Parvati Dev Amia Tutorial 2009

Simulation Parvati Dev, PhD, FACMI President, Innovation in Learning Inc. Distinguished Scholar, Media-X, Stanford University Former 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

Patient state Healthy Bleeds profusely Sick Very sick Hit by car Stable, recover

Patient Model ‘ PATIENT’ STATE QUERY INTERFACE TEXT SPEECH GRAPHICS ANIMATION INTERVENTION INTERFACE PHYSIOLOGY PROCESS TIME STEP

TEXT 45 y/o female clerk: open, angulated open fracture. rt. upper humerus, C/o severe pain, feeling faint Brisk arterial and venous bleeding, EOIS = 4 (of 6) GRAPHICS #15 #12 ANIMATION SPEECH

Patient Model QUERY INTERFACE INTERVENTION INTERFACE

Basic Logic for Traumatic Hemorrhage Model Vol BP HR Sa0 2 RR • trauma ––> blood loss • blood loss ––> reduced blood volume • reduced blood vol ––> reduced pressure • reduced pressure ––> increased heart rate • increased heart rate ––> decreased Sa0 2 • decreased Sa0 2 ––> increased resp. rate

Model for Traumatic Hemorrhagic Shock Fractured humerus, Hemorrhage rate: 83 ml/min = 2520ml/30min Cardiac arrest . . 35min to ‘death’

Model for Traumatic Hemorrhagic Shock 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 Response of Model PR Sa0 2 X X X X X X X X X X X BP-S RR Compression bandage IV Nacl Dobutamide Trendelenberg Transfuse Send to surgery . . . Home in 36hrs

Ten Trauma Cases #12 illustrated; #13 near death; #11 & 16 walking- wounded B-man, LUQ blow, pain, hemoperitoneum, hypotension, confused M48 5 21 Af-Am, 24wk preg, vag. bleeding, FHT180, S-S anemia, low BP F23 5 20 Obese retiree, RUAbd bruise, hypotension, hemoperitoneum M69 5 19 Exec., traumatic rt. knee disruption, brisk bleeding, hypotension M38 5 18 Athlete, open. frax, rt. tibia & fibula, brisk bleeding, pain, labile BP M22 5 17 Grad. Student, 10cm SQ hematoma, rt mid-thigh, anxious F27 1 16 RLQ penetrating shard, hemoperitoneum, pain, hypotension F58 5 15 Construction worker, crushed chest, ribs visible bilat., hemoptysis M30 6 13 Clerk: open, angulated frax. Rt. humerus, pain, brisk bleeding F45 4 12 Healthy Prof., bleeding lacerations of forearm, anxious, htn M60 1 11 EOIS/THC Score = (0 – 6) based upon anatomic structure, and severity of injury # EOIS Gender-age Description

Organ Injury Scale Extended – Quantifies the Injuries AVULSION ALL LACERATIONS 12) URETHRA LACERATIONS > 2CM LACERATIONS < 2CM 11) BLADDER ALL INJURIES 10) URETER MAJOR PARENCHYMAL LACERATIONS, HILAR VESSELS MINOR LACERATIONS 9) KIDNEY VENA CAVA, ABD. AORTA ALL VISCERAL VESSELS 8) ABDOMINAL VASCULAR PARENCHYMAL INJURY > 25%, JUXTA-HEPATIC VESSEL LACERAT– LACERATIONS, SUB-CAPSULAR HEMORRHAGE 7) LIVER LACERATIONS OF HILAR VESSELS LACERATIONS, SUB-CAPSULAR HEMORRHAGE 6) SPLEEN RUPTURE LACERATIONS, 5) DIAPHRAM FLAIL, CRUSHED CHEST LACERATIONS, RIB FRAX, 4) CHEST WALL BLUNT, DYSFUNCTION, AND PENETRATING BLUNT, NON-PENETRATING 3) HEART LOBAR, VASCULAR CONTUSION, SIMPLE LAC. 2) LUNG VASCULAR TREE CHEST WALL VESSELS 1) THORACIC VASCULAR EOI-SCALE 4-5 EOI-SCALE 1-3 ORGAN AVULSION ALL LACERATIONS 21) EXTERNAL GENITALS MAJOR VASCULAR INJURY, OPEN OR CLOSED FRACTURES PELVIC WALL VESSELS, REPRODUCTIVE ORGANS 20) PELVIS MAJOR MUSCULAR INJURY, VERTEBRAL FRACTURES LACERATIONS, CLOSED CONTUSIONS 19) BACK, BUTTOCKS MAJOR VASCULAR INJURY, OPEN FRACTURES LACERATIONS, CLOSED FRACTURES 18) LOWER EXTREMITY – Lt. MAJOR VASCULAR INJURY, OPEN FRACTURES LACERATIONS, CLOSED FRACTURES 17) LOWER EXTREMITY – Rt. MAJOR VASCULAR INJURY, OPEN FRACTURES LACERATIONS, CLOSED FRACTURES 16) UPPER EXTREMITY – Lt. MAJOR VASCULAR INJURY, OPEN FRACTURES LACERATIONS, CLOSED FRACTURES 15) UPPER EXTREMITY – Rt. MAJOR VASCULAR INJURY PERFORATIONS, LACERATIONS 14) GI TRACT MAJOR VASCULAR INJURY, FRACTURES LACERATIONS 13) NECK

Traumatic Hemorrhage Classes (THC) determine Blood Volume Deficit. ATLS Guideline & Rooke, et al. 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 55 Class 6 = 3880ml 0 0 0 0 (Agonal) (Average Blood Volume = 5000ml) Quantifies the Blood Loss Blood Volume-driven system: e.g., hemorrhage  Vol   BP   HR   Sa0 2   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

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
Male: pneumothorax and femur fracture after auto collision
Male; bicycle rider falls from bike path, suffers spleen rupture
Male; car driver, hypoglycemia and femur fracture
Male; ethanol induced fall, with head injury, obstructed airway
Female;(2 nd trimester pregnancy); with renal laceration after auto collision
Male; construction worker fall, liver rupture, fracture of femur
Male: construction worker, flail chest and dislocated shoulder
Male: bicycle rider with severe hand and abdominal injury after auto collision and being ‘run-over’
Female; elderly pedestrian with facial fractures and unconsciousness after auto collision.
Female (3 rd trimester pregnancy); auto collision with femoral neck fracture, and vaginal bleeding (placental abruption)

Roles Role player Learner Facilitator

EMCRM Performance Rating Scale

A debrief session

EMCRM Performance scores N=15 N=16 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 Group

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_address]

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Parvati Dev Amia Tutorial 2009

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