Nick Adkins is a healthcare executive and serial healthcare entrepreneur from Nashville, Tennessee. He is the creator of the exponentially growing #pinksocks movement. #pinksocks is a global community trying to the positively affect the world, largely through a variety of missions within healthcare and #digitalhealth.
Nick used to wear a suit and tie to work. After a life-changing experience at Burning Man Festival in 2010 he started wearing a kilt every day and moved to Portland, Oregon. He now spends his time keynoting at conferences around the world about the importance of human connection (usually in the context of healthcare), and focusing on the abundance of love that exists in our world as opposed to media-fuelled fear. He also serves on the advisory board at Cloudbreak Health, a leading telemedicine company in the US.
The Burning Man principle of Gifting gave birth the #pinksocks movement.
00:24 – How I became exposed to Nick’s work
03:46 – Telemedicine
14:05 – Poor uptake of new technology in NHS hospitals/more on telemedicine
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 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.
During my six months working in the paediatric emergency department, I’ve noticed that the vast majority of young children are petrified of needles.
A huge amount is at stake when a child requires an intravenous cannula. If the procedure is unsuccessful:
It increases the time prior to administration of treatment (like IV antibiotics).
It means subjecting the child to another dose of pain during the second attempt. That prospect could make them agitated and even more difficult to cannulate the second time. Repeated failures could mean a procedural sedation or intraossesous access is required. Potentially risky stuff.
It’s time-consuming for staff. This is expensive and potentially dangerous as staff are unable to be elsewhere in a busy department.
Particularly harrowing experiences might lead to crippling needle phobia or PTSD. This could be problematic for future hospital visits, particularly if the child turns out to have a chronic illness like diabetes..
During intravenous cannulation (or any other painful procedure in the ED), the gold standard includes the services of a play specialist working together with a parent +/- an iPad/handheld electronic device. However, if the child catches a glimpse of the needle, it doesn’t matter how expertly the child is being distracted – it tends to be game over and brute force is usually required. Experiencing this happen on repeat for 6 months has led me to my lightbulb moment: Virtual reality as a means of procedural distraction in the paediatric ED.
Here is my idea for a small RCT…
Patients in the paediatric ED requiring IV cannulation between the ages of 6-16
Interactive virtual reality experience delivered via Samsung Gear VR head-mounted-display and earphones.
Standard of care. This would include the presence of a parent, play specialist, and iPad.
Parent-reported pain scoring
play specialist-reported pain scoring
Length of procedure
Number of procedural attempts
We are also considering a concurrent qualitative study of patient experiences of IV cannulation with and without VR.
PonderMed Podcast with Dr. Grimes, “The VR Doctor”
Evidence for procedural distraction
Uman, L. S., Chambers, C. T., McGrath, P. J., & Kisely, S. (2008). A systematic review of randomized controlled trials examining psychological interventions for needle-related procedural pain and distress in children and adolescents: An abbreviated Cochrane review. Journal of Pediatric Psychology, 33, 842–854.
Oliveira NCAC, Gaspardo CM, Linhares MBM. Pain and distress outcomes in infants and children: a systematic review. Braz J Med Biol Res. 2017 Jul 3;50(7):e5984.
Miller K, Tan X, Hobson AD, Khan A, Ziviani J, OʼBrien E, Barua K, McBride CA, Kimble RM. A Prospective Randomized Controlled Trial of Nonpharmacological Pain Management During Intravenous Cannulation in a Pediatric Emergency Department: Pediatric Emergency Care. July 2016 – Volume 32 – Issue 7 – p 444–451.
Moadad N, Kozman K, Shahine R, Ohanian S, Badr LK.Distraction Using the BUZZY for Children During an IV Insertion. J Pediatr Nurs. 2016 Jan-Feb;31(1):64-72.
Evidence for VR and procedural distraction
Gold J. I., Mahrer N. E. Is Virtual Reality Ready for Prime Time in the Medical Space? A Randomized Control Trial of Pediatric Virtual Reality for Acute Procedural Pain Management. J Pediatr Psychol. 2017 Oct 19. (See video above for more info on this study)
Gold, J. I., Kim, S. H., Kant, A. J., Joseph, M. H., & Rizzo, A. S. (2006). Effectiveness of virtual reality for paediatric pain distraction during IV placement. CyberPsychology and Behavior, 9, 207–212.
Gold J. I., Reger G., & Rizzo A. A., et al. Virtual reality in outpatient phlebotomy: evaluating pediatric pain distraction during blood draw. Presented at the 10th Annual Poster Session of the Saban Research Institute. Los Angeles: Children’s Hospital Los Angeles; The Journal of Pain 6(3), Supplement, Page S57, March 2005.
Hua, Y., Qiu, R., Yao, W. Y., Zhang, Q., & Chen, X. L. (2015). The effect of virtual reality distraction on pain relief during dressing changes in children with chronic wounds on lower limbs. Pain Management Nursing, 16, 685–691.
Hoffman, H. G., Patterson, D. R., Seibel, E., Soltani, M., Jewett-Leahy, L., & Sharar, S. R. (2008). Virtual reality pain control during burn wound debridement in the hydrotank. The Clinical Journal of Pain, 24, 299–304.
Das, D. A., Grimmer, K. A., Sparnon, A. L., McRae, S. E., & Thomas, B. H. (2005). The efficacy of playing a virtual reality game in modulating pain for children with acute burn injuries: a randomized controlled trial [ISRCTN87413556]. BMC Pediatrics, 5, 1.