Our group at Sainte Justine has just published an article, now available on-line in Pediatrics. (Lizotte M-H, Latraverse V, Moussa A, Lachance C, Barrington K, Janvier A. Trainee Perspectives on Manikin Death During Mock Codes. Pediatrics. 2015) We had originally called the article “Should the manikin die during mock codes?” but the editors didn’t like the question in the title.

The basic idea was to try and deal with one of the unrealistic characteristics of mock codes, which is that usually, during a simulated resuscitation scenario, if you follow guidelines and act correctly, the patient gets better. So if you follow NRP standards, the heart rate will come back, the patient will improve and you send them on to the NICU.

In real life, not always.

We are teaching trainees to have unrealistic expectations of the responses to their interventions. This has been addressed theoretically before, but I don’t think anyone has doe what the team here did, which is to evaluate how caregivers respond when the manikin dies, even after they have done everything correctly, and what they thought of the experience. A simulated baby was born pulseless, and residents were randomized to either have a baby that responded to NRP interventions, or one that did not, and remained pulseless. They were then exposed to the other scenario.

Firstly, we found it was difficult for people to stop, NRP teaches that after 10 minutes of asystole, once you have performed the appropriate steps, you should stop resuscitation, as survival is extremely uncommon. Many of our participants were still trying to resuscitate after 20 minutes (at which time the scenario was shut down).

Our participants were surprised that the manikin died, after they had done things well. They thought they must have made a mistake or missed something. They also appreciated the experience and thought they had learned something valuable, and did not want to have a “death disclosure” warning them before the simulation that the manikin might die. Even though they found the death of the manikin to be more stressful on a subjective stress scale.

I think occasional death of a manikin during resuscitation scenarios should be the norm. Residents and other trainees could learn that good interventions don’t always lead to good outcomes, about how to deal with stopping an unsuccessful resuscitation, and most importantly, how to deal with the family. Although it would make the simulation much more difficult and expensive than just an “NRP drill”, having a simulated mother and/or father could be a very valuable learning experience.