A review of epidural simulators: Where are we today?

Thirty-one central neural blockade simulators have been implemented into clinical practice over the last thirty years either commercially or for research. This review aims to provide a detailed evaluation of why we need epidural and spinal simulators in the first instance and then draws comparisons between computer-based and manikin-based simulators. This review covers thirty-one simulators in total; sixteen of which are solely epidural simulators, nine are for epidural plus spinal or lumbar puncture simulation, and six, which are solely lumbar puncture simulators. All hardware and software components of simulators are discussed, including actuators, sensors, graphics, haptics, and virtual reality based simulators. The purpose of this comparative review is to identify the direction for future epidural simulation by outlining necessary improvements to create the ideal epidural simulator. The weaknesses of existing simulators are discussed and their strengths identified so that these can be carried forward. This review aims to provide a foundation for the future creation of advanced simulators to enhance the training of epiduralists, enabling them to comprehensively practice epidural insertion in vitro before training on patients and ultimately reducing the potential risk of harm. © 2013 IPEM

MIXED REALITY IN MEDICAL SIMULATION: A COMPREHENSIVE DESIGN METHODOLOGY

AbstractIn the medical education field, the use of highly sophisticated simulators and extended reality (XR) simulations allow training complex procedures and acquiring new knowledge and attitudes. XR is considered useful for the enhancement of healthcare education; however, several issues need further research.The main aim of this study is to define a comprehensive method to design and optimize every kind of simulator and simulation, integrating all the relevant elements concerning the scenario design and prototype development.A complete framework for the design of any kind of advanced clinical simulation is proposed and it has been applied to realize a mixed reality (MR) prototype for the simulation of the rachicentesis. The purpose of the MR application is to immerse the trainee in a more realistic environment and to put him/her under pressure during the simulation, as in real practice.The application was tested with two different devices: the headset Vox Gear Plus for smartphone and the Microsoft Hololens. Eighteen students of the 6th year of Medicine and Surgery Course were enrolled in the study. Results show the comparison of user experience related to the two different devices and simulation performance using the Hololens

Effectiveness analysis of traditional and mixed reality simulations in medical training: a methodological approach for the assessment of stress, cognitive load and performance

