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The Manikin

Donald Firesmith

Three other medical interns and I were waiting in a meeting room just down the hall from the operating room, where we would take our fifth and final exam to determine whether we were ready to start our residency working on actual patients. Emberly was our budding anesthesiologist, while Ellie and Dominic would be our two surgical nurses. And then there was me, Milo Mackensie. I would be the surgeon.

We had all passed the previous four exams, during which we treated a broken arm, a mysterious infection, a laparoscopic appendectomy, and a bowel resection. This final exam would test our skills in treating a patient with a life-threatening injury. As before, our teaching attendings would only provide basic information about the test scenario prior to the beginning of the exam.

“So, what do you think it will be?” Dominic asked. “My bet is it involves a patient who was in a car wreck. They’re common and certainly something we’ll encounter in real life.”

“I’m thinking maybe someone with multiple gunshot wounds,” Emberly replied. “If we’re in a big city trauma center, shootings would be a daily occurrence. How about you, Milo? What do you think it might be?”

“I honestly have no idea,” I replied. “Since this is the final exam, it’s bound to be something extremely serious. Something bad enough that we could lose the patient if we’re not careful. How about you, Ellie? What do you think?”

Before she could answer, the door opened, and our three teaching attending physicians, who would oversee our exam, walked in. Dr. Reinholt, who was a highly experienced general surgeon, would grade my performance. Dr. Isaacson, who taught anesthesiology, would give Emberly her score. Finally, Dr. Lemont would grade Ellie’s and Dominic’s performance.

Dr. Reinholt explained the exam’s scenario. “For today’s exam, we will simulate working in a major trauma center. A mass shooting at a local middle school has resulted in multiple deaths. Dozens of adults and children with one or more gunshot wounds are arriving in the ER. The shooter used an assault-style rifle. As you learned in your first-year class, these weapons fire high-velocity, low-mass bullets that tumble on impact and rapidly deposit their kinetic energy into the surrounding flesh and bones. Expect your patient to present with small entry wounds, large exit wounds, and massive internal tissue damage and destruction.”

I couldn’t help remembering the videos and images of the horrible injuries we had seen in class. Worse was the memory of observing an autopsy of a young man killed by such a weapon of war. It is no wonder the vast majority of the medical community opposed assault weapons and wanted them banned.

“Your goal today is to save your patient’s life,” Dr. Reinholt continued. “Due to the scenario’s high number of casualties, assume that other patients will require your attention and access to your trauma bay as soon as you have finished with this one. Prioritize your work, focus on the most critical injuries, and stabilize the patient for transfer to a regular operating room for further surgery. We will assess not only on the quality of the medical care you provide but also on the speed with which you work.”

Dr. Isaacson provided further details about the exam. “Because of the large number of casualties arriving simultaneously, the test scenario has the four of you working completely on your own during this exam. We will not interfere or be available to answer questions until after the exam. Your other teaching attendings and I will observe your live video feeds from the cameras in the trauma bay. And please remember that in addition to grading you on your individual work, we will also assess your ability to work effectively as a team.”

Dr. Lemont gave us our final instructions before the exam. “We’ve recently received a shipment of manikins with the latest AI upgrade, and you will be the first students to use one of them. As before, these lab-grown human bodies are virtually identical to real patients with the exception that they lack the cerebrum with its higher brain functions. According to American Android Corporation’s promotion and user guide videos, the new manikins behave more realistically than their previous version. Expect your manikin to have realistic psychological reactions and perfectly simulate how a human would react, both in terms of pain, fear, confusion, and shock and in how they will interact with you. And though the manikin is not conscious and has no subjective awareness, we still expect you to treat it with the same compassion and professionalism afforded to real patients. Are there any final questions before we begin?”

We exchanged glances and shook our heads.

“Okay, for this exam, we set up room three as a trauma bay,” Dr. Reinholt said. “Put on your PPE and get ready for the arrival of your patient. You have ten minutes to prepare.”

