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Spring 2012

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main image for Behling Profile Student team simulates health care delivery down to the finest detail.

A Healthy Simulation

Hyper-realistic scenarios allow students to practice high-quality patient care

Story by Riley Mackenzie; photos by Douglas Levere, BA '89

It wasn’t Heather Scott’s best day. The 57-year-old woman had been wrenched out of sleep at 4:30 a.m. by severe chest pains, but had waited four hours before calling her daughter, who took her to the hospital. Now she lay in an intensive-care bed, the focus of attention by a nurse, two third-year medical students and her very worried daughter. Then she started having trouble breathing. The medical team made some quick decisions, giving the patient morphine, nitroglycerine, a beta-blocker—all standard treatments for chest pain—as well as oxygen to help her respiration. Her blood pressure and oxygen levels were perilously low. Things were moving fast.

Then, a little more than 11 minutes after the medical students came into the room, it was over. Ms. Scott—a sophisticated medical mannequin—fell silent. The human beings gathered to discuss the surprisingly tense scenario that had developed.

Emergency responders (from left) Candace Waggoner, Justin Janig and Denise Cuillo resuscitate a patient. Cynthia Curran, MS ’88, clinical assistant professor of nursing, gives voice to participants from a control room. Medical residents Dhanashri Kohok (with ultrasound equipment) and Tam Huynh (delivering baby, above) simulate health care practice, from mastering technology to sharing a new parent’s joy.

This is how medical education happens at the Behling Simulation Center, the university’s new immersive health care learning facility. Conceived and developed to serve students in the five health care disciplines of UB’s Academic Health Center—medicine, nursing, public health and health professions including physical therapy, dentistry and pharmacy—the center opened in September and is already changing the way future health care professionals learn their craft.

“Immersive patient care management simulation” is what Behling Center director Jeffrey W. Myers, EdM ’07, calls what happens at the South Campus facility. “We’re re-creating reality, trying to get students to suspend their disbelief,” he says.

This process begins with sophisticated medical mannequins that can simulate conditions from preeclampsia to stroke to chronic conditions; whose eyes blink and pulses beat; who can deliver simulated babies; and who, thanks to the machinations of technicians in a sophisticated “mission control” room, can evidence all sorts of surprising symptoms—and talk to their caregivers all about them.

The simulation experience goes far beyond the lifelike patients, however. In the center, which covers 10,000 square feet on the fourth floor of Farber Hall, eight clinical settings can be staged to represent anything from an operating theater to an ICU room to a patient’s home. There are even screen-printed curtains that create the illusion of an outdoor setting for training first responders—complete with the piped-in noise of joggers and tennis players.

The goal, Myers says, is to create learning situations as close to reality as possible, so that students can test their skills in a low-stakes environment. A wrong decision here hurts only the students’ pride; the mannequins always live to suffer another day.

Interprofessional Skills

But more than technical skills, the center’s goal is to develop interprofessional skills, says Myers, an osteopath and assistant clinical professor of medicine in the UB School of Medicine and Biomedical Scienc es. “Health care is a team sport,” he says. “It takes the talents of all those individuals to really take care of a patient. We all have the same goals: high-quality, good patient care. But most students in the health professions don’t actually talk to someone in another profession until they graduate. In their clinical rotations, often they’re not interacting with other pharmacists, nurses, doctors. They talk mostly to their preceptor. It’s no wonder people are scared to talk to each other. We’re trying to break down those silos.”

“This is the only simulation center where all these departments were pulled in to get their ideas. Every department was really involved from the very start.”Ralph Behling, MD '43 & BS '40

“Many people don’t have these experiences and are not entirely sure what people in each discipline are capable of,” adds fourth-year nursing student Dennis Alex. “You find out all the resources you could have used—the nurse knows this, the pharmacist knows this. It gives you a better understanding of what they can do for you and what you can do for them.”

The ultimate goal, Myers explains, is to keep patients safer when they’re in the health care system. Myers cites studies showing that 70 percent of medical errors can be attributed at least in part to miscommunication. “If we can get these students talking to each other very early in their careers and improve that communication, we can significantly improve patient safety,” he points out.

