Diary of a Sim Man

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They call me stan.
I was born in a factory, hand-made by skilled workers who painstakingly assembled all of my intricate parts into a life-sized replica of a human being. I talk, blink, and breathe; I can belch and vomit; my pupils react to light; my heart pumps; my bowels gurgle; my lungs respire. I can take an endotracheal tube, IV lines, a chest tube, a foley catheter, and CPR. You see, I’m a high-fidelity, computer-based, medical simulation mannequin. And they call me Stan. Let me tell you my story.

Simulation actually began several decades ago during the early years of public aviation and government-sponsored space travel. Flight and safety engineers for these (then) new modes of travel understood the inherent dangers in sending people to the moon and flying them in tin capsules at thirty thousand feet. They realized that humans make mistakes. In fact, they make mistakes quite often, and during high-stakes activities like moon travel, errors can be catastrophic, expensive, and fatal. These same engineers also discovered that by practicing real-life procedures, modeling high-risk scenarios, and scrutinizing human error in a safe, replicated environment, astronauts and pilots were acutely more aware of their potential for error, even before it occurred. If they made a critical, mission ending error in the simulator, they were more prepared to anticipate and avoid errors during the real flight. By practicing for disaster, they found the risk of an actual disaster could be minimized; flying to the moon was dangerous, but its risk was manageable. Flight simulation quickly became the standard in aviation training, as well as other high-stakes industries like oil platform drilling.

The application of simulation to patient care wasn’t even considered plausible until anesthesiologists seized the opportunity and developed the science. In the 1980s, patients were dying in operating theaters at rates that were unacceptably high. Anesthesiologists adopted many of the ideas set forth by the aeronautical industry. Using an educational theory known as Crisis Resource Management, they hoped that patient care could be improved by simulating routine and complicated clinical scenarios in a safe, yet realistic environment. It was soon obvious that clinicians could train for operating room disasters and then provide safer care during the real patient encounter.

The first generation human patient simulators were born. Now, my ancestors weren’t pretty or fancy like me; they were very basic. They did, however, serve as an invaluable resource to the anesthesia and surgical worlds because simulating real patient encounters indeed did reduce real world error. Surgical mortality declined considerably, medico-legal costs fell, and patient outcomes improved. Since then, high-fidelity patient simulators have appeared in many of the academic medical centers and disciplines around the United States. 

Now you might be asking yourself: why has it taken so long for simulation in health care to catch up with other areas of industry? Historically, there have been significant technological and financial barriers to the widespread application of simulation in health care. First generation simulators were prohibitively expensive, cumbersome, and low-fidelity. Their application was limited to large scale industries. The technology has advanced considerably in the last few years. Systems are now of a manageable size, costs have fallen, and the fidelity and realness of the systems have improved. More importantly, as health systems, government regulators, and health professionals focus more on patient safety and quality outcomes, the application of simulation to help reduce error and improve patient outcomes seems intuitive. Simulation is no longer just a tool of anesthetists: all medical disciplines are utilizing simulators for training students, physicians, and allied health professionals.

As a high-fidelity simulator, I have unique insight into what goes on during these training sessions. I’m currently living at the UC Davis Health System’s Center for Virtual Care in Sacramento, CA. I’m an essential element of the Department of Emergency Medicine’s residency training program and have been in operation for almost five years. Once a month, as part of their EM resuscitation curriculum, my operators send each resident through challenging patient scenarios that are modeled on real patient encounters.

The benefits of medical simulation for physicians-in-training seem obvious: residents are able to experience cases on-demand rather than by chance; high-stakes illnesses with little or no room for error are easily modeled; my operators can stop, fast forward, rewind, re-run me, then debrief residents on their performance; residents can repeat cases until they demonstrate mastery of concepts; innumerable permutations of disease and physiology can be modeled and tested. Every quarter, EM residents are tested using standardized patient encounters and me, the high-fidelity human patient simulator. Each scenario is a graded activity in multiple areas: medical decision making, critical medical actions, ACGME core competencies, teamwork, core knowledge, procedural competency, and professionalism. After each case, residents are debriefed on their performance, and residents who fail critical actions or score under a level considered competent for that case repeat another patient encounter of equal difficulty.

You might ask how the residents like this new addition to their training. I watch their eyes when they come into the room. I see that they treat the cases as if they were real world encounters. The monitors, airway equipment, nurses, and staff are the same as when they work a shift in the ED. They tell my operators they are nervous; ultimately, they feel more prepared for real life encounters after a few times in the sim lab. Whether simulation training translates into better doctors, higher board scores, or more lives saved is anybody’s guess; a lot of work lies ahead for educators to establish outcome data for this growing field. But as I watch resident performance improve over their three years of post-graduate education, I think it’s clear that as confidence and competence in simulated patient encounters increases, so too does overall patient safety.

The future of simulation at UC Davis is bright. The Department of Emergency Medicine is in process of starting a Simulation and Education fellowship. My operators are planning newer, more advanced patient scenarios and have expanded simulator-based training to paramedic and ancillary staff education. Simulation now plays an integral role in medical student education at the UC Davis School of Medicine. I would even look for simulators to play a role for board certification and procedural competency testing by physician licensing organizations in the near future.

I think it’s clear that simulator-based education is here to stay. And as simulator technology becomes more affordable, look for other high-fidelity mannequins like me to pop up in a hospital near you. 

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