La simulazione nell'educazione in medicina è considerata un metodo di formazione in grado di migliorare le competenze cliniche e il comportamento degli operatori sanitari e, di conseguenza, la qualità dell'assistenza per il paziente. Inoltre, l'utilizzo di nuove tecnologie come la Realtà Aumentata, offre ai discenti l'opportunità di esercitarsi in un ambiente immersivo. L'opportunità di sperimentare questo innovativo metodo didattico è efficace non solo nel ridurre il rischio di errori e approcci sbagliati ma anche nel provare ansia e stress simili a quelli avvertiti nella pratica reale. La sfida sta nel trovare il giusto equilibrio. I discenti devono infatti provare lo stesso stress che avvertirebbero lavorando ad un vero caso clinico ma, allo stesso tempo, devono essere controllati ed evitati possibili disturbi da stress post-traumatico, verificabili soprattutto nel campo della gestione delle emergenze (pronto soccorso). Inoltre, è fondamentale anche ottenere alte prestazioni e un apprendimento adeguato, evitando sovraccarichi cognitivi che influenzerebbero negativamente l’apprendimento. Tuttavia, ad oggi mancano ancora studi approfonditi sull'impatto che le simulazioni mediche hanno su stress, frustrazione, carico cognitivo e apprendimento dei discenti. Per questo motivo, l'obiettivo principale di questo studio è valutare l'efficacia del training tramite simulazione, analizzando prestazioni, ansia, stress e carico cognitivo durante simulazioni cliniche tradizionali (con manichino) ed avanzate (in realtà mista). A questo scopo, è stato sviluppato un approccio metodologico strutturato e completo per valutare le prestazioni, le condizioni emotive e cognitive degli studenti. Questo comprende l'acquisizione e l'analisi di parametri psicologici (valutazione soggettiva), segnali biometrici (valutazione oggettiva) e prestazioni. Questa indagine consente di evidenziare i punti deboli delle simulazioni e offre l'opportunità di definire utili linee guida per la riprogettazione e l'ottimizzazione delle stesse. La metodologia è stata applicata su tre casi studio: il primo si riferisce a simulazioni ad alta fedeltà per la gestione del paziente in pronto soccorso, il secondo si riferisce a simulazioni a bassa fedeltà per la pratica della rachicentesi. Per il terzo caso studio, è stato progettato e sviluppato un prototipo di simulatore in realtà mista per la rachicentesi, con l'obiettivo di migliorare il senso di realismo e immersione della simulazione a bassa fedeltà. 148 studenti sono stati coinvolti nei primi due casi studio osservazionali, mentre soltanto 36 studenti hanno preso parte allo studio pilota sulla simulazione in realtà mista. In tutti i casi di studio sono state effettuate analisi descrittive delle prestazioni, degli stati cognitivi ed emotivi. Per le simulazioni ad alta e bassa fedeltà, le analisi di regressione statistica hanno evidenziato quali variabili influenzano le prestazioni, lo stress e il carico cognitivo degli studenti. Per lo studio pilota sulla realtà mista, l'analisi della user experience ha sottolineato i limiti tecnici della nuova tecnologia.Simulation in medical education is considered a training method capable of improving clinical competence and practitioners’ behaviour, and, consequently quality of care and patient’s outcome. Moreover, the use of new technologies, such as augmented reality, offers to the learners the opportunity to engage themselves in an immersive environment. The opportunity to experiment with this innovative instructional method is effective not only in reducing the risk of errors and wrong approaches but also in experiencing anxiety and stress as in real practice. The challenge is to find the right stress balance: learners have to feel as if they were practicing in the real stressful clinical case, and, at the same time, post-traumatic stress disorders, verifiable especially in the emergency field, must be controlled and avoided. Moreover, it is fundamental also to obtain high performance and learning, thus avoiding cognitive overloads. However, extensive researches about the impact of medical simulations on students’ stress, frustration, cognitive load, and learning are still lacking. For this reason, the main objective of this study is to assess simulation training effectiveness by analysing performance, anxiety, stress, and cognitive load during traditional (with manikin) and advanced (with augmented reality) clinical simulations. A structured and comprehensive methodological approach to assess performance, emotional and cognitive conditions of students has been developed. It includes the acquisition and analysis of psychological parameters (subjective assessment), biometric signals (objective assessment), and task performance. This investigation allows to point out simulations’ weaknesses and offers the opportunity to define useful optimisation guidelines. The methodology has been applied to three case studies: the first one refers to high-fidelity simulations, for the patient management in the emergency room, the second one refers to low-fidelity simulation for rachicentesis. For the third case study, a prototype of a mixed reality simulator for the rachicentesis practice has been designed and developed aiming at improving the sense of realism and immersion of the low-fidelity simulation. While 148 students have been enrolled in the first two case studies, only 36 students have taken part in the pilot study about mixed reality simulation. Descriptive analysis about performance, cognitive and emotional states have been done in all the case studies. For the high-fidelity and low-fidelity simulations, the statistical regression analysis has pointed out which variables affect students’ performance, stress, and cognitive load. For the pilot study about mixed reality, the user experience analysis highlighted the technical limitations of the new technology

Influence of Haptic Communication on a Shared Manual Task in a Collaborative Virtual Environment

International audienceWith the advent of new haptic feedback devices, researchers are giving serious consideration to the incorporation of haptic communication in collaborative virtual environments. For instance, haptic interactions based tools can be used for medical and related education whereby students can train in minimal invasive surgery using virtual reality before approaching human subjects. To design virtual environments that support haptic communication, a deeper understanding of humans' haptic interactions is required. In this paper, human's haptic collaboration is investigated. A collaborative virtual environment was designed to support performing a shared manual task. To evaluate this system, 60 medical students participated to an experimental study. Participants were asked to perform in dyads a needle insertion task after a training period. Results show that compared to conventional training methods, a visual-haptic training improves user's collaborative performance. In addition, we found that haptic interaction influences the partners' verbal communication when sharing haptic information. This indicates that the haptic communication training changes the nature of the users' mental representations. Finally, we found that haptic interactions increased the sense of copresence in the virtual environment: haptic communication facilitates users' collaboration in a shared manual task within a shared virtual environment. Design implications for including haptic communication in virtual environments are outlined

