Practice Makes Perfect

Photography by Greg Ruffing/Redux

Cleveland Clinic Children’s Hospital resident Siva Paramasivam, MD, (right) checks the heartbeat of a simulated 14-year-old with seizures. Residents (from left) Helen Tewelde, MD, and Meghan Drayton, DO, confer as Laura D’Anniballe, RN, evaluates the situation.

In a quiet hospital corridor, an elderly man lies on a wheeled bed, forlorn and in discomfort. A passing resident notices him. “How are you doing, sir?” the resident asks.

“Doc, I feel like I could die,” rasps the patient, Mr. Perez. “I can’t breathe and my chest hurts.”

“Let me listen to your chest,” the resident says, arranging his stethoscope.

He calls for backup. The man’s heart stops — a nurse detects no pulse.

“Call a code!” the resident yells. In a matter of seconds, Cleveland Clinic staffers stream in, until a crew of 15 is working bedside. They hook up Mr. Perez to monitors and a defibrillator, do three cycles of chest compressions, and administer drugs intravenously. After about 20 minutes, vital signs pick up. “I feel better now,” he announces flatly.

If that response sounds a bit robotic, it’s because Mr. Perez is not a flesh-and-blood human being. He’s SimMan — a training mannequin that is as realistic a fake patient as you can get these days. SimMan can talk, wheeze, sputter, “bleed” distilled water mixed with red food coloring, and urinate Mountain Dew. Put your ear to his chest and you can hear his heartbeat. Press his wrist with your finger and you can feel a pulse.

A nurse controls SimMan’s actions, speech and vital signs from behind a half-wall. “I call this The Wizard of Oz area,” says Joan Kavanagh, MSN, RN, Associate Chief Nursing Officer, Clinical Education and Professional Development at Cleveland Clinic. “There’s just a little laptop back here, but this is command central.”

Laura D’Anniballe, RN, and Jennifer Sherman, RN, perform a physical assessment on SimMan, a programmable mannequin designed for realistic medical training.

Call it The Wizard of Oz meets Star Trek. Technologically sophisticated mannequins, robots with 3-D vision, and computers that can “feel” are part of the cutting-edge technology that Cleveland Clinic uses to train its medical personnel. The expectation is that medical staff will be better prepared when they encounter actual patients.

Training Days

SimMan is the pièce de résistance of the Stanley Shalom Zielony Center for Advanced Nursing Education’s simulated critical care area, a large room set up exactly like an Intensive Care Unit (ICU), with a few key differences: a built-in audiovisual system that can record simulated hospital procedures from various angles and distances so it can be viewed and parsed later, and monitors that not only read the pseudo-patient’s vital signs but also transmit them back to the control area so the instructor can make SimMan’s software respond accordingly.

The software is scripted before a simulation, but teachers can improvise depending on the trainees’ actions. “If they do something that really would have an adverse effect on the mannequin,” like not using the defibrillator when they should, “I can change the heart rhythms,” says Leslie Simko, RN, BSN, MS, Nursing Simulation Coordinator. “I can put the mannequin into flatline, and his other physiological parameters will continue to deteriorate until the participants administer treatment.” She also can make the patient talk: “I’m really not feeling well.”

And she can do it with different voices for different scenarios, says Ms. Simko, who spent 17 years as a critical-care nurse before earning her master’s degree in nursing informatics, specializing in simulation. If the “patient” is an adolescent (SimMan can be dressed to look like SimWoman or SimTeen), she has her nieces and nephews record voices and statements into the software.

On a recent weekday morning, SimMan trainees included a dozen nurses from several departments who were honing their skills, plus two or three residents who were there as part of their training.

During a debriefing session, trainees watched video of themselves to critique their performance. Under Ms. Simko’s direction, they found some areas that needed attention.

“Let’s talk about the bedside monitor for a second,” Ms. Simko told them. “If you walk into the patient’s room, the patient’s just lying on a bed, not hooked up, and not talking. You know there’s something going on. You called for a nurse to hook him up. What could you have done in that situation? Hooked him right up to the defibrillator. You don’t even need to use the bedside monitor.”

Leslie Simko, RN, BSN, MS, demonstrates rescue breathing on an infant simulator with respiratory distress.

“The debriefing session is probably more important than the actual scenario,” Ms. Kavanagh says. “This is a safe place for nurses, for doctors and respiratory therapists to develop critical thinking and judgment.”

The simulation center might seem space-age, but its technology may eventually be a necessity. “This is the future,” says Ms. Kavanagh, whose nurse’s training took place back in the day when students practiced by giving IVs to oranges. “Physicians down the road will have to have so many hours of simulation to maintain their license, their certification. I’m sure the same thing will happen for nursing, as well.”

SimMan is just one component of Cleveland Clinic’s high-tech nursing simulation program. The center also is equipped with an untethered mannequin that trainers can wheel to various parts of the hospital for on-site surgeries, and a SimBaby that can cry at an ear-splitting volume.

