How manikins may help save kids' lives

In late November 2015, an eight-year-old Wisconsin boy was airlifted to the Level I Pediatric Trauma Center at Mayo Clinic's campus in Rochester, Minnesota. Seriously injured in a tractor accident, he was hemodynamically unstable with a grade V liver laceration and severe fracture of the left proximal tibia.

Alerted to his arrival, the trauma team assembled for the initial evaluation and resuscitation. Team members included a trauma surgeon, senior and junior trauma residents, emergency department (ED) physicians and residents, pediatric physicians, an anesthesiologist, three ED nurses, and an IV transfusion nurse as well as a respiratory therapist, pharmacist, radiologist, lab technician and social worker.

"The team is like a finely tuned orchestra; they go to their designated positions and fulfill their roles," explains Carol J. Fahje, M.S., R.N., RN-BC, a nurse educator at Mayo Clinic's campus in Rochester, Minnesota. "Our goal is to determine within 20 minutes if the patient is going to the scanner, the operating room or intensive care."

This time, the patient survived — thanks mainly to the efforts of the trauma team but also because he wasn't really injured or even human. Instead, the boy was a realistically moulaged manikin standing in for an injured patient in a trauma simulation.

Although mock traumas occur every six weeks at Mayo's campus in Minnesota, they aren't announced ahead of time "to really test the system," says emergency medicine specialist Mark S. Mannenbach, M.D.

He explains: "Mayo has a state-of-the-art simulation center off-site with a great staff, but we like to do on-site simulations because that's the best way to test how personnel and systems respond in real-life situations. We create a scenario or case and write a script.

"Then we ask people to show up and do the things they normally would do, using the same paging system and same equipment. Do we have the right equipment in the room, and do people know where it is? If we can't locate a pediatric chest tube, for example, it's far better to find that out during a simulation than when a real child comes in."

How it started

Mayo Clinic has been using trauma simulations for a decade. Dr. Mannenbach says they were initially instituted because pediatric trauma occurs far less often than adult trauma does, so providers have fewer opportunities to treat children.

"In our ED, the number of adult patients compared to pediatric patients is on the order of eight or 10 to one — thankfully," he says. "But at the same time, things that are routine in caring for adults may give us pause when it comes to kids; what works for injured adults doesn't necessarily work for children. And we don't want people to walk into a challenging situation unprepared. Trauma simulations help fill in the gaps for people who are new to the system, to the ED or to pediatric care in general."

How it works

To avoid interfering with regular patient care, mock traumas are brief — 20 minutes for the actual simulation plus time for debriefing. Fahje says the debriefings are always sensitive and respectful; the idea is not to embarrass or cast blame, but to learn.

"We start with what went well, though people immediately tend to focus on what didn't," she notes. "I have never been as proud of my colleagues as during these debriefings. People make themselves vulnerable and share their mistakes, so the rest of us don't make them."

In addition to in situ drills, trauma team training is scheduled in the simulation center eight afternoons a year. Those sessions are especially intended for people new to Mayo or pediatric trauma.

"In the simulation center, we don't have to worry about interfering with regular patient care," Dr. Mannenbach says, "and it is certainly another way to do trauma training. But though it can be helpful to have people gather around a table to discuss how to do things, the rubber really meets the road when you create a situation and see what happens. To ascertain that patients are getting good care — or to improve that care — a real-world setting is the real test.

Fahje adds that the real-world setting doesn't have to be all that real to be effective. "Our simulations are completely replicable in the smallest hospitals," she says. "You don't need the best equipment or high-fidelity manikins. You can do the same thing with a pillow and a blanket and have someone simply say, 'The child is crying or moaning.' You can use pictures of a cardiac monitor and tape up new vital signs as the patient is treated. Anyone can do it in any environment, and it is just as powerful and just as valuable."

Dr. Mannenbach stresses that communication, teamwork and the best interests of patients are the most important aspects of simulation training.

"This is a coordinated, multidisciplinary effort, and we want people to understand how the process works," he says. "Children are different from adults, and things don't come as easily to us for a 4-year-old patient as for a 44-year-old. So each community hospital has to develop a system that allows providers to confidently and accurately give the right drug doses and use the right size equipment for children. Our patients are injured, some seriously, and we have to be prepared to take the best possible care of them."