EMS Magazine`s Resource Guide: Pediatric Care: The CAPE Manikin Gives Birth

Almost any medic will admit to it: It’s the pediatric calls that take the most toll. They don’t happen often, but when they do, the technical challenges, while considerable, are not what you’re talking about. The hardest part is how personal it feels, and it’s this emotional challenge that asks the most out of you professionally.

Louis Halamek, MD, the founder and director of the Center for Advanced Pediatric Education (CAPE) at Lucile Packard Children’s Hospital at Stanford University in Palo Alto, CA, might tell you it’s the fact they don’t happen often that makes pediatric emergencies so difficult to deal with. Professional caregivers’ emotions need training, too, and that’s one strong argument for CAPE’s employment of simulation-based methodologies and state-of-the-art technologies to train providers of pediatric medicine. The Center offers technical and team practice, and emotional and behavioral processing, in a realistic setting where no lives are at stake—a model the aviation industry has been perfecting for 50 years.

Halamek says the aviation model is one medicine needs to take seriously. Studies of the black box recordings in downed airliners have shown that two-thirds of the errors that cause planes to crash are not technical or “content knowledge” errors. They are errors caused by behavioral problems in the crew, whether a communication issue or teamwork issue. It stands to reason the same is true in medicine, especially in emergencies that do not happen enough for providers to gain experience in the field.

CAPE’s simulator training runs the gamut of pediatric medicine, encompassing the entire range of fetal, neonatal, pediatric and obstetric fields—including a three-level simulation scenario with a sick mother, pregnant with a sick fetus, giving birth to a sick baby.

All the scenarios are developed for multidisciplinary teams, says Halamek, because that’s the way care is usually delivered. “Most of the time, we’re working in at least small teams, and many times those teams are in communication with larger teams or experts at a distance. We create a lot of the environmental cues that are necessary to set up those teamwork issues—those communication issues.”

All levels and divisions within healthcare are invited to participate in the trainings. Trainees range from nursing and med students in the very early phases of their training to seasoned professionals in practice for 20–30 years, including emergency responders.

CAPE’s state-of-the-art simulator room can be configured to simulate any room you would find in a hospital or in the field, with all the equipment you would have in a real setting. Its built-in auditory, visual and kinesthetic cues help round out the realism of each scenario, assisting participants in the “suspension of disbelief” that makes the experience so powerful. Manikins are hooked up to monitors that are controlled from behind a two-way mirror. When you put your stethoscope on the patient’s chest, the monitor provides the heart rate, the respiratory rate, and the pertinent beeps and alarms that the scenario requires. The fetal monitor indicates the state of a fetus before delivery as well as the maternal contraction pattern.

Participants move around each other with real instruments and real jobs to do. Patients might seize, presenting real tremors in their extremities. Newborns might present with any number of malformations that have been set up beforehand with moulage kits.

The teams are a mix of trainees and trainers who act as confederates in the scenarios, helping to create an emotional atmosphere with all the interpersonal situations that can arise. “If part of the scenario is a difficult communication, for example, our staff can recreate that,” says Halamek. “This is one way we transform our challenging experiences to let others benefit from them. All our scenarios are based on real-life encounters.

“Everything we do is realistic. Anything you can do to a real patient you can do to our manikins. No one says, ‘At this point I would intubate, or at this point I would put a chest tube in’—you intubate, you set the IV. There’s no faking it. And if you don’t do what’s needed, the patient doesn’t do very well. This is where our colleagues in the room might say, ‘You’re drawing up a syringe of air; you better not inject that.’”

It’s so real, in fact, that Halamek says it’s not uncommon for participants to continue working after the session has been called. “We have had numerous episodes where someone is performing CPR or some other procedure and one of our instructor colleagues in the room literally has to go over and pull the trainee’s hands off the manikin. They don’t want to abandon the child.”

The training scenarios are videotaped, an invaluable tool in the debriefing sessions that follow each scenario. Furthermore, everyone signs a confidentiality agreement before going in to ensure that people can talk freely when debriefing.

“Everything that happens in these rooms stays here,” says Halamek. “Because we’re not just training technical skills. The behavioral skills we focus on are the critical issues for taking care of patients: teamwork and communications. And those are the things that come out in the debriefing. Certainly we talk about techniques—intubation techniques, dosages, all those sorts of things are there. But we spend a lot of time on the behavioral issues. The debriefing is the place to emotionally unload. People find that catharsis very helpful.”

CAPE’s scenarios range from high-tech programs like ECMO (extra-corporeal membrane oxygenation), a long-term form of cardiopulmonary bypass that’s only done in about 100 pediatric hospitals across the U.S., to procedures which are lower-tech but just as intense. “We do a lot of resuscitation training—resuscitation in the hospital, resuscitation in the field. Those are really our core programs,” says Halamek.

Halamek says the Center’s goal is not to be the site where everybody in the world comes to train, but to set a standard for ped/obs training throughout the country and the world. He points out that the Mayo Clinic will have some pediatrics when their center opens in September, with one of CAPE’s former fellows on the team. The University of Texas-Southwestern has a center as well. “We have some very nice collaborations with people around the country,” he says. “But I think we are unique in that we span the breadth of pediatrics.”

Visit www.lpch.org/cape for more information.

—KR