Debra Barksdale vividly remembers her first nursing school clinical rotation.
“It was terrifying,” said Dr. Barksdale, who is the president of the American Academy of Nursing. “Your head is full of all this knowledge, but actually putting it in practice in front of a real live human being is very daunting.”
It’s been 40 years since then, and things have changed. Increasingly, students in training are not starting with human patients. They are working on lifelike manikins.
While mannequins are used to model clothing, these manikins are models of the human body used to train medical professionals. Also known as “high-fidelity medical simulators,” they can cry, sweat, bleed, blink and breathe. Some of them can convulse and foam at the mouth.
At a recent training at Seton Hall University’s Clinical Simulation Center in New Jersey, Juliana Vitolo, a nursing student, had an appointment with a “pregnant” manikin named MamaAnne.
“How are you feeling?” Ms. Vitolo asked.
MamaAnne blinked a few times and answered: “I’m having a little pain in my lower abdomen.”
The use of medical manikins has grown significantly in recent years; in professions such as nursing, they have become a training staple. Research has suggested that working with these manikins not only enhances knowledge and performance, but improves “non-technical” skills such as communication, confidence and empathy.
But the expense can be a barrier: Laerdal, a Norwegian company that specializes in products and programs for health care providers, makes the ones used at Seton Hall; each costs between $30,000 and $130,000.
There are roughly 200,000 of these simulators in the United States, said Inger Stenberg, head of public affairs at Laerdal, and they are used in hospitals like the Mayo Clinic as well as in trade schools. The United States Army, Navy, and Coast Guard use them, too.
Trainees can feel a realistic pulse that can be programmed to race. They can draw “blood,” a red fluid that can “clot” when mixed with gelatin. And they can inject fluids into a manikin’s arms, which are covered with soft silicone. Some simulators even have pupils that contract when their eyes are examined with a flashlight.
Premature baby manikins have fine hair (from a goat), and geriatric models have wrinkled skin and cataracts. There are interchangeable “headskins,” silicone faces in different skin tones, to represent diverse patient populations.
‘You feel like there’s the weight of a real-life situation’
Manikins have been used in health care training for decades, but today’s high-fidelity medical simulators allow students to rehearse complex, dynamic procedures.
Kevin Ching, medical director of the Simulation Center at NewYork-Presbyterian/Weill Cornell hospital, says the technology helps trainees build “high-stakes, low-frequency skills.”
“Students can rehearse everything from respiratory failure to shock, sepsis, cardiac arrhythmias,” he said.
If you’re working with a team on these realistic manikins, he added, “you feel like there’s the weight of a real-life situation.”
The manikins at the simulation center at the UNC Greensboro School of Nursing are so sophisticated, Dr. Barksdale said, that “if you’re walking around at night, and you stumble into one of our labs, you would think it’s a room full people.”
“It can be kind of scary,” she added.
For health care trainees, the prospect of medical errors is far scarier — and research suggests that simulation-based training with instruments like high-fidelity manikins improves performance in real-life clinical environments.
This training stresses the need for precision, which can enhance patient safety down the line, said Jennifer McCarthy, director of the clinical simulation program at Seton Hall. When trainees administer medication to a manikin, the technology inside of it measures the exact volume delivered.
“If a team is expected to give two milliliters of a medication but only administers 1.8 milliliters, that discrepancy may not seem like a big deal,” she said. “But this is an error, and errors can have harmful consequences.”
At Seton Hall, the manikins actually “talk,” so health care workers can rehearse patient interactions like the one between MamaAnne and Ms. Vitolo.
A simulation operations specialist speaks from inside a control room, and their voice is modulated to mimic a male, female or child voice for the manikin. For professions like nursing, which involve frequent communication with patients, this feature is especially helpful, said Fiorella Carvo, a nursing student.
“The manikin will say things like ‘Ouch,’ or ‘My stomach hurts,’ or ‘How come I’m getting this medication?’” Ms. Carvo said. “So you need to be prepared to answer, just as you would in the real world.”
“We’re learning how to build rapport in an environment that can be intimidating,” said Brittany Hague, a speech-language pathology student who also trains with manikins.
‘You have to be able to act quickly’
Some manikins can also be programmed to have medical conditions that change suddenly, Dr. Ching said.
At Seton Hall, for instance, a baby manikin can be engineered to become lethargic, and students have to check vitals to assess the problem. If the baby manikin is not given enough oxygen, the skin around the mouth will turn blue, which mimics a condition called hypoxia, when tissues in the body lack oxygen.
“When these things happen, you have to be able to act quickly and think critically,” Ms. Vitolo said. “Like if the manikin’s blood pressure suddenly lowers, and you have to decide whether you should give them fluids to bump it up.”
For added realism, instructors might leave personal effects on a table next to the manikin, such as a pair of eyeglasses or a phone — things patients might have with them. Sometimes an actor is hired to play a concerned relative, a training method known as hybrid simulation: “The family member will ask you questions, like, ‘So what’s the next step for my mom?’” Ms. Carvo said.
“It’s so easy to kind of get wrapped up in all these cool toys and tools,” said Yue-Ming Huang, executive director of the U.C.L.A. Simulation Center. But especially critical, she said, is the feedback the students receive from their instructors.
Ms. Hague, the speech-language pathology student, said that the most valuable aspect of learning on a manikin was the self-assurance it gave her. “The more mistakes you make in a safe environment, the more you’re able to learn,” she said. “So that it doesn’t happen in the real world,” she added.
Jancee Dunn, who writes the weekly Well newsletter for The Times, has covered health and science for more than 20 years.
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