Simulation Parvati Dev, PhD, FACMI President, Innovation in Learning Inc. Distinguished Scholar, Media-X, Stanford Univers...
Overview <ul><li>Visualization, simulation , 3D models and spaces in virtual worlds </li></ul><ul><li>Comparison of using ...
Browse … Experience … Act <ul><li>Virtual world as a social space </li></ul><ul><li>Virtual world as a space with interact...
Social spaces (Second Life)
Piet Hut, astronomer <ul><li>“ I realized how different this type of medium of communication is from anything I had tried ...
The world feels real - “concrete” Teleplace, previously Qwaq Forums
The world feels concrete -  because it is an authentic simulation <ul><li>The 3D world itself is a simulation </li></ul><u...
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 ...
TEXT 45 y/o female clerk: open, angulated open  fracture. rt. upper humerus,  C/o severe pain, feeling faint Brisk arteria...
Patient Model QUERY INTERFACE INTERVENTION INTERFACE
Basic Logic for Traumatic Hemorrhage Model Vol  BP  HR  Sa0 2   RR   •  trauma ––> blood loss   •  blood loss ––> reduced ...
Model for Traumatic Hemorrhagic Shock Fractured humerus, Hemorrhage rate: 83 ml/min = 2520ml/30min Cardiac arrest   . . 35...
Model for Traumatic Hemorrhagic Shock 250 200 150 100 50 0 Fractured humerus, Hemorrhage rate: 83 ml/min= 2520ml/30min Vic...
Ten Trauma Cases #12 illustrated; #13 near death; #11 & 16 walking- wounded B-man, LUQ blow, pain, hemoperitoneum, hypoten...
Organ Injury Scale Extended – Quantifies the Injuries AVULSION ALL LACERATIONS 12)  URETHRA LACERATIONS > 2CM LACERATIONS ...
Traumatic Hemorrhage Classes (THC) determine Blood Volume Deficit. ATLS Guideline & Rooke, et al. Rooke, et al.  1995 Anes...
A Medical Virtual World
Scripted objects vs role playing <ul><li>Comparison of using scripted objects vs role playing with real people controlling...
Reflection and Discussion
Using reflection and discussion to build on virtual experiences <ul><ul><li>Preparation for a medical virtual experience <...
Clinical Scenarios for Virtual ED <ul><li>Male:  pneumothorax and femur fracture after auto collision </li></ul><ul><li>Ma...
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 Pre...
Summary <ul><li>Virtual worlds where you can do work </li></ul><ul><li>World simulates authentic work environment </li></u...
Links to our movies <ul><li>Virtual Emergency Department (VEDII) - Users </li></ul><ul><li>Virtual Emergency Department (V...
Thank you ! [email_address]
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Parvati Dev Amia Tutorial 2009

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This slide set was part of an AMIA 2009 tutorial on Virtual Environments led by Ed Hammond of Duke University.

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  • In contrast to the abstract nature of the two-dimensional web, virtual worlds offer a very concrete three-dimensional information structure, modeled after the real world. While these worlds are virtual in being made up out of pixels on a screen, the experience of the users in navigating through such a world is very concrete. Virtual worlds call upon our abilities of perception and locomotion in the same way as the real world does. This means that we do not need a manual to interpret a three-dimensional information structure modeled on the world around us: our whole nervous system has evolved precisely to interact with such a three-dimensional environment. Remembering where you have seen something, storing information in a particular location,getting an overview of a situation, all those functions are far more natural in a 3D environment than in an abstract 2D tree of web pages.
  • With the Serious Games movement, the cinematic value and realism became important. We move beyond the clinical encounter. This is now a dynamic patient whose condition evolves with time. Your management of the patient determines the clinical outcome. (Source: 2006, Pulse!!, http://www.sp.tamucc.edu/pulse/home.asp )
  • There are many flavors of virtual patients. Online virtual patients fall into a few major categories. This one is probably the most common. (source 1990, Real Problems, Perper, Felciano as key authors, Stanford SUMMIT lab). Presents a snapshot, an encounter with a patient. Particularly useful for teaching the basics of history taking and the principles of physical examination. Also for clinical reasoning.
