Hector M. Garcia

Augmented standardized patients now virtually a reality

Standardized patients (SPs), individuals who realistically portray patients, are widely used in medical education to teach and assess communication skills, eliciting a history, performing a physical exam, and other important clinical skills. One limitation is that each SP can only portray a limited set of physical symptoms. Finding SPs with the abnormalities students need to encounter is typically not feasible. This project augments the SP by permitting the learner to hear abnormal heart and lung sounds in a normal SP.

A Virtual Operating Room for Context-Relevant Training

A fully immersive virtual environment simulating an operating room is described. The Virtual Operating Room (VOR) is a platform that integrates procedural medical simulators into a coherent, context-relevant training environment. Trainees interact with a surgical team comprised of real and/or virtual team members (e.g., attending surgeon, anesthesiologist, scrub technician, and circulating nurse). All characters are defined by their procedural knowledge and personality. The interface capitalizes on natural interactions and is largely driven by voice recognition and text-to-speech software. A custom designed controller manages the VOR functionality, rendering platform, speech recognition, and text-to-speech generation modules. The VOR allows instructors and researchers to simulate the physical and social context in which surgical procedures are performed. The VOR can be used to train surgical teams and address issues in judgment, decision making, team dynamics, and interpersonal skills. Most importantly, the VOR allows medical teams to train the way they operate without putting patients at risk.

Testing a Novel 3D Printed Radiographic Imaging Device for Use in Forensic Odontology

There are specific challenges related to forensic dental radiology and difficulties in aligning X‐ray equipment to teeth of interest. Researchers used 3D printing to create a new device, the combined holding and aiming device (CHAD), to address the positioning limitations of current dental X‐ray devices. Participants (N = 24) used the CHAD, soft dental wax, and a modified external aiming device (MEAD) to determine device preference, radiographers efficiency, and technique errors. Each participant exposed six X‐rays per device for a total of 432 X‐rays scored. A significant difference was found at the 0.05 level between the three devices (p = 0.0015), with the MEAD having the least amount of total errors and soft dental wax taking the least amount of time. Total errors were highest when participants used soft dental wax—both the MEAD and the CHAD performed best overall. Further research in forensic dental radiology and use of holding devices is needed.

Surgical Skill Performance Under Combat Conditions in a Virtual Environment

A group of medical students were taught to perform a tube thoracostomy on a mannequin simulator in a traditional medical school setting and demonstrate competency in that environment. Immediately afterward and again four months later, they performed the procedure in a CAVE virtual environment running a combat simulation under day and nighttime lighting conditions. The results showed that accuracy suffered in the simulation. Participants also needed more time to perform the procedures under the nighttime conditions. Further, performance did not change over the retention interval. The results suggest that although the surgical skills acquired by students in a traditional medical school setting are robust, they may still be compromised under hazardous conditions. More important, these findings show that virtual environments can provide a safe and effective venue for military medical personnel to train for dangerous duty.

Board 542 - Technology Innovations Abstract Tablet App for Training Patient Blood Management (Submission #311)

