Simulation Training in Virtual Reality

Recently I’ve been thinking a lot about how new technology will affect my life as an ED doctor. It’s 2018, and the un-ignorable hype surrounding #MedTech is reaching fever pitch. In my opinion, the big players are machine learning, telemedicine, and virtual reality (VR). Their impact promises to be unprecedented across the spectrum of medical environments, with patient outcomes and reported patient experience set to be the key beneficieries. Of these three technologies, the one that feels closest to becoming a part of my daily working life (at a midsized District General ED) is VR. There will need to be some pretty seismic infrastructure improvements before the other two hit the mainstream in the UK.

It is hard to believe anybody reading this won’t have heard of VR, but for those that haven’t: it is an artificial 3D environment that the user experiences through visual and auditory stimuli. Visually, the experience is delivered via head-mounted display (HMD/headset), and the audio is delivered via headphones connected to the HMD. Head motion is tracked so that the user seems to move naturally around the virtual space (full 360-degrees). Audio is also simulated in 3D, so the user can locate sound at a real location in the environment. The result is that the user becomes so immersed in the simulation, that rationality is overridden and a sensation of genuine presence in the virtual world is experienced.

There is a hugely noticeable difference between the physical world and the abstract, packaged versions of reality that we routinely experience through multisensory media like movies and videogames. We always know we’re not experiencing something that is immediately ‘real’. When immersed in VR, that difference is far less easy for the rational mind to discern. At the touch of a button, our subconscious might be genuinely fooled into thinking we are swimming with sharks, flying through space, or living in a cartoon world full of teddy bears.

Strictly speaking, it’s incorrect to call VR a ‘new’ phenomenon, as the technology has been around for several decades. The reason it’s picked up steam recently is the exponential growth of computing power, and because HMDs are now comfortably affordable for consumers. They are lighter, transportable, and standalone – you can just slot your smartphone in and you’re all set. VR has gone from lab experiment to consumable, and it’s as user-friendly as putting on a pair of ski goggles.

Historically, VR has been limited to the entertainment and gaming industries. However, the recent explosion of public interest has prompted experimentation with the latest iterations of the technology across multiple domains, including healthcare.

How might VR be utilised in the ED? The answer to this question will evolve in parallel with the technology of course. Clearly though, it already represents a huge opportunity for education and training.

Experiential learning via simulation training is now well established as a mainstay of any reputable EM curriculum, but high-fidelity manikins and simulation labs are expensive and labour/equipment intensive. As such, sim opportunities for trainees are all too infrequent. In-situ simulation, the fashionable cousin of high fidelity sim, is an even rarer occurrence as it requires wide-scale hospital buy-in and, of course, a quiet department.

VR simulation represents a cheaper, more versatile alternative to traditional sim. When one considers the quality and variety of virtual environments that have been designed in other industries, it seems pretty feasible to design a range of virtual scenarios that would simulate the practical curriculum of the emergency physician in-training.

The same thought processes and (more challengingly) practical skills could be tested and honed, and all that would be required is the trainee putting on an HMD and pair of headphones. The breadth of sim scenarios that could be accessed in a VR library would dwarf the offerings of even the most impressive sim lab, as the limit of what could be trained would be reflected by the imagination of the VR software developers as opposed to the practical constraints of the lab. It’s conceivable that trainees could run through sims in the comfort of their own home, and then debrief with their supervisor via Google Hangout at a convenient time afterwards.

To many, the unsung hero of sim training is the ‘stress inoculation’ element. Whilst crucial to test scenario-specific knowledge-base and decision-making, it is the rehearsal of having to put on a performance in the presence of heightened emotional and physiological states (‘being under pressure’) that is most useful to the trainee the next time they are in a real resuscitation room managing a real crashing patient. When deliberately increasing stress levels mid-scenario to challenge the trainee, surely the immersive and artefact-free nature of VR will be vastly superior to traditional sim. It’s a digital treasure trove of potential scenario modifications and curve-balls, as opposed to the clunky, frankly un-human manikin and predictable supporting cast found in a sim lab. VR will be simulation training 2.0.