That critical need for improved communication is important to Ralph Behling, MD ’43 & BS ’40, whose $3 million gift to UB—augmented by $2.7 million from the State University of New York—funded development of the center that now bears his name. During the planning process, Behling, who lives in California, looked at Stanford University’s simulation facilities, but found them to be disjunctive. “The good thing about the simulation center at Buffalo is that it was developed by every medical group,” he says. “This is the only simulation center where all these departments were pulled in to get their ideas. Every department was really involved from the very start.”

As well, Behling says, the technology that enables groups of students to dissect their peers’ performances is an irreplaceable learning tool. “The movies which are taken of the students while doing the performance in the simulation center are very helpful for showing the students their mistakes. Most students can see their mistakes; if not, they can be pointed out by the instructor,” Behling says.

Debriefing the Team

Such was the case as a class of medical students debriefed their two members’ performances with the unfortunate Heather Scott. Wayne Waz, a pediatric nephrologist and clinical associate professor in the UB medical school, led the discussion, nimbly drawing out the students’ medical knowledge and their critical thinking about how to manage this patient in crisis.

“What did they do well?” Waz asks the group of six men and two women. “They seemed confident,” someone says. “They always seemed to have something positive to do.” “They called for a cardio consult.” “They worked well as a team, and they stayed calm.”

“Was there anything they did that could have made things worse?” Waz asks. He continues to prod: “What are your goals? What do the different pressors [anti-hypotensive drugs] do, and how do they affect blood pressure? If the stuff you do doesn’t work, how would you help her to breathe in that circumstance?”

At this point, Waz cues up the digital video, saying, “Let’s watch the part where they tell her she’s having a heart attack.” He then addresses one of the simulation participants, asking, “Did you realize you put your hand on her shoulder when you started talking to her? That was good.”

And then they talk about it—about how at one point the two medical students were piling orders on a confused and overburdened nurse, about how the patient’s daughter (played by an actor) asked one question and never got it answered. The talk progresses to a discussion of how to manage when a family member is demanding information but the caregiver has his hands full with a patient’s fast-moving situation. The consensus: You can have the daughter stay on one side of the bed and hold her mother’s hand, or you can send the daughter out of the room temporarily but appoint someone to stay with her.

And this is only one scenario. The facility and the technology are almost infinitely flexible, and the training, Myers says, can range into areas like how to break bad news to a patient compassionately or how to overcome cultural barriers, such as deeply held religious beliefs about personal modesty.

Patricia Ohtake, associate professor of rehabilitation science in UB’s School of Public Health and Health Professions, served on the advisory committee that developed the simulation center. She says medical simulation benefits students in three ways. It develops specific technical skills, such as intubation and CPR. It makes students into team players in the health care environment, teaching them how to communicate effectively with both the patient and the other providers involved in his care. And, she says, it teaches students how to approach clinical decision-making—“probably the highest-level component that we see happen. That is what makes a great clinician, being able to interpret a situation, recognize that there is a change in the situation and respond appropriately.”

In their clinical work, says Ohtake, some students are exposed to some of these skills, but it’s catch-as-catch-can. “With simulation, every student can have that experience,” she says. “It affords us the opportunity to provide students with experiences they might not otherwise have, especially in a critical care environment.”

The students’ sweaty palms and pounding hearts, when they’re in the midst of a simulation, testify to the effectiveness of the process. No matter what happens, their instructors say, nobody gets hurt and everyone gets better at delivering great health care. As Waz says to his students, “If you fail miserably, you’re going to learn a lot. If you succeed tremendously, there’s still more to learn.”

“It’s like learning to play an instrument,” adds Myers. “These students are training to cope with events they might see once in a lifetime, but they’re also practicing good behavior—the skills that they’ll need in practice every day.”

Riley Mackenzie is a Buffalo freelance writer.

Behling Simulation Center Video Library

Students practice their skills; benefactor Ralph Behling, MD ’43 & BS ’40, visits center; and Jeff Myers, Behling Center director, talks about immersion care learning. >watch