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Preparing for the worst, staffers at Johns Hopkins All Children's learn through simulation

Teressa Russell, a professional medical simulation patient from USF's medical school, plays the part of difficult patient and is restrained by pediatric residents at Johns Hopkins All Children's Hospital. The hospital's simulation center is moving into new, larger quarters this year. [JIM DAMASKE   |   Times]
Teressa Russell, a professional medical simulation patient from USF's medical school, plays the part of difficult patient and is restrained by pediatric residents at Johns Hopkins All Children's Hospital. The hospital's simulation center is moving into new, larger quarters this year. [JIM DAMASKE | Times]
Published Apr. 17, 2018

When the patient got violent, Dr. Michelle Hidalgo didn't have time to think. She had to react.

The woman was moving strangely and seemed erratic. Hidalgo had to make a tough call — it was time to physically restrain her for everyone's safety.

Then the patient reacted badly to the medication Hidalgo's team administered.

"It's a very nerve-wracking experience and honestly not something we deal with regularly," said Hidalgo, a third-year pediatric resident at Johns Hopkins All Children's Hospital in St. Petersburg. The team Hidalgo was leading was taking part in a simulation designed to hone the staff's reactions to tough emergencies by acting them out in a medical setting.

The violent "patient" was an actor playing the role of an adult on drugs. "She started to harm herself, and that's when the pressure to act kicked in," Hildalgo said.

The hospital is expanding and investing in its new medical simulation center, which soon will move into a 13,000-square-foot space in the $85 million Johns Hopkins All Children's Research and Innovation Building, set to open in September. In addition to the bigger footprint, the center will own and operate its own 3D printer that physicians will use to build organs or tumors on which to practice tough medical procedures before ever stepping into an operating room.

The goal is to become one of the premier education-driven medical simulation programs in the country, said the department's medical director, Dr. Jennifer Arnold.

"When something goes wrong, it goes wrong fast. We want physicians and nurses to be prepared to react quickly," said Arnold, who also stars in the TLC television series The Little Couple. She joined the hospital last summer to lead the simulation program.

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A 2016 Johns Hopkins study suggested hospital errors account for more than 250,000 deaths a year, making it the third-leading cause of death in the United States. Arnold's goal is to improve that through simulation.

"My dream is to run through every worst-case scenario for a high-risk patient before a procedure ever happens," she said. "That way we can train physicians and staff on every possible outcome."

Simulation isn't uncommon in medical schools and most hospital systems these days, but it's still a relatively new training and safety technique in the medical field. The University of South Florida Center for Advanced Medical Learning and Simulation in downtown Tampa is one of the world's largest free-standing simulation facilities, which trains health care professionals for continuing education accreditations and team trainings. It opened in 2012.

Melissa Mathews, a certified health care simulation educator at Johns Hopkins All Children's, said the hospital and the USF facility, known as CAMLS, compete to some degree.

But the St. Petersburg center focuses on pediatric medical simulation, "and we have state-of-the-art simulation technology," she said. "We also will be training home care providers and home caregivers, which is something CAMLs doesn't do."

The industry has strong ties to the Sunshine State. The University of Florida is known as one of the first academic institutions to operate a medical simulation center. And two of the biggest producers of high-tech mannequins used for medical simulation are based in Sarasota and Miami.

The field also pulls from other industries like aviation, where hours of training make all the difference for safety and successful outcomes. Pilots are required to log so many hours in simulator cockpits, ones that vibrate and move, before taking to the skies themselves, Arnold said.

When the Firestone Grand Prix of St. Petersburg came to town last month, Arnold spent a day with a team of INDYCAR pit crews, analyzing their on-track pit stops and how the team worked to get the race car in and out of the pits as fast and as safely as possible.

Arnold, a neonatologist by training, is a firm believer that simulation will save lives.

"Simulation isn't required for all doctors, but think about how much better we could be," she said. "We can lower the rates of medical errors with communication and safety protocols."

Johns Hopkins All Children's has two mannequins for regular simulation trainings. The child-like dummies, "Tory" and "Hal," are technologically advanced enough to run on medical machines used for humans. They can bleed and turn blue if proper measures aren't taken to help them.

"In the past, we've had to use water in the place of medications, but it's not the right volume, so it doesn't feel the same weight in a doctor's hand," Mathews said. "But now there are simulated medicines too. The more we can embed simulation into every day work life, and not just be a once-a-year 'extra' training, the more successful we'll be."

The hospital also works with a team of a dozen "actors" from the Morsani College of Medicine at the University of South Florida. They role play as patients and family members. Often, physicians run through simulations where they have to break bad news to a parent or other loved ones.

At the new innovation building, Arnold and Mathews will have more room to run a wide variety of simulations. With the 3D printer, physicians can practice procedures over and over on a printed heart or another organ before heading into real surgery. Mathews said the printing is so sophisticated they can replicate a tumor identified in an MRI scan, and a physician can practice with the printed material to weigh if the risk of real surgery would outweigh the benefits.

"The technology is getting so good that even the doctors are saying it's so lifelike, they don't notice a difference in feel," Mathews said. "Back in the day, we learned by watching other doctors, then trying it on real patients, then teaching it to someone else. We don't have to do it that way anymore."

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A new conference room in the innovation building will allow Johns Hopkins physicians to telecast simulated procedures to other experts and doctors around the world. "We could guide a surgeon in Toronto right from the screen," Arnold said.

Most of the simulation trainings offered at the hospital focus on high-risk neonatal patients who may struggle before, after or during a complex surgery, Hidalgo said.

"It's very realistic," she said. "You feel the same pressure as if it was the real thing. We use it for emergency situations."

That includes situations that are hard to predict, like the adult who suffered a heart attack in the garage. How does a staff trained to treat children react? "We've run simulations on how to handle that," Hildalgo said. "How do we quickly get them to the trauma center?"

She says it can be tough to remember everything you learned in medical school, and that paramedics and emergency medical technicians are more accustomed to working in a high-pressure environment every day. Simulation can be a good refresher that way.

One day at the hospital, a patient had a medical emergency while receiving dialysis.

"That area of the hospital is set up more for out-patient care, so there were no real beds, just couches," Hildalgo said. "We had a simulation running through that same scenario again, and went through how to properly give CPR and how to safely lower the patient to a flat surface. It's all about trouble-shooting the best way to handle that situation, so we feel prepared."

Contact Justine Griffin at or (727) 893-8467. Follow @SunBizGriffin.