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UMass medical students can learn a lot of practical knowledge from dummies; Robotic simulators react like real people in controlled situations.

Byline: Geraldine Collier

The birth of Noelle's baby boy is not going well.

Somehow, during delivery, the baby's shoulder has caught behind Noelle's pelvic bone. It's not an uncommon problem, but not an everyday occurrence either.

When it happens, the obstetrician needs to maneuver the baby's shoulder until it comes free.

It's a tricky situation - if the shoulder is not manipulated properly, there's a possibility of stretching, potentially ripping nerves that connect the shoulder, arm and hand to the spinal cord. Bone injuries are also possible.

But, there's an even greater fear present in the "labor-delivery" room.

With the head and right shoulder out - left shoulder in - the baby is caught in the birth canal. His chest can't expand to breathe and his umbilical cord may be getting pinched off as well. If not enough oxygen reaches his brain, the baby will have brain damage.

The situation calls for a quick response - and a mother-in-labor can only hope that the medical people around her have seen this complication of childbirth time and time again and know exactly what to do.

Unfortunately for Noelle and her baby, the medical people assigned to her delivery have no experience in coping with this problem of shoulder dystonia.

Time stands still and you can feel the tension rise.

Each member of the medical team has a job to do: a nurse monitors Noelle's vital signs; another monitors the baby's vital signs; a doctor tries to free up the baby's shoulder, but fails. He tries again and fails again.

Finally, the baby's shoulder slips out and the rest of his body quickly follows. Everyone is relieved and there are smiles all around - except for Noelle who maintains her usual calm, mannequin-like demeanor.

You see, Noelle is not real. She is a computerized birthing simulator created by Florida-based Gaumard Scientific Co. and one of several different simulator-mannequins now used to educate and train students. Fourth-year University of Massachusetts Medical School students know Noelle very well and practice delivering her baby several times.

While Noelle - a slim blonde in her mid-20s - can simulate a normal birth with no complications, she can also be programmed to simulate more challenging problems, such as a seizure caused by high blood pressure.

Noelle's baby, which is also a simulator, can also be programmed to show various signs of medical trouble, such as a drop in the fetal heart rate.

Both baby and mother can produce different heart and breath sounds and both can be intubated - clearing the airways by inserting a tube through the mouth to the lungs.

Unlike store mannequins, simulator mannequins come with some life-like internal and external structures. Noelle, for example, has an IV arm for medications and fluids, a removable stomach cover and an automatic birthing system, including four dilating cervices and four umbilical cords.

And, just to add to the reality, after the baby is born, Noelle can also expel her robotic placenta - well, a placenta-like fluid.

Medical students can intervene to improve the condition of the mother and the baby, say through medication or a C-section - the procedure that would have had to be done if Noelle's baby's shoulder had not come free - or the use of forceps. They would then see the results of their interventions, good or bad.

The "Grey's Anatomy" crowd pretty much learns clinical or manual dexterity skills the old-fashion way - watching and working next to the experienced doctors. That type of on-the-job apprentice training works, but sometimes it's uncomfortable, painful and even detrimental for the patient.

By practicing high-risk, low-frequency events on simulators rather than talking about a problem or waiting until you see the problem, medical students can master the skills they need to possess long before they are confronted with a real patient in a real-life emergency, according to Dr. Edward Peskin.

As associate professor of obstetrics and gynecology at the University of Massachusetts Medical School, Dr. Peskin was teaching an interactive lesson on shoulder dystonia by having the medical students practice the hand positions necessary to manipulate Noelle's baby's shoulder.

He said using the mannequin is a much better way to learn than thumbing through diagrams in a medical book.

Working with simulator mannequins also has other benefits, according to Dr. Peskin, who is also chief of the Division of Obstetrics and Gynecology at UMass Memorial Medical Center.

"They (simulator mannequins) generate more excitement and heighten people's ability to learn. They (students) are ready to learn more because it is a new, fun way to do it."

While students often have both a lecture and a demonstration session before the simulation learning experience, it's the latter that may leave the most lasting impression on them.

Dr. Peskin said that studies have shown, "People hearing an hour-long lecture only retain about 20 percent of its content, while those engaged in interactive learning retain about 70 percent to 80 percent of the content."

The impetus for this new way of learning comes from the Institute of Medicine, which estimates that as many as 90,000 Americans die each year from preventable medical errors. Most bad outcomes in medicine that could have been prevented can be traced back to a lack of communication among caregivers.

"Part of the benefits of simulation also involves practicing those communication skills as well as the technical skills," said Marybeth Meservey, clinical nurse specialist for the UMass Memorial Maternity Center, who works with Dr. Peskin in training medical and nursing students.

"You want the medical team to be able to respond immediately and effectively," said Mrs. Meservey. "You want them to have already accessible - in their minds - what the basic steps should be. And you want everyone on the team to share the same picture of what those steps should be so they can work in a coordinated effort."

Simulation training is not a new idea. For example, the airline industry for decades has used simulator cockpits to train pilots how to handle crises in the air before they actually take off. The result: a sharp decline in the number of airline accidents.

Having seen the connection between simulated training and reduced errors in the aeronautical field, Dr. James Bagian, a former NASA astronaut and physician, thought the new way of learning could also reduce errors in the medical world.

Through his position as director of the VA National Center for Patient Safety, Dr. Bagian has traveled around the U.S., including a trip to Worcester, explaining the virtues of simulated training.

