Yale Team Helps Improve Emergency Care for Kids

Simulation has become a key training tool to help medical professionals deliver the best possible pediatric emergency care.

Expanding expertise in the ED

Yale Medicine's Marc Auerbach, MD, explains elements of a medical simulation exercise at Stamford Hospital.

Credit: Robert A. Lisak

A four-month-old baby’s life is in jeopardy. She cries inconsolably. Her heart beats dangerously fast as an ambulance transports her to a local emergency department. There, a team of doctors, nurses and technicians only has one minute to prepare for her arrival. As the child’s distraught mother shouts information about her symptoms, the medical team gets to work.

“Is she going to be OK?” the panic-stricken mother asks, as a nurse administers an intravenous medicine to lower the baby’s abnormally quick heart rhythm, also known as supraventrical tachycardia. “Will that fix her?”

“It should, and if that doesn’t work, we’ll shock her,” a doctor responds calmly.

But the medicine doesn’t help, and the baby’s pulse weakens. The doctor prepares a set of pads and gives her tiny chest an electrical shock. Finally, the baby’s heart rate stabilizes, and she quiets. Just 12 minutes have passed since she came to the hospital. The team prepares to transfer her to Yale New Haven Children’s Hospital, where a pediatric cardiologist will get to the root of her problem.

High drama, then lessons learned

While this type of emergency happens frequently around the country, in this case, the dramatic scenario was actually a simulation performed at Stamford Hospital and facilitated by doctors, nurses, technicians and medics from Yale New Haven Hospital and Yale Medicine. The “baby” can indeed cry, breathe, turn blue and respond to medical interventions—but she is a mannequin made of plastic and programmed through a sophisticated computer.

Practicing on a mannequin

Alex Villegas and Shivani Patel, both of Stamford Hospital, treat a simulated infant during a practice drill.

Simulation, which includes using mannequins, technological devices, and/or other tools to mimic clinical care scenarios, has become a key training tool to help medical professions delivery the best possible pediatric emergency care.

Though Connecticut has 36 emergency departments, there are only two children’s hospitals—Yale and Connecticut Children’s Medical Center in Hartford—with 24-hour pediatric EDs. The team has come to Stamford Hospital to train the emergency room staff there because the Hospital recently opened an eight-bed pediatric unit within its ED, where children are treated daily from noon until 10 p.m.

“We want to ensure the same level of pediatric emergency care throughout the state for every ill or injured child,” explains Yale Medicine’s Marc Auerbach, MD, who is medical director of Connecticut Emergency Medical Services for Children (EMSC), which runs the simulation program at hospitals around the state. The coalition includes medical personnel, parents, volunteers and community groups.

“It isn’t about having the child go to this hospital or that hospital but that every kid gets the best care whenever and wherever it is needed, and if necessary, they can be transferred to New Haven or Hartford," says Dr. Auerbach, who is also director of pediatric simulation at the Yale Center for Medical Simulation and associate director of trauma at Yale New Haven Children’s Hospital.

Children aren't just small adults

Specialized training is vital, Dr. Auerbach notes, explaining, “Children are not just small adults.” Medications must be dosed appropriately and special equipment is often needed.

EMSC’s outreach work is funded through federal grants, the administration of which is handled by YNHH and Yale School of Medicine. In addition to Dr. Auerbach, the work is led by Yale Medicine’s Mark Cicero, MD; Pina Violano, PhD, of YNHH; and Marcie Gawel, MSN, of YNHH.

Life-like practice

Simulation is a key training tool for pediatric emergency care.

The mobile simulation team is an important piece of EMSC’s work. A "parent," a mannequin, nurses, doctors, residents and an EMS provider travel to EDs throughout the state. Members of the Yale staff play the parent roles and observe how the local medical workers respond to a scripted emergency. Sometimes, professional actors perform the parts.

After each simulation, the Yale experts lead a debriefing session to identify strengths and weaknesses“Our goal is not to critique or improve their knowledge base, but to talk about operations, systems and resources,” Dr. Auerbach explains. “Maybe it’s about not having the right equipment, or knowing where it is, or having it be expired or not working.”

Many of the local clinicians have training in pediatric care, but they may not have experience dealing with children in their EDs with their colleagues and equipment. In Connecticut, only one out of nine children comes to the pediatric emergency departments in New Haven or Hartford, Dr. Auerbach says.

Dr. Auerbach coaches

Yale Medicine's Marc Auerbach, MD, discusses the importance of simulation training for pediatric medical emergencies.

"That means nine out of 10 are going to smaller community hospitals, and that’s where we want to expand the level of preparedness,” Dr. Auerbach says. “When a parent calls 911 and goes to the nearest hospital, they want to get the same level of care no matter where they go. And if their child doesn’t get that best level within in the first five to 10 minutes of the child arriving, they aren’t going to make it to a transfer to Yale or anywhere else.”

Gladys Tejada, a registered nurse at Stamford Hospital, says she has participated in a pediatric simulation before, but never one as detailed as the one in Stamford. In this simulation, three different cases unfolded over the course of three hours.

“This felt real and it will stick in my head. SVT (supraventrical tachycardia) is rare with kids who come in here, but now I will remember all of this if I see it again,” Tejada says.

Samuel Maryles, MD, an emergency specialist at Stamford Hospital, agrees. “It’s nice to get back out there, sharpen our skills and be reminded of how to handle those really sick babies,” he says.

Meanwhile, in a different room in the pediatric ED, a second team of Stamford and Yale medical experts tends to another patient: another four-month-old infant, this one in acute respiratory failure. After interviewing the baby’s “father,” the team decides to administer a breathing tube. It goes in smoothly, and the mannequin baby’s chest begins to move up and down.

“There was no obstruction and no physical abnormalities, but let’s talk to Yale and get him up there for further evaluation,” a doctor says.

Practice makes a difference

After the drill wraps up, Heather Machen, MD, director of pediatric emergency medicine at Stamford Hospital, stresses to her team the value of simulation drills. The cases presented in Stamford that morning are rare; it could easily be a few years before the emergency department sees such a medical event in real life. This underscores the importance of being prepared for various scenarios.

Debriefing

Marcie Gawel (center right), MSN, of Yale New Haven Hospital, and Matthew Lipshaw, MD, of Yale Medicine, listen as Heather Machen, MD, of Stamford Hospital, debriefs the team after the simulation drill.

“No matter how good you are, you always keep training,” Dr. Machen says.

So far, EMSC has brought its mobile simulation program to 20 of the state’s 36 hospitals, and to 25 emergency departments outside of Connecticut. Dr. Auerbach says he hopes eventually to reach every hospital in the state—and then visit them again and again to follow up. Practice might not always make perfect, but when a child’s life is at stake, it’s well worth the effort.