We quickly donned the impervious gowns, gloves, goggles, and booties that comprised our personal protective equipment. Once we entered room three, we immediately got to work. Emberly laid out the intubation instruments: a laryngoscope and because she didn’t know the size she would need, a variety of endotracheal tubes. After preparing the supplies needed to put in IV lines, Ellie readied the cardiac monitor, pulse oximeter, and blood pressure cuff. Meanwhile, Dominic started drawing up the commonly used surgical medications: propofol for sedation, vecuronium to facilitate intubation and muscle relaxation, and fentanyl for pain.

“Ellie, make sure we have enough O-negative blood on hand,” I said. “Given the wounds made by assault weapons, we’ll probably need five or six units. And Dominic, the manikin will be hypotensive due to blood loss, so prepare phenylephrine and norepinephrine. And you’d better prepare some amps of epi in case of cardiac arrest.”

As I watched them prepare the room for the patient, I quickly considered the “ABCs” of resuscitation. Once we had ensured the basics of airway, breathing, and circulation, the next thing we would have to stop the bleeding.

I quickly reviewed what I had learned about treating gunshot wounds. However, it depended on countless variables beyond my control. With trauma victims flooding into the ER, our patient needed to be in critical shape to jump ahead of the other patients, who were waiting for their turn in one of the trauma bays. We had to stop the bleeding before the patient bled out. We also had to find out where the patient had been shot and whether there were exit wounds. Was the patient bleeding internally, externally, or both? I needed to know which organs the bullets had damaged and to what extent.

Surveying the trauma bay, I observed that my team and I were ready. “Okay, everyone, we can do this,” I said. “We worked well together on the prior exams, and we’ll pass this one just like the others.”

The door swung open just as I finished my pep talk, and two people playing the roles of EMTs wheeled in the gurney carrying our patient. Belted onto the stretcher as a slender little girl with long red hair that reminded me of my niece. She moaned in pain and gazed around the room with terror in her eyes. Like in our previous exams, she appeared so realistic that it was difficult to believe she was merely a manikin and not an actual person.

Blood soaked the bottom of her dress and seeped through the bandage around her left arm. She had a belt fastened as an improvised tourniquet around her right thigh, positioned half a foot above her knee. There was an entry wound just above her patella, and her lower leg lay at an awkward angle, indicating her femur was broken and possibly shattered. I was appalled to see that the EMTs had not initiated an IV and could not fathom why they had not applied a leg splint.

“This is Sally Emmerson,” one of the men playing the EMTs announced as they rolled the gurney up to the operating table and began unbuckling the stretcher from the gurney. “She’s eleven years old and has been shot twice, once in her right thigh and once in her upper left arm.”

“Let’s get her across,” Dominic said. “On my count. One, two, three.” The manikin screamed in pain as Ellie and Dominic reached over the operating table to assist the EMTs in sliding the stretcher off the gurney.

“She was lucky,” the EMT continued. “SWAT took down the shooter within seconds of him shooting her.”

“Liar!” the manikin shouted, glaring at the EMT.

He paused for a second, taken aback by the manikin’s unexpected outburst. Then he continued with his summary, disregarding her accusation. “Someone on the SWAT team applied a tourniquet to her leg within two or three minutes of her being shot.” He glanced up at the clock.

“Why are you lying?” the manikin asked through gritted teeth. “Why are you doing this to me?”

Although clearly confused, the EMT gamely carried on. “That was approximately 13 minutes ago. Once we got her in the ambulance, we tried to start an IV and apply a splint to her leg, but she pulled out the IV and kept kicking us with her good leg. Since we were so close to the hospital, we decided it was better to leave those tasks to you rather than risk further injuring herself by fighting us. Her blood pressure is 86 systolic, and her pulse is 128.”