A comprehensive method to design and assess mixed reality simulations

AbstractThe scientific literature highlights how Mixed Reality (MR) simulations allow obtaining several benefits in healthcare education. Simulation-based training, boosted by MR, offers an exciting and immersive learning experience that helps health professionals to acquire knowledge and skills, without exposing patients to unnecessary risks. High engagement, informational overload, and unfamiliarity with virtual elements could expose students to cognitive overload and acute stress. The implementation of effective simulation design strategies able to preserve the psychological safety of learners and the investigation of the impacts and effects of simulations are two open challenges to be faced. In this context, the present study proposes a method to design a medical simulation and evaluate its effectiveness, with the final aim to achieve the learning outcomes and do not compromise the students' psychological safety. The method has been applied in the design and development of an MR application to simulate the rachicentesis procedure for diagnostic purposes in adults. The MR application has been tested by involving twenty students of the 6th year of Medicine and Surgery of Università Politecnica delle Marche. Multiple measurement techniques such as self-report, physiological indices, and observer ratings of performance, cognitive and emotional states of learners have been implemented to improve the rigour of the study. Also, a user-experience analysis has been accomplished to discriminate between two different devices: Vox Gear Plus® and Microsoft Hololens®. To compare the results with a reference, students performed the simulation also without using the MR application. The use of MR resulted in increased stress measured by physiological parameters without a high increase in perceived workload. It satisfies the objective to enhance the realism of the simulation without generating cognitive overload, which favours productive learning. The user experience (UX) has found greater benefits in involvement, immersion, and realism; however, it has emphasized the technological limitations of devices such as obstruction, loss of depth (Vox Gear Plus), and narrow FOV (Microsoft Hololens)

Computer simulated needle manipulation of Chinese acupuncture with realistic haptic feedback.

Leung Ka Man.Thesis submitted in: August 2002.Thesis (M.Phil.)--Chinese University of Hong Kong, 2003.Includes bibliographical references (leaves 81-84).Abstracts in English and Chinese.Abstract --- p.iiAcknowledgements --- p.ivContents --- p.vList of Figures --- p.viiiList of Tables --- p.xChapter 1. --- Introduction --- p.1Chapter 1.1 --- Surgical Needle Simulation --- p.4Chapter 1.1.1 --- Data Source --- p.5Chapter 1.1.2 --- Computer-aided training simulation --- p.6Chapter 1.1.3 --- Existing Systems --- p.8Chapter 1.2 --- Research Goal --- p.10Chapter 1.3 --- Organization of this Thesis --- p.12Chapter 2. --- Haptization of Needle Interactions --- p.13Chapter 2.1 --- Data Collection --- p.13Chapter 2.1.1 --- Force Measurement --- p.14Chapter 2.1.2 --- Data Correlation --- p.17Chapter 2.1.3 --- Expert Opinion --- p.18Chapter 2.2 --- Haptic Display Devices --- p.18Chapter 2.2.1 --- General-purpose Devices --- p.19Chapter 2.2.2 --- Tailor-made Devices --- p.20Chapter 2.3 --- Haptic Models for Tissues --- p.21Chapter 2.3.1 --- Stiffness Models --- p.21Chapter 2.3.2 --- Friction Models --- p.22Chapter 2.3.3 --- Modelling of needle operations --- p.23Chapter 2.4 --- Chapter Summary --- p.24Chapter 3. --- Haptic Rendering of Bi-directional Needle Manipulation --- p.25Chapter 3.1 --- Data Source and Pre-processing --- p.26Chapter 3.1.1 --- Virtual Body Surface Construction --- p.28Chapter 3.1.2 --- Tissue Mapping for Haptic Rendering --- p.29Chapter 3.2 --- The PHANToM´ёØ Haptic Device --- p.31Chapter 3.3 --- Force Profile Analysis --- p.33Chapter 3.4 --- Haptic Model Construction --- p.37Chapter 3.4.1 --- Skin --- p.41Chapter 3.4.2 --- Adipose Tissue --- p.48Chapter 3.4.3 --- Muscle --- p.49Chapter 3.4.4 --- Bone --- p.50Chapter 3.5 --- Force Composition --- p.51Chapter 3.5.1 --- Structure Weight Compensation --- p.52Chapter 3.5.2 --- Path Constraint Force --- p.52Chapter 3.5.3 --- Needle Axial Force --- p.53Chapter 3.6 --- Interactive Calibration --- p.60Chapter 3.7 --- Skin Deformation --- p.61Chapter 3.8 --- Chapter Summary --- p.63Chapter 4. --- Parallel Visual-Haptic Rendering --- p.64Chapter 4.1 --- Parallel Network Architecture --- p.64Chapter 4.2 --- Visual Rendering Pipeline --- p.65Chapter 4.3 --- Haptic Rendering Pipeline --- p.67Chapter 4.4 --- Chapter Summary --- p.67Chapter 5. --- User Interface --- p.68Chapter 5.1 --- Needle Practice --- p.68Chapter 5.1.1 --- Moving Mode --- p.69Chapter 5.1.2 --- Acupuncture Atlas --- p.70Chapter 5.1.3 --- Training Results --- p.70Chapter 5.1.4 --- User Controls --- p.71Chapter 5.2 --- Device Calibration --- p.72Chapter 5.3 --- Model Settings --- p.72Chapter 5.4 --- Chapter Summary --- p.72Chapter 6. --- Conclusion --- p.73Chapter 6.1 --- Research Summary --- p.73Chapter 6.2 --- Suggested Improvement --- p.74Chapter 6.3 --- Future Research Works --- p.75Appendix A: Mapping Table for Tissues --- p.76Appendix B: Incremental Viscoelastic Model --- p.78Appendix C: Model Parameter Values --- p.80Bibliography --- p.8

