I could feel the sweat rolling down my head as I entered the room. You know that feeling of doom and dread. It was palpable as the team walked in behind me. They were afraid, too. Everything was riding on this moment. Pass or fail. Do or die!
We were summoned to Trauma Bay 1, and today, I would call the shots. I'd been preparing for this moment for months, but I had no idea whether I could really do it. I swallowed hard and started making my way into the chamber that would test my skills.
Success would result if I passed the test. The patient would live and I would sit back with a tall cold one at the end of the day. Failure would mean I had missed something and the patient would die. As I entered Trauma 1, the only information I received was that the patient had been in a motor vehicle crash.
I tried to keep my composure. I could hear my Quark surgical shoes make that annoying squeak on the shiny floor. But drowning out that horrible squeak, I could hear loud breath sounds. For a quick second I wasn't sure if those sounds were coming from the patient or from me.
"Are those agonal respirations . is head trauma involved?" The differentials started flooding my mind. I knew what to do, but part of my brain wanted to slip in to differentials by book-like categorization, ". most likely . most deadly . everything in between ." My instructors had always hammered the mnemonic VINDICATE for differentials. It was comprehensive, but it seemed too slow and organized for my scattered type A brain.
My head was spinning and I had a flashback to Rafi Israeli, a Cleveland Clinic ER physician and friend. He once saw my hand shake in a clinical situation and said, "Joe, relax. The enemy of performance is anxiety." As I heard my friend's voice echo through the hollow chamber in my cranium, I took a deep breath and went to work.
"Ok everyone, let's get going here. Let's remember ABCs and start from the top. Steve, I need two large-bore IVs started. What do we have? OK, Dawn, start bagging him. I need vitals here . nothing . no pulse. Ok, Mae, please start chest compressions. I agree . OK, Mike, you run the paddles . 200 joules . unsync . give him space . all clear ... Yes, I need epi onboard. Ok . 260 joules and shocking. Danielle, I need a CBC, CMP, ABG, tox screen . you guys are doing awesome here. Call out if we're missing something ."
As I asked for vitals, I could hear a voice booming over what sounded like a megaphone in my ear. Yes, that was a familiar voice. I didn't see his face as he called out the answers to my questions, but I could picture that wide grin and toothy smile. Darn, he's playing with my mind again - intentionally throwing information in that I didn't ask for. He's trying to throw me off track. He's knows what's at risk here. I could fail! I kept wondering, "Is that relevant information or is that a zebra?" Damn, I hate when he does that, but at least I know why he's doing it. He's trying to teach me a lesson but I don't want a lesson right now! Just answer my damn questions! Let me save this patient's life and pass the test!
We were moving fast, but I really had no idea how long we had been in Trauma 1. At some point, I felt a dark shadow in the room. Like a voyeur, he was watching. I knew he was there and that he was just waiting to teach me something. But this was my code and my team. This patient was mine until time was called or the patient was dead. He watched my every move, he recorded my every gesture, and he listened to my every word. I knew I would see my mistakes again, and again . and again.
I was standing at the side of the trauma bed, and I reached down instinctively and felt the patient's arm. It was cold and felt like rubber. Of course, I had felt this before, but this time it was different. The patient's face had an eerie look and his eyes were open. This time the blank stare, the lack of emotion, the eyes . this time it was different and it was haunting.
"Ok . what's that . let's check a rhythm . what do we have? . I agree . I need an amp of atropine ..." This does not look good, I thought. He's dying, or maybe more precisely, he's dead and we are trying to revive him.
We did everything. We shocked him several times and we gave meds. The rhythm changed for a moment. We thought we had made progress. We did labs; we reviewed H's and T's, and we saw the rhythm change again. The patient would crash and then somewhat recover, then crash hard again. Scenario after scenario, it was like we were running through the entire ACLS book. Our team was good, and we did everything we could think of. But nothing worked.
"This is a no-win situation here," I kept thinking. He's dying and I'm failing. Was he somehow programmed to die today? There has to be a point to this chaos other than causing me pain. Our team worked diligently, but all we saw was asystole on the monitor. All we could hear was the audible hum of nothingness. The patient's breathing, which I had heard so loudly as I entered the room, was now gone. There was nothing left to do. Our patient was dead.
"Time of death, 14:10 . we're done here . you're an awesome team and I'm proud of your work . we did what we could do. Let's debrief and get ready for the family."
"IT'S OVER!" boomed the voice over the loudspeaker. "Everyone out of the sim room and let's debrief!" At this point, the medical simulation director appeared. He had a wide smile on his face as he strolled into the medical simulation laboratory. The director had decided the patient would die today, and there was nothing I could have done to prevent it. Today's lesson was that even when you do all you can, death happens.
How did we get such a positive rush from a medical simulation? We had "played" with the simulator many times before. Why was it different now? What did we do wrong? Why did our patient die? As computer scientist Randy Pausch said in the Last Lecture, was this a "head fake?" Did the sim director want to send a message here?