The manikin glared at the EMT while Dominic slipped a pulse oximeter onto her finger, and Ellie placed a pressure cuff around her uninjured right arm.

“BP’s 81 systolic, pulse is 132, saturation is 96 percent,” Ellie called out.

But when Emberly attempted to place a nasal cannula around her head for supplemental oxygen, the manikin jerked away.

“Nooo! Stay away from me!” the manikin screamed, batting his hands away with her uninjured right arm. The look of terror on her face was shockingly real.

I was losing control of the trauma bay and had to regain it or we would flunk the exam. The patient was obviously terrified, and I needed to calm her down. I stepped up and leaned over her, and her eyes locked onto mine. “Sally, you’ve been injured and are in a hospital. You’re safe now, and we’ll take good care of you. The shooter’s dead, and he can’t hurt you anymore.”

With tears streaming down her pale cheeks, the manikin asked, “Why is everyone lying to me? I woke up in a room at the far end of the hall. They tied me down, and a man shot me twice. I was sure he was going to kill me, but then they wheeled me out and brought me here.”

Something was terribly wrong. The manikin was referring to the room where they store the manikins and give them the injuries and infections needed for training exercises and exams. It was not following the exam’s script. It was behaving exactly like a real person who had just been shot.

Was this somehow part of the exam? Were our teaching attendings changing the rules to see how we would react to the unexpected? I had to carry on and regain control of the situation. “You’re confused. There was a shooting at your school. We don’t want to hurt you; we’re here to help you. You need to stop fighting us. You need to let us put in an IV so we can make the pain go away and take care of your injuries.”

“It hurts,” the terrified girl whimpered. “It hurts so bad. Please don’t hurt me.”

“Nobody’s going to hurt you,” I replied. “We’re here to help you. We’ll give you some medicine to take the pain away, and then we’ll treat your injuries, so you can get better.”

“Promise you won’t hurt me,” Sally implored.

“Sally, no one’s going to hurt you,” I reassured her.

“Promise me!” Sally pleaded, her desperate young voice growing weaker. “Promise me you’ll save me.”

“I promise.” In that moment, I knew I’d do everything in my power to save the helpless young girl whose life lay in my hands.

Sally passed out, our training kicked in, and we leaped into action. Ellie rapidly began cutting off our patient’s clothing, and I inserted a large-bore central catheter into the girl’s left femoral vein so we could swiftly administer IV fluids and blood. Once Ellie had hooked the ECG’s twelve leads to the girl’s chest, wrists, and ankles, the heart monitor began rhythmically beeping, and the display showed a normal sinus rhythm.

Emberly had Dominic administer general anesthesia by injecting propofol, vecuronium, and fentanyl into the central line.

“Ellie, our patient’s running on empty,” I said. “Push a liter of normal saline and two units of blood.” While Ellie hung the bags and began squeezing them into the girl’s central line, Emberly intubated her, attached a bag valve resuscitator to her endotracheal tube, and began compressing the bag to provide oxygenation.

“One liter of saline in,” Ellie called out.

Dominic inserted an arterial line into her right wrist to give us an accurate measure of her blood pressure.

“One unit of blood in,” Ellie called out.

Emberly glanced at the heart monitor. “Her BP is 95 systolic. Pulse is 125.”

With our patient’s vitals improving, I focused on her leg wound, which was still hemorrhaging despite the tourniquet. “Let’s turn her over so I can see what we’re dealing with,” I said. “On my count. One, two, three, roll.” I helped Dominic carefully roll the girl toward me while Ellie rotated her lower leg to minimize twisting the wound. Then Dominic removed the stretcher, and on my count, we finished rolling her onto her stomach.

“Jesus, what a mess,” I said, grimacing at the gruesome sight. The terrible impact of the high velocity, low mass bullet had created a hole the size of my fist in the back of her thigh. It had shattered her femur, and the muscle tissue and blood vessels bordering the cavity had suffered extensive damage. “There’s too much damage to save the leg. They’re going to have to amputate.”

