Preparing for the worst: Doctors gain practice in treating victims of terror attacks through simulation. The young woman staggers into the emergency room, sweating profusely and frothing at the mouth. “Help me,” she cries.
The doctors have another case of nerve gas poisoning on their hands.

This scene unfolds regularly at Israel’s largest government hospital – the Chaim Sheba Medical Center at Tel HaShomer. Fortunately, it is not real. The woman is an actress; the other nerve gas ‘casualties,’ lying unconscious on stretchers, are hi-tech mannequins.

But this scenario, with its precise rendering of symptoms and effects, offers Israeli and American doctors the chance to hone their skills on the closest thing to a real chemical warfare attack – as well as a myriad of other less chilling but equally challenging medical situations.

It is one of the reasons why the Israel Center for Medical Simulation at Tel HaShomer has become a world leader in medical training in general, and emergency medical training in particular. It is also why the facility, near Tel Aviv, has been selected as a model for similar medical simulation centers now being set up in the United States and Canada.

“I have never experienced anything comparable to the simulation center in Israel,” said Dr. Alan Schorr of St. Mary Medical Center near Philadelphia. Schorr was one of 20 American physicians who took part in a training session at the Center during a week-long course in emergency and disaster management, held in Israel last month, under the auspices of the American Physicians Fellowship.

“I was able to understand the complexities involved in diagnosing, treating and preventing these scenarios,” said Schorr, an endocrinologist, who treated a baby with smallpox and two adults exposed to nerve gas during the simulations.
“I am now more aware of the possibility of an unconventional medical emergency and have brought this information back to my emergency room colleagues.
“It’s amazing how difficult these simulations are and how frightening it could be to the unprepared.”

Preparing for the unknown is precisely the point of such a facility, explains Dr. Amitai Ziv, director of the three-year-old Israel Center for Medical Simulation, also known by its Hebrew acronym MSR. It was during his pilot training that Ziv, a former fighter pilot in the Israel Air Force, first encountered simulation-based training.

“When I went into medicine, I became aware of how much medicine can learn from aviation,” Ziv, a pediatrician, told Israel 21c. “In a nutshell, you need to ‘take off’ on a simulator before you ‘take off’ on a real patient.”

Ziv, who is also deputy director of the Sheba Medical Center, has testified before the US Congress on MSR’s medical emergency preparedness programs and briefed the US office of Homeland Security. “Since 9/11, there is much more awareness about the need to prepare for emergency scenarios,” he notes.

“Because there is little experience in treating victims of such attacks, it is of utmost importance to train and drill repeatedly in these areas,” said Dr. Michael Frogel, Chief of Pediatrics at Schneider Children’s Hospital on Long Island, NY, who also took part in a chemical and biological warfare drill recently at the Israel Center for Medical Simulation.

“If these scenarios were to occur in the US, many lives would be saved by having highly-trained, healthcare providers who have undergone such drills.”

There are already several medical simulation centers in North America and other Western countries. But the Israel Center for Medical Simulation is unique in several respects.

Most existing centers are devoted exclusively to one application – usually anesthesia simulations. The Israeli center has a wide range of applications including anesthesia, emergency medicine, chemical and biological warfare casualties, obstetrics, pharmacology, and general communications skills.

Doctors can practice everything from delivering a baby and performing neonatal intensive care, to treating car accident victims and cases of domestic violence. They hone not only their medical skills but also their basic communication skills – by watching videotapes of their handling of various tricky situations.

During one training session, for instance, pharmacists encounter a scenario in which a “patient” (played by an actor) brings some 12 different prescriptions for medications, many of which interact adversely with each other. Meanwhile, another “patient”, this one with a prescription for a psychiatric drug, begins acting aggressively.

“These are drawn from real-life situations that a pharmacist may have to face,” notes Ziv. The trainees watch a videotape of the scenario in a debriefing room, where they can, with the help of experts, evaluate and improve their responses.

In another scenario, physicians attend to victims of a terror attack in a marketplace. With the press of a button, thick smoke, sirens, gunfire and the sound of helicopters hovering overhead can fill the simulation room.

“Being put on the spot in front of video cameras creates a difficult pressured situation, but this only enhances your skills for dealing with real-life scenarios,” said Frogel, who took part in a chemical warfare scenario which “required complex patient care and rapid decision making.

“I found myself believing this scenario was really happening, with concomitant anxiety and trepidation on my part, hoping that we were administering the appropriate treatment.”

The Israeli center is also unusual in combining both “low tech” and “high tech” types of simulation – from a pool of some 100 professional actors who feign scenarios (“How was I?”) asks the frothing chemical warfare victim after her “scene” is over) to a battery of some of the most sophisticated – and costly – medical mannequins available, some of which have been custom-made for the Israeli center.

Typically, the mannequins have what Frogel described as “almost human qualities”. They exhibit vital signs like heart rate, blood pressure and oxygen saturation, and have the ability to bleed, convulse or go into anaphylactic shock in response to “treatment.”

It is the diverse range of applications and methods of simulation that have made the Israel Center for Medical Simulation a model for several centers now being planned at medical facilities in North America, among them, the Mayo Clinic, the Cleveland Clinic/Case Western Reserve, McGill University in Montreal, and the Winnipeg Regional Health Authority, also in Canada.

In addition to the need to gain more practice in handling various emergency scenarios, there is another impetus for setting up medical simulation centers in North America – and that is the issue of patient safety.

Experts estimate that as many as 98,000 people die in any given year from medical errors that occur in hospitals in America, according to the ground-breaking report, “To Err is Human,” published in 2000, by the Institute of Medicine. That’s more than the number that die from motor vehicle accidents, breast cancer, or AIDS.

“We see simulation as a major tool in reducing medical errors and improving patient safety,” said Dr. John Wade, chairman of the board of the Canadian Patient Safety Institute, during a recent visit to the Israeli center. “We think this is the leading medical simulation center in the world — and we hope, through collaboration, to be able to bring the benefits of such a center to Canada,” said Wade, who was part of a Canadian delegation that signed an agreement last month to establish such a center in Winnipeg, Manitoba.

“The premise,” explained Ziv, “is that if you do it on a simulator, you’ll be more competent to do it on a real patient.”

In Israel, MSR has trained some 15,000 trainees from various health professions, including doctors, nurses, pharmacists, social workers, and paramedics from all over the country. In addition, the center has provided training to several groups of American health professionals, including doctors studying emergency medicine and social workers improving communication skills.