Nothing like a life-sized doll when the stakes are life and death
When a state-of-the-art simulation learning center was proposed at the Greater Baltimore Medical Center (GBMC), nurse educator Deborah Higgins was thrilled with the idea of such a creative way to bring superior training and education not only to the nursing staff, but to the hospital’s entire health care community.
“This is the realest you’re going to get, next to being there with the patient,” says Deborah, the center’s simulation coordinator. “And this learning center is not only for nurses, but also for nursing assistants, doctors, respiratory therapists, and medical assistants from our private physician practices.”
It was my longtime friend and retired school nurse, Judy Elbaum, who prompted me to take a tour of the GBMC Simulation Innovation Learning Center, located on the grounds of one of the largest community hospitals in the Mid-Atlantic region. Judy works under Deborah in a volunteer capacity at this center that trains physicians, nurses, and support techs in the 342-bed acute and subacute medical center in a true-to-life hospital ambiance on practice mannequins.
The simulation center, created to imitate real-life settings, train personnel for almost any medical situation, from inserting an IV to performing complex surgery to practicing difficult conversations with patients. It’s a critical part of GBMC’s continuing education program, helping staff grow their skills and adapt to evolving medical techniques and technology.
“When you look at one of these mannequins, it might at first seem like a plastic doll, but it actually ‘breathes,’ and, for example, its pupils dilate if you shine a light in its eyes, so a trainee can actually listen to the sounds of its lungs and other internal organs,” says Deborah, who started her medical career as a paramedic and has been working at GBMC for the past 30 years, spending 21 years in the emergency department, and more recently as an education specialist. “We practice a lot of code situations here, so they’re able to recognize a deteriorating patient and have a trial run on what to do, which teams to call in, and so forth. Staff trainees can always take away something they can bring back to the bedside.”
Not every hospital, even teaching ones, have simulation centers. A lot of smaller ones may have a room dedicated to simulation with a single mannequin, which may ultimately remain in its box because no one there has learned what to do with them.
“We really wanted to mimic the hospital environment in our center,” says Deborah, leading the way into a hallway complete with Purell dispensers and equipment carts. The center has been her baby from the get-go. “Before consulting with the architects who designed this center which I was to head, I went to the hospital and took pictures of every corner of every unit. I had a vision.”
“Since its opening in 2012, we’ve undergone expansion and renovation to this all-donor-funded center,” continues Deborah, clad in a white monogrammed lab coat, with Judy at her side, as we enter the low fidelity simulation room.
“When we talk about simulation, we have to look at the level of fidelity, or realism, in the mannequin. These people are all task trainers,” Deborah explains, pointing out the teachers hovering over the least costly mannequins. “Here they concentrate on tasks such as Foley catheter insertion. We also train physicians in here to do things like inserting a larger central catheter. And we simulate scenarios such as the chest ceasing to rise and fall, or if there is no pulse. I can use various mannequin makeup techniques to demonstrate bruising or different types of injuries as well.
“We also do ergonomics training in here. We have the lift here to teach our staff how to transfer the patient the most easily and efficiently — out of bed and into a chair, from a bed to a stretcher, or a stretcher to a wheelchair. How do you do those things safely so you don’t hurt yourself or the patient?”
Code Blue for Dummies
As we walk into the brand-new high-fidelity section of the center, Deborah explains that the mannequins can be turned on from her control booth.
“If I have them turned on, you can feel their pulse just like I can feel your pulse, their pupils will react to the light, and they will blink, just like yours, the chest will rise and fall, just like yours does; and you can listen to heart, lung, and bowel sounds.”
“When I went to nursing school, we didn’t have mannequins — we had patients,” recalls Judy, who graduated back in 1967. “And we did assessments on each other. But when we learned how to do injections, we practiced on oranges. And when it came to things like catheters, you were told, ‘this is how you do it,’ and then you did it.”
From the beginning, Deborah puts out a disclaimer. “I tell all the trainees, ‘This is not nursing school, and these are not high-stake evaluations. You’re not going to lose your job here because you do something wrong. You’re here to learn, you’re here to make mistakes, you’re here to learn from those mistakes and be able to do the right thing at the bedside with the patient.’ “
Deborah, however, realized her limitations in teaching physicians, and so she enlisted the assistance of GBMC pulmonary medicine physician Dr. Donald Slack, who collaborates with her as the center’s director of medical education.
“Since I can only speak to the practice of nursing and not to the physicians regarding what they should be doing and what their practice should be, Dr. Slack does all the resident and hospitalist group training and writes scenarios for them, and then I complete the templates,” she says.
The material for their teaching scenarios is culled from cases on the actual hospital units.
“I sit on the Rapid Response, Code Blue, and Critical Care committees,” explains Deborah. “If there’s an interesting case, I’ll look up the case number on the computer and write my simulation off that case. There are also plenty of simulation books from which you can take parts of cases and ad-lib to what you need in your area.”
I Try It Out First
As we enter an outpatient room, Deborah adjusts the eyeglasses on the toupee-clad male dummy laying in his hospital bed.
“The emergency room and all our PACUs — our pre-op and post-op anesthesia care units — are outpatient and have bays,” explains Deborah. “In the pre-op, they have a chair here, so I can move this stretcher out, put a chair in here, have a mannequin in the chair, and you can do whatever you need to do for your pre-op work to get somebody ready for surgery. When they come out of surgery, they get wheeled on their stretcher into a bay, and you can do the same exact thing here.”
Deborah next points out the emergency department with its characteristic glass door and pull curtain around the patient’s bed that can be drawn for privacy.