I cannot express how exhilarating it was to be challenged like this. Although my simulated patient had died, I learned so much! Compare this experience to the traditional PowerPoint lecture given in NP and PA programs through the country. There is no comparison.
To me, medical simulation is one of the highest highs you can get if you love medicine. Ideas and concepts are crystalized. Skills are honed. Lessons are learned. Most important, you have a blast! I was playacting but I was learning more than I could have imagined, and I certainly learned more than sitting in a boring lecture hall staring blankly at a screen listening to the monotone sound of yet another lecturer.
Medical simulation technology is improving at a rapid pace, and we are only in the first inning of the game. Check out the amazing work being done at Stanford University by David Gaba and Sandi Feaster. They are two of the pioneers leading the charge in immersive medical learning. Northwestern University and Harvard University also have implemented sophisticated medical simulations. And physician assistant programs at Gannon University and Lock Haven University are also embarking on simulation centers.
Why Medical Simulation?
Medical simulation offers many advantages:
No threats to patient safety
Reproducible scenarios to build proficiency
Can be used in testing scenarios across the curriculum
No ethical concerns about real patients
Scenarios can be built for variably sized simulations
Advantages over didactic learning when students can actively learn in the lab
Debriefing assists the team in decision making, protocols, teamwork and other variables.
My work in software development and network design prior to becoming a physician assistant draws me to medical simulation technology. Even as I purchased my first Xbox 10 years ago, I was wondering how I could make a medical simulation game. My struggle at the time was how to leverage technology in medicine. I was a computer geek, not a medical freak. So, there was only one thing for me to do, and that was to earn another master's degree - this time in physician assistant sciences. My dual training enhances my understanding of the many possibilities of medical simulation and other modalities of immersive learning.
These days, my mind spins not only on differential diagnosis, but also on ways to take medical simulation to the next level. Many NP and PA programs have purchased medical simulators, but I wonder about the usage. My general impression is the simulators are purchased, placed in a remote lab location and used about an hour a week to take blood pressure or listen to a heart sound. What a waste of resources.
I realize it's hard to break into the traditional didactic learning environment. Consider a new paradigm. Suspend disbelief for a minute and go with me on a thought experiment.
Imagine that you are getting on a plane bound for Japan. You have your choice of two pilots. One spent 90% of her training in the traditional classroom. Lots of PowerPoint presentations on the theories of flight, a great deal of information on plane operations, a tremendous number of photos of what the cockpit looks like, and lots of stories from veteran pilots who have flown before. She spent 1,000+ hours in the classroom.
Your second choice is a pilot who spent 90% of her time in a highly advanced flight simulator. She learned on the plane. Her classroom had no fixed chairs, just stools on wheels that she could roll around a massive flight lab. She could go from station to station and the environment would adapt to her skills, pushing her to the next level. She learned in a highly interactive environment. She spent 1,000+ hours in the simulator learning to fly in every conceivable flight condition. Who do you want in your cockpit?
When the lab becomes the classroom, we have made progress. If we want to take NP and PA education to the next level, toss out the chairs and have students stand around a cadaver or a medical simulator. Let them roll on casters from station to station. I know! Heresy.
What if we took all the various types of immersive learning technology and made that the classroom? What if we literally ripped out the seats in the classrooms and surrounded our students with massive lab space where they could roll from station to station? What if the classroom consisted of an ER bed, an ICU bed, NICU bed, a radiology station, a nursing station, a pathology lab and other key centers where students learned hands on? What if from day 1 of NP or PA school, students were given a white coat and stethoscope and ushered in to a lab instead of a classroom? What if we eliminated chairs and chalkboards and students worked in a lab for 90% of their training? What if medical students had to write medical scenarios in a virtual reality environment? Instead of seeing PowerPoint slides, students would program a virtual reality environment of a patient with the disease? What if we consider using augmented reality in medicine? I'm only scratching the surface of 'what if" analysis.
I sure wish Pausch were here because I would love to have coffee with him and ask him how to make virtual reality an absolute reality in NP and PA education. I watched Pausch's Last Lecture again, but this time with a group of new PA students. I saw smiles and tears. Randy was such a powerful force, and his ideas live on and continue to resonate with us because he touched the heart of learning with his wonderful ideas:
· Make things fun.
· Dream a big dream.
· Learn from all the people in your life.
· Dare to do things differently.
· Find the right place to nurture your dreams.
· Never lose the child-like wonder.
· Brick walls are there for a reason: they let us prove how badly we want things.
Think back to your own education. Which environment did you learn the most in? The seats and lectures or the labs and hands-on care? I'm interested in how other NP and PA programs are incorporating immersive technology. Let me know at firstname.lastname@example.org.
Joseph G. Weber is director of the physician assistant program at Lake Erie College in Painesville, Ohio.