Lights. Camera. Robot Action!
With baby and mother dummies, Paul Preston directs a labor-and-delivery rehearsal that's become a smash hit
The staff in operating room 2 is performing a C-section one morning last month at the Kaiser Permanente hospital in Walnut Creek, Calif. "Baby's out at 9:50 a.m.!" says the obstetrician. "I'm going to clamp the cord." No one hears anesthesiologist Helen O'Keeffe: "I have a rising CO 2 here! I need help!" O'Keeffe shouts again: "I'm really having a problem here!"
Someone does hear her: Paul Preston, a tall guy in scrubs wedged in a corner of the OR. But rather than answer her plea, he keeps tapping on a laptop that controls the 19-year-old patient's vital signs. He keys in rising carbon dioxide levels and temperature, symptoms of malignant hyperthermia (MH), a rare complication of anesthesia that's fatal if not quickly treated. O'Keeffe tries again. "I need an MH cart, and I need some Dantrolene! I need some ice!"
Suddenly, everyone is listening. One nurse runs for ice to place around the patient's neck. Someone wheels in the cart stocked with Dantrolene, the only medication that can halt MH. O'Keeffe mixes and injects the drug. "It's working," she says, staring at the monitors. "Her CO 2's coming down. Her temp's coming down."Someone shouts, "It's a wrap!" and the room erupts in cheers. "Don't clean up," says Preston. "Go straight to the debriefing room."
The doctors, nurses, and operating room in this drama are all real, but the mother and baby are not. They are robots, complete with plastic skin, and computer controlled to simulate real obstetric emergencies such as fetal distress or shoulder dystocia. Preston, who pioneered Kaiser Permanente's three-year-old perinatal safety program, designed the robot theater as a tool for harried doctors and nurses to "learn how to react with calm and precision in emergencies without having to learn on real people."
Guinea pigs. That's no small achievement. Although medicine has been transformed in the past century, most doctors and nurses still learn their crafts the old-fashioned way--by practicing on their patients. That "see one, do one, teach one"approach leaves a lot to be desired, not the least for the patients who serve as guinea pigs. Since 1999, when the Institute of Medicine reported that preventable medical errors kill up to 98,000 people a year, pressure has mounted to improve patient safety. But change has been difficult. All too often, trouble comes not from one grievous error but from a series of miscommunications and slip-ups.
Preston discovered that as an anesthesiologist, a high-risk specialty. After a close call, say, an obstructed airway, "I would just tear myself up, wondering what I could do better," says Preston. "We should be practicing these rare events on a regular basis." About 12 years ago, seeking a way to prepare better for emergencies, he met David Gaba, founder of the nation's leading center for medical simulations at Stanford University. He was dazzled by Gaba's lab. "It wasn't just about simulation," Preston says. "It was about psychology and human behavior," too.
Indeed, medicine is just beginning to use the same sort of simulators that other complex, high-risk enterprises, notably aviation, nuclear power, and the military, have been using for decades to train workers. Aviation training takes into account that many disasters are caused not by faulty equipment or skills but by human factors like poor communication. That holds true for medicine as well. For example, surveys have shown that nurses often hesitate to tell a doctor about problems, even though they spend more time with patients and often have a much better idea of what's going on. "Nurses are taught that there's no way you can make a diagnosis, and you can't tell the doctor what to do because he'll throw a hissy," says Preston.