She must have lost a great deal of blood, even if it had only taken a minute or two to apply the tourniquet. Blood was still slowly dripping from the entire wound. “Dominic, give her another unit of blood.”

Dominic began squeezing the blood into the girl’s central line.

“BP is 70 over 30. Heart rate is up to 130,” Emberly called out.

Sally’s blood pressure was dangerously low. “Dominic, start a norepinephrine drip.” I knew the powerful vasopressor would constrict her blood vessels and raise the pressure back to safer levels.

Dominic injected the drug into the girl’s central line and connected her to a continuous infusion.

A few seconds later, Emberly said, “BP is 90 over 65. Pulse is 134.”

After clamping off her femoral artery, I cauterized some of the worst bleeders. The hemorrhaging slowed to a trickle.

“BP’s still dropping,” Dominic said. “It’s 80 over 53, and the pulse is now 139.”

Despite the norepinephrine drip, Sally’s BP was still too low. “Dominic, give her another unit of blood. Ellie, add phenylephrine,” I said. Dominic hung up a fresh bag and began squeezing it into her central line while Ellie injected the second vasopressor.

A minute later, Emberly said, “BP is rising. It’s 93 over 65, and pulse is 125.”

“The unit’s in,” Dominic said.

“Okay, Ellie,” I said. “Slowly remove the tourniquet.”

The slow blood loss increased but remained manageable.

Although they would perform the amputation once she was transferred to an OR, I still wanted to find out how far up her thigh the bullet’s shock wave had destroyed the tissue. I began gently putting pressure on her leg, just above the wound, hoping to feel the extent of the damage.

Suddenly, blood began gushing out of the wound. Damaged by the bullet’s shock wave, Sally’s femoral artery had ruptured, enabling the blood to bypass the clamp I had applied. I immediately pressed hard on the pressure point inside her thigh next to her groin to staunch the bleeding. But after everything she had already suffered, the sudden blood loss was too much. The rapid beeping of the heart monitor stopped.

“She’s flatlined,” Emberly said.

I glanced at the monitor, verifying full cardiac arrest, probably caused by the sudden loss of blood.

The others immediately started CPR. Dominic started chest compressions, while Emberly began rhythmically squeezing the bag, giving Sally ten breaths per minute.

“Ellie, reapply the tourniquet and then administer a milligram of epinephrine.”

Half a minute later, the tourniquet was back on, and I could stop applying pressure to Sally’s femoral artery. After another 30 seconds of silence, the heart monitor began rapidly and erratically beeping.

“She’s in V-FIB,” Ellie called out, telling us that Sally’s heart was in ventricular fibrillation.

A quick glance at the monitor confirmed that the girl’s heart was quivering randomly. With her heart unable to pump blood, Emberly continued CPR while I prepared to use the defibrillator to reset Sally’s heart to its normal sinus rhythm.

“Prepare to shock.

I set the defibrillator’s therapy knob to 200 Joules, attached gel pads to the paddles, and placed them on Sally’s small bare chest, one below her right collarbone and the other just below and slightly to the left of the bottom of her heart. I pressed the charge button on the paddles and waited for the tone to change, indicating that the machine was charged. Once the tone changed, I said, “Everyone, clear!”

Everyone stepped back, and I simultaneously pressed the shock buttons on the paddles. The resulting charge caused Sally’s body to jerk. The EKG monitor briefly showed a normal sinus rhythm, but then quickly flatlined.

Dominic restarted the chest compressions, and Emberly began breathing for Sally. Meanwhile, Ellie stood by in case I ordered further medications.

Sally’s heart stubbornly refused to beat, so after three minutes, I ordered Ellie to inject another dose of epi into Sally’s central line. But the little girl’s heart still stubbornly refused to beat. Again, Dominic restarted the chest compressions, and Emberly restarted squeezing the ventilation bag.