Simulated Learning for Clinical Skill Acquisition and Retention: Report on a Research Project with Trainee Medical Interns

This paper reports on a research project conducted at the Advanced Clinical Skills Centre, University of Auckland, to determine whether the provision of a carefully engineered integrated virtual reality simulator for male and female urinary catheter insertion would increase student confidence levels and competency for those two skills. We present a literature review that demonstrates the increasing importance of simulation in medical education whilst detailing the perceived benefits and drawbacks of using simulations in medical education. We then present our research methodology including student numbers, procedures followed during the research, forms of evaluation carried out during the research and the current research stage. We conclude with the difficulties encountered in our study and a statement concerning the current status of our research

A Simulation-Based Teaching Strategy to Achieve Competence in Learners

Background: Simulation-based education has become the mainstay of clinical education in health sciences and medical education. A simulation-based education is a result of work hour restriction placed on graduate learners, increased number of students requiring clinical experience, decreased number of clinical sites and lack of the availability to perform certain procedures by learners. Research has demonstrated that integration of a simulation-based educational teaching strategy in a curriculum and throughout continued learning achieves competence in learners. Methods: The review of the literature highlighted the following topics: (a) history of medical simulation, (b) fidelity used in simulation training, devices and equipment, (c) learning theories associated with simulation-based education, (d) role of simulation training in medical and health sciences education, e) advantages and disadvantages of simulation training, f) competence in simulation-based education, g) debriefing/reflection in simulation. Results: An extensive review of the literature supports the use of a simulation-based teaching strategy in health sciences and medical education. Learning theories associated with simulation-based education allow educators to provide teaching strategies that align with learner’s ability to achieve competence in learning clinical and procedural skills required for their profession. Conclusion: A simulation-based education integrated in all stages of learner education that provides deliberate/repetitive practice and feedback achieves competence in learners throughout a life-time of learning

Haptics Rendering and Applications

There has been significant progress in haptic technologies but the incorporation of haptics into virtual environments is still in its infancy. A wide range of the new society's human activities including communication, education, art, entertainment, commerce and science would forever change if we learned how to capture, manipulate and reproduce haptic sensory stimuli that are nearly indistinguishable from reality. For the field to move forward, many commercial and technological barriers need to be overcome. By rendering how objects feel through haptic technology, we communicate information that might reflect a desire to speak a physically- based language that has never been explored before. Due to constant improvement in haptics technology and increasing levels of research into and development of haptics-related algorithms, protocols and devices, there is a belief that haptics technology has a promising future