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Hospitals and teachers have discovered that one way to help students and professionals improve patient care is by faking it.
More and more, they use mannequins, simulator gadgets and mock hospital and operating rooms to expose nursing and medical students, resident doctors and others to crucial procedures. These include putting in intravenous lines and catheters, performing surgeries, working as a team, responding to crises and delivering babies.
The trend recognizes that novices practicing on actual patients is a favor to neither novice nor patient. It also responds to a 1999 Institute of Medicine report that said 44,000 to 98,000 patients die in hospitals annually because of medical errors. The report recommended, among other things, that hospitals and schools use simulation for training, much like aviation uses simulators for pilots.
A 2011 national survey of medical schools found that 95 percent use full-scale mannequins, 93 percent use training devices and 60 percent use screen-based, virtual reality systems.
Dr. Chandra Are, a surgical oncologist at the University of Nebraska Medical Center, said an old med school adage — “see one, do one, teach one” — minimized the difficulty of many procedures. That notion has been replaced by the importance of practice. Are demonstrated a new device in UNMC’s simulation laboratory that closely imitates the touch and dexterity needed to perform colonoscopies or to place an endoscopy tube down a patient’s esophagus.
“Oh, it is a very good representation,” Are said.
At Nebraska Methodist College, nursing students Katelyn Smith and Kali Bernstrauch practiced adjusting and changing the colostomy bag on a mannequin in the college’s simulation area, which opened in 2012. The area features three clinic suites and mannequin patients, some of which make lung and heart sounds or simulate having a baby.
The colostomy bag used for a patient with bowel disease contained a mixture of chocolate frosting, guinea-pig food and corn meal to mimic the material that flows from a real colostomy.
Simulation hasn’t terminated student rotations in hospitals, lectures and textbooks. Nor has it replaced cadavers, which allow students to see the uniqueness inside each human body when learning basic anatomy.
Simulators provide great training — to a point, said Dr. Paul Paulman, assistant dean in the UNMC College of Medicine. “It’s impossible to capture the full richness of the human response” through simulation, Paulman said. “It can’t pick up all the unpredictability.”
But simulation has broadened the scenarios students might encounter and gives them more hands-on training.
“A lot of times you don’t necessarily see certain things in the hospital,” said Smith, a third-year student from Nevada. “We don’t know what to expect” from simulated situations, she said. “When we come in here, it’s a surprise.”
Bernstrauch, a second-year student from Norfolk, said it’s nice to practice procedures without worrying about hurting a patient.
Nursing students for decades used oranges to practice giving shots. The first widely used mannequins appeared in the 1960s.
College of St. Mary nursing student Natalie Pfeifer said she’s more at ease assessing a real patient after training with mannequins that simulate abnormal heart and lung sounds. She has worked on putting in catheters and starting an IV.
“You get to practice different skills with the simulators,” said Pfeifer, of Madison, Nebraska. “You can only learn so much out of a book or from lecture.”
Today’s simulators can be sophisticated and expensive. UNMC this year purchased an $80,000 “virtual dissection table.” The table, a bit bigger than the human body, contains a computer that projects onto the surface three-dimensional views of the skeletal system, muscular system, organs and nerves. Users can rotate the images, scroll through the body, slice the body and compare a normal MRI to an abnormal finding.
The device Dr. Are demonstrated doesn’t look like a mannequin but is the latest in simulators for endoscopic training. The Society of American Gastrointestinal and Endoscopic Surgeons said UNMC is one of 20 testing centers with the device. The American Board of Surgery will include in its requirements testing with the device for general surgery residents beginning in the 2017-18 academic year.
UNMC built a $1 million mock operating room last year. Students and resident physicians practice teamwork under pressure when a mannequin suddenly suffers breathing problems or cardiac arrest.
Some devices are built cheaply by a faculty member or physician. “You don’t always need this fancy stuff,” said Dr. Kelly Kadlec, a critical care physician and the simulation director at Children’s Hospital & Medical Center.
Kadlec said he didn’t like what was available for practice putting an intravenous line into a newborn’s umbilical artery. So he made a device in part from a trash can, a shower curtain and a plumbing valve. The device closely enough imitates the feel of inserting the line, he said.
Nevertheless, some devices have become increasingly lifelike. Some “speak” in English and Spanish. Others speak through the voices of faculty members, who usually watch from observation rooms.
At Creighton University Medical Center’s new simulation center, a mannequin named Noelle screamed, “This is the worst pain ever!” as her mechanical innards began to push out a baby mannequin. The university paid $87,490 two years ago for Noelle, a mobile version of Noelle and two mannequin babies.
“This is one of the areas that they’re pretty scared of, especially the guys,” Jan Stawniak, nurse education director in Creighton’s simulation center, said of labor and delivery.
Noelle the mannequin then piped up to admit: “I did cocaine today.” Various scenarios compel students to consider what to do next.
Claire Zach, a third-year Creighton med student, said she learned in the simulation center how to put a central line into the jugular vein. A couple of weeks later, she assisted a resident physician in putting one into a hospital patient.
“It was, literally, step-by-step what I learned here,” said Zach, of Omaha.
Kadlec and others said it’s vital that faculty members have a clear learning objective for the simulation session.
Practicing with simulators requires good coaching and teaching, said William McGaghie, a professor of medical education at the Stritch School of Medicine, Loyola University Chicago. “So it’s far more than the technology.”
Studies have shown that simulation improves performance and quality of care. Cardiac arrest team responses improved with simulation training in one study, and intravenous line insertion for experienced nurses improved with continuing education using simulation.
UNMC’s Paulman expressed his belief in the usefulness of simulation with a question: “Do you want to be practiced on?”
UNMC's virtual dissection table