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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 [page 2]
 By Charles Slack // Photographs by Ken Schles
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Today there are hundreds of simulation centers around the world, compared with fewer than 20 a decade ago, according to James Gordon, a Massachusetts General Hospital emergency physician who directs the Gilbert Program in Medical Simulation at Harvard Medical School. Yet simulation training plays only a small role in most students' education—in part because the cost of simulators, ancillary gear and expert instructors can strain training budgets. (Medium-capability simulators cost up to $50,000.) Gordon believes prices will drop as simulators become more widely used, and whereas today Harvard Medical School students may train on simulators a few times a year, he foresees a day when such training will become routine.
Gordon tapes simulator sessions so medical students can review their performances. On one such tape, four novices are working anxiously to figure out how to help their mechanical patient breathe after a morphine overdose. Though the patient could easily have been revived with Narcan, a readily available drug that counteracts the effects of narcotics, none suggests it. "All of them would have gotten it right on a written test," Gordon says.
Such training blunders could become real tragedies a few years later when young residents find themselves flying solo for the first time. "Most errors occur early in a doctor's career—in her first 10 cardiac catheterizations, or his first 20," says Steven Dawson, a Massachusetts General Hospital interventional radiologist who now directs simulation research at the Center for the Integration of Medicine and Innovative Technology (CIMIT). Based in Cambridge, Mass., the medical technology partnership links several Harvard-affiliated hospitals and the Massachusetts Institute of Technology. Looking back on his own training, Dawson expresses a common frustration—that his hands-on experience was limited to cases that happened to present themselves. "If you came in and you needed a procedure, I learned on you," Dawson says. "If a given disease or injury didn't come through the door, I didn't see it."
Nor do young doctors typically get much practice working as part of a group under fire, when an individual is most error-prone. Physicians, nurses and technicians may talk over one another and miss key messages; they may intimidate or be intimidated by those below or above them in the medical pecking order. Jeffrey B. Cooper, director of biomedical engineering for Partners Healthcare System, thinks that by training together in simulated emergencies, groups can recognize trouble signs and work to prevent them from being repeated when lives are on the line. In addition, the training can help foster a culture in which clinicians feel comfortable critiquing their own performances.
A mentor to Stanford's Gaba, Cooper has been studying simulator training methods since the late 1980s. He now heads the Center for Medical Simulation, which regularly hosts groups of practicing anesthesiologists, obstetricians, physicians from other specialties, nurses and emergency medical teams. They work in facilities like operating rooms and critical-care units that, except for the mannequin lying prostrate on the bed in lieu of a patient, are realistic down to the final detail. There are clamps and bottles of medication, surgical gloves, even boxes of Band-Aids. "We believe people will learn best if it feels real to them," says Cooper, who is also a biomedical engineer in the Massachusetts General Hospital's department of anesthesia and critical care. "They'll buy in if they can relate it to their real work."
A few doors down from Cooper's office at CIMIT, Dawson's team seems determined to simulate every kind of clinical conundrum. Tapping the keys of his computer, Dawson calls up an X-ray of a human skull. Though sharp and clear, the image seems ordinary until he reveals it's not an actual skull but one created artificially using mathematical calculations.
"I'm a radiologist, and I can't tell the difference between that and a real X-ray," Dawson says. With a few keystrokes, the cranial cavity fills with a network of blood vessels that are then suffused with a contrast medium, as though injected to pinpoint carotid disease. Next, a catheter snakes to the brain. A few more strokes and the image rotates, displaying the skull and vessels from every angle. What had been a static X-ray image blossoms to three-dimensional life.
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