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| Archive : Fall 2005 |
Put Away Your Textbooks, Class, and:
Figure out what's wrong as a patient cries in agony // Stand up to your superiors // Try not to stab a soldier's liver // When he dies, thank God he's not real.
All Too Human
 By Charles Slack // Photographs by Ken Schles
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K nowing it was a game didn't make Ning Tang, a third-year Harvard Medical School student,
any less tense. Her patient seemed to be suffering a heart attack; he was having trouble breathing and complained of severe chest pain radiating to his arm. But his plummeting blood pressure complicated the diagnosis. After an EKG, Tang surmised that the problem might be with the right side, rather than the left, of the man's heart, and that damage to either side could be responsible for the drop in blood pressure.
If Tang administered dopamine, making the heart pump harder and raising the blood pressure, the added stress could jeopardize an already compromised heart. But a second option—administering fluids—would work only if the right-side diagnosis was correct; for a left-side problem, too much fluid might be a death sentence. "I found myself thinking, I'm taking too long to make these decisions," Tang recalls. With time running out, she called for fluids, then sighed in relief as the patient's blood pressure began to rise.
Tang's patient, of course, was a computer-automated mannequin. Yet even months later, every detail of the experience remains etched in her memory. "To be put into that kind of situation, you remember what happened, why it happened and why it could happen again," she says. "You never want to lose a patient, whether it's a game or not."
That's the thing about medical simulators: They make doctors sweat, and they make them learn. Willingly suspending disbelief, students, residents and even experienced physicians thrust themselves into unfamiliar or uncomfortable clinical situations. They snake catheters through lifelike webs of veins and arteries, treat gaping chest wounds and struggle to revive anesthetized patients who have gone into cardiac arrest. Working as part of a team in the emergency room or surgical suite, they deal with medicine's often rigid hierarchies. And they make mistakes—some negligible, some fatal. The lessons learned may ultimately save some of the estimated 195,000 patients a year in the U.S. who die because of medical errors. Advocates of simulators believe their widespread adoption could greatly improve those numbers.
Some of the earliest simulators, still commonly used in medical schools and hospital training programs, are by far the most lifelike. They walk, talk, breathe and moan. But these living, breathing actors, trained to sharpen physicians' diagnostic acumen by aping the symptoms of various diseases, can't raise or lower blood pressure on command, fill chest cavities with blood or put themselves under a surgeon's knife. They aren't able to take an overdose of medication to see how a young resident will respond, open their arteries to receive catheters or have their hearts stopped and restarted.
Those tasks are left to mechanical simulators, and after some 40 years of development, today's most sophisticated models are remarkably adept. Their crude forebears began to appear during the 1960s, creatures of early computer technology. Sim One, designed by engineer Stephen Abrahamson and physician Judson Denson at the University of Southern California, could blink its eyes, open and close its mouth and breathe. A cardiology patient simulator named Harvey, developed by Michael Gordon in 1968 at the University of Miami Medical School, featured pulses, blood pressure and heart sounds (the latest model is still in use).
By the late 1980s and early 1990s, smaller, more powerful computers led to exponential leaps in simulation technology. Among a new generation of pioneers was David Gaba, then a young anesthesiologist at Stanford University. "I was a big aviation buff as a kid, and I'd known about simulators for a long time," says Gaba, who is now the associate dean for Immersive & Simulation-Based Learning at Stanford. "Putting a patient under anesthesia is intrinsically hazardous—just like taking a plane up. Things happen in seconds, minutes and hours, not days, weeks and months." In 1987, Gaba and his team introduced the first of a series of simulators known as CASE (comprehensive anesthesia simulation environment). About the same time, a University of Florida team created its own anesthesia simulator.
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