Wm. LeRoy Heinrichs

Design, Development, and Evaluation of an Online Virtual Emergency Department for Training Trauma Teams

Background: Training interdisciplinary trauma teams to work effectively together using simulation technology has led to a reduction in medical errors in emergency department, operating room, and delivery room contexts. High-fidelity patient simulators (PSs)—the predominant method for training healthcare teams—are expensive to develop and implement and require that trainees be present in the same place at the same time. In contrast, online computer-based simulators are more cost effective and allow simultaneous participation by students in different locations and time zones. In this pilot study, the researchers created an online virtual emergency department (Virtual ED) for team training in crisis management, and compared the effectiveness of the Virtual ED with the PS. We hypothesized that there would be no difference in learning outcomes for graduating medical students trained with each method. Methods: In this pilot study, we used a pretest-posttest control group, experimental design in which 30 subjects were randomly assigned to either the Virtual ED or the PS system. In the Virtual ED each subject logged into the online environment and took the role of a team member. Four-person teams worked together in the Virtual ED, communicating in real time with live voice over Internet protocol, to manage computer-controlled patients who exhibited signs and symptoms of physical trauma. Each subject had the opportunity to be the team leader. The subjects’ leadership behavior as demonstrated in both a pretest case and a posttest case was assessed by 3 raters, using a behaviorally anchored scale. In the PS environment, 4-person teams followed the same research protocol, using the same clinical scenarios in a Simulation Center. Guided by the Emergency Medicine Crisis Resource Management curriculum, both the Virtual ED and the PS groups applied the basic principles of team leadership and trauma management (Advanced Trauma Life Support) to manage 6 trauma cases—a pretest case, 4 training cases, and a posttest case. The subjects in each group were assessed individually with the same simulation method that they used for the training cases. Results: Subjects who used either the Virtual ED or the PS showed significant improvement in performance between pretest and posttest cases (P < 0.05). In addition, there was no significant difference in subjects’ performance between the 2 types of simulation, suggesting that the online Virtual ED may be as effective for learning team skills as the PS, the method widely used in Simulation Centers. Data on usability and attitudes toward both simulation methods as learning tools were equally positive. Discussion: This study shows the potential value of using virtual learning environments for developing medical students’ and resident physicians’ team leadership and crisis management skills.

Simulated Medical Learning Environments on the Internet

Learning anatomy and surgical procedures requires both a conceptual understanding of three-dimensional anatomy and a hands-on manipulation of tools and tissue. Such virtual resources are not available widely, are expensive, and may be culturally disallowed. Simulation technology, using high-performance computers and graphics, permits realistic real-time display of anatomy. Haptics technology supports the ability to probe and feel this virtual anatomy through the use of virtual tools. The Internet permits world-wide access to resources. We have brought together high-performance servers and high-bandwidth communication using the Next Generation Internet and complex bimanual haptics to simulate a tool-based learning environment for wide use. This article presents the technologic basis of this environment and some evaluation of its use in the gross anatomy course at Stanford University.

Learning medicine through collaboration and action: collaborative, experiential, networked learning environments

The SUMMIT Lab and William LeRoy Heinrichs, at Stanford University, were honored to be the 2002 awardees of the Satava Award for Virtual Reality in Medicine. Since the award, the group has followed two main threads of research, which we describe below. The first, “building a high-performance, network-aware, collaborative learning environment” has investigated the framework and components needed when students in multiple locations collaborate using computation-intensive simulations and large image datasets. The second thread, “online, interactive human physiology for medical education and training”, has focused on the application of interactive physiology models embedded in 3D visualizations of virtual patients in naturalistic medical environments. These environments support immersive, experiential learning where students act as medical providers and manage authentic medical events and crises. These research efforts, and our conclusions, are presented in the chapter below.

Simulated learning environments in anatomy and surgery delivered via the next generation internet.

The Next Generation Internet (NGI) will provide high bandwidth, guaranteed Quality of Service, collaboration and security, features that are not available in todays Internet. Applications that take advantage of these features will need to build them into their pedagogic requirements. We present the Anatomy Workbench and the Surgery Workbench, two applications that require most of these features of the NGI. We used pedagogic need and NGI features to define a set of applications that would be difficult to operate on the current Internet, and that would require the features of the NGI. These applications require rich graphics and visualization, and extensive haptic interaction with biomechanical models that represent bony and soft tissue. We are in the process of implementing these applications, and some examples are presented here. An additional feature that we required was that the applications be scalable such that they could run on either on a low-end desktop device with minimal manipulation tools or on a fully outfitted high-end graphic computer with a realistic set of surgical tools. The Anatomy and Surgery Workbenches will be used to test the features of the NGI, and to show the importance of these new features for innovative educational applications.

Patients Should Not Be Passive! Creating and Managing Active Virtual Patients in Virtual Clinical Environments

Games can be serious. In the case of games for medical professionals, often very serious, as they are used to train for activities that are literally lifesaving. To achieve ’suspension of disbelief’ among medical professionals, a game must be realistic in terms of its’ interactive elements i.e. both the objects and the actors in the virtual environment. The central and key actor is the patient. Given the complexity of the real world patient, then it is unsurprising that ‘the patient’ in most virtual environments is but a pale representation of real world patients. This paper describes work-in-progress in an already widely deployed clinical immersive environment, CliniSpace, in building believable, and as importantly manageable, real time virtual patients with an approach called ‘active virtual patient management’ which offers both stand-alone customisable authoring and real-time virtual patient management to deliver believable virtual patients for medical education.

