worked you 36 hours on and 12 off for weeks and weeks. You were working 110 hours a week. We’re not allowed to do that anymore, which is good. We can conduct simulated medical encounters and simulated medical events without real patients. There’s no risk of harm, and residents are at a higher proficiency level when they do start out.”
And the realities of modern medicine in the United States dictate that doctors must often work in a limited time window, or on an outpatient basis, with patients who would previously have stayed in the hospital for days at a time.
“We don’t have patients in the hospital as long as we used to,” Darby says. “We’re lucky if patients stay in the hospital for 23 hours. So, as you can imagine, there’s not as much teaching material around for residents to get their hands on.
“Simulated systems aren’t ever going to replace seeing patients in the hospital, but what we can do is get their level of training quite a bit further down the road using these systems and not have to rely on time and chance. Part of the reason residents used to spend so much time in the hospital is that you had to be around the hospital enough times to see enough stuff to be trained. We now try to do that synthetically.”
The big question is: Does it truly work? Does the training residents receive at the simulation center translate into real results in real hospitals? The sim technology and practices are new and the results data curve is correspondingly short. “I caution people about the science,” Darby says. “There’s no absolute proof that someone who performs well in a simulated environment will perform well in a clinical environment. I think it’s here to stay, though. I think you’re going to see more and more technology-based learning, in part because of the time pressures on the learning system.”
Young doctors like Delaney, who now works in the emergency room at Portland’s Mercy Hospital, say the simulation center training is tremendously beneficial. “Almost everything that can go wrong I’ve seen go wrong,” he says. “When you see it for the first time in real life it’s nice, because you have that muscle memory and some idea of what you’re doing. You do it five or ten times in here, so when you treat a real person, it’s the same sort of thing: You plug your oxygen in, set the patient up the right way. It’s like tuning your guitar; it’s nice to have that stuff be automatic.”
The training is not all technical, however. “There’s a real risk of doctors becoming technicians rather than doctors,” Darby explains. “We spend a lot of time talking about how to take 21st-century technology and inject it into the traditional doctor-patient relationship. Sometimes patients don’t like it when doctors are typing away on a computer and not looking at them. Medical schools in the past did not always select for people with good interpersonal skills. This becomes particularly important in rural areas where a doctor has a very intense relationship with the community.”
The center’s goal is to make simulated training available to medical professionals throughout the state and in all departments of the hospital. Plans include providing remote electronic access to medical practitioners in rural areas.
“None of this would happen without the production staff, IT, engineers,” Darby says. “We were very lucky in terms of who we were able to convince to come join us and make the thing fly. It’s a great team effort.”
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Extremely Patient Patients
The medical mannequins at Maine Med’s Sim Center “live” to help students hone their skills.
Harvey the heart mannequin doesn’t have any legs. But that’s okay, because he doesn’t need to get up and go anywhere. His job—at a cost of over $100,000—is to lie on the table and mimic various heart conditions in humans.
Harvey was built at the University of Miami, and now spends his days at the Hannaford Center for Safety, Innovation and Simulation at Maine Medical Center. He’s hooked up to an elaborate speaker system and a control board, which instructors can use to impart valuable lessons regarding the care of cardiac patients.
The mannequin has sensors that can detect where a student places a stethoscope and respond accordingly. “You have to have the stethoscope in the right place for it to transmit the correct sound,” says Dr. Randy Darby, director of the simulation center. “An instructor can come in here and cover up the control panel and ask a student to do an exam. The mannequin senses where the bell of the stethoscope is and responds accordingly.”
Harvey is one of 12 sophisticated mannequins, or “patient simulators,” in service at the simulation center. Two adult mannequins used in operating room simulations can actually “breathe,” meaning they take in oxygen and exhale carbon dioxide. A mannequin named Hal (no relation to Harvey) comes equipped with a synthetic lung.
“We can intubate Hal, and his lung functions can be programmed to behave like he’s had trauma to the lung, or he has pneumonia, or he has asthma,” Darby says. “We can use Hal not only to train OR ventilation issues, but we can put Hal over in the ICU room and have a respiratory therapist learn how to use the ventilators to respond to certain underlying lung conditions.”
Perhaps the most complicated mannequins are the two pregnant ones, the birthing simulators, which can be programmed to represent a mother in various stages of pregnancy and can simulate the birth of a baby. The center also has mannequins that stand in for newborns and premature infants, as well as the pediatric mannequin featured at the beginning of this story.
A fully computerized patient simulator can cost as much as $300,000. But there’s also a low-tech element to some of the training. The center employs a number of sand-filled dummies that cost less than $12,000 but weigh 250 pounds. Darby points out that nurses and other hospital personnel need practice in getting inert patients from bed to gurney and back again without injuring themselves in the process. “Most patients who faint in the hospital collapse in the bathroom,” he says. “You have someone who’s curled up around a toilet on the floor, what do you do? We’ll stick a mannequin behind the toilet and let them practice. It’s a simple educational tool that’s very effective.”
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Company Brief:
Hannaford Center for Safety, Innovation and Simulation
Portland, Maine
Year founded: 2010
Employees: 11
Startup cost: $5.8 million
Annual operating budget: Approximately $500,0000.
Creation details: Created by Maine Medical Center as a training center for students in the Maine Medical Center-Tufts University School of Medicine medical school program, and to support ongoing training for MMC staff. Financed by Maine Medical Center, with a $500,000 gift from Hannaford.
Positions: Software engineers, production staff, information technologies specialists.
Future challenges: Expanding training opportunities to include EMT/paramedic training, partnerships with nursing schools, travel training programs for rural healthcare providers.
To learn more: http://simulation.mmc.org
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