Virtual simulation

Cite this article as:
Nick Peres + Tim Mason. Virtual simulation, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.26002

What do you think of when you hear the words Virtual Sim? If your mind goes to Neo (Editors note: Keanu was actually quite good in the first Matrix- feel free to argue) then we are of like mind. If you think of the stereotypes of mainstream media, you will likely think Ready Player One, Tron, or even Lawnmower Man!

COVID-19 has changed our world with “socially close” teaching universally banned. Simulation is no different and I, for one, miss it! We know sim has its benefits, in situ, and for hands-on practice. Can we get back to that reflective learning we know and love?

Medical simulation is a tactile, experiential teaching modality, however, as sim trainers, we are often told “the learning is in the debrief”. This leaves us to beg the question – can we re-create or port something like a debriefing session virtually? And if so, should we be pausing activity in our sim centres and giving all trainees a VR headset?

 

 Looking at the realm of Twitter and our practical experience, how have people tried to bridge this gap? What’s out there?

Remote sim

Passive: Watching a live simulation session streamed to a video conferencing application via the sim centre camera(s) (or mobile) whilst a team perform the sim. This is then followed by a facilitated debrief taking place remotely, again utilising a video conference platform.

Interactive: A simulation takes place but there may be some interactivity with a confederate in the room being directed via video by a learner as a team lead. The debrief then follows on the video conferencing platform. Pre-recorded video can be repeated as appropriate.

 

A quick note on cameras

We are investigating the types of camera that best convey a remote simulation scenario. These include fixed-angle cameras (such as utilising those cameras already within a simulation suite), handheld or accessible cameras, such as a body-worn GoPro or even utilising a 360-degree camera, which can then be explored by participants or debriefer using their mouse to navigate the 360 recorded space.


 

The advantage of the passive approach is that we do get to be involved in the process, however, there may only be one or two fixed-view cameras impacting on your impression of the scenario. It may recreate some of the visceral feelings we get in a resus but you are still physically and psychologically removed. The alternate scenario adds an element of interactivity but the action in the room won’t reflect reality as it won’t directly represent the real team. Both measures will need clear learning objectives that fit these new methods. One interesting thought is if this actually represents the way senior doctors view their department and “direct” their juniors remotely without the need to physically be present (i.e. overnight on calls)?

Others have tried methods such as Telesimbox where a video is played whilst a facilitator guides the learners (over video) through a pre-set scenario.

Other paid-for services include app-based 360° films which may have a degree of interactivity or higher-tech solutions using headsets.

 

360° Sim

We’ve been doing something a little bit different which is 360° Virtual sim. 360° video is filmed using a fancy camera that can record all the way around it with two fisheye lenses. The camera then stitches together the images into a sphere which you can then look around by swiping the screen on a tablet or moving your head around a VR headset. 360° video has been used as a debriefing tool in itself with some success. Medical students found it gave them a deeper appreciation of their communication skills during the simulation.

Two years ago I was helping run a Return to Paediatric Training Sim course in the south-west, We didn’t have any time to add in resus but felt that it was an area people worry about. With the expert help of Nick of the Torbay VR team, we made a Neonatal Life Support (NLS) and an Advanced Paediatric Life Support (APLS) simulation utilizing  360° video which participants could access at home. The learners on the course loved it, though some felt it was stressful or uncomfortable, The sights and sounds of the room meant everything soon felt familiar. For others, it inspired them or put them back in the zone.

 

When the world became socially distant, it gave us the opportunity to debrief these videos over a video conferencing platform. Using 360° videos, the viewer becomes an active observer right in the centre of the action.  Although they can’t truly interact with the scene, they are still placed in media res. This really helps to bring about discussion of non-technical skills, with associated feelings and humanistic considerations, in the debrief.

If you have content that is created and shared with you to use, it then essentially becomes an accessible and free setup with no need for manikins, faculty, or dealing with the frustrating lack of parking spaces. Here’s an example of a 360° sepsis sim we ran and debriefed remotely.

 

There is also the potential to teach larger groups than what would normally be run through an in-person simulation session.  

 

Making your own 360° content

  • Write your simulation with learning objectives appropriate to your learners – think, medical, technical and non-technical.
  • Think about which scenarios work. Emergencies with lots of different teams to follow may be fun, but think about the difficult communication scenarios (safeguarding, breaking bad news) as it may be a safe way to sharpen communication skills.
  • A 360° camera (roughly £400) and stand (grip/ microphone stand).
  • A computer capable of editing (it needs a good graphics card)
  • When filming, position your camera at eye height in the centre of the action (hanging from the curtain rail is good).
  • Take away all patient identifying info if in situ (the camera sees all).
  • Think if you are going to tell the sim participants the theme of the sim. It adds to psychological safety but you may not get the authentic simulation experience.
  • Film it again if things go wrong as it is harder to edit afterwards.
  • Editing- steep-ish learning curve but simple things can be done easily in free packages.

