Parvati Dev Amia Tutorial 2009

© 2009, Dev AMIA 2009 Tutorial1 of 80


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Simulation

Parvati Dev, PhD, FACMIPresident, Innovation in Learning Inc.Distinguished Scholar, Media-X, Stanford UniversityFormer Director, SUMMIT Lab, Stanford University


Overview

• Visualization, simulation , 3D models and spaces in virtual worlds

• Comparison of using scripted objects vs role playing with real people controlling characters

• Using reflection and discussion to build on virtual experiences

• Using virtual world to capture activities in the real world

• Future of simulation


Browse … Experience … Act

• Virtual world as a social space• Virtual world as a space with interactive simulations

• Building a Clinic space• Simulated patients• Richly interactive virtual medical environments

• Movie – a Virtual Emergency Department


Social spaces

(Second Life)


Piet Hut, astronomer

“I realized how different this type of medium of communication is from anything I had tried before, whether telephone or email or instant messaging or shared screens.

There was a sense of presence together with others that was far more powerful and engaging than I had expected. I quickly realized the great potential of these worlds for remote collaboration on research projects.”


The world feels real - “concrete”

Teleplace, previously Qwaq Forums


The world feels concrete - because it is an authentic

simulation• The 3D world itself is a simulation

– of a real space, or a designed space

• Being a simulation, you can “operate” it– A “left turn” is the same in the real and virtual worlds

• Our brain “understands” 3D space– We know how to function in a 3D space


Collaboration using visualization

Green Phosphor and GlassHouse: http://www.youtube.com/watch?v=Z-EU3LITMmQ


Visualizing microarray data

Green Phosphor and GlassHouse


Medical visualization

Teleplace.com; Cleft Palate patient from NYU Medical Center


Simulated experiences

(Forterra Systems)


Interactive simulations

(Pulse!! - Breakaway)


Building a 3D space


From real to “mirror” world

Forterra Systems


Virtual Stanford

Forterra Systems


3D medical spaces


Building a 3D clinic


Building Virtual Patients

Appearance - normal plus trauma or disease

Behavior - movement plus other actions


Building an Avatar(Poser, )


Adding trauma appearance(Forterra)


Specialized Behaviors

Simulating Physiology


HealthyHealthy SickSick Very sickVery sick

Hit by car

Bleeds profusely

Stable,Stable,recoverrecover

Patient state


‘PATIENT’ STATE

QUERYINTERFACE

TEXT

SPEECH

GRAPHICS

ANIMATION

INTERVENTIONINTERFACE

PHYSIOLOGY PROCESS

TIME STEP

Patient Model


TEXT 45 y/o female clerk: open, angulated open fracture. rt. upper humerus, C/o severe pain, feeling faintBrisk arterial and venous bleeding, EOIS = 4 (of 6)

GRAPHICS

#15#12

ANIMATION

QuickTime™ and aTIFF (Uncompressed) decompressor


SPEECH


QUERYINTERFACE

INTERVENTIONINTERFACE

Patient Model


Vol BP HR Sa02 RR

• trauma ––> blood loss

• blood loss ––> reduced blood volume

• reduced blood vol ––> reduced pressure

• reduced pressure ––> increased heart rate

• increased heart rate ––> decreased Sa02

• decreased Sa02 ––> increased resp. rate

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Basic Logic for Traumatic Hemorrhage Model


Model for Traumatic Hemorrhagic ShockVictim 12: 45 yr old woman: EOIS=4

0

50

100

150

200

250

1:42 1:45 1:50 1:55 2:00 2:05 2:10 2:15 2:20 2:25

Time in minutes

Response of model

Sa02%

PR

RR

BP-S

Fractured humerus, Hemorrhage rate: 83 ml/min = 2520ml/30min

Cardiacarrest

. . 35min to ‘death’