The center also has a virtual component — computers with haptic, or tactile, software for practicing techniques such as inserting IVs. Students click and drag a mouse to select the equipment (tourniquet, gloves, dressing) and procedures (washing hands, turning the arm this way or that), then the computer grades them on whether they made the right choices in the right order. Then they insert a needle into a device, and the computer “reads” their competence. If it’s the right spot, they feel the appropriate pressure. “You get that ‘pop’ that you would when you put it into a vein,” Ms. Simko says.

“It’s kind of like a video game,” she adds. “Our younger generation takes to this stuff, because they grew up with it. My 14-year-old niece was in here for her student day, and she did so much better than I ever could, because she’s just used to it.”

Bringing It Together

Artificial arms provide a painless way for medical professionals to practice injections.

On a small scale, the Nursing Simulation Center is a model for what Cleveland Clinic hopes will be an interdisciplinary, high-tech training center.

“We have pockets of simulation capability right now,” says James K. Stoller, MD, MS, Chair of Cleveland Clinic’s Education Institute and the Jean Wall Bennett Chair for Emphysema Research. A new training center will bring everything together, he says. A faculty of 10 to 15 Cleveland Clinic staffers will create curricula for skills they want to develop in trainees.

“The goal is to have all the resources in place — building, technology, people — so a doctor could call and say, ‘I would like to schedule a session on central line placement,’ and schedulers would know exactly what algorithms to use and would arrange the session like scheduling a room for a lecture,” he adds.

The training will consist of three components: team-based sessions (simulated surgery using mannequins or actors); procedure-based sessions (practicing basic skills, such as suturing, at a virtual station); and clinical examinations, in which students practice taking medical histories and giving physical examinations to actors who are pretending to be patients (at some point in the future, Dr. Stoller says, the “patients” may be computer-generated avatars).

J. Eric Jelovsek, MD, Cleveland Clinic’s Director of Surgical Education, will direct the new training center. The new facility will re-create urgent care, the emergency room, the trauma bay, and the labor and delivery room. “Everything from the exact lights, storage cabinets, placement of the light switches, a telephone that works,” he says. “All of those things have to be strategically placed to re-create the team interaction.”

Simulation training centers are becoming an essential element of medical education. “It’s getting to be that many of the specialties are requiring simulation as part of their maintenance of certification,” says David Brown, MD, Chairman of Cleveland Clinic’s anesthesiology unit and a member of the training center’s development team. Some residency programs, such as general surgery, are requiring it as part of training.

According to Dr. Jelovsek, simulated training started to become more of a priority in medicine around 2000, when a seminal report by the Institute of Medicine, To Err Is Human: Building a Safer Health System, focused on the problem of doctors making more errors as medicine became more specialized.

“Plus, with healthcare reform, there’s been an increase in accountability,” he says. “It’s no longer acceptable to learn on a patient.”

Training staff on simulators could help reduce medical errors, says Grace Peng, PhD, Program Director at the National Institute of Biomedical Imaging and Bioengineering.

“The idea is to have more checks and balances within the field of medicine,” Dr. Peng says. “A lot of this includes practicing skills with simulators to emulate the environment of the operating room. Most medical errors occur during the first 100 patients operated on, and errors decline dramatically after that.” Simulations can also change the surgical workflow and help the staff work better as a team. “A lot of times, people don’t want to contradict the surgeon. This is the time gross errors can occur.”

Along with $6.9 million in the capital budget, two philanthropy-driven projects on the drawing board figure heavily into Cleveland Clinic’s plan: the Debra Ann November Pediatric Airway Simulation Program and the Dr. Archie Brain Difficult Airway Simulation Center. Both use simulation to teach physicians and other clinical personnel — including first responders — how to insert breathing tubes into patients. It’s a tricky procedure that, when done incorrectly, can lead to injury and death in medical emergencies. Cleveland Clinic proposes to develop a program that will fill gaps in education and translational science.

Robots in the Operating Room

One of the most futuristic corners of the Cleveland Clinic campus is an extra-large operating room (OR) in the Sydell and Arnold Miller Family Pavilion, where surgeries are performed and training takes place. Prepping for a mitral-valve repair surgery, scrub nurses and technicians adjust the arms of the da Vinci Surgical System, an octopus-like robotic machine that performs surgery with micro-size instruments, dramatically decreasing incision sizes and recovery time.

The robotic da Vinci Surgical System not only aids surgeons such as Tomislav Mihaljevic, MD, but also includes training consoles for practice.

