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Patient simulators provide vital experience for nursing students

This article first appeared in the St. Louis Beacon: November 12, 2008 - High tech devices mimic real world medical maladies. Even the vomit smells real.

Pilots learn to avoid airplane crashes using flight simulators. These days, nurses learn to keep patients alive by using robotic human simulators.

Hospital stays today are reserved for the very sick. "The patients that used to be on general care floors are now being treated at home," Linda Haycraft of St. Louis University School of Nursing tells her students. "Patients that used to be in ICUs are now on general care floors. The patients that are currently in the ICUs used to be in heaven."

That means even when student nurses practice routine procedures like taking vital signs, their patients often have a complicated illness. At the same time, students may find themselves pushed to the back of the room when crisis situations arise, watching as more experienced professionals respond. When those students become floor nurses, however, they will need to perform many tasks requiring a high degree of skill. They need experience.

Enter the patient simulator. These programmable manikins, like Sam at the University of Missouri, allow the students to experience situations that may not occur when they provide care to actual patients in the hospital. For example, says Diane Saleska, coordinator of the simulation center at UMSL, a student may never encounter a patient receiving a blood transfusion. But when Sam needs blood, that student can start the IV, begin the transfusion and monitor for signs of a transfusion reaction. Sam may complain through a speaker in his chest of low back pain, or that he feels funny. The student needs to recognize that a reaction may be occurring and stop the blood flow. Sam can be programmed to continue deteriorating if the transfusion is continued, and may go into shock or even die.

New technology that is both complicated and flexible

Although the technology is less than 10 years old, St. Louis nursing schools are already using the second generation of these teaching wonders, and most are preparing to purchase newer models. Most of the schools have one or more adult male simulators that can swap out their genitalia for female. UMSL and the Goldfarb School of Nursing at Barnes-Jewish College have Noelle, a pregnant simulator, complete with computerized fetus. Noelle and child can breeze through childbirth, or can encounter such complications as having the umbilical cord wrap around the baby's neck. St. Louis University has a baby simulator. The Goldfarb School has two simulators of 6-year-old children.

The simulators look like life-size dolls, but in reality they are complicated, sophisticated machines. (For a look inside the most high-tech simulator out today, view the "Making of iStan" video .) All patient simulators are operated by computer. They have several pulse points, variable respiratory rates, all kinds of EKG patterns, measurable blood pressure, and a number of lung, heart, and bowel sounds. They have bladder reservoirs, and blood reservoirs. They can be intubated with nasogastric tubes, or breathing tubes. They have chest leads for defibrillation, and can respond to a standard defibrillator. When their skin has too many IV punctures, they can be fitted with new skin. They may have surgical wounds added to their skin.

Teaching with simulators

Pedagogical use of the simulators varies with instructors and institutions. Some write their own programs, some use purchased programs, often modified for their own students. Many programs are constructed as decision trees. If things are done correctly -- a medicine given in the correct dose, oxygen given when the hemoglobin saturation is low -- the simulator's symptoms will improve. If the students make poor nursing decisions, the simulator's condition will continue to deteriorate.

Instructors go to great lengths to make the simulations realistic. When students come to a simulation, they must wear nursing uniforms. Beth Haas, director of the Clinical Simulation Institute at Goldfarb School of Nursing, reports that they have been perfecting recipes for such props as emesis (vomit) with the appearance and smell of the real thing, and poop from breastfed babies. Linda Haycraft records the different cries of infants to use with the baby simulator.

Students are always debriefed after a simulation, and most simulations are recorded for the students to review. At the Goldfarb School, students run through a scenario, are debriefed, and then repeat the same scenario -- hopefully with improvements.

A student's first exercise with a simulator may be simply a head to toe assessment, taking vital signs, listening to heart, lung and bowel sounds, and explaining the process to the patient. If the patient happens to be a baby, a student must learn to assess a heart rate twice that of an adult, and a breathing rate three times as fast. Heart, lung, and bowel sounds will all be heard in the same six inch area of the baby's trunk, and will overlap.