250

200

150

100

50

0

Fractured humerus, Hemorrhage rate: 83 ml/min= 2520ml/30min

Victim 12: 45 year old Woman: EOIS = 4

1:42 1:45 1:50 1:55 2:00 2:05 2:10 2:15 2:20 2:25

Time in Minutes

Res

po

nse

of

Mo

del

PR

Sa02

XX

X X XX X

XX X X BP-S

RR

Compressionbandage

IV Nacl Dobutamide

Trendelenberg

Transfuse

Send tosurgery

. . . Home in 36hrs

Model for Traumatic Hemorrhagic Shock


B-man, LUQ blow, pain, hemoperitoneum, hypotension, confusedM48521

Af-Am, 24wk preg, vag. bleeding, FHT180, S-S anemia, low BPF23520

Obese retiree, RUAbd bruise, hypotension, hemoperitoneumM69519

Exec., traumatic rt. knee disruption, brisk bleeding, hypotensionM38518

Athlete, open. frax, rt. tibia & fibula, brisk bleeding, pain, labile BPM22517

Grad. Student, 10cm SQ hematoma, rt mid-thigh, anxiousF27116

RLQ penetrating shard, hemoperitoneum, pain, hypotensionF58515

Construction worker, crushed chest, ribs visible bilat., hemoptysisM30613

Clerk: open, angulated frax. Rt. humerus, pain, brisk bleeding F45412

Healthy Prof., bleeding lacerations of forearm, anxious, htnM60111

EOIS/THC Score = (0 – 6) based upon anatomic structure, and severity of injury

# EOIS Gender-age Description

#12 illustrated;#13 near death;

#11 & 16 walking-wounded

Ten Trauma Cases


ORGAN EOI-SCALE 1-3 EOI-SCALE 4-5

1) THORACIC VASCULAR CHEST WALL VESSELS VASCULAR TREE

2) LUNG CONTUSION, SIMPLE LAC. LOBAR, VASCULAR

3) HEART BLUNT, NON-PENETRATING BLUNT, DYSFUNCTION, AND PENETRATING

4) CHEST WALL LACERATIONS, RIB FRAX, FLAIL, CRUSHED CHEST

5) DIAPHRAM LACERATIONS, RUPTURE

6) SPLEEN LACERATIONS, SUB-CAPSULAR HEMORRHAGE

LACERATIONS OF HILAR VESSELS

7) LIVER LACERATIONS, SUB-CAPSULAR HEMORRHAGE

PARENCHYMAL INJURY > 25%, JUXTA-HEPATIC VESSEL LACERAT–

8) ABDOMINAL VASCULAR ALL VISCERAL VESSELS VENA CAVA, ABD. AORTA

9) KIDNEY MINOR LACERATIONS MAJOR PARENCHYMAL LACERATIONS, HILAR VESSELS

10) URETER ALL INJURIES

11) BLADDER LACERATIONS < 2CM LACERATIONS > 2CM

12) URETHRA ALL LACERATIONS AVULSION

Org

an In

jury

Sca

leE

xten

ded

–

13) NECK LACERATIONS MAJOR VASCULAR INJURY, FRACTURES

14) GI TRACT PERFORATIONS, LACERATIONS MAJOR VASCULAR INJURY

15) UPPER EXTREMITY – Rt. LACERATIONS, CLOSED FRACTURES MAJOR VASCULAR INJURY, OPEN FRACTURES

16) UPPER EXTREMITY – Lt. LACERATIONS, CLOSED FRACTURES MAJOR VASCULAR INJURY, OPEN FRACTURES

17) LOWER EXTREMITY – Rt. LACERATIONS, CLOSED FRACTURES MAJOR VASCULAR INJURY, OPEN FRACTURES

18) LOWER EXTREMITY – Lt. LACERATIONS, CLOSED FRACTURES MAJOR VASCULAR INJURY, OPEN FRACTURES

19) BACK, BUTTOCKS LACERATIONS, CLOSED CONTUSIONS MAJOR MUSCULAR INJURY, VERTEBRAL FRACTURES

20) PELVIS PELVIC WALL VESSELS, REPRODUCTIVE ORGANS

MAJOR VASCULAR INJURY, OPEN OR CLOSED FRACTURES

21) EXTERNAL GENITALS ALL LACERATIONS AVULSION

Quantifies the Injuries


Blood Volume-driven system: e.g., hemorrhage Vol BP HR Sa02 RR Class: 0 = 0 ml MAP 96.0 70 98 14 Class 1 = 750 ml 87.7 75 97 16 Class 2 = 1500ml 88.6 86 96 20 Class 3 = 1980ml 57.7 140 80 35

Rooke, et al. 1995 Anesth Analg 80:925-32

Class 4 = 2520ml 47.7 180-irreg. 50 45 Class 5 = 3240ml 37.7 200–AF 30 55Class 6 = 3880ml 0 0 0 0(Agonal) (Average Blood Volume = 5000ml)

Quantifies the Blood Loss

Traumatic Hemorrhage Classes (THC) determine Blood Volume Deficit. ATLS

Guideline & Rooke, et al.