 

Running your remote or 360° virtual Sim teaching session

  • Planning is key- time and place are less of an issue but think of your learners. How is the session going to meet their learning needs? Is there something particular that you are going to focus on?
  • Pick your video conferencing application of choice – we all have our favourite/ the one our trust allows us to use. Are you sharing your screen? Are you using sim centre cameras or mobile phones?
  • Practice using the kit/ technology before you do it live – not once but a good few times.
  • Solid Pre brief/ ground rules for the session are important.
  • Beware of “Zoom Fatigue”- try not to run a session longer than 1 hour. Most of ours have been 45 minutes at most.
  • Is the Wifi good enough? Will the videos cut out?
  • During the sim think about allowing learners/ observers to type thoughts and feeling that come to mind that you can then cover in the debrief.

 

Some thoughts on the virtual debrief

In a study looking at debriefing after medical serious games, in-person and virtual debrief both rated highly (self was the lowest). Remote debriefing has been used to train teams and faculty  in countries that do not have access to resources or experience in simulation.

 Make sure someone is designated to lead the debrief. Use the standard sim structure- Defusing, Discovery and Deepening. This model is based on Kolb’s experiential learning theory. This has made its way into many different models including Diamond, Pearls and ITRUST.

Who’s watching the watchmen? We’ve had more consultants during our sessions than the usual weekly sim. This changes the dynamic of the discussion. It skipped the medicine and went straight to the communication and processes seen. This may not be a positive for the junior members who needed experiential medical learning.  If using pre-recorded 360° content that is not live make sure you make it personal exploring real-life experiences. Has anyone seen this before? How does this work in your ward? Where’s the protocol kept?

As with all forms of online facilitated tuition, it is important to set the ground rules at the offset. Do you have learners muted? This will depend on the numbers in the debrief considering microphone echo verus silence.  You may need to use a signal to talk (i.e. Zoom thumbs up!). Everyone should keep their cameras on so you can see everyone and try to “read the room” keeping all involved.

So what might the future hold? It may be live streaming 360° content (which a lot of 360 cameras can do), a virtual space we can easily watch 360° video together, or Mozilla hubs where our avatars we can meet to watch content together. I don’t see this a replacement for regular simulation. It is an adjunct, a complimentary tool for the SBE toolkit.le.

Virtual Reality: Camilla Sorensen at DFTB19

Cite this article as:
Team DFTB. Virtual Reality: Camilla Sorensen at DFTB19, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.21504

Imagine a world where you could teach CPR from a thousand miles away, a world where you can guide clinicians on the other side of the world. In this groundbreaking talk from DFTB19 Camilla Sørensen tackles another side of virtual reality. This one involves the clinician as power user.

 

 

©Ian Summers

(Editor’s note – I was so excited when I watched this talk that I promptly bought myself a VR headset)

 

This talk was recorded live at DFTB19 in London, England. With the theme of  “The Journey” we wanted to consider the journeys our patients and their families go on, both metaphorical and literal. DFTB20 will be held in Brisbane, Australia.

If you want our podcasts delivered straight to your listening device then subscribe to our iTunes feed or check out the RSS feed. If you are more a fan of the visual medium then subscribe to our YouTube channel. Please embrace the spirit of FOAMed and spread the word.

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DFTB go to SMACC

Cite this article as:
Andrew Tagg. DFTB go to SMACC, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.18334

Without SMACC there would be no Don’t Forget the Bubbles. But little did Tessa and I know that despite being at the same conference it would be another four years before we actually met in person at DFTB17 in Brisbane.

Nobody knew what to expect at that first SMACC as we sat in the dark waiting for the conference to begin.  I had just signed up with Twitter and was just excited to be in the company of people who thought the same as me, who were excited to learn, and were using this new thing called #FOAMed. As I am the shy retiring type I barely said hello to people that now, a lifetime later, I would be proud to call friends. Instead, I just sat in the audience and absorbed all the knowledge and positivity that flooded my way.

Flash forward a few years and those friendships, forged online, have grown as Twitter avatars are replaced with real people. No longer am I as shy to go up to someone I have never met in real life and I’m glad others have taken up the challenge too (Andrew and Sarah,  I am looking at you).