Not confident managing major trauma? Download a few appropriate scenarios onto the VR Sim app on your smartphone, and then spend an evening ‘playing’ them as many times as required. VR will gamify quality medical training, and make it available on demand. Perhaps the future will bring us an artificial intelligence algorithm that will be able to supervise a trainee’s performance during the virtual sim, and give constructive feedback, negating the need for human supervision.

Self-directed training optimised.

Robert Lloyd
@PonderingEM

The role of research in emergency medicine training

Research matters to all of us training in Emergency Medicine. It must do: otherwise, the likes of St Emlyn’s, Life in the Fast Lane and The Bottom Line would not get millions of views every year from clinicians hungry to access the critical appraisal and practical recommendations that #FOAMed has become so adept at generating. Today’s research is tomorrow’s standard of care. Look at the modified Valsalva manoeuvre in supraventricular tachycardia, for example (1, 2). Without research we simply do not know whether the care we provide to patients benefits them, and we are unable to challenge pervasive dogma—even if we suspect that it might be wrong (3).

Figure 1. Research is essential to bridge the gap between what we know and what we need to know (Creative Commons Robert Donovan)

Research drives positive change. In fact, just being more research active in general might improve patient outcomes (4). However,  very few emergency medicine trainees engage with research.  Those who do—like us—get branded  “academic” somewhere along the line. Being “academic” somehow suggests that we love statistics, like to say things like these data, and love nothing more than a good bit of critical appraisal at the weekend. Barring the odd exception however, we’re not especially different from any other trainee. We are lucky, in that we can access a research community which comprises some of the most clinically engaged, supportive, friendly and inspiring emergency physicians out there. Everyone can access this community if they choose to. Not many do.

So why is there such a barrier to general engagement with research?  Why is emergency medicine training in the UK considered so separate from “academic” training?  Why are we not like our colleagues in oncology, cardiology and surgery? In those specialties it’s seen as a bit odd if you haven’t engaged in research during your training.

“TIME!” you are shouting at the screen, “PRESSURE!” as you hang your head in despair, “I DON’T KNOW HOW” you sigh exasperated.

Or not. The truth is we don’t know why so few of us do research: we are a practical lot who thrive off evidence based practice and advocate for our patients, irrespective of tertiary advice. We’re one of the few specialties with  essential critical appraisal as part of exit exams. It is clear that we value research and it probably isn’t just time and workload that stops more of us getting involved.

Figure 2.  Note to self: Do more research (Thanks to Dave Hartin for sharing)

This is a point that desperately needs addressing. Emergency Departments should be research hotbeds. Let’s face it, we certainly have the patient  numbers, a universal front door and there are fundamental uncertainties in every corner of our practice (adrenaline for that cardiac arrest, anyone?) (5). We should be one of the highest recruiting areas of the NHS to both clinical trials and observational studies. On multiple fronts, research involvement affords us the chance to make a big difference and, currently we as a specialty are missing the boat. However, we are keen to catch it up. And we have the support of a growing and dynamic Royal College behind us to make change happen. Change that could influence our training and culture, to make research more widely accessible and engagement more interesting.

So, with this in mind, let us tell you about two things:

  1. We want to know what you think about Research engagement. PLEASE. Do the RCEM trainee research survey.

We want to understand views on research engagement from all trainees and clinical practitioners in emergency medicine. We want your opinion on research, how it does or doesn’t fit into your life and what we can do as a college to make it more appealing and get you involved.  Previous surveys have included only small groups of research-interested “academics” (there goes that word again) (6). We don’t need to patronise you about the detriment of respondent bias, so please spend five minutes filling it in so we can find out what everyone thinks, evidence what is already going on and use this information to drive the trainee research agenda of the future.

The survey can be accessed here and features heavily on our twitter feeds if that is easier.

