Joan Wilder: Journalist, Writer, Editor

High tech medical breakthroughs

Breakthrough technologies offer new options for busting clots, robotically removing prostate glands, and simulating patients in crisis. Nurses and patients alike are benefitting from these new devices.

From mechanical clot de-cloggers to robots to computer-run simulated patients, new developments in health care technology are on a roll. The promise — patient outcomes will improve, and nursing practice will become more effective and rewarding.

Until June 2002, when the Stroke Center at Connecticut’s Hartford Hospital began using the MERCI (Mechanical Embolus Removal in Cerebral Ischemia) Retrieval System as part of a multihospital trial, it had very little to offer some ischemic stroke victims. One treatment — the clot-busting drug tissue plasminogen activator (tPA) — couldn’t be used in all patients. Since then, however, the center has successfully removed a number of brain clots using the MERCI retriever manufactured by Concentric Medical.

The retriever works so well — achieving a revascularization rate of nearly 50% in the 141 trial procedures — that the U.S. Food and Drug Administration approved it on Aug. 16, 2004. Treatment with tPA, on the other hand, has only a 15-30% success rate and the added disadvantage of having to be administered within three hours of the onset of stroke. MERCI extends that window up to eight hours making treatment available to many more people.

Much of MERCI’s magic depends on the “shape memory” of its inner coil. Using standard catheterization techniques, the physician threads the device through a tiny incision in the groin. At this point, the spring-like device is stretched straight inside a catheter. Two imaging cameras, rotating around the patient’s head, give the surgeon the 3-D view needed to maneuver MERCI through the arteries of the brain until it snakes past the clot. Once the retriever is in position it is deployed to engage and ensnare the clot. The surgeon then slowly withdraws the clot.

A patient treated successfully with a MERCI retriever is likely to be out of the ICU within 24 hours and spend a total of two days in the hospital. In a parallel situation with a successful tPA treatment, the hospital stay would be doubled.

“With tPA, you’re much sicker, have to be hospitalized longer, may not be able to swallow … and may have to be tube fed,” says Dawn Beland, RN, MSN, CCRN, CS, CNRN, Hartford Hospital’s Stroke Center coordinator. Still others, whose stroke treatment isn’t successful, require a tremendous amount of care.

“It’s so much less work when you have a patient who can talk and tell you what they need,” says the Stroke Center’s Gretchen Wolf Riggot, RN, MSN, CNRN, EMT-P, nurse manager, neurotrauma ICU, referring to the aphasia of patients with a stroke who cannot understand others or make themselves understood.

da Vinci gets high-handed

For the last year, in a different part of Hartford Hospital, nurses have had similarly positive experiences with another high-tech device – Intuitive Surgical’s da Vinci Surgical System. Originally used for thoracoscopic surgery, da Vinci is helping Hartford Hospital surgeons perform prostatectomies that are even less invasive than the least invasive type of prostatectomy performed in the past.

Da Vinci is all arms: two for instruments and one for an endoscope. Its amazing “hands” have a vast range of motion and can mimic the complex movements of a human wrist. While viewing the procedure on a computer screen, the surgeon moves the hand-like instruments by moving his or her own hands, which are sheathed with the controls. Da Vinci mirrors the movements.

Extending the range of tasks that can be accomplished by endoscopy, da Vinci has reduced the standard seven-hour prostatectomy at Hartford by two hours. This advance in minimally invasive surgery translates into faster recoveries for patients for several reasons.

“There’s usually no incision pain, which is nice… so they don’t arrive with an epidural [for pain management] and it’s likely they won’t have to have PCA [patient-controlled analgesia],” says Julie Deshaies, RN, BSN clinical leader on Hartford’s general surgery floor.

Da Vinci patients typically begin on clear liquids soon after surgery and are up and walking with a “heplocked IV” that evening. Advancing to full liquids the next morning, they typically go home the evening of post-op day one, or on post-op day two.

