Q. What is the human patient simulator?
A. What you see is a human patient simulator and it’s designed to allow us to simulate many of the things that we used to learn on patients that now residents and people in training can learn on the simulation model, and what we are doing here now is a learning program on how to perform CPR and resuscitate somebody from cardiopulmonary resuscitation, and where this is really critical and what we are focusing on is building the team dynamics of the resuscitative effort because historically the CPR team is composed of many people. It has physicians, nurses, respiratory therapists, pharmacists, and all of those people receive some training in basic CPR or advanced cardiac life support, but they never trained together. And the problem is is that when you have a patient suffering from cardiopulmonary arrest everyone shows up and they have to work as a team right away, and there is really no time for them to learn at that point. And so what this allows us to do is bring all those people in together in a simulated environment and very realistically recreate a code environment and let them learn how to work as a team. And so what we hope to do is, is to have a continuous training process year round where we bring new nurses, new respiratory therapists, and even nursing students and RT students and pharmacy students and let them all go through this training module where they work as a team so that the first time they show up at a real code, it’s not a new experience. And again, they’ve gone through the whole process. They understand everybody else’s responsibilities during a code and how just the team dynamics work so that in a real code we hopefully have it, you know, them working seamlessly together and giving the patient the best chance to wake up.
Q. So in the past I guess that you started by standing back and watching others more experienced respond to a code. Is that how the training was done in the past?
A. It really was, you know, the old adage see one, do one, teach one has been through medicine throughout and most of us learned about what to do, how to be a team leader during a code, what our responsibilities were from watching several codes as a medical student, as an intern, and then as a second year resident you are expected to run your first code. And so we pretty much did learn by going through the ACLS course and then just observing and doing.
Q. I have to think this must be such an invaluable tool because it must take some of the edge off the first time you actually do it. I mean you are actually feeling you know what it feels like to do the compressions and running into some of the things you might run in to. Is that part of what makes it so valuable?
A. Oh I think it absolutely does and we started this back in the summer with the residents and part of what this does is besides just bringing the whole team in to work together is you really can replicate the tension of and just the stress in a real code pretty effectively, and the feedback from the residents has been that it really did help them when they had to go to their first code that the speed of it and how quickly things moved and just the whole pace of trying to resuscitate somebody, they were better prepared. And so I think that, and that really was the first step. The first step was focusing on the medicine residents who are the team leaders who run the code, but the next step is to build the team dynamics as I said, and that’s where when they get the new training protocol up and get everybody involved, you know, that will take it to the next level.
Q. How does being a teaching hospital contribute to our clinical success?
A. The literature is out there about what having a teaching program does to the quality of the care throughout a hospital, and so I think that there is no doubt that having a training program enhances every aspect of patient care and then I think that having this kind of technology, I mean it really is not even so much the future of medical education, I think it’s the current, it’s current state of the art, and I think as a community hospital we are very lucky to have this kind of technology and there is no, I have no doubts that this is going to improve patient care and in many environments. This is just one application of the human patient simulator and there is so many other ways we are using it and again it comes back to if you can practice on a model that is a realistic simulation of a real patient, then when you go to your first patient, it’s not new. It’s not the first time.
Q. Let’s talk now about the hypothermia protocol. Tell me how that works, what it is.
A. Well basically with the hypothermia protocol what we do is we lower the patient’s body temperature down to around 90 to 93 degrees. Your normal body temperature is around 98 to 99 so we consider that moderately reducing your body temperature, and the real purpose of that is to try to really lower their brain temperature because what we are trying to prevent with the hypothermia is what’s called reperfusion injury because there is sort of two stages where the brain can be injured when somebody has a cardiopulmonary arrest. First is when there is no blood flow and that’s the main area of concern, and certainly that’s where getting them revived as quickly as possible is important, and that’s where the human patient simulator training comes in and the team aspects we talked about. And you would think once we had the patient revived and they are pumping blood to their own brain again that they are out of danger, but that actually brings up a new area of danger. Once we revive them that actually introduces a new risk to them that as blood starts going back to the brain reperfusion, toxic substances can be produced in the brain that can cause further brain injury and brain damage. So that’s where the hypothermia protocol comes in. They’ve shown that by lowering the patient’s body temperature that it does prevent some of those toxic substances from being released and it’s shown that it increases your chance of waking up.
Q. You don’t use this on everybody. How you decide when this is appropriate?
A. Well the first criteria is they suffered a cardiopulmonary arrest and in some patients it may be a very brief arrest and you revived them very quickly and they start waking up right away. And if the person is waking up very quickly after being revived then you don’t need to do the hypothermia protocol. It’s really the patients that have been successfully resuscitated from cardiopulmonary arrest and they are not waking up. Those are the ones that we then activate the hypothermia protocol and start cooling their body down as quickly as we can.
Q. How does the new technology help with the process of cooling the body?
A. Well when we first started this protocol over five years ago the technology was pretty simplistic. We really just sort of put a cooling blanket on top of them, one beneath them. We used ice packs, whatever we could to cool the body down and so it was obviously very imprecise, and we do have new technology now and we really have two ways of cooling the body down. We can do it internally where you put a special catheter into one of the large veins in the body and you directly cool the blood down. The other way that we have been using primarily is there is new technology where you cool them externally. You put a special device on their skin and you cool their skin down and by extension cool down their body. And with the new technology it does allow us to cool them down faster which is critical and also it allows us to keep them in that target range where we want their body temperature more precisely. So I think it really has improved our ability to, as I said, cool them quickly and then keep them locked in where we need them.