  1. Interested but in need of support to engage? Think about joining the Trainee Emergency Research Network (TERN)

For those of you who know you’d like to be more research active but are after doing so in a supported way, meet TERN. The Trainee Emergency Research Network—approved, supported and funded by RCEM—will allow us to identify and answer clinically important questions collectively, as a trainee group. The underlying principle is that more hands makes less work, and the process is simple. Firstly, we agree on an important research question. Secondly, find a pragmatic way to answer the question and third, use lots of trainees in different localities to collect more data more quickly than anyone would manage individually.  As we all know, bigger numbers in studies equals more confidence in the answer to the question. It also means infrastructure and support, so that the paperwork and set up can be done in one place, and everyone else is left to get on with seeing patients. As TERN takes off (excuse the pun) we’ll likely have more than one study running at any one time. Specialties like anaesthetics and neurosurgery already have well established networks that have proven the concept and demonstrated the potential when it comes to recruiting large numbers of patients quickly and easily (7-10).

Network based research differs from pursuing formal academic training or an individual award like a PhD in that it is for the collective good, and not all about personal career development. That said, TERN participants could certainly expect to access some research training, develop additional skills and generate a meaningful output from the project regarding publications and presentations. Discussions have already begun around how TERN might contribute to future portfolio assessment outcomes—for example, by taking place of audit or other mandatory requirements. If successful, TERN might give powerful leverage to lobby for more protected time in training.  All of this will only happen if, once TERN gets off the ground, you can help it stay in the air (really excuse the second pun).

Interested? If you are a trainee (of any grade), an advanced practitioner or an emergency doctor working in a trust post interested in contributing to TERN either now or in the near future, please get in touch. Research experience is not required.  Our first scoping meeting is on the 4th April at the College headquarters in London. More will follow after that meeting, but until then please register your interest here so we can keep you posted about progress. With your help and enthusiasm, we can TERN around research engagement in emergency medicine (a comedy step too far? apologies…)

This is now the part where we should insert an over-the-top sign off about emergency research changing the world,  but we think you get the message.

So, let’s just get on with it, no nonsense, EM-style.

 

Thanks for reading.

Anisa Jafar @EMergeMedGlobal

ST4 Trainee and a current RCEM PhD fellow with interests in disaster and humanitarian medicine. Royal Bolton Hospital

 

Blair Graham @Timecritical

ST4 Trainee and a current RCEM PhD fellow with interests in patient outcomes and experience. Derriford Hospital, Plymouth

 

Dan Horner @RCEMProf Professor of the Royal College of Emergency Medicine. Consultant in Emergency and Intensive Care Medicine. Salford Royal NHS Foundation Trust

 

References

  1. Appelboam A, Reuben A, Mann C, Gagg J, Ewings P, Barton A, et al. Postural modification to the standard Valsalva manoeuvre for emergency treatment of supraventricular tachycardias (REVERT): a randomised controlled trial. Lancet. 2015;386(10005):1747-53.
  2. R B. Board SEE, editor2015. [cited 2018]. Available from: http://stemlynsblog.org/the-revert-trial/.
  3. Loubani OM, Green RS. A systematic review of extravasation and local tissue injury from administration of vasopressors through peripheral intravenous catheters and central venous catheters. J Crit Care. 2015;30(3):653 e9-17.
  4. Ozdemir BA, Karthikesalingam A, Sinha S, Poloniecki JD, Hinchliffe RJ, Thompson MM, et al. Research activity and the association with mortality. PLoS One. 2015;10(2):e0118253.
  5. Long B, Koyfman A. Emergency Medicine Myths: Epinephrine in Cardiac Arrest. J Emerg Med. 2017;52(6):809-14.
  6. Olaussen A, Jennings PA, O’Reilly G, Mitra B, Cameron PA. Barriers to conducting research: A survey of trainees in emergency medicine. Emerg Med Australas. 2017;29(2):204-9.
  7. Chari A, Jamjoom AA, Edlmann E, Ahmed AI, Coulter IC, Ma R, et al. The British Neurosurgical Trainee Research Collaborative: Five years on. Acta Neurochir (Wien). 2018;160(1):23-8.
  8. Jamjoom AA, Phan PN, Hutchinson PJ, Kolias AG. Surgical trainee research collaboratives in the UK: an observational study of research activity and publication productivity. BMJ Open. 2016;6(2):e010374.
  9. Kolias AG, Cowie CJ, Tarnaris A, Hutchinson PJ, Brennan PM, British Neurosurgical Trainee Research C. Ensuring a bright future for clinical research in surgery with trainee led research networks. BMJ. 2013;347:f5225.
  10. RAFT. 2017 [Available from: http://www.raftrainees.com.

