Sophisticated instructional simulators provide practice to healthcare students, professionals

The three anesthesiology medical residents spoke with the patient as they prepared him for surgery. Stan D. Ardman, a 55-year-old truck driver, was complaining of chest pain following an accident. The surgeon had not yet arrived when the monitors went haywire — the patient's blood pressure was falling precipitously as his heart beat erratically.

The residents snapped into emergency mode. One took charge as she shocked the patient with a defibrillator, began chest compressions and instructed her impromptu team to inject epinephrine and deliver oxygen.

Stan died 30 minutes later, but the procedure was deemed a success — the residents intubated the patient smoothly, made critical management decisions and performed well as a team. And after all, he was programmed to die without surgical intervention. That's because Stan, also known as Standard Man, was really not alive to begin with. He is a sophisticated instructional simulator used to provide practice to health-care students and professionals.

Stan is but one of the high-tech simulation systems in the newly opened Center for Virtual Care, a state-of-the-art facility consisting of a variety of cutting-edge tools. Established by the UC Davis School of Medicine and Medical Center, the center is located at the main hospital in Sacramento.

Simulation systems have come a long way since the introduction of awkward mannequins on which many have learned CPR. Stan, developed by Medical Education Technologies, Inc., in Sarasota, Fla., can be injected, intubated and catheterized. He has pulses, normal and abnormal breath and heart sounds, pupils sensitive to a flashlight, and an airway that swells if Stan is exposed to a medication for which he is programmed to show signs of an allergic reaction.

Sophisticated programming allows a variety of medical scenarios to play out, the outcome of which depends on actions taken. Stan may suffer from vascular, cardiac and respiratory emergencies, and — with some modifications — obstetric crises as well. Instructors can change parameters as a scenario proceeds or stop the action to provide instruction.

New way to learn

The Center for Virtual Care is in the forefront of a national trend in medical education to supplement the traditional "see one, do one, teach one" approach. This system of training doctors is increasingly regarded as insufficient in a world of increasing complex medical intervention and management. Peter Moore, professor and chair of the Department of Anesthesiology and Pain Medicine, is the medical director of the Center for Virtual Care and a longtime advocate of simulation training in medicine. He believes that the new technology is sophisticated enough to benefit health delivery personnel of all levels.

"We can provide a realistic setting to develop critical thinking and practice a variety of techniques that play out in real time," Moore said. "This is of enormous benefit not only for students to learn new skills, but for professionals to perfect their roles as part of a smoothly running team."

From aviation to medicine

David Dawson, an associate professor of vascular surgery at UC Davis, has had years of experience with simulators in other settings. He served 10 years in the Air Force before coming to UC Davis, including a stint as senior NASA manager and aerospace medicine specialist at the Johnson Space Center in Houston. At NASA, he "flew airplanes that developed engine fires and landed the space shuttle" — on flight simulators, that is.

"Simulators mimic the entire airplane and create situations that a pilot may see only once in a lifetime," he said. "But traditionally, when a physician wants to learn new techniques or handle emergencies, the 'simulator' is the patient. There is no transition between 'read' and 'do'."

When Dawson decided to learn catheter-based techniques, no training simulators sophisticated enough to meet his needs were available in medicine. He had to take three months off from his practice to train with an experienced endovascular surgeon in a different state.

Virtual navigation

"The way we treat patients has changed," said Dawson. "Until recently, we had conventional tools for surgery. Now our interventions are almost like a video game — our hands and eyes are removed from what we're actually doing. Doctors need to develop a new skill set that is image-driven."

The risk-free environment of a simulator is ideal for learning such complex skills. Down the hall from Stan, an interventional surgical team is practicing on "Simantha™" of the SimSuite Training System, developed by the Medical Simulation Corp. in Denver.

The video game analogy is apt. Just like in a real procedure, the surgeon's hands are manipulating the catheter on Simantha's leg; his feet are operating the pedals to deliver radiation for fluoroscopy viewing and to inject contrast dye. Of course, the "real action" is taking place in the "patient's" coronary artery, while all eyes follow the monitor screen as the surgeon moves the catheter through the arteries, inflates and deflates the balloon, and snaps a stent in place, relieving the blockage.

Similar to Stan, a variety of real-life scenarios are available, but based on blockages in the coronary, renal, iliac or carotid arteries. Advanced scenarios help experienced users deal with patients with unusual vascular anatomy or an unexpected reaction to a drug.

After completing a scenario, the team finds out how they handled the case compared to national guidelines and standards, including the drug and radiation doses to which the patient was exposed.

Dawson emphasized that simulation practice is meant to supplement rather than replace traditional medical training. Preliminary evaluation of simulation methods has shown encouraging results, with students completing procedures faster and with fewer errors after simulation training.

Looking ahead still further

UC Davis Medical Center is the first site in California and only the third in the country to offer the state-of-the-art SimSuite system. Dawson hopes it can serve as a regional training facility, giving physicians opportunities to practice using new devices or acquire new skills.

And while Moore is excited about the simulation tools the Center for Virtual Care has to offer now, he knows a tertiary care institution can't sit still for long. The medical center is already looking to take training to a whole new level — creating a virtual hospital and critical care environment, where students and professionals in various health-care capacities can learn to deal with multiple challenges at once to provide a smooth flow of care.

With perhaps a half-dozen mannequins — in addition to Stan and Simantha, the center already has a child mannequin, Morgan, with pediatric physiology, and will soon have a portable model for field work — one could simulate a busy intensive care unit or a multi-vehicle crash or terrorist attack to allow paramedics, nurses and physicians to practice their roles in tandem.

"The bottom line is patient safety," said Moore. "When healthcare professionals have the chance to practice skills as well as work together as a team, patients benefit from the experience gained. The reason we are taking a leadership role in developing system-level education is to improve the health of our patients."