Six Wichita health workers see how simulated training works

WSU nursing student Rachel Wilson checks her watch during a simulated cardiac arrest at the Johns Hopkins Simulation Center in Baltimore. (June 23, 2011)
WSU nursing student Rachel Wilson checks her watch during a simulated cardiac arrest at the Johns Hopkins Simulation Center in Baltimore. (June 23, 2011) The Wichita Eagle

BALTIMORE — The obvious question, after the announcement that some people in Wichita want to raise $14 million for a medical training simulation center, is why give money to it?

Betsy Hunt, who runs the Johns Hopkins Medicine Simulation Center in Baltimore, thinks she has three good answers:

Saving lives, Hunt said.

Making patients suffer less.

And averting lawsuits.

Do you really want to hold down costs in a hospital town like Wichita, she asked?

Train medical people like we train our aviators, then.

Aviators live for near-endlessly repetitive simulations, practicing their art on dummy runs long before they risk passengers.

But medical people don't do things that way, she said.

Sometimes that person sticking a tube down your throat is doing it for the first time.

* * *

Six Wichita doctors, nurses and medical students flew a Hawker Beechcraft business jet to spend five hours at Hunt's simulation training center on Thursday.

Hunt put them through three scary simulations: resuscitating two high-tech mannequin guys and a mannequin baby, all in cardiac arrest.

All six Wichitans are highly trained and motivated, yet Hunt saw them make minor mistake after mistake after mistake that might have prolonged patient suffering.

In medicine, Hunt said, no one trains together enough. From medical school on, doctors train separately from nurses, nurses train separately from pharmacists and anesthesiologists, and so on.

Turnover among team members in high-stress critical care units is high sometimes, so new faces always show up to help save the fast-dying man.

Any time you see a group of people working fast to save a dying person in a hospital, it's likely that some members of the group are working together for the first time — all while trying to restart a heartbeat and get a person breathing again.

Aviation people never work that way, she said. They live for simulations first.

* * *

If your heart stops in a hospital in Wichita, two people who might save your life are Orion Dyson-Smith and Tanya Kajese.

Dyson-Smith is a critical care nurse at Wesley Medical Center; Kajese is a surgical resident physician who works at both Wesley and the Via Christi hospitals.

What happened at about 11 a.m. Thursday Baltimore time was typical of what can happen in a crash code anywhere — it's unplanned and someone is dying unless everyone moves fast.

Dyson-Smith is used to it. But when it was time for the first simulation at Johns Hopkins, he looked nervous.

"I don't want to kill a mannequin," he said.

None of the five Wichitans standing with him laughed; they looked tense, too.

It began.

"Someone needs help in here!"

The Wichitans hurried into a room to find a high-tech dummy in cardiac arrest.

To an untrained eye, the life-savers looked superb: physician Eli Brumfield called out instructions in a level voice; everyone yanked on gloves. Dyson-Smith put both hands over the dummy's heart and pushed rapid chest compressions.

"Is the patient breathing?" Kajese asked. When Dyson-Smith said no, she calmly began trying to force a tube down the patient's throat.

Rachel Wilson, a Wichita State University nursing student, grabbed a marker and wrote down times, names of drugs being used, and procedures in big letters right on the wall in the patient's room. Anyone at a glance could track the procedure.

Everyone's eyes looked wide open and resolved, like the eyes of veteran athletes in the last seconds of a close game.

When two minutes of chest compressions passed, Mary Koehn, who runs the department of nursing at WSU, seamlessly took over from Dyson-Smith in that tiring effort.

When it ended, with the patient alive, everyone smiled.

But Hunt then spoke unseen, like the voice of God, through a microphone from behind an opaque control room window.

"Now let me tell you what you did wrong."

They did a lot wrong.

* * *

The Wichitans chimed in, volunteering their mistakes.

Dyson-Smith said he failed to try to talk to the patient before pumping his chest.

Brumfield, a teaching physician for residents at Wesley, said he had called out instructions without telling team members who he was, and that he was calling the shots.

The team had failed to quickly grab a small step-stool so Dyson-Smith could stand on it, elevating his already tall body so he could use more arm strength in chest compressions.