Tessa and I feel very privileged to have played some small part in the success of SMACC as we run the very final SMACCmini paediatric workshop. If you couldn’t come along then here are some of the things you missed.

 

Sweet Child O’ Mine (A neonates journey) – Trish Woods

Trish is no stranger to the DFTB ethos and as a neonatologist stopped to make us reflect on one of our basic assumptions – just who is the patient.  Just because our tiniest patients lie in their cribs, helpless, requiring help with all of their daily cares, does not mean that we should not consider them as people. It might be an alien thought to some – that the patient in front of us hears what we say, and how we say it, but they are not just a disease or a problem to be dealt with or the one in pod 3. They are a person with a name.

Seeing the team through the eyes and ears of the patient, Trish helps us enter the sensory (and often-overstimulating) world of the NICU.

Why not take a look at this paper on some of the ways we can start treating the patient and not the disease.

Roué JM, Kuhn P, Maestro ML, Maastrup RA, Mitanchez D, Westrup B, Sizun J. Eight principles for patient-centred and family-centred care for newborns in the neonatal intensive care unit. Archives of Disease in Childhood-Fetal and Neonatal Edition. 2017 Jul 1;102(4):F364-8.

I Want Candy (neonatal pain relief) – Justin Morgenstern

Justin Morgenstern, one of everyones favourite Canadians, has recently relocated to our side of the world and is practicing in New Zealand. Knowing that he is such a fan of evidence based medicine we set him the task of finding out if sucrose is as good as we think it is as an analgesic in neonates.

Here, for your delectation, is his take on analgesia for kids.

I don’t want to spoil his conclusion but this slide might give you just a little clue…

He started by challenging a fundamental assumption – that we can accurately tell whether a neonate is in pain or not. Or, more accurately, he challenged our assumption that we could tell when a medication worked.  We know the limitations of the traditional Wong-Baker Faces scale in older children and most of us probably use some combination of our clinical gestalt and the FLACC (Face/Legs/Arms/Cry/Consolation) score in neonates. But is it some sort of surrogate marker for distress, rather than pain? If fMRIs show no difference in an infants brain when they receive sucrose does that mean it does nothing for pain?

Of course there are a lot of things we can do that we know do work:-

  • Limit painful procedures
    • If venipuncture is less painful than a heelprick why not use it.
  • Let nurses treat the pain
    • Nurses are amazing (full stop) but they are also so much better at giving analgesia by the clock than any doctor
  • Address the underlying issues
    • Splint the obviously broken arm  before x-ray rather than waiting for them to get some imaging and then feeling guilty about it.
  • Consider non-pharmacological adjuncts
    • Dogs, clowns and bubbles are all powerful distractors.

 

Straight Up (bilious babies) – Camille Wu

Camille Wu last spoke for us at DFTB17 on testicular tribulations so it was a pleasure to welcome her back to join us to talk about surgical causes of bilious vomiting.

Rather than put words in a parents mouth she suggested asking exactly what colour was the vomit. If they answer Pantone 2565C then you are in trouble. Green vomit suggests a higher up obstruction that might require surgical intervention and certainly requires surgical assessment. Likewise rather than asking if the vomit was projectile, it is better to ask “How far did it go?

Whilst it is important to remember that there are a number of significant medical causes of bilious vomit (such as sepsis and CPAP belly) we really need to be concerned about surgical causes. Camille broke these down into mechanical causes and functional causes.

Mechanical causes

Intrinsic

  • Duodenal atresia
  • Small bowel atresia
  • Ano-rectal malformation

Extrinsic

  • Malrotation/volvulus
  • Congenital bands
  • Intestinal duplication

Functional causes

  • Hirschsprung disease
  • Meconium ileus/plug
  • Necrotising enterocolitis

The more proximal the obstruction the less bubbles of gas you will see on initial imaging. Camille reminded us that early imaging and intervention can make all the difference. If in doubt, pick up the phone, no matter the time of day or night.

The Safety Dance – Linda Durojaiye

Linda Durojaiye is a staff specialist at Sydney’s Children’s Hospital at Randwick. In her talk on leadership and patient safety she owned up to mistakes that have been made and shared some lessons from her department on how they have created a safer environment where everyone is accountable. Given that we have no control over who comes in we need to take ownership of what happens to them once they pass through our doors.

Linda and her team created a culture of safety – starting with regular team huddles to identify potential threats to safety. Using a strong leadership team they created a model of care that engaged both medical and nursing staff as well as the patient/parent consumer. She highlighted the resources freely available on the Institute for Healthcare Improvement website.