A Medical Virtual World


Scripted objects vs role playing

• Comparison of using scripted objects vs role playing with real people controlling characters– Virtual patients– Human Patient Simulator mannequin as example of human-controlled character

– Turning behaviors on and off– Computer-controlled behaviors– A dynamic model of pathophysiology – trauma and hypovolemic shock

– Advantages of a dynamic model


Reflection and Discussion


Using reflection and discussion to build on virtual

experiences

– Preparation for a medical virtual experience• knowledge prerequisites• use of virtual worlds

– Assessment during the experience• Assessment instruments

– Facilitated reflection and discussion after the experience


Clinical Scenarios for Virtual ED

1. Male: pneumothorax and femur fracture after auto collision2. Male; bicycle rider falls from bike path, suffers spleen

rupture3. Male; car driver, hypoglycemia and femur fracture4. Male; ethanol induced fall, with head injury, obstructed

airway5. Female;(2nd trimester pregnancy); with renal laceration

after auto collision6. Male; construction worker fall, liver rupture, fracture of

femur7. Male: construction worker, flail chest and dislocated

shoulder8. Male: bicycle rider with severe hand and abdominal injury

after auto collision and being ‘run-over’ 9. Female; elderly pedestrian with facial fractures and

unconsciousness after auto collision.10. Female (3rd trimester pregnancy); auto collision with

femoral neck fracture, and vaginal bleeding (placental abruption)


Roles

Role player Learner

Facilitator


EMCRM Performance Rating Scale

SUBJECT ID: __________________ EVALUATOR ID: _______________ Ten behavioral components of Emergency Medicine Crisis Resource Management are listed below. For each component circle the number that best describes the participant’s performance. 1 = not acceptable 2 = poor 3=acceptable 4=good 5 = excellent

1. Knowledge of the Environment 1 2 3 4 5

2. Anticipation of & Planning for Potential Problems

1 2 3 4 5

3. Assumption of Leadership Role

1 2 3 4 5

4. Communication with Other Team Members

1 2 3 4 5

5. Distribution of Workload/Delega-tion of Responsibility

1 2 3 4 5

6. Attention Allocation

1 2 3 4 5

7. Utilization of Information

1 2 3 4 5

8. Utilization of Resources

1 2 3 4 5

9. Recognition of Limitations/Call for Help Early Enough

1 2 3 4 5

10. Professional Behavior/Inter-personal Skills

1 2 3 4 5

11. Overall Behavioral Crisis Management Skills

1 2 3 4 5


A debrief session


EMCRM Performance scores

0.00

10.00

20.00

30.00

40.00

50.00

HPS Group

Pretest Sum Scores

Posttest Sum Scores

Pretest Sum Scores

Posttest Sum Scores

Virtual ED GroupN=15 N=16


Summary

• Virtual worlds where you can do work• World simulates authentic work environment

• Embedded documents, models and simulations– Make the world interactive– (beyond navigation, browsing, socializing)

• Scenarios for relevant work experiences• Metrics, reflection and discussion needed for experiential learning


Links to our movies

Virtual Emergency Department (VEDII) - Users

Virtual Emergency Department (VEDII) Interface - GUI

Virtual Emergency Department (VEDII) - entire video (2:11 min)

http://www.youtube.com/watch?v=zUb2Z8ZTl6g

http://www.youtube.com/watch?v=6FEdUndV1Aw

http://www.youtube.com/watch?v=7KfO4vjf_II


Thank you !

[email protected]

Health & Medicine

Parvati Dev Amia Tutorial 2009