The lead surgeon on this case, Tomislav Mihaljevic, MD, the Donna and Ken Lewis Endowed Chair in Cardiothoracic Surgery, won’t even touch the patient, a 55-year-old woman. Instead, another surgeon will make the initial small incisions, and Dr. Mihaljevic will sit alone at one end of the room, controlling the movements of the robot’s arms with toggle-like hand controls. He rests two fingers of each hand on ring-like controls that work the tiny instruments attached to the robotic arms, which include tweezers that look like hummingbird beaks.

Rather than looking directly at the patient or making much eye contact with his team, Dr. Mihaljevic peers into a microscope-like eyepiece with two separate channels that create visual input for each eye, giving him a 3-D view of the woman’s heart.

The surgical team, which during the prep had been making small talk, is silent now, watching the surgery on two large flat-screen monitors mounted on the ceiling above the operating table. The quiet, occasionally punctuated with Dr. Mihaljevic’s brief play-by-play comments to the group, will last a little over an hour, until the robotic portion of the surgery is complete.

Four observers are in the OR: a doctor from Beijing, two medical students from Brazil, and a medical fellow at Cleveland Clinic. The students say they’ve never seen anything like this. Cleveland Clinic has the nation’s largest robotic heart surgery department in terms of the number of operations performed (more than 600, with a 100 percent recovery rate); only a handful of hospitals do robotic heart surgery.

The fellow sits at a training console directly across from Dr. Mihaljevic, following his moves on her viewer until he tells her to take over and tie the final sutures. She’s ready — she has already trained on a da Vinci console in the lab and the OR, performing simulated heart surgeries on cadavers, mannequins and high-tech chest and heart models.

“We can simulate almost the entire operation,” says Dr. Mihaljevic of the robotic surgery training program. “[Trainees] have to be extremely well-informed and trained about the specifics of instrumentation in the lab before we have them in the operating room.” And once in the operating room, surgeons need to perform 150 to 200 robotic surgeries before they are adept at the procedure, according to a 2010 study published in the New England Journal of Medicine, so working alongside an experienced surgeon is key.

Eventually, Dr. Stoller says, simulated robotic surgery will be conducted at the training center. By then, computer-controlled mannequins and haptic software might be everyday training tools at Cleveland Clinic.

“We’re talking with companies that make simulation equipment — very high-tech stuff, mannequins that breathe and have pulses, and their pupils dilate and they cough,” he adds. “Mannequins managed by radio-frequency computer signals that simulate real experiences and give you physiologic and clinical feedback about the procedures you’re doing. This is sophisticated stuff.”

In the meantime, back at the Zielony Nursing Education Center, Ms. Simko and her crew are making the most of their mannequins by wheeling them around campus for surprise on-site visits. “Last week, we took our baby simulator into the pediatric ICU,” Ms. Simko says. “We used one of their staging areas, their beds, and called a code.”

The training is more real when it happens on-site, she reflects. “They really get a good feel for, ‘Where is the emergency equipment that I really need to grab? How do I use it, how do I turn it on?’ ” By the time they enter a real situation, they’ll know the answers.

Better than a Slide Show: The Face Transplant in 3-D

Through high-tech 3-D imaging, Cleveland Clinic doctors explain a groundbreaking face transplant.

In 2009, Cleveland Clinic surgeons made headlines when they performed the first near-total face transplant surgery in the United States. But ­Daniel Alam, MD, Section Head of Facial Aesthetic and Reconstructive Surgery at the Head and Neck Institute, said that what impressed his colleagues at other hospitals was not only the surgery, but also how, through 3-D imaging, Cleveland Clinic shared information about how the surgery was performed.

Mark Sabo, a medical illustrator who is Cleveland Clinic’s resident 3-D imaging guru, took Dr. Alam’s 40-page, single-spaced protocol for the surgery and distilled it into a five-minute movie that captures the high points of the surgery from multiple angles.

“In medical illustration, it’s not about defining every nook and ­cranny,” says Dr. Alam. “It’s about defining what’s important. You don’t have to see [the patient] bleeding. You have to have a way for the audience to understand the important elements of a procedure without becoming lost in the details. Footage of the surgery is often far less effective than animation, where you can make things transparent or opaque, disappear or reappear. This allows the viewer to appreciate the surgery from a true three-dimensional perspective.”

Starting with written data — as well as the doctor’s hand sketches and 3-D CT scans of the patient’s face — Mr. Sabo used a movie industry software program called Maya to build virtual models of the patient’s face from various angles and at certain points in the surgery. Dr. Alam gave feedback (“the cartilage doesn’t look like this — it was aligned this way instead of that”) and Mr. Sabo made adjustments. The images were then sequenced and animated.

The software’s 3-D feature meant that Dr. Alam could rotate images so doctors could view the surgery from any angle, including the side, front, and back of the head.

“In five minutes, you can begin to communicate with doctors in a way they can understand,” marveled Dr. Alam, who says a traditional slideshow on the subject would require about 500 slides. “It’s a really beautiful way of virtually creating models of what happens to patients in a surgery.