Homeless Stan at UMSL

In a simulation at UMSL School of Nursing, "Homeless Stan" came to the emergency room thinking he had stomach flu. The three students reported his distended stomach, lack of urine in his catheter, and repeated vomiting to the physician, who ordered the administration of intravenous fluids. They also reported symptoms that would have led the physician to test for a bowel obstruction. During the simulation, the instructor sat behind a one-way mirror operating the computer.

After the short simulation, ending with the IV insertion, instructor Amanda Finley turned off the computer and continued in a classroom discussion. What happens with dehydration? What kind of lab results should be expected? What can cause a bowel obstruction? What happens with a bowel obstruction if untreated?

Renal Failure Post-Surgery at St. Louis Community College at Forest Park

In a simulation observed at St. Louis Community College at Forest Park, eight students rotated roles as they attempted to save the life of a "patient" in acute renal failure. The patient was in contact isolation because he had contracted a MRSA bacterial infection in a surgical wound. But he was having a severe reaction to the antibiotic coming through his IV, and deteriorating rapidly.

Two instructors were present. Gwen Breed sat at the patient's head, alternating acting as the patient and as his family members. She prompted the students constantly with reminders: "Remember to flush the IV." To the student acting as RN, "Can't your CNA take blood pressure while you call the nurses in dialysis?" Nina Raheja, the second instructor, operated the computer, generated lab results, and played the role of physician.

During the course of the simulation, the patient complained often of pounding in his chest and had trouble breathing. Among other symptoms, he had a rapid pulse, low oxygen saturation, and low blood pressure. The students had to note all symptoms and complaints, constantly monitor vital signs, draw blood and take a urine sample for lab analysis. When they had all the information together and called the physician, they were given about ten separate orders.

Doctor's orders come with no specific sequence. The students had to set priorities. All groups discontinued the antibiotic, some with more prompting than others. In one group the patient died because they inserted a Foley catheter before administering the lifesaving drugs indicated by the lab results. Students had to work as a team, dividing the work so that all the orders could be carried out in time to prevent further deterioration. In two of the three groups, the patient pulled through.

This scenario replaced two days of hospital clinical time. The students had previously studied electrolyte balance (potassium should be low, sodium high,) but not renal diseases. To prepare, they were given a number of questions, estimated by one student during the debriefing to have required 18 hours to complete. But all the preparation did not keep them from becoming flustered during the crisis. In the final analysis, most found the simulation to be a valuable learning experience, and thought that simulation time should be tripled. Up to 25 percent of clinical training may be done with a simulator in some states.

Simulators are needed for state-of-the-art nursing education

"Ninety-nine percent of our students love working with the simulator" said Karen Mayes of St. Louis Community College. They can make mistakes without actually harming someone. They learn to prioritize and think critically." Diane Saleska of UMSL pointed out that if she is supervising in a hospital and sees a student about to make a mistake, she intervenes and asks "Are you sure you want to do that?" Thus the teacher, not the student, is doing the thinking. In a simulation scenario, the teacher may coach a bit, but ultimately the student is permitted to make the mistake, and learn from the outcome of those mistakes.

Simulators are expensive, costing about $25,000 to $100,000 each. Like all computers, they become dated in about six months. Teaching with them is highly time intensive for the instructors, and they must be trained in their use. Nonetheless, area nursing schools plan to keep incorporating more and newer computerized "patients" into their curriculum. Just as airline pilots must spend weeks on a simulator before stepping into a commercial cockpit, future nurses will routinely practice their skills on a patient simulator before they practice those skills on real people. Everyone should benefit.

Jo Seltzer is a freelance writer with more than thirty years on the research faculty at the Washington University School of Medicine and seven years teaching tech writing at WU's engineering school. 

Jo Seltzer