  • Has builds. Purpose is to explain “states” and state transitions.
  • Ten trauma situations were developed.
  • The team around the bed included Learners and Role Players. The role players played supporting roles in the team, while the learners took the role of the lead physician and the supporting physician. A Facilitator observed the performance of the team members in the virtual world and could, if necessary issue comments, suggestions or instructions.All team members wore headsets with microphones, allowing them to sit in different rooms but to be virtually in a common space, around the patient’s bed.
  • Each learning session consisted of one of the trauma scenarios, followed by a debrief session with the facilitator. During the debrief, the facilitator led a non-judgmental discussion about the actions taken during the scenario, with the learners discussing their thoughts, concerns and opinions, Typically, most of the learning takes place during this discussion rather than during the scenario itself.
  • The two groups were termed the HPS group (Human Patient Simulator, or the physical manikin) and the VED group (the Virtual Emergency Department). The pre-test and post-test performance was measured for both the groups. The results are graphed above. Two conclusions can be drawn. First, in both the HPS and VED groups, learning occurs, as shown by the improved performance during the post-test compared to the pre-test. Second, both HPS and VED groups show similar improvement from pre- to post-test, indicating that the virtual environment has resulted in learning comparable to that with the gold standard, the physical manikin. This key result encouraged us to continue our development of virtual learning environments,and we will continue to test the efficacy of these new learning environments.
  • Parvati Dev Amia Tutorial 2009

    1. 2. Simulation Parvati Dev, PhD, FACMI President, Innovation in Learning Inc. Distinguished Scholar, Media-X, Stanford University Former Director, SUMMIT Lab, Stanford University
    2. 3. Overview <ul><li>Visualization, simulation , 3D models and spaces in virtual worlds </li></ul><ul><li>Comparison of using scripted objects vs role playing with real people controlling characters </li></ul><ul><li>Using reflection and discussion to build on virtual experiences </li></ul><ul><li>Using virtual world to capture activities in the real world </li></ul><ul><li>Future of simulation </li></ul>
    3. 4. Browse … Experience … Act <ul><li>Virtual world as a social space </li></ul><ul><li>Virtual world as a space with interactive simulations </li></ul><ul><li>Building a Clinic space </li></ul><ul><li>Simulated patients </li></ul><ul><li>Richly interactive virtual medical environments </li></ul><ul><li>Movie – a Virtual Emergency Department </li></ul>
    4. 5. Social spaces (Second Life)
    5. 6. Piet Hut, astronomer <ul><li>“ 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. </li></ul><ul><li>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 .” </li></ul>
    6. 7. The world feels real - “concrete” Teleplace, previously Qwaq Forums
    7. 8. The world feels concrete - because it is an authentic simulation <ul><li>The 3D world itself is a simulation </li></ul><ul><ul><li>of a real space, or a designed space </li></ul></ul><ul><li>Being a simulation, you can “operate” it </li></ul><ul><ul><li>A “left turn” is the same in the real and virtual worlds </li></ul></ul><ul><li>Our brain “understands” 3D space </li></ul><ul><ul><li>We know how to function in a 3D space </li></ul></ul>
    8. 9. Collaboration using visualization Green Phosphor and GlassHouse: http://www.youtube.com/watch?v=Z-EU3LITMmQ
    9. 10. Visualizing microarray data Green Phosphor and GlassHouse
    10. 11. Medical visualization Teleplace.com; Cleft Palate patient from NYU Medical Center
    11. 12. Simulated experiences (Forterra Systems)
    12. 13. Interactive simulations (Pulse!! - Breakaway)
    13. 14. Building a 3D space
    14. 15. From real to “mirror” world Forterra Systems
    15. 16. Virtual Stanford Forterra Systems
    16. 17. 3D medical spaces
    17. 18. Building a 3D clinic
    18. 19. Building Virtual Patients Appearance - normal plus trauma or disease Behavior - movement plus other actions