If you want to know more about the Clinical Emergency Response System then you can find it here.

 

One Vision (VR in paediatrics procedures) – Andy Weatherall

If your idea of virtual reality is still stuck in the last century and The Lawnmower Man (a poor 34% on Rotten Tomatoes) then you might not be aware of some of the advances that are putting the technology in the hands of normal people. Andrew Weatherall is the co-chair of paediatric anaesthesia at the Children’s Hospital at Westmead and has been looking at the role virtual reality may play as an adjunct to standard anaesthesia techniques.

He has written about his experiences here. Whether as a means to reduce anxiety before a procedure or as a distraction from the procedure itself virtual reality is no longer priced out of possibility. With Google Cardboard costing just a few bucks and lots of open source software available it won’t be long before we see more departments trying it out. We hope to hear more from Andrew and his team in the near future to see how they are going.

The Model (3D printing in paeds) – Jasamine Coles-Black

Carrying in on with technological advancements in paediatrics Jas Coles-Black from the 3D lab at the Austin in Melbourne made the audience realise just how affordable 3D printing can be. A technology that once cost six figures is now cheaper than the average consultants coffee habit. After a quick jaunt through the various methods of printing she went through some of applications relevant to paediatric practice. With printable task trainers costing just a couple of dollars (after the capital expenditure) we could all have our own paediatric can’t intubate – can’t oxygenate model. Or perhaps you want your trainees to learn how to ultrasound the neonatal spine to improve their success at lumbar puncture – a task trainee is yours for less than a latte.

3D printing can also be used to help patients understand complex ideas and a number of cardio-thoracic surgeons have used 3D printed models of congenital heart defects to help explain complex anatomy. We are looking forward to hearing more from Jas about this exciting technology and how it can benefit all of us. And, if people are interested, we could create our very own DFTB 3D printing workshop at a future conference.

Jas' favourite 80s movie

https://www.youtube.com/watch?v=1g3_CFmnU7k

(Yes – I know it was 1977 – Ed)

Sound and Vision (Critical care ultrasound) – Tom Rozen

SMACCmini was competing against the very practical paediatric ultrasound workshop but we couldn’t make it through without mentioning it at least once. Tom Rozen, intensivist at the Royal Children’s Hospital, used the example of René-Théophile-Hyacinthe Laennec’s (yes, really!) most famous invention, the stethoscope, to demonstrate how medical fashion has changed. A device that once took up an entire room can now fit in your pocket and with ultra-cheap, ultra-portable devices entering the market it will not be long before clinicians can have a device of their very own.

If you want to know what all the fuss is about then why not sign up for one of our pre-DFTB19 workshops.

Too Shy (20 minutes of bottom jokes) – Ross Fisher

Mr Fisher was set the challenge of making talking about constipation interesting and he succeeded. From his opening Limahl tribute to the crowd singalong he soon had us tapping our toes to the 1983 Kajagoogoo classic. He began by asking us to turn to the person sitting next to us and take a bowel history. After a round of sniggers a fair percentage of the delegates were unable to complete the task. Fortunately I was sitting next to Tessa and we know each others bowel habits intimately. If we are too shy shy to ask a grown up about what they get up to in the toilet no wonder we are pretty awful at asking children. Most children are all smell, noise and little substance in the bathroom so the only way to really find out what they are up to is to ask them, in their own language.

Constipation and its consequences can be stigmatising to a child and so the mindful clinician should sit and listen to the parent and their concerns, without judgement. Treatment can be a long and drawn out affair taking as long to fix as the child has had the problem for.  Take a look at our series on constipation here.

Faith (It takes a team) – Bec Nogajski

The final talk of the morning, by Bec Nogajski, brought it all together and reminded us of the importance of teaming. We’ve all been a part of dysfunctional teams and Bec challenged us to look at our role in the team, not as a passive sheep to be lead around, but as an integral unit with worth. There are many ways of finding out how you might fit in the team – Belbin’s team roles, DISC, Myers-Briggs (INTJ in case you were wondering) – but it is worth considering  that there is no perfect recipe for an effective team.

The team sets the behaviour, what is tolerated and what is not. As David Morrison said, “The standard you walk past is the standard you accept.” So do you check your mobile phone during clinical handover, and allow others to do the same or is this type of behaviour below the line?

 

 

Our eternal thanks, as always, to the SMACC OC throughout the years, especially, Chris, Roger and Oli who made such an impact on four aspiring paediatricians that they decided that they could run their own conference. If you want to see what all the fuss is about then there are still a handful of tickets left for www.dftb19.com in London, this June.