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.
In 2001, Preston decided that his new mission in life would be to help create a healthcare system where no one would be intimidated. A minister's kid from Wheeling, W.Va., Preston is particularly well suited for the job. He is as affable and ingenuous as an 8-year-old and seemingly bereft of doctor ego. He knew that Kaiser wasn't about to pop for a multimillion-dollar simulation lab. So Preston--working with many colleagues and the advice of Gaba and aviation researchers--put together a robot roadshow. Since 2002, he has spent about half his time traveling to hospitals, running training sessions for the thousands of men and women who staff the labor-and-delivery units in Kaiser's 29 California hospitals. "He's the guy who will finish a day in the operating room, throw the robots in the car, drive for two hours, and spend the night setting up the robots," says Michael Leonard, Kaiser's physician leader of patient safety.
The robot patients, who can gasp, urinate, undergo surgery, and give birth, are surprisingly realistic, right down to their pulse rates. "You lay aside that it's pretend," O'Keeffe said after her first experience practicing medicine on a robot. "It's amazingly real." That's despite the fact that Preston, unable to spend $25,000 on another pregnant robot, improvised by oufitting the male model O'Keeffe used with a womb made of carpet padding and duct tape.
Playback. But Preston is the first person to say that the point is not that the robots are cool gizmos. "If I were the patient, would I want it to be the first time the doctor had done the procedure? Of course not! Clearly, we need robots," says Preston. "And clearly, we need people to be trained as part of a team." The program includes communication skills training as well as motivational data: For example, birth injuries to children are the most costly malpractice claims, and 1 in 4,000 deliveries ends in a bad outcome.
Thrilling though the robot theater may be, the heart of the session at Walnut Creek was the debriefing. The OR team watched a video playback of the delivery and quickly spotted where things went wrong. One nurse said she couldn't hear the anesthesiologist. Another said that because she doesn't work in a regular OR, she wasn't aware that malignant hyperthermia was a life-threatening emergency. But they also noted when things went right. For example, O'Keeffe recognized the condition as the first symptom appeared, and the whole team mobilized quickly once they realized what was afoot. One result: The hospital is considering putting a second cart with Dantrolene closer to the obstetrics operating suites. (Dantrolene is expensive and rarely used, so most hospitals stock just one cart.) "We find stuff that really should be attended to," says Preston. "When we go back later, we find out they've fixed it all."
Kaiser managers say that after team training, staff attitudes improve dramatically, doctors communicate better, and nurses are less likely to quit (high nurse turnover increases the odds of mistakes). And Preston is now taking the robots to Kaiser nationwide, branching out into cardiac catheterization labs and medical-surgical wards, and is training doctors and nurses to be robot impresarios, too. Ascension Health is launching a perinatal safety program building on the Kaiser model in 43 of its hospitals next month. "I don't go to these places with answers," he says. "I go with, gee, how can we work on this together? It's always fun."
Born: Wheeling, W.Va., 1959 Family: Married; one daughter Education:B.S., Transylvania University, Lexington, Ky., 1979; M.D., Johns Hopkins School of Medicine, 1983 Summer vacation:Volunteers to teach anesthesia at medical schools in Africa. This year, he's heading to Zimbabwe.
This story appears in the January 23, 2006 print edition of U.S. News & World Report.