 

Christmas message and update on EMJ.

Below is a short letter from Ellen sent out to the editors on the journal. It outlines where we came from, what we’ve done and where we are going. Although originally intended for the internal team I really felt this encapsulated how Ellen has led us to improve, develop and future proof the journal. With her permission I have reproduced it here.

Ellen Weber

From Ellen Weber. Editor in Chief. Emergency Medicine Journal

A holiday message from the Editor of the Emergency Medicine Journal

As 2017 closes, I wanted to take a moment to look back and reflect on what we have accomplished at EMJ and a bit about my vision and hopes for the coming years. We could not have gotten where we are without such a dedicated and talented editorial and publishing team, and the credit belongs to you.

There were two questions that I was asked when I started as editor of the EMJ. At my interview, I was asked: Who is the journal for – the author or the reader? At my first appearance at the CEM meeting, I was asked if the EMJ needed to be more selective.

These questions have helped to shape my vision of what I’ve hoped we can accomplish with the EMJ. First is to raise the quality of the articles we are publishing, and secondly to make the journal more relevant to readers. This continues to be my vision for the journal. To provide a high quality journal, that readers look forward to receiving, and which publishes research that has an impact on policy, practice and patient and physician well-being.

Here’s what we’ve accomplished so far:

Quality: We have set several editorial standards that have helped to improve the quality of the papers, while at the same time providing clearer guidance for authors so that their submissions are more likely to meet these quality standards.

All research papers must now be submitted with a research checklist. This helps to ensure that the papers contain all the necessary information on methods so we can evaluate them fully.

Statistical review: We have developed a cadre of statisticians who review almost all of the original articles before they are published. The statistical reviews have raised the quality of our papers immensely. It is extremely rare that a statistician does not find a major issue with the statistical analysis in the paper, despite prior content reviews.

Standards have been gradually implemented. We began with requiring that all clinical trials must be prospectively registered to be considered for publication, as recommended by the ICJME. We then added a requirement that uncontrolled before and after studies include an interrupted time series to account for secular trends. Authors are instructed to use confidence intervals instead of p values; sample size calculations must be included; surveys must have a clear response rate; chart reviews must report inter-rater reliability. We have essentially stopped publishing audits.

We are far more selective about what we publish; papers need to have generalizability, international relevance, clear implications for practice, an unbiased interpretation of the results, and an honest discussion of limitations. Our acceptance rate for original research articles is about 20%, which is typical of higher quality journals.

To educate the authors, we have published several editorials explaining our policies, and have included on our website a section that provides additional guidance on meeting our standards. The editor recorded 4 videos for the website to help authors understand what was needed in their articles and has spoken at a number of conferences to provide authors with guidance on how to write their manuscripts.

Our Impact Factor has improved, from 1.64 in 2013 1.861 in 2016 (2017 figures are not yet out).

Reader Interest and Relevance
While many of our readers are researchers as well, by far the majority are practicing physicians who may find it difficult to see how original research articles will affect their practice. We’ve addressed this in two ways: one, doing more to put the articles in context and explain the value to the reader and 2, providing other types of content that are educational and evidence-based.