Q. You also mentioned that it helps because then if you need to take them in the Cath Lab you don’t have to undo what you’ve done to go on and do other procedures.
A. Right and that really is initially one of the unexpected things that it’s added because many people who have a cardiopulmonary arrest it’s as a complication of a heart attack. And so most patients or many patients that have an acute heart attack will go straight to the cardiac catheterization lab and with the old system you couldn’t do a catheterization with the cooling blankets on and so we really had to pick one or the other, either go to cardiac catheterization or start cooling them down. With the new technology it’s designed so that you can start cooling them down so for example a patient can present to the emergency department in full cardiopulmonary arrest, they can be resuscitated, we can start the cooling process in the emergency department, and then they can go to cardiac cath, and you can do the cardiac catheterization while they are still being actively cooled and then we bring them right up to the ICU. So, you know, with the old system you sort of had to pick between the heart or the brain and that’s obviously a tough choice and so now we can really direct treatment at both.
Q. That’s fascinating. I read in here though you said that 74 percent of physicians critical care aren’t using this protocol.
A. Well it’s, you know, I think this shows, you know, certainly our commitment to try to be state of the art in our patient care up in the ICUs and the original studies came out back in early 2002 so almost six years ago now and when they did this survey over three years after that sort of landmark data was released, they found that almost 75 percent of physicians involved with the care of patients after cardiopulmonary arrest were not using hypothermia protocol. And so that’s been two years now so I think the numbers gone up but we had a hypothermia protocol in place I think within six months of the data coming out so we’ve had our protocol in place for, you know, five and a half years.
Q. And you think it makes a big difference.
A. I think it does. I mean the literature certainly suggests it does. It’s, you know, on an individual basis you can never really say did it make this person wake up or not but, you know, the literature, and more literature has come out supporting that yes. It doesn’t guarantee someone is going to wake up but it certainly gives them a better chance.
Q. How is this used then, it’s not just used for cardiac arrest but I know in the case of the football player that was injured, it was also used in spine injuries. Is that right, and are there other areas that are being explored with this?
A. Well as far as the hypothermia, you know, that was a high profile case and obviously a different form of nervous system injury. That is still certainly more experimental at this point and as I think something they are investigating and our neurosurgeons are looking at investigating as well so I think it’s sort of an earlier stage of the experimental evaluation to see, you know, does it make a difference and should we use it for every person that has a spinal cord injury. So they are looking at other forms of neurologic injury to see whether hypothermia does make a difference. They’ve looked, for example, at patients who have had traumatic brain injury to see whether lowering their brain temperature helps. So they are exploring different injuries and seeing if it does help.
Q. Memorial has been recognized for the quality of its care. What’s your level of confidence in the care and the ICU? Do you think the community is pretty lucky to have this Level here?
A. I’ve practiced critical care in university settings, military, tertiary care centers, community centers, and truthfully I would put the level of care and just the commitment to excellence that, you know, I see every day here, you know, up against any of those places. I think that, you know, the initiative that we see from, you now, our nurses and respiratory therapists and all the ancillary staff to improve themselves and to do a better job, initiatives they start on their own, it’s just amazing and, you know, certainly all of medicine is multidisciplinary in 2007 but probably no more so than the ICU and so it really takes experts from every department in this hospital to care for ICU patients and, you know, we have multidisciplinary rounds every week, twice a week where everyone is there. We talk about every patient and so that we make sure that everything is coordinated and so, you know, I just, I honestly think the level of care here is outstanding and, you know, the people are not just technically excellent. The patients or the people aren’t just technically excellent but, you know, just the level of care and empathy is remarkable.
Q. Being a critical care specialist must be intense but rewarding.
A. Well it is. I mean in the ICU it’s, you deal with so many things. I mean you have sort of the high tech medicine, the acute care medicine, but you know really I think even the interpersonal demands and the dealing with families, dealing with patients are even more important, not that they’re not important everywhere and, you know, and to be honest that’s probably the most consistently rewarding part for me because, you know, there is the medicine and obviously it takes a whole team to take care of a patient and it takes a whole team to help a family get through their loved one’s critical illness, but, you know, I mean that’s probably the most consistently satisfying part is the human part of it. You know, not just doing what is right for the patient but it is a very stressful time for families and, you know, I think the ICU team does a great job helping the families get through that as well.
Q. With the hypothermia protocol, people are sedated for 24-hours – why is that?
A. Right, part of the protocol is we keep them sedated during the 24 hours so as we tell families we have to kind of wait 24 hours to know if they are going to wake up. Back before we had this hypothermia protocol we really just had supportive measures and so sometimes you would see patients start to wake up in four to six hours or less and so we knew earlier on that they were waking up and recovering. With this protocol because we do keep them sedated because the cooling blankets can be uncomfortable as you start to wake up, we keep them heavily sedated for the 24 hours and then once we stop the cooling process then we stop the sedation and then we see how they do. So we all have to kind of just go in the dark for 24 hours and then all wait to see if the person wakes up.
Q. That must be a hard 24 hours for you and for the family just waiting, knowing that you have to do that.
A.Oh it certainly is. I mean everyone wants to know as soon as possible if their loved one’s going to wake up and we obviously want to see them waking up as well but what I tell the families is that, you know, this has been shown to give them a better chance so if that’s the price we have to pay to give them a better chance to wake up it’s well worth it. It’s our anxiety but hopefully they are doing better.