Orchestrating real-time crisis simulations is where three biomedical professionals found their niche. Could you, too?

F01a.jpg (16645 bytes)Executive Director Jeffrey B. Cooper, PhD, left, and Program Director Dan Raemer, PhD, ponder a technical issue with one of the simulators at the Center for Medical Simulation, Cambridge, Mass. INSET: A team of anesthesia residents work to resuscitate a "patient" during Crisis Resource Management training.

The modern medical dummy ain’t no dummy. She/He (dummy sex change operations are quick and painless) can blink, inhale and exhale, change pulse and blood pressure, respond to drugs and other treatments, and even, through an interpreter, say a few words.

A decade ago, these full-sized anatomical mannequins were few and far between. Now, they’re much more common—and expensive (see “Meet the Sims” sidebar, page 15).

The mannequins are used at several facilities located in the hospitals affiliated with Harvard Medical School. Among those is a center constructed primarily to stage medical crisis mock-ups for the benefit of caregivers from many different health care specialties. The mannequins stand in for patients, but the medical teams who train with them may save real lives because of them.

Called simply the Center for Medical Simulation (CMS), the facility is the size of a large house—about 4,000 square feet. Located in Cambridge, Mass, it is in politically correct fashion nearly equidistant from the five hospitals it serves.

Jeffrey B. Cooper, PhD, is the executive director of CMS, but he is more than that: He is the visionary behind CMS. It was his belief in simulation and his perseverance in pursuing it that got CMS under way.

In addition to his role at CMS, Cooper is director of biomedical engineering for the Partners Healthcare System, an umbrella entity that encompasses several hospitals in the Harvard system. Cooper is also an associate professor of anesthesia at Harvard. It was his devotion to anesthesiology that led him to medical simulation.

In the 1970s, the numbers of patient deaths during anesthesia nationwide prompted Cooper to study how errors could be involved. He used those findings to partner with other leaders in anesthesia to found the Anesthesia Patient Safety Foundation (APSF) in 1985.

“Within APSF we created a research program where people applied for grants in patient safety,” Cooper says. “Among the grant proposals were some to develop simulators in anesthesia.”

Through his interest in simulation, Cooper got to know David M. Gaba, MD, a Stanford University anesthesiology professor who was working on mannequins to train anesthetists and others who worked in operating rooms (ORs).

Cooper convinced Gaba to take a sabbatical at Harvard in the late 1992.

“Gaba brought his simulator [mannequin], and we put 70 doctors, nurses, and technicians through his anesthesiology training program,” Cooper recalls.

That program was a success, and by 1993 Cooper had convinced the anesthesia departments in the five Harvard hospitals to fund a simulation program. In 1994, the Boston Anesthesia Simulation Center was opened. As that facility grew, it was moved to a more central location, its name was changed to CMS, and it took on many more simulation projects than just training in anesthesiology.

In the beginning, the simulation classes ran only 1 day per week. Today, CMS operates 3–5 days per week and has an ambitious program that provides clinical training to clinicians who work in the OR, the emergency department, radiology, labor and delivery, and elsewhere. The CMS team has even modified one of its mannequins so that it can deliver a baby during abnormal circumstances, creating different types of critical situations.

F01b.jpg (14365 bytes)Meet the Sims
“Yes, the mannequin can talk,” says the Center for Medical Simulation’s (CMS) operations manager, Jordan Halasz. “But it’s all smoke and mirrors. We talk for the ‘patient’ from the control room.”

Computers also guide the modern medical mannequin through a range of clinically significant behaviors, from blood pressure and breathing changes, to altered vital signs, to drug and allergic reactions. These complex

mannequins are at the center of creating a believable medical crisis for purposes of simulated training.

One manufacturer of mannequins claims its “patient” is so lifelike that people on simulation teams have actually cried when it “died.”