Making research more accessible:

  • We have added a box at the beginning of each article that explains what is already known on the topic (i.e. where the paper sits in current literature) and then, how the findings of the study may affect practice or add to our knowledge.
  • Primary survey – The primary survey is not new, but is used to also provide background and context for the articles we are publishing in that issue.
  • Editor’s and Reader’s Choice – We developed these to highlight two articles per month. The Editor’s choice is free to access (as is any accompanying commentary) and the Reader’s choice is selected based on downloads from the website since it was published. Both are highlighted on the cover and their relevance explained in the Primary survey. Thank you Tomasso at BMJ for continuing to adjust our covers and TOC’s to perfection!
  • We have published articles that explain statistical concepts that appear in some of our research papers.
  • Article length: To the extent possible, we have attempted to keep all research articles to 3000 words or less through careful editorial suggestions, and have expanded the use of the “short report”. Shorter articles are preferred by busy readers.
  • Topic headings: We have recently created topic headings for groups of articles published in a single issue (e.g. Paeditrics, Geriatrics, Meeting Demand for Services) to help guide the reader to articles that may have special interest in.

Non-research articles that provide perspective, education, and insight. For example:

  • We launched the Top Ten, a brief review article that allows readers to quickly obtain new information, eg.. Top Ten Apps for the Clinician, Top Ten Ways to introduce In Situ Sim; Teaching Tips, etc.
  • The View from Here – This first person narrative allows readers to learn aboutunique experiences in practicing emergency medicine, or experiences that may change how they practice. Examples have included clinical experiences in limited resource countries, working with the elderly in the EDs, being a pioneer in the early days of emergency medicine.
  • Reviews: We continue to [publish both narrative and systematic reviews. However, we have begun a new type of review – Expert Practice Review. Experts are asked to address clinical questions that are relevant to the emergency physician or prehospital practitioner at the point of care. References are minimized to only those that have formed the experts’ opinion on those specific issues. The first of these is being published in February and a second is about to be accepted. Two others are currently in progress.
  • In Perspective – While some journals do a “journal review” where they cite a half dozen papers of interest from another journal, we feel that this is not very educational for our readers. For this reason, we’ve started the In Perspective series, where an expert in the field discusses the implications of recent research. Thus far we’ve run these on chest pain diagnosis, frequent use of emergency departments, the new ATLS guidelines, the association of costs of care and outcomes. These have gotten excellent coverage on social media.
  • Innovations in Emergency Medicine – These are short reports on new ways of delivering health care or adjunctive services. They have included a visual triage method for limited resource countries and a new legal service for victims of trauma. These innovations are often difficult to test formally, but generally have some metrics showing their success.
  • Image Challenge – Images in EM was converted to a quiz to provide interactive content and self-assessment. 

Social Media

Overall in the past year, our altmetrics scores appear to have improved from prior. This is difficult to evaluate as we don’t have a “journal” score, but on browsing our website, I see more high numbers than I have in the past.

  • “Predicting outcomes in traumatic out-of-hospital cardiac arrest: the relevance of Utstein factors” Altmetrics 125
  • Relationship between non-technical skills and technical performance during cardiopulmonary resuscitation: does stress have an influence? Altmetric 131
  • Ibuprofen versus placebo effect on acute kidney injury in ultramarathons: a randomised controlled trial 14 2 (Picked up by 10 news outlets including Outside, Newsday, Medscape, Yahoo News)
  • Increased weekend mortality is not associated with adoption of seven day standards. Altmetric 245.
  • We have a monthly podcast of our primary survey..
  • We have 30 K Twitter followers.
  • A fantastic blog
  • We have an automated feed of articles when they are first released on line. 

We have clearly done a lot in terms of our quality, relevance and recognition. But we are not resting here. We have a great product. We need to ensure its sustainability and do more to let others know about what we have to offer! In the next years we will continue to work on improving our media presence, commissioning thought- provoking commentary, truly useful expert reviews. We will continue to work on shortening n turn-around times (Shout out to Princess and the EMJ team at BMJ!) and finding ways to attract high quality research papers.

Thank you all for your hard work to this point and I look forward to taking the next steps together with you.

All the best for 2018!

Ellen Weber