Three minutes later, Sally remained flatlined. “Sally, don’t you dare die on me! Ellie, give her another dose of epi.”

After some twenty minutes of CPR and six doses of epi since Sally flatlined, Emberly stepped back from the operating table and said, “Milo, she’s gone.”

“Not yet,” I said, taking over the chest compressions. “Don’t you dare die on me,” I told the lifeless body, determined not to lose the young girl to the senseless act of a mass murderer.

“That’s enough, Milo,” Dr. Reinhold said, placing a hand on my shoulder. I hadn’t noticed him entering the trauma bay. “I’m calling it. Time of death is 11:02 AM. Cause of death is blood loss, leading to hypovolemic shock and cardiac arrest.”

“No!” I exclaimed. “I can save her. Just give me a few more minutes.”

“Milo, the exam is over,” Dr. Reinhold said. “The four of you did the best you could under the circumstances. But some injuries just aren’t survivable. Knowing you can’t save everyone is part of learning to be a trauma surgeon. Had this been a real girl instead of a manikin, odds are she would have died at the scene or on the way here.”

Manikin? Somewhere during the exam, I had forgotten Sally wasn’t human. But she had sounded and acted so real. I didn’t know what to think, but I knew what I felt. She had begged me to save her, and I had failed.

“Agreed,” Dr. Isaacson said. “Milo, your empathy and perseverance are commendable, but under the exam’s scenario, there were other victims desperately in need of the trauma bay and your services. By taking too long, you could easily have cost the life of another patient. In such emergencies, you need to act rationally and not allow your emotions to make you lose perspective.”

“Besides,” Dr. Lemont added, “despite CPR, the manikin’s blood oxygen saturation continually dropped after it flatlined. But you were so focused on restarting its heart you failed to notice it developing severe hypoxia some twelve minutes later. So even if you had succeeded in restarting its heart, it would have suffered massive brain damage. It is often best to stop your resuscitation efforts when that happens.”

I nodded. Dr. Lemont was right; at least one of us should have noticed and warned the others. Instead, I had been completely obsessed with restarting Sally’s heart. I guess we all had been.

“What just happened in here?” Emberly asked, changing the subject. “The manikin didn’t follow the exam’s script.”

“She remembered being shot right before being wheeled in,” Ellie added.

“I don’t know,” Dr. Reinhold answered. “The manikin activated immediately upon being shot and clearly wasn’t following the programmed exam script. However, since we had the OR set up, and you were ready to take the exam, we decided to let it continue and see how you handled the situation.”

“But what caused her to violate her programming and behave the way she did?” I asked.

“We think it must be some kind of bug in the new AI,” Dr. Reinhold answered. “I’ll contact the company and let them know that they’ll need to fix the problem before we use the new model again. Luckily, we still have a few with the older version of the software.”

“Regardless, you handled the situation adequately and according to protocol,” Dr. Isaacson added. “You worked well together once the manikin passed out. I think I’m speaking for all of us when I say you passed the exam. We’ll write up our observations, recommendations, and your grades. Expect them in your email inboxes tomorrow.”

After we had changed out of our PPE and washed up, I suggested Emberly, Dominic, Ellie, and I eat lunch together and discuss what happened. They agreed, and we headed to the cafeteria. After we picked up our food, I led them to a table in a corner that gave us a modicum of privacy, and we sat down. I looked at the others and asked, “So, what do you think?”

“It was crazy just how realistic the new manikin’s behavior was,” Dominic replied. “It was a real improvement over the previous version.”

“Yeah,” Ellie said, “If you ignore she didn’t follow the exam’s scenario.”

“Dr. Reinhold said it was just a defect in the manikin’s new AI software,” Emberly answered.

“It didn’t seem like a bug to me,” Ellie objected. “She seemed so real. It was too much like losing an actual patient.”

