A safer OR

David M. Gaba, M.D. ’80, was bent over the operating table, working intently on a car crash victim. The woman had suffered a broken leg, and Gaba and his surgical team were busy repairing the damage. For a time, everything went according to plan. Then, the team noticed climbing blood pressure and a dropping heart rate—an unusual combination that suggested a problem in the brain. One of the victim’s pupils began to dilate.

“It’s the left eye,” said the attending anesthesiologist. “Looks like potential trauma to the head.”

The anesthesiologist immediately called for back-up from a neurosurgeon, then moved into a set of carefully scripted emergency procedures. Hyperventilation, to reduce pressure inside the victim’s brain. A steroid, to reduce inflammation and pressure. Then a diuretic to draw water from the brain. Despite these temporizing measures, a hole would probably have to be drilled in the victim’s head to release the pressure.

As Gaba and his team worked, three video cameras monitored their every move and computers monitored the patient’s electrocardiogram, blood pressure, blood oxygen saturation, carbon dioxide output and more. After the surgery, Gaba and his team could go back through every stage of the crisis to see how they had performed—and where they could improve. In a few minutes, the crisis was over, but the patient did not exactly come through alive.

Why? This “patient” was actually a programmable polymer mannequin laced with wires and sensors—the centerpiece of an innovative crisis management training program that Gaba has developed with colleagues at the Veterans Affairs Palo Alto Health Care System and Stanford University School of Medicine. The aim of the program is to teach anesthesiology residents and more experienced practitioners how to respond in sudden and often unpredictable crises.

Training like an astronaut

“Most medical schools are very good at teaching normal medical procedures,” Gaba explained. “The point of simulation training is to expose people to events and challenging situations they have not seen before, but could see, and then use them as generic springboards to teach all the behavioral issues of crisis management, dynamic decision-making, leadership and teamwork, and the processing of information. Those things have not been traditionally taught in health care.”

Though he pretended to be a surgeon during today’s simulation, Gaba is a veteran anesthesiologist with a passion for research and advanced simulation techniques. He serves as the director of the Patient Safety Center of Inquiry, which he created at the VA facility in Palo Alto, and as a tenured professor of anesthesiology at Stanford medical school. One day a week Gaba works clinically in the real OR, and the remainder of the week he conducts research or these kinds of training sessions. He and his colleagues have refined their simulation-based training course into an effective teaching tool that is now being adopted by other hospitals and universities here and abroad, including Harvard, Penn State, UCSF and Yale. The key is creating lifelike situations in dynamic clinical settings like the ER, the ICU and the OR, as with today’s car-crash victim.

“We believe that part of a doctor’s training should be comparable to that of a pilot or an astronaut. Doctors should know how to respond to medical crises—and to external crises such as equipment failures, power failures and even earthquakes.” To support their training program, Gaba and his team have published a textbook on crisis management to improve human performance—and reduce mistakes—in the operating room. “Our aim,” Gaba said, “is to apply organizational safety theory and practice to health care.”

Thanks to this innovative work, Gaba is now widely regarded as an important pioneer in the field of medical simulation and patient safety. In his book Complications, author Atul Gawande, M.D., M.P.H., credits Gaba among several figures in anesthesiology responsible for drastically cutting the rate of accidental deaths. Before reformers like Ellison C. Pierce Jr., M.D., and Jeffrey B. Cooper, Ph.D., pushed for systematic analysis of why anesthesia deaths occurred and instituted new practice standards, one or two patients died per 10,000 operations. Thanks in part to Gaba’s anesthesia simulator, the number is now one in 200,000.

Gaba’s contributions to medicine come as no surprise to his former mentors at Yale. “David was a superb medical student,” recalled Roberta L. Hines, M.D., HS ’77, professor and chair of anesthesiology at Yale. “He was always looking to do things in new and innovative ways.” Hines said that Gaba’s work has had a profound impact on Yale medicine and on the medical profession as a whole.

“Simulation has been a feature of NASA and the airline industry for many years, but David was certainly the first person to apply it to medicine in a rigorous way, using simulation for emergency procedures and the many repetitive things we do. At Yale, Hines said, “simulation has become an important part of the training process across the profession, not just for resident anesthesiologists but also for nurses, paramedics and emergency room personnel.”

Despite his stature in the field, Gaba comes across not as an éminence grise, but as a spirited, overgrown techno-kid with some of the coolest toys on the block. In fact, much of the inspiration for his pioneering work traces right back to his childhood in Kansas City, Mo., and his early fascination with the NASA space program, which uses simulation for training and accident prevention. “I was one of those kids who audiotaped the TV broadcasts of all the Apollo missions,” Gaba said. “And Alan Shepard’s historic flight was launched on my seventh birthday.”

Gaba attended Northwestern University, where he studied biomedical engineering and artificial intelligence, and he created for himself a specialized field of study called “high-level information processing.” He entered Yale School of Medicine in 1976 and soon was doing research on defibrillators in the lab of Norman S. Talner, M.D., who at the time was chief of pediatric cardiology. “The hallmark of Yale for me, and I think for most people, was the freedom to learn the way we wanted to learn and investigate the things we wanted to investigate. I like the Yale System a lot and I benefited a lot from it.”

After graduating in 1980, and after interning at the Yale-affiliated Waterbury Hospital nearby, Gaba moved to Stanford for a residency in anesthesiology. Soon after joining the faculty at Stanford, Gaba read a book that would set him on his path: Normal Accidents, by Charles B. Perrow, Ph.D., a professor emeritus of sociology at Yale. Perrow examined a series of accidents, including the nuclear disaster at Three Mile Island, and then analyzed the human, social and organizational errors that can lead to such accidents. Inspired, Gaba immediately decided to develop an accident-prevention program for the practice of anesthesia.

By 1986, Gaba and Abe DeAnda Jr., a medical student with a background in electrical engineering, were building their first “patient simulator.” With John Williams, another medical student with an engineering background, they later created a more advanced simulator, whose successors Gaba and others continue to fine-tune today. Today’s wondrous models, implemented on a single computer, can simulate an array of body movements and symptoms, including heart dysrhythmias, airway swelling, bleeding, thumb twitching, eye dilation and even the presence of a fetus. They can also detect a wide variety of gases and medications and their concentrations in the “patient’s” system.

“We don’t just do drills,” Gaba said. “We try to replicate, as closely as we can and in a very high-level way, a real clinical environment. We focus on issues that we always expect people to be good at, but that nobody ever teaches us.”

His childhood heroes at NASA would surely be impressed. YM