PETER Oliver won’t wake up. The patient had been admitted to an acute ward the night before, intoxicated and suffering from a minor assault. A wedding party had got out of hand and Peter’s arms and face show minor bruising and he has a contusion on his forehead. Someone in A&E mentioned a pool cue.
Earlier that morning he complained of pain and was given a small dose of morphine but now nurses cannot rouse him. Two foundation year doctors along with two medical students attend the patient. One calls in a loud voice: “Mr Oliver. Are you with us?” But the patient’s eyes remain shut and he snores loudly.
One of the medical students checks his BP: 172/90; another draws bloods. A foundation year doctor – Victoria – checks his pupils. The left is fixed and dilated; the right normal. The other FY shouts again: “Mr Oliver!” But the patient snores on – except he is not actually doing the snoring. I am watching this scenario from a one-way mirrored control room. Sitting next to me in front of a bank of computer screens with multi-angle audiovisual feeds is Alistair Geraghty, doing a surprisingly credible imitation of snoring into a desktop microphone.
In reality Peter is not a live patient but an automated mannequin and this scenario is part of a technical skills course being conducted in one of two multipurpose simulation suites at the Scottish Clinical Simulation Centre (SCSC). Alistair is a simulator fellow at the centre which is based at the Forth Valley Royal Hospital in Larbert not far from Edinburgh.
The SCSC is the only high-fidelity simulation centre in Scotland and was established in 1998 with part-funding by NHS Education for Scotland. The Centre provides training for over 1,000 doctors and other healthcare professionals each year through a variety of courses both on-site and out in the field in hospital wards, emergency departments, resus rooms and even ambulances.
Course participants range from paramedics, ambulance crew, midwives, nurses, advance care practitioners to trainees in various fields, such as paediatrics, emergency medicine, anaesthesia and obstetrics. Training is conducted on a range of mid and highfidelity mannequins including adult, child and baby simulators which can be programmed to mimic different medical conditions, replicating the appropriate physical response to particular interventions and drugs.
On the day of my visit Alistair is running a course for a group of fourth and fifth year medical students. Centre stage is an automated mannequin, nicknamed Reg. His chest rises and falls as he breathes. A course participant listening with a stethoscope will hear heart and breath sounds over his chest, and bowel sounds over his abdomen. Watching the computer monitor I can see his simulated vital signs – heart rate, ECG, oxygen saturation. Alistair can change parameters with a simple drop-down menu – give Reg a wheeze or a heart murmur or put him in cardiac arrest.
Today the course objective is assessing acute medical problems on the wards. Says Alistair: “The focus of the scenarios are things that are very common like sepsis, or things that are rare but very serious such as anaphylaxis. The main focus is having an ABC [airway, breathing, circulation] approach and getting to a differential diagnosis and making sure they have the correct management in place.”
In the case of Peter (or Reg) – so far, so good.
Director of the SCSC is consultant anaesthetist Dr Michael Moneypenny and I speak to him later in his office. He was appointed to the job in June of 2012 and in addition to his medical qualifications Michael is an expert in how “human factors” contribute to medical error. He is also, unsurprisingly, an enthusiastic advocate for simulation in ongoing medical training. I ask him what are the advantages of using simulation alongside learning on real patients.
“One major advantage is the centre offers a safe environment,” he replies. “Safe for the learner and safe for the patient. The mannequin doesn’t die. You can make mistakes on him, you can give him the wrong drugs, you can give him too much adrenalin.”
“Our ethos here is that you will make mistakes and that’s acceptable because we all do and we can all learn from them. But you’re better off making the mistake here on this mannequin than on a patient.”
Another advantage is repeatability. Staff at the centre can create whatever clinical situation is required, be it acute asthma or myocardial infarction or pneumothorax. “And you can do it again, again and again,” says Michael. “It will not change. It’s the same scenario for a hundred people.”
This reduces any potential bias and is of great value in assessment. Simulation also allows healthcare professionals to deal with clinical conditions they might see only once or twice in a career.
Stan the man
Reg – the mannequin the students are working with – is a medium-fidelity simulator. Lying unused on a gurney in the second simulation suite is the centre’s most advanced mannequin – Stan (short for Standard Man). Costing over £100,000, Stan is attached by wires and tubes to a large metal box containing a powerful computer and sensors as well as a bellows to drive his lungs.
“The reason he is so expensive is because he has a true physiology,” says Michael. “Sophisticated computer algorithms work in the background which means that if we give him 500 ml of fluid and tell the computer, this will bring his BP up a little bit. His heart rate will come down and his central venous pressure will change. He’s an extremely complicated piece of equipment.”
Stan is used mainly for anaesthetic training and actually breathes out CO2 into a mask which can be visible on a trace using an anaesthetic machine. He also absorbs anaesthetic agent and reacts in the same way as a living patient. In the simulation suite anaesthetic trainees have access to everything they would find in a real surgical theatre – tubes, cannulas, masks, simulated blood and fluids. All this adds to the realism of the training sessions.
“We tell people it’s not pretend,” says Michael. “They don’t say, oh, I would take a blood gas now, they go and do it.”
Simulators or mannequins do have some obvious drawbacks in terms of realism. “For example, mannequins don’t go the blue deathly colour that you get in real patients,” says Michael. “Some of them have cyanosis but it’s so unrealistic it actually throws people off. They go blue but it’s an LED type of blue glow as opposed to the pallor of approaching death.”
He acknowledges this lack of realism can be a problem in some scenarios. Mannequins don’t move for the most part and although someone can speak for them via a mike there can be a crucial “disconnect” or lack of “human touch”. To overcome this some centres use part-task trainers such as cannulation arms or chest drain prosthetics strapped onto real actors in order to get a more genuine doctor-patient interaction.
Michael believes that in the future with advanced robotics, patient simulators will get better. “But for the moment mannequin-based simulation is more about emergency management,” he adds. “The patient is not irrelevant but you are looking at maintaining physiology, maintaining life, as opposed to how they are feeling about their anaphylactic reaction.”
Back in the simulation suite Victoria decides to phone out from the ward for some assistance in assessing Peter’s condition. In the control room Michael plays the role of the medical registrar. Victoria summarises her observations over the phone including the head injury and the blown pupil. “We’re thinking CT scan,” she says and Michael agrees and tells her to phone for a neurological consultation.
Five or so minutes later Alistair calls time on the simulation and the group moves back to a classroom where two other groups of medical students have been watching the action on a video feed. He then leads the team in a debrief using a white board with video playback – assessing how they used their ABCs to start focusing in on the diagnosis of raised intra-cranial pressure due to subdural haemorrhage.
And this harkens back to something Michael Moneypenny said to me earlier in the day. “The actual stuff in the simulator is not that important. You have to do it – but the most important thing is the debrief when you all go back into the room and have a chat about what’s happened, what went wrong, what went well and how we can do it better next time.”
Jim Killgore is editor of Summons