Michael Foss remembers the day, during his medical training, when lightning struck — a moment both terrifying and valuable.
“I was transporting a patient down an elevator, and lightning struck outside,” said Foss, now dean of the School of Health at Springfield Technical Community College. He recalled that the elevator suddenly stopped, the lights switched off, and the patient, who was hooked up to a respirator, stopped breathing.
“It scared the hell out of me,” he said. “In a matter of seconds, I was completely alone with the patient. All of a sudden, the lights came back on, the elevator jumped, and the patient started to breathe again.”
As Foss related this tale, he leaned forward with a sneaky grin. “We can do that kind of cool stuff here, any time we feel like it,” he said — thanks to a growing collection of state-of-the-art patient-simulation mannequins that can replicate virtually any situation a nurse or other medical professional might encounter in real life.
Say a couple of students are transporting a ‘sim’ patient, thinking they have done everything properly to stabilize him. “If they start to get complacent, thinking everything is cool, we can make everything not OK,” Foss said. “We can have that patient take a dive in the hallway or the elevator or anywhere else we feel like.”
These sim patients — which simulate movement, breathing, and a host of vital signs — are given the human touch by a professor, who monitors students’ interaction with the patient from another room using a camera. The professor not only serves as the patient’s voice, but uses a computer to direct responses and vital signs.
Patricia Hanrahan, director of Clinical Education at STCC’s School of Health, used the example of a blood draw to compare patient simulators to ‘task trainers’ like a realistic — but unmoving — arm.
“When they put the needle in the patient’s arm and the patient passes out, they not only have to figure out what to do with the patient, but what to do with the needle,” she said. “There are two sets of expectations that are simultaneous.”
But then, she said, there’s a payoff. “A student came to me with a great big smile on her face and said, ‘I did it.’ The same thing happened to her in a clinical setting, and she knew exactly what to do. The people at the agency were so impressed that they hired her on the spot for an externship.”
This month, The Healthcare News looks into the history of patient simulation at STCC — and why it is proving beneficial not just to students, but to real patients everywhere.
The college’s first attempt at patient simulation was in its sonography program, and was a computer-based simulator that looks and acts like a real ultrasound scanner. When a student moves a probe across the patient’s body on the table, the screen brings up actual ultrasound images on the screen.
“That’s how we got started in simulation,” Foss said. “Then we decided to go to full-size human patient simulators, so we made a large investment in an adult male and a pediatric male that could be plugged into the same piece of computer equipment. We opened our patient simulation center and used it for respiratory care, mostly.”
Meanwhile, other faculty members were intrigued by the possibilities of this pair of talking, breathing simulators. Soon after, a nursing graduate who was working for a simulation company approached the college about lending another full-size sim in exchange for the chance to conduct some research on campus.
As time went on, the roster of sims in the department continued to grow to its current total of 14, with a mix of different ages, genders, and ethnicities.
“For a long time, the airline industry has demanded that pilots go through cockpit training in simulators,” Foss said. “We thought, if it’s good enough for pilots to keep people alive, it would probably work for students going into the health care field.”
Each year brings further advances, so that the sims can be updated completely through software. The newer models are also mobile and not confined to a bed setting.
Mobility has opened the use of sim patients to many more departments than the original models did. For instance, the first patients couldn’t be moved into the chair for Dental Assisting students to work on, as is possible today.
“We put a portable patient in street clothes, put him in the chair, and one of the faculty acted like the doctor and gave him a shot of anesthesia,” Foss said. “As the patient was conversing with the dental assistant student, he started to have slurred speech and wasn’t very responsive. We were watching this on a camera and changing all the vital signs, just like what might happen in a real patient situation.”
Confidence and Competence
It’s important, he explained, for students to experience these bumps in the road during seemingly routine procedures now, when no one’s health or safety is actually at stake.
“We’re making sure that the context and environment students learn in is as close as possible to the environment they’re going to work in after graduation,” he told The Healthcare News. It’s an effort that goes beyond the sims; the college has been renovating its health education facilities to make the rooms look more like real medical settings as well.
That realism today will build some essential skills that aren’t learned in a textbook, Hanrahan said.
“In clinical education, confidence and competence are very important,” she explained. “When students feel more confident about their skills, they tend to act more competently in the clinical area, and that gives them even more confidence to make clinical decisions.”
The hands-on training is not to be understated, Hanrahan said, recalling one student who aced a written exam, yet flunked the accompanying simulation test. Better to fail in class, of course, than with real patients.
