It’s a Wednesday morning and in Amanda Delaurier’s world that means one thing: simulation. The second-year nursing students have a standing appointment with the simulation lab and on this Wednesday the high-fidelity patient simulator, ‘Carla Shapiro’ was just admitted to the medical unit – and really has to go to the bathroom.

“Make her really miserable,” says nursing instructor Sandra Fritz to Delaurier, the simulation technician.

Delaurier pushes the microphone button and tells students Jacey Starner and Stephanie McCutcheon she didn’t feel well through the night and needs to use the washroom. The students instantly get to work on the simulator finding a pulse and checking the blood pressure while Delaurier and Fritz observe through a two-way mirror.

The high-tech mannequin breathes and has a heartbeat. Its eyes open and its blood pressure rises or drops all at the command of Delaurier’s laptop.

“I really have to pee,” she makes the simulated patient say.

“Okay, Mrs. Shapiro. Here’s a bed pan; you shouldn’t be standing,” says Starner.

The ‘patient’ refuses the bedpan and insists she can make it to the washroom on her own. The two students try to prop up the life-size, weighted mannequin and maneuver the IV tubes but as soon as the patient moves her condition changes. The symptoms should alert the students that the patient is deteriorating. Instead, a technical glitch drops the heart rate on the monitor to 27 and the students call an emergency code.

“I love when things go wrong,” says Fritz. “It’s a great learning experience. You can’t always rely on technology in the real world. There’s a simple way to find out if 27 is her actual pulse. Forget the monitors, assess your patient.”

When the code is cancelled over the intercom by Delaurier the nurses search for a pulse and realize the monitor was incorrect. With the ‘crisis’ averted, the students take the appropriate actions to address the change in patient status and Delaurier calls the simulation complete.

A week later, second-year paramedic students are called to a scenario of a 35-year-old woman with a cast on her right leg and a pain in her chest.

“Keep up the pressure,” says paramedic instructor Tyler LeBlanc to Delaurier. “Really stress them out.”

Delaurier whines and moans in pain over the speaker and the students’ nerves become apparent.

“I’m only 35! I can’t be having a heart attack,” she says. “Am I going to die?”

During the 25-minute scenario the students never verbalize the diagnosis but still take all of the proper procedures needed to stabilize ‘Wendy’ before transporting her to the hospital.

Simulation is a major part of the learning experience for health studies students. Paramedic students experience medical and trauma simulation labs as often as twice a month and nursing instructors use simulation to practice scenarios that test their ability to insert an IV, assess patient status, decompress a lung and even deliver a baby.

After each simulation the instructor and students conduct a reflective, non-judgmental debriefing. By reviewing their performance the students are able to see where they excelled and where skills fell by the wayside in a moment of stress. When LeBlanc told his group of students the ‘patient’ in a scenario earlier that day had such low blood pressure it could have resulted in kidney, liver, and pancreatic failure the students were stunned.

“There is a natural deterioration in the disease process,” said LeBlanc. “It’s important to expose the students to these scenarios because if you miss steps, the patient suffers consequences. These are realistic outcomes.”

Amber Marcinkoski was a part of the scenario LeBlanc referred to and said tunnel vision takes over in the scenario but hindsight is always 20/20.

“It’s easier to sit back and criticize someone else in the simulation and pick it apart,” said Marcinkoski. “But when you are in it and trying to concentrate your mind is going everywhere.
You really have to block out the external noises and just focus on doing it right.”

Marcinkoski and her classmates participated in a trauma simulation scenario in the carpentry lab. The simulator was dressed in coveralls and portrayed a tradesperson who fell off a ladder, broke a leg and had head trauma. With the rest of the second-year class watching from the balcony the team raced to stabilize the patient.

“It was so much pressure to be in front of everyone and still try to do things with a clear head,” said Salena Fieldberg. “His neck was twisted so even though I thought I had a good seal on the ventilation bag, the SATs (oxygen saturation level) showed that he wasn’t getting enough oxygen. With HAL all of that is monitored so you can’t fake it like you can on a regular mannequin. It’s a much more effective learning tool.”

HAL is just one of the high-fidelity patient simulators MHC has on campus. SimMan, baby HAL and even NOELLE, the birthing simulator, are all used by health studies students to provide a situation as realistic as possible to an actual patient encounter. Third-year nursing students use baby HAL and NOELLE, who experiences contractions, dilates and contains a simulated placenta, as part of their obstetric studies.

“High-fidelity simulation (HFS) is a customized learning experience meant to identify strengths and deficiencies in students,” said Matthew Jubelius, manager of the simulation program. “It’s a real-time, real-stakes environment. It’s medical theatre.”

Integrating simulation into the learning experience goes beyond simply “placing the technology in a room and learning from it,” said Jubelius. When he was asked in July 2010 to take on the role of manager he recognized simulation was not optimized or fully operational and no formal process for debriefing existed.

“Learners today are passionate about alternative learning. HFS is nothing without theoretical background in the classroom but simulation allows students to have that hands-on experience before dealing with real patients,” he said.

As a nursing instructor, Fritz teaches the students theory and skills and requests scenarios that will challenge those skills. Scenarios can highlight and test a specific skill in a safe environment.

“We can teach skills in the classroom but in the real world it’s not always a choice between A, B, C, or D. It’s not true or false answers. It’s a real patient and you have to think on your feet,” said Jubelius.

Simulation allows the students to succeed or stumble without real-life consequences and provides a solid knowledge and experience base for practicum placements in a real health-care setting. It also allows students to develop critical thinking ability and build their confidence.

“That time I was able to intubate (insert a breathing tube into the simulator’s trachea) on my own, I felt so good about myself,” said Marcinkoski.

Despite limits in technology, students  buy into the realism of the situation.

“It could be easy to just look at it as a fake patient but she talks to you, she seizes, she throws up and when she becomes unresponsive and unconscious it really does get stressful,” said Fieldberg.

The simulation scenario is also a learning tool for the instructors. Fritz runs the same six scenarios with her class and said each pair of nursing students reacts differently to the same scenario.
 
“It’s so interesting because every student approaches the same scenario in their own way. Every student does something different and shows his or her strengths and weaknesses. Some recall their terminology quickly, others are more attentive to the patient and try to calm her down and rub her hair, others are level-headed while others panic.”

The simulation program is expanding to include as many programs on campus as possible. Drama students will be playing the role of distraught family members in medical scenarios or patients in simulation for social work students.

Delaurier would like to see more life-like simulators in the future, with female mannequins looking more feminine (Delaurier simply places a long wig and fake fingernails on the male HAL) and the ability to have the skin turn pale or flushed depending on the scenario.

The integration of simulation into curriculum could give MHC students the leading edge employers are looking for: experience without compromising patient safety. Accreditation standards could potentially help alleviate clinical issues such as a lack of practicum sites; however, this needs to be investigated further and much more in depth.

“I wish we could do more simulation,” said Marcinkoski. “The simulators are money well spent. We are better prepared for the real world and to deal with real patients. It makes us better paramedics.”