Saving the dummy saves lives

Training nurses on high-tech simulators can avoid costly errors in care

Simulators are time-honored tools for teaching critical thinking skills to physicians, but they have only recently been added to nursing programs. (Salem State College)

The patient was having acute chest pains with falling blood oxygen levels and an irregular heartbeat when nursing student Courtney Proctor first checked her. Proctor's own adrenalin surged as she realized this was her first heart attack patient. After getting quick orders from the attending physician, Proctor went to work, administering nitroglycerin and an EKG. Within minutes, the monitors showed heart and breathing rates heading towards normal. It was a textbook save, even though the patient was a dummy.

But Proctor, a senior at University of Massachusetts Amherst, and other nursing students say they learn a lot more from working on a high-tech mannequin than the old-fashioned Annie CPR dolls that many students remember from water safety classes.

Salem State nursing student Meagan Whitaker says virtual reality mannequins, often known by the manufacturer's brand name SimMan, are good learning tools. "The SimMan talks back to you," she says. "It tells you, 'Ouch, don't do this to me.'"

The mannequins can mimic everything from anaphylactic shock to a blood transfusion to a teenage athlete with fluid and electrolyte imbalance. The student can see the dummy's chest rise and fall with breath, can hear abdominal sounds and heart rate. In fact, the dummy mimics all the vital signs of trauma. The dummy's talking is actually done by an instructor behind a one-way mirror who can tweak the computer program to make the "patient" get better or crash or experience all sorts of medical complications.

"The professor can tell you the patient is in afib [irregular heartbeat]. But when you come in and hear the alarms on the monitors, it's really happening," says Whittaker.

Training on simulators is a time-honored practice for teaching critical thinking skills to pilots and physicians. Training nurses on simulators has gone in five years from cutting edge to standard practice. Now simulators are seen as frontline tools to combat medical errors and improve care.

"Given shorter patient stays and sicker patients, nurses are increasingly asked to make more complex judgments," says David McCauley, director of nursing and deputy chancellor of the state Board of Higher Education. "We are allowing students to experience standard types of situations they will experience as well as those situations that are less frequent before they have to do them on a person. And we want them to do it in a safe environment first."

Massachusetts is in the process of reviewing applications before awarding seven of the $48,000 mannequins from Laerdal Inc. to educational and medical facilities. Applicants have to show how they will partner with others agencies to maximize the use of the simulators and commit to the expensive maintenance and updating of the devices, McCauley says. In addition, the state is asking medical professionals to write more scenarios for critical situations to go into a library for shared use. Currently, the manufacturer provides a package of scenarios with each mannequin. In Massachusetts, adult simulators were in 32 medical and educational facilities as of late 2006 and baby simulators were in all the Boston teaching hospitals and a few schools such as Salem State and Mass Bay Community College. Boston College is just creating its simulation lab and is considering a partnership with the theater department to add a layer to the training. Robin Y.

Wood, a professor who is setting up the lab, says the students can play family members at the bedside. "They can become increasingly demanding, concerned, and frightened and the student has to learn to stay focused on the patient at the same time he or she is interacting with the family member."

Five years ago, UMass Amherst was a pioneer in using the high-fidelity mannequins that were often found in teaching hospitals, where students could use them while on clinical rotations. Helene Cunningham, director of the nursing simulator lab at UMass, says instructors embed a medical error in each scenario. The critical learning juncture is the discussion that the instructor and student have after the simulation while reviewing the videotape. "If they make a mistake, they didn't hurt a patient, they hurt a mannequin," Cunningham says. "If we can interrupt one medical error, we have saved a patient's life or avoided a bad situation."