Five-year old Hal was showing dangerous signs of respiratory distress. His lips were turning blue, his eyelids were drooping and the bedside monitor showed oxygen levels in his blood dropping fast.
His nurse — suspecting a problem with the tracheostomy tube that was helping Hal breathe — snapped into action.
“It looks like you are not doing well,” nurse Heather Grace said calmly as Hal moaned. “We are going to do a trach change.”
If Hal were in a hospital, a team of caregivers would quickly descend on the 50-pound boy to restore his breathing. But Hal, who requires mechanical breathing assistance, is one of a growing number of children being cared for at home. That means his nurse must act quickly, correctly — and largely alone — to prevent a crisis such as cardiac arrest.
Grace replaces his tube. Hal coughs and opens his eyes. His blood oxygen levels quickly recover.
“There was an obstruction in your trach, Hal,” Grace says.
It is a scenario Hal will experience again and again. Some nurses will fail him and other nurses will succeed, but Hal helps all of them learn because he is a robot.
He doesn’t walk and he can’t wave his arms, but Hal is one of the most advanced human simulators, sometimes known as medical dolls or mannequins, to come to market.
He can replicate many human vital signs — heart beat, blood pressure, pulse, blood oxygen levels and breathing. He has a dozen facial expressions and eyes that blink, move and dilate. He can talk, bleed and urinate.
“It is a little discombobulating when you think it is a doll,” Giel said.
Hal was developed by Miami-based Gaumard Scientific Co., a company founded by a physician after World War II to make simulators and other educational products for the health care industry.
Developing muscle memory
Simulators are not new to health care training and education. Perhaps one of the best known is Resuscitation Annie, a doll that has helped teach thousands of medical professionals and lay people how to conduct CPR.
But simulators are becoming increasingly important in medical training at all levels, especially as the technology improves to help health care workers learn how to react to emergency situations or complex cases they don’t always experience in hands-on medical training.
“It allows us really to have clinical people practice and develop that muscle memory so they are prepared to respond should any type of emergency or care need happen quickly,” said Giel.
That’s especially critical for Pediatric Home Service, which cares for many children who go home straight from a hospital pediatric intensive care unit and still need mechanical assistance to breathe.
“Pediatric experiences for nursing students are very limited,” said Giel. Many students, for example, won’t be exposed to an emergency such as a seizure or a failure of the breathing line.
After a year of researching available products, Pediatric Home Service bought Hal, along with an infant robot and the accompanying software, for $131,000. The company began working with him last August.
“It is worth the investment,” said Bruce Estrem, manager of clinical education for Pediatric Home Service. He is often the man behind the curtain, so to speak, who issues commands from a laptop computer that wirelessly instructs Hal to behave based on a preprogrammed scenario. Estrem can also create spontaneous reactions.
In fact, Hal adds an entirely new dimension to training that low-tech simulators cannot — the ability to create the unexpected behaviors that can occur in human patients.
All training scenarios with employees and students are video recorded using three cameras. Participants then review how well they did or where they fell short.
“That is where the real learning begins,” said Estrem. “We don’t want patients to go back to the hospital because of mistakes made in an in-home environment.”
Reading non-verbal cues
Grace, who helps train other nurses to work with patients, said using Hal improves training because the simulator exhibits vital signs, including heart, lung and bowel sounds. He is also hooked up to the same equipment used in the home, including a mechanical ventilator and a basic vital signs monitor that sound an alarm when Hal’s vital signs go south.
“You are seeing the actual symptoms of the patient,” Grace said. “You can do an action and the simulator is going to have a response.”
Even Hal’s rudimentary movements, facial expressions and voice add to the experience.
“No child is laying still and flat when you are changing the trach,” said Grace. “Even that little bit of interaction with Hal, turning his neck and blinking his eyes, is more like reality so you get used to other things that are going on at the time.”
Hal has sensors built into his face as well that can detect when a hand or face is close. His eyes will also track a pen moving from side to side.
“We worked with pediatricians to get the facial expressions and tracking as best as we could,” said Jim Archetto of Gaumard Scientific. “Children do not always communicate verbally. We had to make sure that nonverbal cues were incorporated into the design.”
The newest version of Hal was introduced in January — the fourth iteration of a Pediatric Hal, said Archetto.
“We still have the other ones because not everyone needs the sophistication that Pediatric Home Service needs, especially with ventilators.”
Among its other simulators, Gaumard makes products for military medical training, including mannequins that have amputated limbs. It also has female mannequins that can simulate childbirth.
“You can simulate almost anything you can imagine,” said Jane Miller, director of the Academic Health Center Simulation Center at the University of Minnesota. The center works with products from many different manufacturers.
“They aren’t passive mannequins anymore,” she said.
At a basic level, simulators help the novice practitioner learn skills, such as drawing blood, without harming an actual patient.
But simulators are also common at the advanced level, including for students on medical fellowships and postdoctoral pursuits in fields such as nursing, pharmacy, dentistry, medicine and veterinary medicine. The demand is so great that the U’s simulation center will combine with another university unit in 2020 to create a new center that will have twice the space of the current facilities.
Pediatric Home Service will also use Hal to train family members and emergency medical service workers, who often have to deal with emergency situations in complex pediatric patients, as well as improving the skills of its nurses.
“It is extraordinarily important that our nurses feel that they have the adequate training and resources in order to perform these jobs in the home,” said Giel.
“In the hospital you call the cavalry, but in the home you are the cavalry.”