By Jonathan Pitts,The Baltimore Sun
4:21 AM AKST, February 18, 2013
A surgeon enters the operating room, offers his hands to a nurse and watches as she helps him into his rubber gloves with a snap.
He glances at the patient on the table. A cloth covers the man's torso but for one area. Three trocars — tubes into which the doctor will slide high-tech cables — protrude from the abdomen.
The procedure is nothing new for Dr. Adrian Park, a surgeon at Anne Arundel Medical Center who has fixed thousands of abdominal walls, watching his handiwork on a video screen as he replaces herniated tissue with state-of-the-art mesh.
This time, though, the patient is a $200,000 mannequin. And that mesh is a kind he found at a craft store.
It's a simulated operation, the kind that will lie at the heart of efforts at the Simulation to Advance Innovation and Learning Center — or SAIL — a new multimillion-dollar teaching-and-research facility at the hospital.
In simulated surgery, a broad array of learners — from medical students and longtime doctors to nurses and operating-room technicians — can practice procedures familiar or new, working all the while under relatively low-stakes conditions, said Park, the center's founder and chairman.
At the learning center, "we can simulate everything from basic procedures to rare but potentially catastrophic events, even integrating them into the larger work flow of the hospital, and it will all contribute to our goal of being able to offer better patient care," said Park, known worldwide for his pioneering work in laparoscopic, or minimally invasive, surgery.
Hospital officials recently held a ribbon-cutting ceremony for SAIL, a 10,000-square-foot site made possible by a grant from Sylvia and James Earl of Annapolis. It opens for business Monday, playing host to a conference of neurosurgeons who will use virtual reality to study a new technique for removing certain brain tumors.
In a sense, there's nothing groundbreaking about the use of simulated patients in medical training. Instructors have used inert mannequins to showcase various forms of disease for centuries, and it was 45 years ago that a doctor at the University of Miami created the so-called "Harvey Mannequin," a $100,000 interactive dummy that could replicate the body's most basic cardiac functions.
Over the years, engineers devised ever more sophisticated mannequins, drawing on simulation technology in fields such as military aviation to allow faux patients to mimic everything from breathing and bleeding to eye movement and the process of giving birth.
Today's version of Harvey, for instance, replicates six different breath sounds and 30 cardiac diseases, and the amplitude and intensity of its heartbeat can be controlled.
Such advances have helped drive an explosion in the popularity of simulation technology.
"The use of simulation in medical and surgical training has increased tremendously during the past decade," according to a 2010 article in the Journal of Surgical Education. "Simulation centers are in development across the country — and the world. Boards of accreditation and professional licensure are increasingly insistent that simulation be incorporated into the preparation and assessment of care providers."
Park has long experience in the field, having founded the Maryland Advanced Simulation, Training, Research and Innovation Center, or MASTRI, at the University of Maryland Medical Center and School of Medicine in Baltimore, a facility that offers advanced training in laparoscopic surgery, among other fields, and integrates simulation-based education into the curriculum.
That's one reason Park was recruited to the 380-bed, Annapolis-based hospital in 2011.
"Adrian is considered one of the elite innovators in minimally invasive surgery, and he has been one of the leading proponents for evidence-based improvement in both the working environment for the surgeon and in outcomes for the patient," said Dr Steven Schwaitzberg, chief of surgery at Cambridge Health Alliance in Massachusetts and medical director of Interactive Surgical Systems Lab (ISSyL), a Harvard-affiliated facility that uses simulated surgical learning environments.
The American College of Surgeons has granted professional accreditation to 83 simulation centers so far, most of them in the United States. Of those, all but a few are affiliated with major university hospitals.
That's a blessing and a curse, Park said, because even though such settings are better able to acquire the funding necessary to equip "sim" centers, they tend to be more enmeshed in bureaucratic red tape.
SAIL isn't the region's only sim center, but it's the only one set in a working community hospital, a fact that appears to have inspired AAMC officials.
"The academic medical centers in this country have a critical role in education and research, but it turns out that most clinical care is actually provided outside of those settings. It's only appropriate for a simulation center of this scope to be deployed in this kind of environment," said Dr. Mitchell Schwartz, chief medical officer at AAMC.
"We have a living laboratory here in the middle of a busy, high-quality regional hospital," Park said. "There's a huge opportunity for simulation-based learning in the broader health-care system, and our aim is to be at the leading edge of that."
SAIL will also feature an "innovation" center, where Park and his staff hope to help private industry develop and test medical devices — like the 24 on which he owns patents.
The faux hernia operation, meanwhile, is a glimpse into how SAIL's sim technology will spark a chain reaction of learning.
Having just completed an interview, Park forgets to don his surgical cap before entering the faux operating room. He's met with the glare of five nurses stationed there.
"When you get started on one of these things, everyone — and I mean everyone — believes from the get-go that the experience is real," he said, laughing as he put on the headgear and gets to work.
A million dollars' worth of Klieg lights beam down as the nurses, clad in blue scrubs, pull back the cloth cover on a mannequin known at Meti-Man. They administer anesthesia and monitor vital signs. Park slides dedicated cables into the open trocars, one bearing a tiny light, another a tiny camera lens, the third a tiny mechanical clamp.
He works his magic, watching on a 4-foot-wide high-definition screen as the clamps grip and maneuver the mesh — a stand-in for the stuff used in minimally invasive surgery to replace weakened tissue in the abdomen. Staffers found it, 5 cents to the yard, at a Michaels crafts store.
Human anatomy is so complex that technology still falls far short of replicating it, Park says, which means sim professionals must be good rummagers.
"Here's a bit of heart, and here's an esophagus," says Ivan George, the facility director, tossing two rubber slabs on a table to illustrate. "I found these plastic pieces. They have close to the right properties for stitching."
The hernia procedure is one of the simpler ones SAIL can stage. Depending on the clientele and the project, staff can set up tracheal intubations, live births, amputations and breathing crises, working up or down to the level of expertise needed.
There's also a control room next door from which staffers can trigger emergencies — sudden excessive bleeding, smoke from an electrical fire and more — and test a team's capacity to respond.
"One anesthesiologist wouldn't talk to me for three weeks" after he pulled such a stunt, George says, laughing. "It's all part of improving the skills needed in delivering health care."
Margaret Saul, a veteran nurse and the clinical director for operating-room procedures in the building, stands in during this day's operation as "RN circulator," the nurse who monitors what goes on in the OR.
Over the years, Saul has borrowed used stuff to improvise crude models of patients, operating tables and the like to help train students and staff.
It's the first time she has seen this facility in action, and as Park works his tiny tools, her eyes go wide above her surgical mask.
"I'm amazed at how realistic this is," she said later. "My mind is spinning as I think of all the ways this is going to help us deliver effective health care. I'm proud to be a part of this."
The center will be used for other purposes, including hosting teleconferences and offering demos for schoolchildren, and eventually serving as a place where surgeons can warm up for procedures they're about to perform.
As a matter of fact, on this day Park has five minutes to make his way upstairs, where he's scheduled to perform just this surgery on a living, breathing human.
"I wish I could stay longer, but I've got to go operate on a real patient," he says, pulling off his gloves and handing them to a nurse. "And I'm ready to get started."