But these stand-in patients aren’t cheap. Halasz says high-end mannequins can cost as much as $230,000. Simpler versions might go for $40,000. At CMS, there are five mannequins of varying degrees of complexity.

As CMS grew it added to its list of services, going so far as to even offer to set up crime scene and courtroom re-enactments.

CMS Program Director Dan Raemer says the center has a budget of about $800,000. But he says no matter how successful it is, it shouldn’t be thought of as a profit center for Harvard Medical School.

“We’re an educational foundation,” he says. “Our interest is not to make money, although we do try to stay in the black.” —GW

CMS also is moving its simulation efforts beyond training clinical personnel to include training of health care executives and managers, manufacturing engineers, and marketing and equipment salespeople in basic clinical tasks. One of its classes is Anesthesia for Amateurs, which is designed to allow nonclinicians to learn hands-on what their products are like to use in a clinical emergency. A similar program is used to train health care management teams in teamwork.

“We have them take care of a patient so they can experience what it’s like to be one of their customers and also to learn how to work better together themselves,” Cooper says.

When CMS started it was a pioneer, and it has served as a model for many of the centers that have proliferated in the United States and around the world.

“Ten years ago, you could count simulators in the United States on two hands,” Cooper says. “Now, there are between 500 and 1,000.”

A Role for Biomeds
Not all of the simulation centers going up are as extensive as CMS—which is unusual, if not unique, in that it is run by people with biomedical rather than clinical back-grounds. Cooper’s roots are biomedical. CMS Program Director Dan Raemer, PhD, holds a doctorate in bio-engineering; and the center’s operations manager, Jordan Halasz, worked as a biomedical technician in the Anesthesia Department at Massachusetts General Hospital for more than a decade before going into BMET management and then moving to CMS.

All three—Cooper, Raemer and Halasz—say simulation is a fast-growing part of health care in which biomeds could, and should, have a greater role.

“These simulators are being purchased at an amazing rate,” Raemer says. “I might get eight or ten emails a week from those who are thinking about setting up such a program. Every simulator needs some involvement from a biomedical engineering technical specialist. The mannequins are interesting to work with. We fill our rooms with props to make them look more like an OR. Most of what we have is equipment that originally came from a biomed department in some state of disrepair.”

Adds Cooper, “There is going to be an increasing need to support simulation centers. For biomeds, this is another area for servicing. Every center needs service.”

Halasz says he loves working at CMS, especially because he gets to help educate caregivers. “For a biomed who doesn’t want to sit and repair equipment and who wants to teach, there is nothing better than this,” he says.

Cooper says that CMS will eventually use simulation to train biomeds within the Harvard-affiliated hospitals. He thinks schools for biomeds should make simulation a part of the curriculum.

“If biomeds can take calls, they can see what it feels like and practice some of the things they have to do. This is a way to practice service calls in a live environment,” he says.

Equipment Testing
Raemer says facilities like CMS may one day be used to let biomeds test equipment. The center already provides some limited equipment testing and evaluation for the Harvard hospitals.

“The biomed department should be interested in ways to apply simulation to test equipment, for user education, and to set up new locations in the hospital,” Raemer says.

One of CMS’s major testing projects to date involved building a mock-up of a proposed OR that was specially designed to let the patient be wheeled, still on the operating table, into either a positron emission tomography/computed tomography (CT) scanner at one end of the room or an magnetic resonance imaging (MRI) system at the other end of the special OR.

“[Brain tumors] don’t reveal themselves to the naked eye,” Raemer says, “but under CT or MR you can see them. [When resecting tumors in the brain,] normally, the surgeon is blindly cutting out the tumor using a map of where it is supposed to be; but in this room, the operating table can go to the scanners. The surgeon can look at the pictures and see exactly where to cut and trim.”

What was discovered under the CMS mock-up, however, was that there were some problems moving the patient from the OR into a scanner and back. These were not easily seen without trying out the system in a realistic setting.