The Critical Path from Tissue Slices to Surgical Simulation: What Do Surgeons Want?

Three themes: Building 3D Geometric Models from Slice Databases Segmentation and Extraction, and Virtual and Physical Modeling Creating an Educational Context with Information Frames The Hidden Curriculum of Surgery: Simulating Manipulations with Instruction Frames Building 3D geometric models from slice databases requires an aligned, (registered) volumetric dataset. Initial visualization of the anatomic region of surgical interest (AROSI), followed by segmentation and extraction of selected structures in each slice produces 2D masks for each anatomic structure. These are stacked to create 3D virtual anatomic models, either surface or volumetric, which can be transformed into physical 3D models by finite element, or other physical modeling algorithms. The methods for building 3D models will be discussed. Examples are: 1. the Lawrence Berkeley National Labs frog 2. the Stanford Visible Female (pelvis) segmentation is the selection of desired structures, and /or suppression of undesired structures prior to rendering extraction of selected structures in each slice allows for visualization of several types: 3D volumetric visualization and analysis can be done from unreconstructed images, reformated planes, curved planar reformatting, surface and volume rendering, maximum intensity projection, and shaded surface displays. transforming 3D volumetric models into physical models by finite element, or other physical modeling algorithms provides opportunity for deformations, incisions, etc. an application of such models, instrumented with accelerometers and pressure sensors is the crash testing of Cyber Dummies

0079 Deploying virtual world and virtual patient technologies to deliver enhanced and less resource intensive clinical education for team inter-professional education (IPE): The US experience

Background/context Clinical Inter-professional education (IPE) is, by definition, a complex and resource intensive experience to both develop and to deliver. Its’ importance, as a required component of a clinical curriculum, is the core around which the delivery of a realistic health care team experience should be centred. The aim of this paper is to showcase an innovative deployment of IPE to clinical professionals outside the US. The Charles R. Drew University/UCLA School of Medicine have developed an innovative model using virtual world and virtual patient technologies and from this have implemented an alternative framework for delivery. Methodology This framework deploys two technologies to deliver IPE. Virtual world technology enables clinical specialists and students to be ‘virtually’ co-present inside a ‘virtual ward’. ‘Virtual patient’ technologies provide students with multiple ‘patients’ running pathophysiological models that the students can interact with to assess and treat in real time inside these ‘virtual wards’. As importantly these two technologies are combined in single platform, CliniSpace, that can now be modified and deployed by mainstream clinical educators to suit the levels of the learners. A comparative study was designed, developed, delivered and assessed using a randomised research design based on two matching groups of healthcare students. Results/outcomes In summary, and on the basis of the results of this preliminary study, it was shown that on-site IPE can be delivered more effectively than using traditional delivery methods. Potential impact Whilst the specific focus of this study was to demonstrate the relative effectiveness of a new mode of delivery for IPE, at the same time it was noted that it was substantially less resource intensive than the traditional labour intensive IPE delivery approaches. This has significant potential implication in lowering barriers to the future wider and regular deployment of IPE. References Mitchell P, Wynia M, Golden R, McNellis B, Okun S, Webb CE, Rohrbach, V, Von Kohorn I. Core principles & values of effective team-based health care. Discussion Paper, Institute of Medicine, Washington, DC, 2012, www.iom.edu/tbc King S. et al. Developing interprofessional health competencies in a virtual world. medical education online, [S.l.], v. 17, nov. 2012. ISSN 1087-2981. Available at: http://med-ed-online.net/index.php/meo/article/view/11213 Shoemaker M, Platko C, Cleghorn S, Booth A, Virtual patient care: an interprofessional education approach for physician assistant, physical therapy and occupational therapy students. J Interprof Care 2014;28(4):365–367

Networked stereoscopic virtual environment system

Advanced collaborative display systems allow users to view a computing desktop environment in a platform- and location-independent fashion. For real-time considerations, these systems become computationally very challenging, especially when video streaming is included. The addition of stereoscopic video streaming is desirable in virtual environments (VE) created for the teaching of anatomy and surgery with real-time collaborative audio and video interactions at many locations. However, this stresses the real-time requirements to the point at which realistic video is difficult to assure. For such a system to work, it is imperative that timing data be collected, analyzed and understood. We describe an experimental system designed primarily for the collection of timing data that is required for robust collaborative medical training applications. The networked stereoscopic system uses a server-swappable multicast network protocol to stream real-time manipulations of 3D virtual body structures at the server site to all clients participating in the multicast session. The three visual modes have dynamic tuning parameters for adjusting the parallax and the focal point for the rendered scene, allowing users to define individual stereoscopic comfort zones. Optimizing the graphics module is critical in achieving the necessary rendering rates. Different techniques of utilizing various memory resources increased the number of polygons rendered per second by over seven million. Depending on the type of memory used, the number of polygons rendered per second varies from 2.25 to 9.12 million.