“If I would have put a wooden door on here, it wouldn’t have been realistic for the trainees,” Deborah mentions. “They have computers here, because the PACUs and the Emergency Department have computers in their room. We have TVs in every room, too, so that if we’re doing a simulation and something is going really bad, we can say, ‘We need to stop this!’ We can actually pull up a segment of the recording and let them watch it in the Simulation Debriefing Room, talk about what happened, and let them try it again.”
Next, we enter the Consult room, complete with a couch, chair, and table. This is where staff members get practice talking to families about everything from living legacy donations to physician consultations and how to speak to family members about their loved one if the news isn’t good. When the room is needed for a different purpose, such as training practitioners to deal with a tracheostomy, all these furnishings are put away and it’s converted to a private physician office.
“This is my Med-Surg Telemetry unit, where we have a patient room with a bed, patient table, nightstand, and chair,” says Deborah. “It includes a full-fledged bathroom with ergonomically correct bars so you can teach staff how to get patients on and off the toilet and to avoid falling in the shower. There are white boards in this room so we can mimic and train nurses and techs who are supposed to go over things with their patients. There is a lift in every inpatient room, because Maryland is a no-lift state — rather than lifting our patients, we should be using a lift. We also have sheets and slings that we put on our patients, depending on if we’re transferring them from bed to stretcher, bed to chair, or bed to a bedside commode.”
As Deborah activates the lift she adds, “I can tell you it’s very comfortable because I was in it when we first got them. You have to know what it is like for your patients, because it might be scary for them.”
We Watch Everything
“This is our ICU room, which also has glass doors as opposed to wooden doors on the inpatient rooms,” explains Deborah as we move on. “This is actually all live equipment like what they have on their units — we bring it up here so we can practice on it. The mannequin we have here can hold a ventilator. Earlier today, we actually had him intubated with a breathing tube down his throat, for training.
“This is a CPAP machine and this is an oxygen delivery device that has a higher flow oxygen that you’ll only see in the ICU,” she continues. “It’s one of the newest machines they’re training on — it’s called a Fast Flow Fluid Warmer with Integrated Air Detector — so if you have somebody really crashing and you need to get fluid in very rapidly, you can put on this machine. Someone in septic shock, for example, will need massive fluid infusion resuscitation.”
Deborah steps into her glass-enclosed control booth to program the ICU mannequin, which is scheduled to simulate a mass gastrointestinal bleed. With the help of her specially programmed laptops inside the booth, she can simulate everything a real patient can experience — blinking eyes (15-30 or more times/minute), a pulse, breathing, bleeding, you name it.
“We usually have the lights very dim while we are in here. They can’t see us, but we can see them,” she says. “I’ll watch everything they’re doing to the mannequin on one computer and control it on the other one. The mannequins have very limited words programmed into them, so we play the voice of the patient to interact with the staff. We can also put all kinds of lung and heart sounds in the mannequins that are breathing, so the trainees can get more practice.”
One of the most fascinating stations — for us moms at least — is the postpartum and labor and delivery room. “Over here is our 25-week preemie that we’ve done pretty cool things with — his arms and legs will go up and down to show that he has tone. Or, if the baby is really sick and his limbs are flaccid, you can lift him up and his arms will just drop, and that means he has no tone. His lips and hands will turn blue when he doesn’t have enough oxygen. He breathes — his chest rises and falls, he has an umbilical pulse, he’s got heart and lung sounds, and a brachial pulse. He cries, he coos, he grunts. They are only about a pound or a pound and a half, or even less, when they’re born like that.”
Before entering the operating room, we pass a kick-activated scrubbing station for the surgical team. In the operating room is a mannequin still draped from his simulated surgery that took place the previous day. It was a bleed, and he’s still full of blood.
“The patient is draped, just like a real patient would be draped,” notes Deborah, as I squint from the extremely bright surgical lighting. “Anesthesia sits back here, monitoring all the medications and gasses; the surgeon and the team works over here on the patient. There’s an opening in the patient’s covers right where they will be making the incision during surgery. We try to make it as real as we possibly can, using simple things.”
Deborah shares her secret of pouring theatrical blood into a baggie and placing it inside a slit pillow that she ordered on Amazon, to simulate the massive GI bleed.
“One of the arteries gets nicked in surgery,” Deborah explains the training scenario. “So they have to stop and open up to do a laparoscopy to find it and fix it. It looks like blood in the belly. I take a bag of blood and stick it under here and put a plastic covering on it so they don’t see it. When they go to cut, all this blood comes running down everywhere, so they have to hurry up and suction. I have the monitor on, the heart rate on, and everything else up and running.”
The center’s 3G mannequin — an advanced patient simulator that can display both neurological and physiological symptoms — weighs about 85 pounds and costs $100,000 with warranties; the draped mannequin in the OR costs about $50,000; and, the preemie cost $9,000. There is also a company that makes real, lifelike castings of people — either people who donated their bodies to science or live people who gave permission to be casted.
Right now, Deborah is virtually a one-woman show, doing everything from managing the entire Simulation Center to teaching, to maintaining the mannequins and the software, to troubleshooting, emailing, writing scenarios and templates, in addition to wearing the training center coordinating hat for the American Heart Association and running all of the AHA heart programs in GBMC.
So Deborah really appreciates Judy’s teamwork. “It’s my pleasure to do what I can to help alleviate the stress that Deborah is under, by taking over some of the technical duties,” Judy shares.
But despite the stress, Deborah feels like she has the greatest job in the world. “There’s satisfaction in getting people up here and teaching them to be better practitioners at that bedside. I love the aha moments when my nurses will come back and say, ‘Deb, you’re never going to believe this… I had the same scenario that we just had up here on the patient unit!’ It makes them feel good because they now know what to do. I’m constantly learning different things, too, because of the different medical specialties I encounter in my work… and besides, who wouldn’t have fun working with mannequins?”
(Originally Featured in Mishpacha, Issue 799)
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