In contrast, patients who have not undergone a prostatectomy via da Vinci start sips of water the day after surgery, clear liquids on post-op day two, and go home on day three. They have more blood loss, more pain, and need to be weaned off medication.

“Robotic patients get up, they’re not drowsy, they’re not sick, they’re like ‘OK, let’s get home,’” says Deshaies.

Ironically, one of the most time-saving aspects of after a da Vinci prostatectomy for nurses at Hartford Hospital is largely the result of a very low-tech procedure the hospital instituted for da Vinci patients, but not for non-da Vinci patients — a pre-op lesson in how to use the urine drainage systems patients are discharged with.

According to Deshaies, da Vinci prostatectomy patients need much less tutoring than the two or three 30-minute sessions she spends with non-da Vinci patients.

SimMan simulates real life

The effort patients expend to learn postoperative self-care is nothing new to nurses whose careers depend on maintaining their competencies and continually learning new procedures.

Enter SimMan™ — another new breakthrough device that is advancing the learning and practice of health care professionals by offering students, new graduates, and experienced nurses an opportunity to interact with a simulated patient with all sorts of conditions. They may encounter a life-threatening situation or a less complicated situation, all in a safe, simulated real-world environment.

Made by Laerdal, the life-size SimMan manikins can be programmed to respond to almost any health condition a human being can experience. The devices are so lifelike and responsive their skin can change color and temperature; they wheeze and make breathing and gastric sounds; their blood pressure and heart beat change; they can be intubated, cannulated, catheterized; have a tooth removed from their lungs; and talk. They can even die.

At New Hampshire’s Dartmouth-Hitchcock Medical Center, SimMan is a key component of a new 12-week nurse residency program designed specifically for new graduates. For several years, SimMan has been an honored member of the teaching team for experienced nurses and physicians and has been used to teach and evaluate competencies.

SimMan is perfect for teaching skills for invasive procedures that can pose a risk to patients, such as IV insertion, urinary catheterization, and naso-gastric tube placement, explains Ellen Ceppetelli, RN, MS, director of nursing education at DHMC. “While human patient simulation provides opportunities to familiarize learners with known, frequently encountered events, an additional benefit is the ability to teach learners to become competent at managing high risk, but low- frequency events,” she says. For example, if SimMan develops an anaphylactic reaction after receiving a medication, the novice nurse has to use several sets of skills, to recognize what is happening, maintain an airway, and communicate with the patient to keep him or her calm while signaling for help.

Run remotely from a laptop computer, SimMan is pre-programmed with a particular condition and responds to the treatment it receives – just as a human would.

“The nurses working with the simulators feel like they’re in a clinical situation,” says Dartmouth-Hitchcock’s Deb Hastings, RN, CNOR, PhD©, OR clinical nurse specialist. “They’re finding it very helpful… They’ve got to prioritize, act immediately, deal with emotions, and perfect motor skills. I think it’s going to be really, really valuable.”

Hastings has been working on a program that will allow OR nurses and others to recognize and respond to malignant hypothermia – a rare, but life-threatening reaction to anesthesia. Although Hastings has never seen a case, she knows that it could happen any day and staff has to recognize it and act fast.

Because SimMan simulators increase nurses’ competencies and familiarize them with presenting symptoms, it seems inevitable that using them will help nurses avert mistakes and intervene before serious complications can develop.

“Focusing on different conditions in a safe setting where mistakes can be made makes them [nurses] much more confident,” says Ceppetelli. “We’re hoping that SimMan will reduce medical errors.”

Recently DHMC’s Office of Professional Nursing received a Health Resources and Services Administration grant to support the use of human patient simulation in the nurse residency program and the research to identify and monitor outcomes of the new teaching method. Ceppetelli says that nurse preceptors are already commenting on the increased confidence and competence they’re seeing in nurses in the new residency program. The research funds will help study these and other outcomes in a systematic way.

Technology has radically changed nursing practice in the last 50 years, and if MERCI, da Vinci, and SimMan are any indication, the next 50 have some magic in store for health care.

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