Real-world medicine in a simulated setting

Hopkins’ $6.8 million training facility aims to be as realistic as possible

Medical students, nurses and other current or aspiring health care providers at Johns Hopkins Medicine are being trained in a new facility meticulously designed to help them hone their skills in a space that replicates what they’d actually see and experience in the field.

The Johns Hopkins Medicine Simulation Hospital, a 13,000-square-foot, $6.8 million state-of-art facility opened earlier this year at the medical campus in East Baltimore. It features the normal array of operating, emergency and intensive care rooms and labs.

It also comes with ready and willing “patients” — life-sized mannequins (or “manikins” in medical parlance) with simulated pulses and traceable vital signs. They lie in hospital beds and can also “breathe” and be programmed to emit a variety of noises, phrases and sounds.

Dr. Elizabeth Hunt, the center’s director and an associate professor of anesthesiology and critical care medicine and pediatrics at Hopkins’ School of Medicine, said she worked closely with architects, the Hopkins facilities team, and contractors involved in designing the center.

“I made the decision that I want it to be clinically realistic,” she said. “I want when they walk in for them to be learning what a hospital feels like.”

Very few medical schools had simulation centers as recently as 15 years ago; most schools now have them. The Association of American Medical Colleges surveyed medical schools from 2013-2014 and found that 136 of 140 schools that participated in the survey had simulation centers.

The University of Maryland Medical Center and the School of Medicine opened a 3,600-square-foot simulation training center in 2006. At the time its MASTRI Center, or Maryland Advanced Simulation, Training, Research and Innovation Center, was one of only 78 facilities of its type nationally or internationally accredited by the American College of Surgeons.

“It’s so important for medical students to move out of the classrooms earlier and be exposed to experiential learning,” Dr. Hunt said. “For example, our first-year medical students learning anatomy will learn in the classroom about the organs, arteries, veins and nerves in the chest, then dissect the chest in the cadaver lab and then go to the simulation lab to learn about chest tubes and CPR on manikins to ‘bring the anatomy to life.’ ”

Simulation is embedded throughout the entire four years of the medical school curriculum ,and students spend an average of 60 hours of learning time per year in the simulation centers, she said.

Scott Shuldiner, a third-year medical student, said even though he and classmates practice on dummies, the simulations have made him more comfortable during highpressure scenarios in real medical wards.

“Like a real situation, you have to think on your feet,” Shuldiner said. “It’s very different from sitting down at a desk where it’s like ‘What’s the next step?’ ”

To the untrained eye, it's nearly impossible to differentiate Hopkins’ simulation hospital from an actual one. The general patient wards and intensive care and labor delivery units, right down to the lighting and noisy medical equipment, look and sound exactly like the real thing.

“We’re very dedicated to making it a realistic experience,” Hunt said. “We’ve invested a lot of money in the technology to represent exactly what we do in the hospital.”

Johns Hopkins’ medical students, licensed faculty and clinical staff such as nurses, pharmacists and respiratory therapists, among others, have free access to the center. Those not affiliated with Hopkins must pay to use it.

Studies conducted by Johns Hopkins showed that training medical students in more realistic settings leads to faster, higher-quality performances in the event of an actual emergency, Hunt said.

This is especially true when it comes to CPR treatment, she said.

Simply walking or talking through the steps of CPR — or learning the procedure while kneeling, as many are taught — is detrimental to medical students who would more than likely perform the procedure on a hospital bed. Hunt has seen students attempt to climb onto hospital beds and get on their knees to administer compressions, rather than calling for a step stool as required.

“There’s what we call ‘negative learning’ when you fake it,” Hunt said. “As soon as you fake it, people think it’s that easy.”

Instead of faking it, students and faculty who train at the simulation hospital must perform as they would in real situations.

“We’re advocating that we have to teach people more realistically,” she added.

Jordan Duval-Arnould, director of research and innovation at the simulation center and an instructor of health sciences informatics at the school of medicine, compared this method to the military model: “Train like you fight, fight like you train.”

During a simulated cardiac arrest, for instance, students at the simulation hospital would have to run and grab equipment from crash carts in the hallway, just as they would in a real emergency.

“It’s no good to teach someone how to use a defibrillator if it’s not going to be the exact same one they’re going to use” in an actual hospital, said Duval-Arnould, who’s also an instructor of anesthesiology and critical care medicine.

Awa Sanneh, another third-year student at Hopkins, said the center gives her and other students a chance to learn from their mistakes by redoing simulations under various circumstances.

“The sim center has provided a perfect environment for us to hone in on skills we’re going to need in the wards,” Awa said, “a situation where it’s okay to fail — it’s okay to make a mistake.”

The simulation hospital’s realistic but low-stakes atmosphere also offers an ideal setting for staff to be introduced to new types of protocol or equipment, Hunt said. The facility has multiple debriefing spaces where participants can reflect on the various simulations in which they particpated.

While simulation centers are not uncommon at universities, Project Manager David Neal of SLAM, the architecture firm that helped design Hopkins’ center, says it stands out because its technology resembles that of an actual hospital so closely.

Typically, SLAM would have to repurpose an academic space into a simulation center, Neal said. But because the simulation hospital used to be an operating center, SLAM was able to keep many of the features intact.

The hospital “creates more of a synergy between the school and hospital in some many different avenues,” Neal said.

The new center is the first phase of a larger project. Eventually an older simulation center will be combined with the new one, adding at least 20,000 square feet and four additional outpatient rooms. Hunt said Hopkins is also hoping to add a dedicated resuscitation center for simulation center users to practice CPR.

The new center is located in the same building where the CPR technique was developed and the original “blue baby” surgery was performed by the celebrated surgeon Alfred Blalock and his assistant, Vivien Thomas, in 1944. The two developed an operation to correct the heart defect known as “blue baby syndrome.”

Hunt said she hopes the space serves as an incubator for the next crop of doctors.

“We’re trying to advance the science,” Hunt said. “Not just have it be a wonderful place to learn but figure out how to teach better and perform better.”