May 3, 2017
At first, Marc Callender felt uneasy and knew everything he had learned in medical school, pediatric residency, fellowship and as a pediatric hospitalist would be tested by 10-day-old Christofer Ter Bush before him in the Emergency Department at Anne Arundel Medical Center (AAMC). The infant’s blood pressure and arterial blood gas levels were dangerously low, he appeared very acidotic with poor organ perfusion, and his heart was barely beating and near arrest. While this was not the first seriously ill neonate Callender had faced, he was perhaps the sickest.
“He came in quite gray, in shock, with shallow and labored breathing, and his blood gas values were quite abnormal and typically not compatible with life,” says Callender. “It’s hard not to be overwhelmed — these situations can be quite harrowing.”
Pushing emotions aside, Callender, as the Emergency Department attending physician, focused on the task at hand and directed the team to start IV infusions of dopamine and epinephrine to increase his young patient’s blood pressure and heart rate. Callender also ordered additional labs and X-rays to diagnose and treat the cause of his shock. Suspecting a heart-related infection as the culprit, he was mostly concerned about his young patient arresting and requiring cardiac resuscitation.
Facing that possibility, he flashed back to resuscitation simulation training he and the Emergency Department team had received just three weeks earlier at AAMC from pediatric intensivists at Johns Hopkins Children’s Center, where he had trained.
“I could hear their instructions over my shoulder as we cared for this child because we had just practiced it,” says Callender.
Jamie Schwartz, medical director of the Johns Hopkins pediatric ICU, explains that the simulation outreach team conducts training sessions not only at the Simulation Center at Johns Hopkins, but also at community hospitals like AAMC because they tend not to see a high volume of critically ill neonates needing resuscitation.
“If you’re not a specialty children’s center, it may be only once a year where you have an event like this,” says Schwartz. “That’s the advantage of simulation outreach — it brings our expertise out into the community and allows pediatricians to practice something that’s rare and time sensitive. It also allows us to partner and support them in their care.”
Indeed, after Callender called the Johns Hopkins pediatric ICU to report his young patient needed emergency transport and extracorporeal membrane oxygenation (ECMO) support, intensivist Courtney Robertson called back to help walk Callender through the resuscitation protocol. Meanwhile, fellow Johns Hopkins intensivist Nicole Shilkofski alerted the transport and ECMO teams, which were instantly activated. With all that support and a fresh dose of confidence, Callender and the Emergency Department team stabilized the child and had him safely transported to Johns Hopkins pediatric ICU and placed on ECMO. At the end of the day, the pediatric ICU team at Johns Hopkins Children’s Center was truly impressed.
“When the heart stops, it’s hard to get it restarted, and you’re then looking at end-organ damage, brain damage and kidney damage,” says Schwartz. “But this child didn’t suffer such damage because they aggressively managed him, prevented the arrest and got him on ECMO, which was key to his survival.”
“I can’t give enough credit to Anne Arundel Medical Center and Dr. Callender,” adds Caitlin O’Brien, the intensivist fellow on the flight transport crew. “Being involved early on and having that communication from the outside hospital, knowing what’s going on and what’s being done for this child, made all the difference.”
For Callender, the patient’s outcome came from “the value of having great teachers and knowing where to ask for help and when you need it. I’m so thankful the patient is still with us and that we had the opportunity in that place and time to be useful in saving this child’s life.”
As it turns out, Callender’s suspicions about a heart-related infection were correct, as doctors at Johns Hopkins diagnosed the child with enterovirus myocarditis, a virus particularly lethal in newborns. After a week on ECMO, the infant recovered in the Johns Hopkins pediatric ICU.
MAKING REAL-LIFE SCENARIOS REAL
In conducting simulation training at community hospitals, like Anne Arundel Medical Center in Annapolis and Sibley Memorial Hospital in Washington, D.C., pediatric intensivist Kristen Nelson’s goal is to make the simulations as real as possible. To pull that off, she employs a high-fidelity mannequin programmed with the signs and symptoms of, say, a neonate in cardiogenic shock. She then throws this real-life scenario not solely at the attending physician, but also at entire clinical teams. That way, they can not only accurately identify the nuances of a critical case to guide care, but also learn how to best work as a team to provide that care.
“It’s their environment and equipment, and they have to manage the patient together, put in real IVs, give fluids and real meds, do everything they would do as if it’s a real patient who just rolled into their ED,” says Nelson, who specializes in cardiac simulation training. “In these simulations they are all doing the event together. As a physician, I can order things, but I don’t make them happen — it’s the nurse that makes them happen.”
Repetition, repetition, repetition is the mantra of the simulation sessions, followed by a debriefing, in which issues like the signs of shock and the potential etiologies of a neonate in shock are discussed, along with an assessment of the team’s performance. Nelson stresses forward thinking by the team as rapid dispatch transport may need to be ordered, as well as consultation with the pediatric ICU at the nearest tertiary care center. Then, there’s the emotional issues that may arise when treating a critically ill neonate.
“I ask them how that felt emotionally — did that emotion make you feel frozen in the moment? How can we get over that?” Nelson says. “Even though it’s heart-wrenching that this patient is coming in, you feel somewhat better because you just went through the simulation.”
How have the teams responded?
“They look at it as an opportunity and an advantage to learn something that will benefit their patients,” says Nelson. “I love these people—they’re so open and eager. I can tell you there are physicians who come in for the training on their day off.”