Stanford Report, October 31, 2001
By KRISTA CONGER
"Well, that was torturous," said Lauren Gale, removing her surgical gloves. Gale, a neonatal nurse practitioner at Lucile Packard Children's Hospital, had just spent an agonizing 18 minutes battling to save the life of a newborn with a congenital defect.Amid escalating tension, Gale and her colleague, Valerie Ruth, struggled to find a way to give the tiny infant desperately needed fluids in the absence of any suitable veins for injection. While the beeping of the baby's heart rate monitor slowed dangerously, the anxious father hovered in the background and the baby's mother pleaded to know her child's condition. Finally, Gale and Ruth stabilized their patient, called for a bed in the neonatal intensive care unit, then turned and walked away, leaving him cold, wet and alone on the table.
Their apparent abrupt neglect is no cause for alarm. Although the nurses' anxiety was genuine, the experience was simulated. It's part of a unique training program for Packard health care providers in neonatal resuscitation in the Simulation Center for Crisis Management Training in Health Care at the Veteran Affairs Palo Alto Health Care System. The center incorporates a sophisticated control room with a one-way mirror overlooking a fully-stocked operating room complete with mom and baby mannequins wired to monitors relaying heart rate and oxygen saturation levels.
The idea of using a simulator to train medical professionals was born out of the aerospace industry, which has used flight simulators for decades to train pilots and astronauts. Simulation training is common for anesthesiologists, but this use of the technology to teach neonatal resuscitation is unprecedented. "We're giving the participants the opportunity to suspend reality," said Lou Halamek, MD, associate professor of pediatrics at Packard. Previous research has shown that the participants' heart rate remains relatively constant during the scenarios – a sign of concentration.
To keep the participants on their toes, Halamek, who pioneered this pediatric simulation-based training program, dreams up life-or-death scenarios that stretch their clinical skills and teamwork to the limit. A debriefing after each episode includes a video replay of the performance and a roundtable discussion of what went well and what could have been done better.
"I didn't realize the experience would be this valuable," said Gale after her time in the hot seat. "It seemed real. I would much rather think things through in a fake scenario than to be in a real-life situation where the solution didn't come to me simply because I hadn't had that particular experience."
"We hear from participants that they think the experience is real, and we know from the heart rate variability data that their bodies think it's real. But is it real enough to allow them to transfer the skills honed in the simulator to real life situations?" asked Halamek, noting that the question has been difficult to answer.
Now the researchers have received a $1.1 million grant from the Agency for Healthcare Research and Quality to train members of the nursing staff who attend deliveries and take a before and after snapshot of delivery room practices.
"We will observe what they do in the delivery room, looking at what we think are the important elements of technical and behavioral performance. After the simulation-based exercises, we will go back and reassess whether the intervention has had any impact on their communication, leadership and technical skills," said Halamek. "We want to take a step-by-step, scientific approach to reinforce what we know on a gut level."
Communication and teamwork are a focus of Halamek's. Currently only two or three of the team members walk into the room blind, not knowing what to expect. The rest of the five or six people in the room are clued-in to the scenario and respond to cues fed to them by Halamek through earpieces. They relay vital details such as the baby's skin tone, breath sounds and overall condition to supplement the information provided by the monitors. Eventually Halamek would like to conduct scenarios in which most of the team members are kept in the dark, requiring them to work closely together.
"None of us works in isolation, and there's a lot we can learn from each other," said Halamek. "I learn from each simulation. You never come out of this with a sense that you've wasted your time; you always take something away."
Participant Leontien Wafelman, MD, chair of the Dutch neonatal resuscitation task force, agreed. She read about Halamek's work with the simulation center in a recent issue of Pediatrics, and traveled from the Netherlands to experience the simulator herself.
"Everyone knows what should be done, but putting it into practice is a whole different ballgame," she said. "This is the future of medical training."
Eventually Halamek would like to construct a facility dedicated to pediatric medicine to ease scheduling conflicts and permit individualized, spontaneous training sessions with interns, residents or staff members who might be struggling with a particular aspect of pediatric care such as intubation. "If we want this to succeed, spread through all of pediatrics, and involve physicians, nurses and allied health care personnel at all stages of training, it's going to require a dedicated facility close to the hospital," he said.
Halamek's research colleagues include David Gaba, MD, professor of anesthesiology; Steve Howard, MD, associate professor of anesthesiology; and Yasser Sowb, PhD. Gaba, director of the Simulation Center, designed the first human patient simulator to train anesthesiologists. Halamek is a member of the steering committee of the Neonatal Resuscitation Program of the American Academy of Pediatrics.