Introduction/Background Simulation engineers at the Virginia Modeling, Analysis, and Simulation Center (VMASC) and physicians at Englewood Hospital and Medical Center have collaborated in developing a tablet app for advancing patient safety via training Patient Blood Management (PBM). PBM is a clinical approach to improving patient outcome by minimizing or eliminating allogenic blood transfusions often associated with increased adverse effects to the patient and high monetary costs to the medical facilities administering them.1,2 The tool aims to train or newly-educate physicians through interactive, immersive instruction focusing on blood management decision-making. The 2013 Patient Safety, Science, and Technology Summit cited transfusion overuse as the third leading challenge to patient safety.3 Red blood cell (RBC) transfusion is the most frequent procedure performed in U.S. hospitals with one in ten inpatients receiving one or more units.4 RBC transfusions rates or practices are highly variable by institution, procedure, and physician.5 Evidence from observational studies shows RBC transfusions can increase mortality by 69% and morbidity by 88%, while restrictive transfusion practices have been proven safe in multiple randomized controlled trials.6,7 This tablet app addresses these significant health concerns as well as practice variability, safety and effectiveness, blood supply burden, and financial cost of blood – the tool serves as a means to increase knowledge of transfusion avoidance. There was no medical simulation training tool that provided the educational substance, experiential learning, and self-assessment for clinicians in this emerging field of study. This app meets that need as it is the most efficient and effective teaching modality for closing the PBM education gap. Methods The technical team began mapping PBM into a system dynamics model. This yielded a visual representation of procedures, factor inter-relationships, and validation of model development for the tool prior to programming and software design. The tool is constructed as a multi-platform application, targeted at tablet computers (Android and IOS), but also accessible on pc’s and through web pages. The tool contains actual patient case studies (for credibility), executes real-time simulation (for temporal decision-making experience), and possesses end-of-the session assessment for trainee to compare his decisions with the actual case (for lessons learned). The tool is scalable, extendable, facilitating the registration of a large number of case studies. The tool presents a 3D environment to the user including responsive patient avatars and simulated medical equipment. The visual presentation is developed in the Unity3D game engine. Interactive user interface presents information ranging from patient demographic information to displaying patient medical status via ECG waveforms, and capturing user input including prescription choices. Unity3D enables the software to be presented on most devices (Android, IOS, PC, Mac, web), though tablets are specifically targeted. The software mirrors the specific procedures and techniques used in PBM dividing the training into pre-, intra-, and post-operative phases of patient care. Results: Conclusion This tablet training app will be populated with case studies from various surgeons and anesthesiologists who have drawn upon their own patient cases and experiences. The cases express their decision-making process throughout the peri-operative care, and it ties those decisions to the current literature for the trainee to review. The app will contain a variety of cases to include abdominal cardio-vascular, orthopedic, trauma, and pediatric procedures. This tablet app is developed with continuous simulation capability for hands-on, real-time exercises. It satisfies an unmet need for simulation training modalities in this medical sub-field and as such it provides the means for comprehensive and effective training to mitigate the issues and challenges surrounding blood transfusion through immersive simulation training of the fundamental principles of PBM. References 1. Speiss B, Spence R, Shander A. Perioperative Transfusion Medicine. New York: Lippincott Williams Wilkins, 2006, pp. 671-672. 2. Shander A, et.al, “Activity based costs of blood transfusions.” Transfusion 50 (4): 753-765, 2010. 3. Patient Safety Summit 2013. Website http://www.patientsafetysummit.org/ Accessed 20 July 2013. 4. AHRQ. Inpatient Sample. 1997-2007. Website http://www.hcup-us.ahrq.gov/reports/factsandfigures/2007/section2_TOC.jsp. Accessed 20 July 2013. 5. Frank S., et al. Anesthesiology. 2012. 117(1): 99-106. 6. Marik PE., et.al. Critical Care Medicine. 2008;36(9):2667-74. 7. Carson J., et al. Cochrane Database Syst Rev. 2012 Apr 18;4:CD002042. Disclosures None.

Me and My VE, Part 3

Virtual environments, simulations and serious games are increasingly being employed for research, training, education, evaluation, and various business endeavors. In a redux of a favorite session from HFES 2012, this session will describe and demonstrate some of the diverse uses for virtual environments (VEs) in an alternate demonstration format. The session will begin with demonstrators providing a brief description of their VE, and how they’ve used it to answer a critical research question or address a unique need, including a video demonstration of the VE in action. After these introductions, all demonstrations will be set up around the room, and session attendees can move around the room for more direct interaction with both the demonstrations and the demonstrators. The objective of the session is to provoke ideas among the attendees for how VEs, simulations and serious games can help address their clinical, research, training, education, evaluation or business needs.

Maturity Enhancements for Aircraft Simulation for Traffic Operations Research

Efforts directed at enhancing and maturing NASA Langley Research Centers Airspace and Traffic Operations Simulation (ATOS) and Aircraft Simulation for Traffic Operations Research (ASTOR) software frameworks are described. ATOS and ASTOR were created to explore future concepts for air traffic management in the national airspace, commonly referred to as Next Generation Air Transportation Systems (NextGen). This software allows for multiple aircraft, both manually controlled and autonomously controlled, to be simulated during airport operations including phases such as approach and departure, landing and takeoff, and taxi and ground movement. This simulation can be used to study the effects of modification to traffic patterns, runway usage, separation constraints, traffic management strategy, technology infusion, and uninhabited air vehicle integration. Specific enhancements addressed development of a dual-crew research station, increased surface operation capability, expanded cockpit view scenery, and improved ground handling model characteristics. The goal is to develop NextGen concepts that will provide high capacity and efficient air operations with enhanced safety and reduced risk in the national airspace system.