“We got the [vendor] to build a working mock-up of this OR, and we filled up 30 pages of easel boards with all the problems we discovered by stepping through how we would deal with getting the patient on the bed, administering anesthesia, keeping the patient sterile, and keeping instruments from flying into the MRI,” Raemer says.

Using the CMS mock-up, clinicians and engineers were able to help work out the bugs.

CMS has also been used to test more routine equipment like infusion pumps prior to a purchasing decision by one or more of the hospitals. Getting manufacturers to use CMS as a test site is, in fact, one goal of the center as it looks for ways to market itself.

“Manufacturers have no way to test prototypes in a clinical environment,” Raemer says. “We offer many advantages over a beta site [trial use at a hospital] in that we can have the same problems occur a number of times. We can use the device and all its features in a single episode. In a hospital, that might take weeks. We can videotape, stop and start, and do all sorts of things in a laboratory sense that you can’t do in a real setting.”

Despite these advantages, CMS has had only “limited success” in gaining the attention of medical equipment makers, Raemer says. “It’s a new concept, and it’s hard to get people to change.”

Team Crisis Management Training
So, CMS remains focused on training clinical teams to perform under the pressure of a crisis.

“Our courses are very high realism, just like a cockpit simulator, just like the real thing,” Cooper says. “Our interests are not primarily in training for technical skills, like how to intubate, although we do some of that. We are more involved with teaching teamwork and how to manage critical events.”

Training on purely technical skills involves simulators too, and these come in various varieties. At CMS, whether the training is geared to surgery, labor and delivery, anesthesiology, or some other specialty where situations can develop quickly and require rapid response, the training sessions almost always involve a crisis. Working with clinicians and other caregivers, the CMS team scripts a crisis that suits the group being trained.

“These are designed for practicing doctors and nurses,” Raemer says. “It’s done with a focus on practicing teamwork. When a crisis occurs, you’d like to think your doctor or nurse has practiced.”

Adds Cooper, “It’s like a realistic environment. The [mannequin’s] blood pressure drops, the heart rate goes up or down, the breathing stops. … We think people learn more the more it feels like the real thing. When something bad happens, they never forget that.”

Raemer says when he first saw a crisis-teamwork simulation, he was amazed. “I had kind of imagined a mannequin sitting in a room with people practicing on it. I didn’t realize how holistic it was. It’s a whole scene; it’s like a play. After a few minutes, everyone is involved in it. It is a simulated world, but the tool becomes invisible, and it becomes a real-life world.”

Raemer compares each training session to a story with a plot twist. “The lights go out, or a piece of information they had assumed turns out not to be true.” He uses the example of an ambulance-type breathing bag having a hole in it and being unusable, so suddenly the team has to improvise. Once a simulated crisis is started, it’s like a play, too, in that it goes on without interruption until it’s over.

An important part of the teamwork training is getting the team simply to acknowledge a leader. “Somebody has to become a leader who can stand back and manage the crisis,” Cooper says. Another vital element is teaching teams to communicate under pressure. “A person must acknowledge when they have received an order. Somebody has to say ‘I put in the IV.’ We call it ‘closing the loop.’ ” Cooper says. “In a crisis situation, people don’t usually talk out loud about what they are doing. We help them do that.”

At CMS, every session is videotaped and then reviewed; each performance is critiqued but not graded.

Because simulation is complex and its effectiveness is very difficult to document scientifically, particularly for teamwork skills, much of the evidence in support of it is anecdotal and from subjective evaluations. Cooper says a trial under way on the effectiveness of simulation in carotid artery stenting procedure may provide some concrete support for the field. In the meantime, caregivers in medicine are demanding simulation training—whether or not it can be proved effective.

Raemer is president of the Society for Medical Simulation. “The size of the annual meeting has doubled every year for the last 4 years,” he says.

With that kind of growth, simulation may be a field where biomedical technicians and engineers will find new outlets for their skills in the future.

George Wiley is a contributing writer for 24×7.