    19. 20. Building an Avatar (Poser, )
    20. 21. Adding trauma appearance (Forterra)
    21. 22. Specialized Behaviors Simulating Physiology
    22. 23. Patient state Healthy Bleeds profusely Sick Very sick Hit by car Stable, recover
    23. 24. Patient Model ‘ PATIENT’ STATE QUERY INTERFACE TEXT SPEECH GRAPHICS ANIMATION INTERVENTION INTERFACE PHYSIOLOGY PROCESS TIME STEP
    24. 25. 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
    25. 26. Patient Model QUERY INTERFACE INTERVENTION INTERFACE
    26. 27. 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
    27. 28. Model for Traumatic Hemorrhagic Shock Fractured humerus, Hemorrhage rate: 83 ml/min = 2520ml/30min Cardiac arrest . . 35min to ‘death’
    28. 29. 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
    29. 30. 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
    30. 31. 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
    31. 32. 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
    32. 33. A Medical Virtual World
    33. 34. Scripted objects vs role playing <ul><li>Comparison of using scripted objects vs role playing with real people controlling characters </li></ul><ul><ul><li>Virtual patients </li></ul></ul><ul><ul><li>Human Patient Simulator mannequin as example of human-controlled character </li></ul></ul><ul><ul><li>Turning behaviors on and off </li></ul></ul><ul><ul><li>Computer-controlled behaviors </li></ul></ul><ul><ul><li>A dynamic model of pathophysiology – trauma and hypovolemic shock </li></ul></ul><ul><ul><li>Advantages of a dynamic model </li></ul></ul>
    34. 35. Reflection and Discussion
    35. 36. Using reflection and discussion to build on virtual experiences <ul><ul><li>Preparation for a medical virtual experience </li></ul></ul><ul><ul><ul><li>knowledge prerequisites </li></ul></ul></ul><ul><ul><ul><li>use of virtual worlds </li></ul></ul></ul><ul><ul><li>Assessment during the experience </li></ul></ul><ul><ul><ul><li>Assessment instruments </li></ul></ul></ul><ul><ul><li>Facilitated reflection and discussion after the experience </li></ul></ul>
    36. 37. Clinical Scenarios for Virtual ED <ul><li>Male: pneumothorax and femur fracture after auto collision </li></ul><ul><li>Male; bicycle rider falls from bike path, suffers spleen rupture </li></ul><ul><li>Male; car driver, hypoglycemia and femur fracture </li></ul><ul><li>Male; ethanol induced fall, with head injury, obstructed airway </li></ul><ul><li>Female;(2 nd trimester pregnancy); with renal laceration after auto collision </li></ul><ul><li>Male; construction worker fall, liver rupture, fracture of femur </li></ul><ul><li>Male: construction worker, flail chest and dislocated shoulder </li></ul><ul><li>Male: bicycle rider with severe hand and abdominal injury after auto collision and being ‘run-over’ </li></ul><ul><li>Female; elderly pedestrian with facial fractures and unconsciousness after auto collision. </li></ul><ul><li>Female (3 rd trimester pregnancy); auto collision with femoral neck fracture, and vaginal bleeding (placental abruption) </li></ul>
    37. 38. Roles Role player Learner Facilitator
    38. 39. EMCRM Performance Rating Scale
    39. 40. A debrief session
    40. 41. 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
    41. 42. Summary <ul><li>Virtual worlds where you can do work </li></ul><ul><li>World simulates authentic work environment </li></ul><ul><li>Embedded documents, models and simulations </li></ul><ul><ul><li>Make the world interactive </li></ul></ul><ul><ul><li>(beyond navigation, browsing, socializing) </li></ul></ul><ul><li>Scenarios for relevant work experiences </li></ul><ul><li>Metrics, reflection and discussion needed for experiential learning </li></ul>
    42. 43. Links to our movies <ul><li>Virtual Emergency Department (VEDII) - Users </li></ul><ul><li>Virtual Emergency Department (VEDII) Interface - GUI </li></ul><ul><li>Virtual Emergency Department (VEDII) - entire video (2:11 min) </li></ul><ul><li>http://www.youtube.com/watch?v=zUb2Z8ZTl6g </li></ul><ul><li>http://www.youtube.com/watch?v=6FEdUndV1Aw </li></ul><ul><li>http://www.youtube.com/watch?v=7KfO4vjf_II </li></ul>
    43. 44. Thank you ! [email_address]

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