Saving SimMan

April 1, 2010
Patient patient: A mannequin endures endless poking and prodding as nursing students encounter a range of real-life simulations during their clinical training;

Patient patient: A mannequin endures endless poking and prodding as nursing students encounter a range of real-life simulations during their clinical training. Jared Lazarus

Imed Hamed is having a bad day. After returning to his Duke hospital room from a battery of X-rays and blood tests, his heart has stopped, and no one is around to help him. A nursing student comes in to check on him. She thinks he might be asleep.

"Mr. Hamed? Mr. Hamed?" She shakes him. No response. She looks at the monitor and realizes he's in cardiac arrest. This is her first time with a patient who is coding, and while she's remembering some procedures from her first few months of training, right now everything's a blur.

Thankfully, both for the student and for Mr. Hamed, this is a simulation. It's the beginning of the spring semester, and a group of about a dozen nursing students is being introduced to a new type of clinical training that is aimed at bringing a sense of realism early on, before students are ready to work with flesh and blood.

The hospital room is actually a second floor lab at the Duke School of Nursing known as the Center for Nursing Discovery or CND. The heart-and-vital-sign monitor is hooked to a computer program that is sending out data associated with cardiac arrest. Mr. Hamed? He is one of the nursing school's lifelike human mannequins known as a high-fidelity SimMan.

Patient patient: A mannequin endures endless poking and prodding as nursing students encounter a range of real-life simulations during their clinical training;

Patient patient: nursing students train on the proper use of a bag valve mask. Jared Lazarus

The past decade has seen a growth in the sophistication of these mannequins and their use for medical training nationwide. Duke's corps of "patients" is technologically similar to that of peer institutions, but educators at the School of Nursing have come up with an imaginative series of ways to animate them, so that they appear to be more than fancy, expensive dummies. (Some adult mannequins cost as much as $50,000; babies, about half that.)

Margie Molloy, coordinator of the CND, has worked for the past three years to make the lab's mannequins more effective teaching tools by making them seem more human. She creates back stories—Mr. Hamed, as everyone calls him, is a sixty-three-year-old retiree—and builds visibility by, for example, taking them to student and staff parties. One of her staff members hand knit caps for ten of the school's baby mannequins.

This year, Molloy sent a holiday e-card to nursing-school faculty and staff members featuring Noelle, the birthing mannequin, and her baby, Holly. Merely naming the mannequins, she says, does something to humanize them. CND staff members often use the names of aunts, uncles, cousins, and even high-school classmates, though Mr. Hamed's was chosen to make students aware that cultural sensitivities also need to be considered.

A number of the nursing students stressed the importance of treating the mannequins—male or female—with the same dignity afforded human patients. Mr. Hamed is dressed in a hospital gown and covered with blankets. When the mannequins are used in patient- care scenarios, Molloy adds to the reality of the situation by concocting realistic-seeming physiological elements. She makes urine, for example, by adding yellow food coloring to water, and, for an obstetrics demonstration, prepares an approximation of the postpartum fundus out of Jell-O and other ingredients. As Molloy puts it, "suspending disbelief is what it's all about."

The crash cart finally arrives, and the students mill around Mr. Hamed's bed. A couple make tentative attempts to begin stabilizing him. Kathleen Turner M.S.N. '93, an assistant clinical professor, interrupts them. First and foremost, she says, they need to get help. But simply asking for it isn't enough. "You can't just call for help. You've got to grab someone and say, 'You, go get help,' or else no one is going to go."

The current exercise is part of a daylong training session for students in the nursing school's accelerated bachelor of science* in nursing program. They are practicing three things today: how to administer medication, how to give an IV, and how to handle an unresponsive patient. The students have yet to go on the kind of hospital rotation that will expose them to real patients experiencing the things they've seen today.

Turner, who is in charge of the unresponsive-patient demo carried out with Mr. Hamed, is with her second group of the day. (There are three groups altogether, comprising about forty students.) She emphasizes composure and confidence in the face of chaos. Imagine a duckling, she tells the group. On top of the water, it appears to move effortlessly. Under water, little legs are kicking. Clinical preparation is one of the most difficult elements of nursing education, she says, and can be paralyzing for new students.

After one student has gone for help, two others resuscitate Mr. Hamed. Turner tells them to make certain the hospital bed is locked in place and encourages them to get more familiar with their surroundings—where the oxygen source is, for instance, and where to find syringes. Details like these add up, and knowing them can put a student nurse at ease, she says.

As they begin doing chest compressions, students learn to use the hospital bed's headboard as a way to stabilize their patient while he is being resuscitated. Outside the familiar classroom atmosphere, they're struggling to get enough leverage to begin giving CPR without getting too tired. They aren't sure whether they should try to kneel on the bed next to Mr. Hamed or stay standing. "We've come a long way from 'Annie, can you hear me?' " Turner says to no one in particular, referring to Little Annie, a popular mannequin used in CPR training. By working through the simulation—monitor beeping, people crowding, bed moving—students get a sense of what will happen and, more important, what to do when their first real patient goes into cardiac arrest.

Turner says when she was studying to be a nurse nearly thirty years ago, there was more rote memorization but also plenty of practical learning opportunities. She remembers giving shots to oranges or even to other students, which, upon reflection probably wasn't such a good idea, she says. Mr. Hamed has one arm that is textured in a way that allows students to make injections. It looks like a human arm and feels like a spongy cork board.

The other arm has sensors that allow students to take his pulse. Mr. Hamed and the other mannequins have faces that look frozen, oversized mouths perpetually agape. They are hairless from head to toe. The "adults" weigh only about thirty or forty pounds. But they are rigged with internal tubing that allows them to urinate, bleed, and ooze. They are anatomically correct, and the external genitals are interchangeable.

Mr. Hamed can be made to simulate a wide range of human medical problems. He is connected to a computer that runs software loaded with scenarios, and he is programmed to follow a script. If he were to have a stroke, the program would begin at the first warning signs and react—positively and negatively—to the care he receives. If students give the wrong dosage of medicine or fail to take needed action, Hamed's condition worsens. If they follow a proper treatment plan, he improves.

Another SimMan mannequin stays in a special room used by nurse-anesthetist students. The room is equipped with two computers and video cameras so the students can record themselves and review the footage later, with critiques from instructors. Along with organizing new training sessions like today's, Molloy also opens the lab during the week for students to have individual and small-group sessions with the mannequins.

Molloy enters a large storage room at the center of the lab, walks over to a wall of floor-to-ceiling cabinets, and begins pulling open doors. On shelf after shelf, mannequins, all adult males, lie in suspended animation. She opens a large Sterilite storage container piled high with a variety of plastic wounds, from big gashes to festering scabs, that can be snapped onto the abdomen, depending on the desired scenario. She mentions that she has a recipe for cooking up a realistic-looking pus that adds olfactory and tactile elements to the visual. Other shelves hold mannequins of babies and young children, all clothed and carefully laid out.

After the students finish their clinic for the day, Molloy goes to her office to check her messages. She finds a surprise waiting there. A suitcase has arrived. Inside is Sim- Baby. Molloy can barely contain her excitement. "His mouth goes blue!" she says.

She will send a birth announcement to the nursing-school community and throw a baby shower in the early spring. "Simulation," she says, "is taking that leap."