Low-risk training in high-stress medicine

by Diana Grier Ayton

The monitors hooked up to the patient starts to flash the jagged patterns of cardiac distress. Doctors, nurses and technicians rush to the bedside and begin the tense task of trying to rescue a dying patient.

That scene was repeated over and over last week at the Royal Victoria Hospital­in a workshop designed to teach critical care skills to medical personnel. The "patient" involved was a lifelike mannequin, a simulator built by CAE Electronics, which can react appropriately to drugs and different types of treatment.

Dr. Ruth Covert, a practising anesthetist from the Jewish General Hospital, was one of the people responsible for setting up the week of workshops with the simulator, part of the events marking this year's 50th anniversary of anesthesia.

"We brought it to show where teaching is going in medicine and to see how much interest there is at McGill in this kind of thing as both a teaching and a research tool.

"But it's a very expensive tool because this is such high technology. The demonstration wasn't intended to be a hard sell, but a feel-out of the Faculty. If there is broad interest, then we could deal with the finances later."

Covert says one of the advantages is that with a simulator, you can expose people to rare medical events.

"If you have a resident who rotates through critical care for a few months, he or she might never see a severe allergic reaction. To tell you the truth, in my 10 years of practice, I've never seen one. However, if one occurs I have to know what to do very fast­there's no time to look it up in a book!"

And, of course, with a simulator there is no real risk. "This allows new learners to reach a much more sophisticated level of training before they ever get to see a patient."

Once she had completed her medical training, Covert went back to school to get a master's degree in health professional education. She has a particular interest in the way physicians learn to problem solve in complex and high stress situations.

"The idea of using a simulator is borrowed from the airline industry," says Covert. "They looked at how people perform under conditions of great risk and showed that a lack of communication and organizational skills are responsible for about 80-85% of major airline mishaps. It's not technical problems with the airplane itself, it's human error."

Covert says the parallels exist in medicine. "An example is the case of a cardiac arrest, when you have a team of people and if you you can't organize them to use all your resources, the patient doesn't haveåå a good outcome. Having the medical knowledge isn't always enough."

Something else taken from the airline industry is the concept of a debriefing. Participants watch a videotape of their performance and see the mistakes they've made.

"Even though it was a simulated event, people suspend their disbelief very quickly. The experience is still very intense. There are simulations where the "patient" can die, but they've stopped doing that, because it was too traumatic. So it takes a lot of skill to debrief a group. It has to be done in a very non-threatening way."

Covert says it's a crucial part of the training process, however. "That's another important skill in dealing with critical events. People always tend to want to hide their mistakes. But if you make a mistake, you have to be able to recover from it. That's not done very well educationally in medicine. Learning from mistakes is not part of the program at the moment."

There are some limitations to the use of simulator, however. "If you have very sophisticated learners, people with a lot of expertise, they sometimes find it's not realistic enough," says Covert. "On the other hand, if you're trying to get everybody to a baseline level of competence, you're not really worried about learners on the high end."

The major restriction is the cost. A patient simulator might cost between $200,000 and $300,000­daunting in times of budget restraint.

Covert says the educational benefits might be worth it. She reports that in the centres that have simulators as part of their training programs, the evaluations from participants have been very good, Covert says. "My feeling is that a lot of students would love to know that they could practise a very stressful event before they have to deal with it on their doorstep."