"Real Simulation"

by Jeffrey Phillips BS, RN (NYUCN '14)

Jeffrey Phillips is an RN at NewYork-Presbyterian Weill-Cornell Medical Center's Emergency Department. He is also the assistant director of the Emergency Department's Nurse Residency Program.  Jeffrey is beginning premedical course work at Columbia University starting this summer.

            A quick change in a patient's condition leads to major expressions of concern from clinical staff.  Hairs stand on the back of necks and shirts moisten as the chain of second guessing begins.  The patient monitor shows signs of decompensation, and proposals of how to proceed are hurried.  Luckily for the staff, a man behind a tinted glass panel says, "thank you everyone, let's stop there".  A collective exhale and shared glances say, where did we go wrong. 

This patient is a clinical simulation - also known as high fidelity simulation. The stakes are low although the venue is real.  A team of nurses and doctors stand inside the same treatment room they frequent daily, where similar circumstances have taken place with real people.  The difference here is that the plights of the rubber and plastic patient are calculated to educate strengthen the treatment team. 

At New York University's College of Nursing, a dedication is made to simulation based learning. Students are exposed to simulation exercise for the duration of their clinical training.  Upon graduation, I thought my days of simulation lab would be replaced solely by real, fleshy human beings.  But two years and roughly fifteen intensive simulations later, my career in imagination continues.  I have encountered push back from coworkers who do not see the utility in simulation learning as I do.  They see it as a cheap and nearly useless exercise that cannot provide the education that a real patient can.  But I want to speak from personal experience via the modern day soap box. 

Simulation provides an opportunity to place participants in circumstances that are not readily available in everyday clinical scenarios.  It takes a lot of luck (or bad luck) to be part of unique circumstances requiring unusual procedures, heroic measures, or non-traditional medications.  For example, in fall of 2015 I completed a stellar two day course in pediatric emergencies.  It consisted of quick succession simulations, dense debriefings, and (spoiler alert) the course concluded with a large mass casualty simulation involving all 40-50 clinical staff participants, along with 20-30 patients and actors.  The simulation came complete with the realities of disaster response: a restriction on supplies, medications, blood products, and clinical staff, as well as convincing acting from volunteers playing the role of stressed and at times aggressive family members.  The situation was loud, communication was difficult, and stress was inevitable.  The 20 minute scenario kept pulses elevated for the duration.  Afterwards, discussions included reflections about the challenges of patient care in such a situation, as well as somber stories of real-life similarities.

The success of simulation only comes with high attention to detail and realism.  The goal is to mirror the stress and decision making necessary in a real life situation. With that experience and a thoughtful debriefing from the instructor, the group can tease out mistakes in a safe environment.  And if the simulation is realistic enough, the participants will take those lessons into a real life patient encounter.  I can recall a specific instance, after having been introduced in simulation to the push-pull method of fluid administration in pediatrics, that I took the initiative to administer fluid resuscitation in this manner to a child.  Without that knowledge, my exposure to the procedure would have been delayed and the patient may have suffered.  If an opportunity arises to take part in simulation, seize it.  I encourage everyone to investigate opportunities in simulation labs at their respective institutions, as well as simulation based specialty conferences.  A real patient tomorrow may be thankful for practice on a plastic patient today.