By Pilar Ulibarri de Rivera
The man lays motionless. The three paramedics who responded to his call for help know only that he is 67 years old and had been watching television when he started to feel a strange heaviness on his chest.
“How are you doing sir?” one of the paramedics asks. “Do you know where you are?”
The man indicates the chest pain is getting worse. The paramedic flips through his notebook while peppering the patient with more questions.
“Better get the stretcher ready,” another paramedic mumbles, and the observers in the room snicker.
The levity would be in poor taste if it were any other man. But this is not just another patient. He’s Stan D. Ardman, or Standard Man, a sophisticated human patient simulator (HPS) used by hospitals, the military and institutions of higher learning to train medical personnel and students.
The paramedics who’ve come to Stan’s aid are first-year students in the Emergency Medical Services program at Miami Dade College’s Medical Center Campus.
“This is your tool,” lab coordinator Fredy Ruiz tells the students by way of introduction. “You can play with it all morning.”
Nursing students at Medical Center Campus have been “playing” with this computer-driven HPS for five years. It blinks, breathes, has a heartbeat and pulse, and accurately mirrors human responses to such procedures as CPR, intravenous medication, intubation, ventilation and catheterization.
It’s an expensive tool, worth $270,000. The Sarasota-based maker, Medical Education Technologies Inc., said “this dramatically functional mannequin exhibits clinical signals so lifelike that some students have been known to cry when it ‘dies.’”
“Its software can reproduce different clinical conditions, which we call scenarios,” Ruiz said.
Scenarios give students hands-on experience they might not be able to get on a real patient. “You can make mistakes here. You can give a wrong diagnosis or give the wrong drugs and the ‘patient’ can die,” he said.
Improved Assessments, Confidence
The use of the HPS in health professions education is on the rise throughout the U.S. Students at all levels of training – from undergraduate nursing and medical assisting students to post-graduate medical interns, spend some time putting theory into practice on these highly specialized mannequins.
A recent study in The Journal of Trauma: Injury, Infection and Critical Care found that the trauma management skill scores of medical interns increased 23 percent in critical treatment decisions, 25 percent in potential for adverse outcomes, and 47 percent in team behavior after spending time with a human patient simulator. Interns’ self-confidence scores also rose significantly.
In “Simulation Technology for Health Care Professional Skills Training and Assessment,” an article published in JAMA: the Journal of the American Medical Association, Dr. S. Barry Issenberg and his co-authors argue that patient simulator systems “help to address the problem of poor skills training and proficiency and may provide a method for physicians to become self-directed lifelong learners.”
MDC originally acquired the HPS to enhance its nursing and physician assistant programs. The results have been consistently positive, faculty and administrators say.
“We’ve seen students get higher scores on tests when they use the HPS,” said Constance H. Miller, senior associate professor in the School of Nursing.
In some cases, Miller said, patient simulators are used in place of some standardized tests to evaluate student proficiency in clinical nursing skills.
“Before we had the HPS, we used to do our clinicals with cassette tapes that played heart sounds and a regular mannequin,” said Miller, who has been at the College for more than 20 years. “The HPS allows students to work on actual patient scenarios in a non-threatening environment.”
When students eventually face clinical situations with a live patient, they are more confident in their skills, she said.
Recently, Miller’s nursing students were scheduled to spend time in a local hospital gaining some of the 675 supervised clinical hours they need in order to graduate and become eligible to sit for state licensure examinations. The students were going to work with stroke patients.
“Before we went to the hospital, I gave them a lecture on strokes, and then we went into the simulator lab to work on a scenario of someone who had a stroke,” Miller said. “It took us about two hours to review treatments, medications and the nursing process in that scenario, and the students were better prepared. I think it also helped to eliminate some of the students’ anxiety.”
The HPS is also being used as much more than a just a precursor to required clinical hours. In some cases, it is being used in place of them.
Alleviating the Shortage
The ideal setting for training health care students is in a hospital with actual patients, said Lessie Pryor, interim director of MDC’s School of Nursing. But due to a recent boom in the number of new nursing programs – in response to a national nursing shortage – there is less available hospital space and time for students.
“There are now more schools competing for time in the facilities,” Pryor said of hospitals where students receive required clinical hours. “There is much more difficulty getting in. Simulation gives students a chance to get practice.”
The Florida Board of Nursing has added the use of human patient simulators to its administrative code for nursing education in the state.
State standards of nursing education indicate that 25 percent of the required clinical experiences may be achieved through work on an HPS.
“We work very closely with schools to make sure students get the appropriate experience,” said Grace Johnson, director of the Board of Nursing’s education unit. “We see that different scenarios can be devised for particular courses on the HPS. It’s very helpful as it relates to critical thinking in those scenarios.”
Sometimes, Miller said, they “prop it up” to really get the students thinking.
“We may provide dressing for a wound or ice for an extremity,” she said. “Or we may put simulated bloody stool next to the patient in a bed pan. It helps us evaluate and test their nursing proficiency.”
Faculty in the Emergency Medical Services program are the newest MDC instructors to incorporate instruction on the human patient simulator into the curriculum. EMS professors are using the HPS in much the same way nursing and physician assistant professors have – to supplement lectures on theory and clinical instruction.
One of the many useful features of the HPS is that it reacts to drugs injected into its system. It can calculate how a specific dose will affect the physiology of a patient. Instructors can input variables into any instructional scenario: A patient can be an 18-year-old athlete in peak condition, a 40-year-old smoker or a 100-year-old diabetic. Or the patient can be like Stan, a 67-year-old man with chest pain.
Ruiz asks for a volunteer to check if the patient is having an anaphylactic reaction. First-year emergency medical services student Oliver Hanna sticks two fingers into Stan’s mouth. “Do you feel pressure,” Ruiz asks.
“Absolutely,” Hanna says. “His entire tongue is swollen.”
Stan also has shortness of breath, which can be a sign of a heart attack.
EMS professor Robert Hardy manipulates Stan’s condition from a nearby computer.
“Check the vitals,” a classmate tells Hanna and Jonathan Stark, Hanna’s partner in the exercise.
After more evaluation and discussion, Stark gives the patient a shot of nitroglycerin, a vasodilator that treats heart conditions. When blood vessels are dilated, it is easier for the heart to pump more blood to the rest of the body.
“Has your pain improved sir?” they ask Stan.
“Yes it has,” Hardy answers for him.
Stark and Hanna announce their next steps: They’d call the receiving hospital to report what they have done and transport Stan to the emergency room.
Stark has wanted to be a paramedic ever since he was a small child and went on calls with his father, a Miami-Dade County paramedic firefighter. He once witnessed his off-duty father save a man’s life after the man sped through an intersection and crashed into a tree. That moment defined what Stark wanted to do with his life. After class, he said: “This is as real as it gets.”