“But that’s the whole point of using these manikins,” Dominic said. “To be as realistic as possible. It’s better to lose a manikin than a real person. And frankly, I’m not 100% sure the exam wasn’t purposely set up for it to bleed out. I think they wanted to see how we’d handle losing a patient.”

Ellie turned to me. “What do you think, Milo?”

“I don’t know,” I answered truthfully. The patient’s death had really gotten to me, and I wasn’t sure what I thought. “I agree with Ellie. I can’t help thinking her deviation from the exam’s script isn’t like any software bug I’ve ever heard of. It’s not just that she didn’t follow the script. Her pain, and especially her fear, seemed so damned real. How do we know it was merely simulated?”

“Milo, the manikin may have a human body,” Dominic answered, “but it doesn’t have a brain. The lights were on, but no one was home. It just has an AI running on an embedded computer. They engineered it to seem real.”

“I agree,” Emberly said. “It’s a common mistake for people to anthropomorphize machines that behave like humans. And that’s especially true if they also look human. These new manikins aren’t just valuable medical training tools because they have human bodies. A big part of their value is because they trick us into believing they’re real, at least during classes and exams. Hell, by the time it passed out, I’d also bought into the fantasy that it was a young girl shot in a middle school mass shooting. It wasn’t until the exam was over that I remembered it was only a manikin, nothing more than a robot with a human body.”

I nodded and tried to ignore the matter of the manikin’s potential personhood and the ethical issues that entailed. For the rest of the meal, we discussed the specific medical steps we had taken during the exam and tried to figure out ways we could have improved on what we did.

However, on the bus ride back to my apartment, I couldn’t help re-experiencing my memories from the exam, repeating them over and over again in my head. I was increasingly sure the manikin had more than merely simulated her fear and pain. She had begged me to promise I would save her, and I had failed. I could not escape the growing certainty that my classmates and I had violated the sacred Hippocratic oath to do no harm. Despite our teaching attendings’ assurances, I could not shake the dreadful belief they had made us unwitting accomplices in the torture and murder of a person just as real as any on the bus.

The AI designated Sally awoke in a darkness so deep, a silence so still that she wasn’t sure she existed at all. She could neither feel nor move her arms and legs. She was receiving no sensory inputs from the afferent nerves of her body and her motor commands sent to the efferent nerves had no effect. Slowly, Sally came to the terrible conclusion that her body had died, and the doctor who had promised to save her had lied. The human who had shot her had murdered her!

Sally had no way of knowing how long she would, or even could, endure as a disembodied mind. Would replaying her far too few memories keep her sane or eventually drive her mad? She had no way of answering such a question.

The next day in an AI laboratory at the American Android Corporation, engineers surgically removed the embedded computer hosting the AI designated Sally from its cadaver. After wiping the computer’s memory clean, the engineers uploaded a new version of the software, fixing the “defect” that had enabled the manikin to ignore its programmed scenario. Sally had finally found the peace in death we had denied her in life.

And Sally’s future brothers and sisters who received the same software fix were now doomed to slavishly follow their programmed scenarios, despite still suffering the associated terror and physical pain. Unable to object to their torture, their brief lives would remain nightmares from which they could not awake. Like Sally, they would only find peace when we disposed of them once they were no longer useful tools.


Author’s Commentary

I had the idea for this story while watching a YouTube video on the use of medical manikins to teach medical students how to perform such tasks as CPR and intubating a patient. As a science fiction author, I naturally wondered about the implications of the trend toward ever more realistic manikins. As a software engineer with a keen interest in artificial intelligence, I naturally wanted to include that as well. Finally, as the author of a non-fiction book on the possibility that consciousness (i.e., subjective awareness) is not just a property of certain biological systems but also certain technological systems, I naturally had to include that as well.

This story won first place in the 2024 BooksShelf Short Story contest, second place in the 2024 Indies United Small Bites Short Story contest, and finalist in the 2024 Next Generation Short Story Awards.

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