They lost precious minutes before they grabbed a backboard (a flat piece of plastic) from the crash cart and stuck it under the patient. By the time they did that, Dyson-Smith and Koehn had been trading off chest compressions for several minutes while the patient lay in a soft hospital bed.

Compressions are more effective at holding off death or brain damage if there is a hard surface like the backboard under the torso.

"These things can make the difference sometimes," Hunt told them.

Most of all, Hunt told them, they'd failed to work seamlessly as a team — just like in many hospital critical care situations every day, all over the country.

At stake, she said, is the comfort and survival of someone's loved one.

* * *

Kajese, the surgical resident, said she hopes the center can be built in Wichita; the city is already "one of the big medical meccas" in the Midwest.

In her medical training, at the University of Kansas School of Medicine, "we (doctors in training) didn't begin to interact with other teams until my third or fourth year in medical school."

In her own encounters with medical crises, "when I go into a room to help a patient, there are frequently new faces, people I never worked with before."

Hunt told them that when inexperience and unfamiliarity is added to stress, and then added to little mistakes — like people not putting tools back into a crash cart after use — patients suffer.

If there is one thing she is trying to change nationally, she said, it is to get doctors and other staff to train together as teams, repetitively, with no patient's life at immediate risk, so they don't have to reinvent wheels in a crisis, as they often do.

Kajese said doing that would change things in hospitals for the better.

"I handled a code last week where... I knew only one nurse in the room," Kajese said. "I had to say who I was, ask who's the pharmacist here, who's doing the documenting, who found the patient, what did you see?

"All new people, trying to work a code like that."

Most hospitals and most schools don't emphasize teamwork enough, if at all, Hunt said. And many of them don't train hands-on until they are working real cases in a crisis. That's not fair and is often harmful to patients, she said.

Dyson-Smith said he got good training, both in nursing school at Butler Community College, and then at Wesley.

But in school, nurses trained only with nurses, and there were perhaps only two simulated critical care crises that he handled in all of nursing school.

Crises like those simulated in Baltimore don't happen every day at Wesley's critical care unit, he said.

"Perhaps only once or twice a week."

When they do happen, the Wesley teams handle them well, he said.

"But there is turnover, and so it is as (Hunt) said, there are often new faces in the room. It goes well, but that's because the experienced people take over.

"What that means is, the less experienced don't get experience, except by watching."

Nothing prepares you for the real thing like doing the real thing, he said. Or at least doing near-real simulations as at Johns Hopkins.

"Nothing you study or hear in nursing school can prepare you for the real thing, such as when you unplug a patient's intravenous bag, the connections can be slippery with blood or fluid, and you've got gloves on, trying to hurry.

"You can't learn to do that by listening in class.

"I don't know why we don't already do what they do here (at Johns Hopkins)," he said. "It would be invaluable."

* * *

The group of doctors, hospitals and other concerned people who want to build a new Mid-Continent Regional Center for Health Care Simulation have all sorts of reasons why people should help them build it.

But money in this recession might not be easy to raise.

The people behind the center are hoping for $8 million in donations from foundations and individuals, plus $5 million from taxpayers and hospitals, plus another $1 million in gifts and cash from the medical profession.

People pushing for the medical simulation center said hands-on training, like the kind done at Johns Hopkins, is going to be expected in the future, not just hoped for.

H. David Wilson, dean of the University of Kansas School of Medicine-Wichita, said the Johns Hopkins way is likely to be how most medical people train in the future.

That's good, he said. Think about a doctor learning, on the job, how to stick an endotrachial tube into a patient's windpipe for the first time. If you are relative of that patient, "You'd like for someone in that position to have practiced that many times."

But that kind of practice, on a dummy, doesn't happen often, or often enough.

Paul Uhlig, the heart surgeon who leads the effort for a new center, said he is confident Wichita will respond.

Aviation people would never dare do their jobs without simulators, he said. Every move a pilot learns, every pilot earning wings, every design an engineer creates, are put through a multitude of simulations before passengers are risked.

"You see how that attitude about practicing everything endlessly has transformed aviation," Uhlig said.

But medical people don't work that way.

They don't think that way, even though the driving worry of both professions is whether everyone goes home alive.

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