“Before they go to their clinical training, they can walk through that environment here,” she said. “Then, when a similar thing happens, they feel like they know what to do.” It helps that all simulations are taped so students may review their decision-making and responses with professors afterward.
“We’ve had task trainers for years — parts of the body,” Foss said. “So they can stick the needle into the plastic arm, but the arm does not react. Our patients will react. We can have them refuse — and that brings up an entirely different set of skills. Then, when they’re in a stressful situation with a patient down the road, they can draw on this and say, ‘I’ve done this before.’ It helps them to relax.”
He compared the experience, again, to flight simulators that train pilots — technology so advanced that it’s indistinguishable from performing actual maneuvers thousands of feet above the earth.
“We’re almost to that point, where we’re suspending the users’ disbelief,” Foss said, noting that the hospital-like settings of the rooms are crucial to the illusion.
When we put the simulator on a hospital bed near the normal things you’d find in a hospital, it becomes more real and meaningful to them. I feel strongly that we’ve often taken hands-on experiences in medical training out of context; with the patient simulators, we’re putting it back into context.”
That context, of course, can be decidedly unnerving.
“I can assure you,” Foss said, measuring his words, “that we can make this one of the scariest moments of your career. We can throw things at you at a very high level that will make you sweat.”
That’s partly because few students ever get everything exactly right, he explained. “You may think you’ve given the right dose for this patient, but you didn’t because you forgot to check his weight. Or perhaps you left the room, and when you came back, you didn’t check his name appropriately. Or you didn’t do chest compressions properly. You thought you did, but the computer knows better.”
But the sims don’t only develop proficiency. They also help students understand that even their best efforts aren’t always enough. “We do, sadly, kill patients,” Foss said. “There are times when you do everything right, and the patient still dies.”
That’s a useful lesson, Hanrahan said. “Students are able to problem-solve not only what they did, but how they feel about it, how to make sense of it, how to communicate with family members. This is not about merely technical or psychomotor skills; it’s about taking care of patients. We give them an environment where they can reflect and faculty who help them reflect.”
Some pick up the concept sooner than others. Foss recalled a tour of visitors to the classrooms during which he voiced one of the patients as a man with Alzheimer’s disease. As the group discussed the patient simulators, Foss, as the sim, kept asking for his long-dead wife, and one of the visitors became intrigued.
“She interrupted the conversation and said, ‘let’s listen to him. He sounds like he has Alzheimer’s.’ And she had it, dead-on,” Foss said. “You can’t do that with a task trainer.”
Then there was the time a student successfully helped his sim through a critical moment and had him stabilized. Another student took over at that point, and instead of taking it easy or asking for help on what to do next, he started talking to the patient, noting on his records that he smoked two packs a day, and that wasn’t good for him.
“He basically went through a very personal health education moment. We were not expecting that, and it blew us away,” Foss said. “Both students did an exceptional job, and because of that, they have the confidence and competence to handle such a situation.”
Expanding upon an Idea
Meanwhile, STCC has achieved the competence with patient simulation to become a model for the other 14 community colleges in Massachusetts. Three years ago, hardly any of the other campuses had patient simulators, and now about half own at least one, with more coming on board all the time. And that’s important, Foss said, because although community colleges aren’t turning out doctors, they do supply the bulk of new nurses and other medical personnel across the state.
“If we can help introduce patient simulation to other schools, we’re actually improving the quality of health care across the entire Commonwealth, so that’s our goal,” he said, noting also that simulation also carries some intriguing workforce-development possibilities, such as hospitals sending employees to a local college campus to train on a new procedure.
“It has even been suggested to us as a pre-hire evaluation,” Foss said. “If you want to know for a fact that an employee can do a whole set of skills, you send them to a patient simulator and let them prove it.”
Hanrahan said such efforts would not be out of line with the patient-safety goals so prominent in the modern hospital setting. “All health care institutions are very focused on patient safety as a quality issue,” she said. “We can create and recreate situations that help people evaluate their ability to practice safely.”
They’re doing so by teaching students how to focus on the patient, Foss said. Instead of asking the professor what to do next, students are gradually trained to direct questions to the patient. And technology is continually improving to help suspend students’ disbelief, including baby sims who are “delivered” from adult-size sims; the babies come out with a blue tint and eventually turn pink — as long as the student makes the right decisions.
“It’s powerful to see students acquire mastery,” Hanrahan said. “These students are providing the employment pool in the local and not-so-local health care arena, and we want them to feel that they’ve mastered what they came here to accomplish.”
It’s a sudden rush of knowledge that can hit a student like — well, like a bolt out of the sky.