As a result, medical schools, such as UMass, have set up simulation training centers where medical and nursing students, interns and nurses can work with simulator mannequins as part of their education.

The five-room UMMS Simulation Center, located on the first floor of the medical school, is home for three simulator mannequins. (Because of the center's space limitations, Noelle and her baby remain on the Memorial campus, where the Obstetrical Services and the Newborn Intensive Care Unit are located.)

SimMan, the most versatile of the simulator mannequins, shares a large room - set up like a real emergency department unit - with "Mega-Code Kid," an 8-year-old child mannequin who can simulate a variety of pediatric medical problems.

Behind their beds, the heart, blood pressure and oxygen monitor flash vital signs; medication carts are nearby, oxygen machines stand ready, IV poles dangle: all the supplies and technology that would be needed in an emergency room setting are present.

In another room across the center's reception area, "Harvey," a brown haired, blue-eyed hunk, awaits those who will train in heart problems. The cardiopulmonary simulator mannequin can be programmed to reproduce 30 different heart conditions, and is of particular importance in teaching new medical and nursing students what to listen for in a physical exam, and how to diagnose an illness from what they hear.

However, students can't clear Harvey's airway with a tube; nor can they practice CPR on him.

While Harvey is somewhat limited, the other two mannequins are not.

"Their chests rise and fall," said Melinda Taylor, senior engineer for the simulation center. "We can change their heart sounds; we can change their lung sounds; we can do clinical interaction such as intubation; we can defibrillate them; we can give them IVs and we can take their pulses."

Veins can also be filled with fake blood. When a student needs to take a blood sample, a red liquid actually comes out.

All this makes a training session as realistic as possible for the medical students.

Almost any part of the body can be represented by a mannequin, depending upon the lesson that needs to be taught. The simulator mannequins also provide feedback, data and tracking to help students learn.

"It gives them a leg up when they first go into that clinical setting," said Ms. Taylor, "so they aren't as frightened or as apprehensive when they meet their first `live' patient because they have dealt with the simulator patients."

Mannequins do have a major drawback; their "skin" can't heal after it has been punctured or cut.

To address that problem, the simulation center can order extra skin flaps, such as wraparound flaps for the neck in order that repeat tracheotomies can be practiced, or extra patches of skin for the arms to be used for repeat intravenous hookups.

"We still do cadaver training," said Dr. Debra Heitmann, assistant professor for the Department of Emergency Medicine.

"However, the truth of the matter is that cadavers are precious things," said Dr. Heitmann, "and there are never enough people who donate their bodies after death to the medical school."

Once a procedure is done on a real body, the damage to the body tissue doesn't allow for the procedure to be repeated by the next student in line. Typically, one student does the procedure while the others stand around and watch.

While a simulator mannequin won't replace cadavers in medical school training, SimMan, developed at the University of Pittsburgh Medical Center, can take on many diverse roles.

For example, the adult-sized male with evenly distributed weight, often takes on the role of a drunk driver brought into the emergency department after crashing his car. And because he did not wear a seatbelt, SimMan sustains a head injury from hitting the windshield.

Dr. Heitmann, who has prepared the curriculum for this lesson, sits behind a one-way observation mirror in a room adjoining the mock emergency department. A video camera films every move made by Rebecca Burch, a fourth-year student at UMass Medical School, as she assesses the patient, decides what needs to be done and in what order it needs to be done.

Ms. Burch will also be doing a skills lesson - clearing the airways of the patient.

Once the lesson is finished, Ms. Burch will sit down with Dr. Heitmann in a debriefing room where they will watch the video together and discuss how things went.

In the observation room, Dr. Heitmann controls the mannequin's vital signs, changing them as the scenario progresses, and speaks into a microphone as the voice of the driver who is too drunk to know what happened to him.

"I want a beer," yells the drunk who can't remember the accident and doesn't realize that he is in a hospital. "What kind of a bar is this, when you can't get a beer?"

As Ms. Burch proceeds to assess his injuries, she tries not to be distracted by the patient's ramblings, while still being alert to his physical complaints: his head hurts and he feels nauseous.

Sure enough, he starts making retching sounds. After all, this is supposed to be realistic.

Ms. Burch is working alongside a nurse on SimMan, but she is in charge of the medical situation.

"That's something that doesn't happen very often in medical school," she said.

Yet she knows that learning how to take charge in a crisis situation is important if she should end up next year as the only intern on night duty in a small community hospital.

"It's very helpful for getting familiar with situations that require quick thinking and are often anxiety-provoking," she added. "You have the time to think a little more about what you are going do, without putting someone's life on the line."

While medical students are given a little more time to think through whatever medical procedure they are doing, there are definite time limits on how far the lesson should proceed or the "patient will fail," said Dr. Heitmann.

Does the patient ever die?

"Sometimes," said Dr. Heitmann. "We might have the patient arrest (have the heart stop) to see what an intern or resident will do in such a situation, but never with a student."

Sometimes you can be too realistic.


CUTLINE: (1) Dr. Jay S. Himmelstein listens to SimMan's vital signs. (2) An instructor and two medical school students in the operating room with SimMan.

PHOTOG: (1) Photo courtesy of UMassMemorial Medical Center. (2) Photo by Rob Carlin, courtesy of UMass Medical School.
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Title Annotation:HEALTH
Publication:Telegram & Gazette (Worcester, MA)
Date:Mar 14, 2007
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