How doctors save patients in virtual reality

Pirogov told about his own method of training doctors using VR simulators at RNIMU

How VR technologies are used to train doctors who write scripts for simulators of internal bleeding and anaphylactic shock, can virtual reality replace real medical practice, and what side effects work with such simulators threatens doctors, the head of the high-tech educational development team told the elements of RNIMU, N. I. Pirogova Maria Potemkina.

What is the place of VR technologies in medical education?

I would call it another educational technique. Simulators created using VR technologies provide high reliability and the maximum effect of immersion in the real work of a doctor. The student can assess the patient's condition, including using instrumental research methods and conduct treatment, including cardiopulmonary resuscitation.

VR simulators are now used in many medical schools. But at RNIMU we ourselves create a virtual environment.

Our task is to develop a VR simulator that the doctor will believe in. Not the one in which he will enter, look and say: “Children's toy!”, But in which he will really feel at the workplace.

And we literally check everything on ourselves. For example, I am a doctor, and I worked in a polyclinic for 15 years. And if I believe in what we have done, then I believe that other doctors will also believe in it. I still remember the moment when I first put on glasses with our program and saw the first patient, and how he looked at me. I believed.

How many such simulators have already been developed?

We have created three independent simulators. The idea first appeared in 2018 and was implemented in 2019 — it was a simulator for working out algorithms for emergency care for clinical doctors.

The location of the simulator is the treatment room of the polyclinic. The doctor is faced with one of six clinical situations: an acute coronary syndrome with pulmonary edema, acute coronary syndrome with cardiogenic shock, syncope, anaphylactic shock, internal bleeding, cardiopulmonary resuscitation. The situation is unknown in advance. The doctor must examine the patient, determine the most life-threatening symptoms and provide assistance.

We then created a similar simulator for doctors and paramedics. Here, the location was an ambulance, the size, and furnishings of which correspond to the real ones.

The third simulator is the provision of emergency surgical care for surgeons, anesthesiologists, resuscitators, and emergency physicians. The location is the operating room.

The development of this program was much more difficult than the previous ones since the very precise use of surgical instruments is difficult in virtual reality.

It is necessary to take into account the specifics of working with each individual tool. This simulator is already working, but we plan to further develop it.

What does this virtual environment look like?

The simulators work in three modes. Demo - the easiest, with many tips. It is needed to adopt a specialist in virtual reality, as well as to show how to behave correctly in a particular situation.

The second mode is training, where a specialist can try to do everything himself. If he made a mistake several times, he will be corrected, or he can ask for help himself if he does not know what to do next.

And the third is the control mode. Everything in it is like in life - a person feels bad, and it gets worse with every second. Time is our main enemy, and procrastination is like death. And this is true, a real patient can die if nothing is done or something is done wrong.

In this mode, the specialist must independently choose the drugs, dosage, method, and place of administration. We have everything - the possibility of introducing the wrong drugs, underdosing or overdosing, and how all this will affect the patient. We tried to work out the scenarios as accurately as possible from a medical point of view. So that our patient is not a static object that he is “alive”.

Do you even prescribe a lethal outcome?

Yes, sure. And then the next block is connected - cardiopulmonary resuscitation. You can save your patient! There is also variability in cardiopulmonary resuscitation. The patient may have asystole or ventricular fibrillation - the actions of the doctor are different. A defibrillator does not always need to be used. It is only in the movies that it is always used. And in fact - no. And you need to understand this and make the right decision.

Thousands of nuances, and dozens of scenario ramifications that we have to think through, and programmers have to prescribe - the main reason that the simulator is being created for so long. And in the end, all this needs to be checked many, many times. For any branching of the scenario, we can reach the end: either to the stabilization of the patient or to clinical death. In my opinion, and in the opinion of experts, VR simulators are valuable because in them we can safely create life-threatening situations for both the doctor and the patient, which we cannot recreate during training.

How is the simulator developed?

This is a big job for scriptwriters and programmers. On average, it takes us about a year to create a simulator, and a team of scriptwriters can number several dozen people. There are several stages. The first is a large pre-clinical part, we come up with and decide which simulator to make, and for which target audience. A virtual reality simulator is a really expensive development, not only in terms of money but also in terms of time. Therefore, our simulators are designed for a wide medical audience.

After we have decided on the goal, idea, theme, and audience, the search for script writers begins. All of our scenarios are based on clinical guidelines, standards, and protocols for providing care. The more professionals are invited from outside at the stage of creating a script, the better it will be worked out. As authors, we invite teachers from our and other medical universities, and various national medical research centers, and ask for all the details in our script. We give an outline of how we see the development of life in this scenario.

It's practically a game. We try to comply with all gaming technologies. We have characters, roles, and plots. By the way, now we even thought about achievements and Easter eggs. So in the near future, we can expect that ratings, titles, and other features will be added to the simulators.

In parallel with this work, the stage of searching for highly qualified technical developers is being launched. We are looking for candidates with extensive experience in the medical field.

And what is the scope of the scenario, taking into account all the scenarios?

Our largest script takes 144 sheets in small print. This is a huge work by a large group of authors. And for technical developers, the difficulty lies in the fact that this is a medical focus. In order to film each action step by step for them, we did everything on mannequins in the simulation center of our university.

The developers and I are trying to understand what can be done in a virtual environment and what is not yet available to us. It makes no sense to paint something that cannot be done reliably. For example, while we cannot provide tactile contact - and we will not be able to for another five years, or even ten. Unfortunately, tactile suits from the cinema are still only at the level of experimental samples. So, if we cannot yet palpate a patient in virtual reality, we do not prescribe it.

Is it difficult to persuade an expert to join the project?

Not all doctors agree to cooperate. The gaming approach is complex and multifactorial. Experts do not always understand why this is necessary. We are looking for those people who are burning, and who are ready to join the project. If they do not understand why they need to prescribe every drug in every dosage and every minimal action, then there will not be such a scenario that we want.

I'm usually glad when a person refuses immediately. He understands that he does not agree with the ideas of gamification, he considers this to be something frivolous. And if he immediately talks about it, it’s easier for us.

And where does the opinion about the frivolity of such an approach come from?

Virtual reality is not perfect, there are no ideal methods. But we are not saying that virtual reality can replace anything. This is not an alternative, but another educational method that will help to gain knowledge, and, most importantly, master the skill in those situations that we cannot offer in life for training our students, and residents. And as an added bonus, she's amazing.

When a person finds himself in virtual reality, he is so involved, so concentrated, so concentrated that, of course, the assimilation of knowledge is high. When working with the simulator, we involve all cognitive systems: we have tips on the plate, tips are given in headphones, and we have the opportunity to take everything and look at it.

We involve the person completely. He is the main character. He does not observe what is happening on the screen. He does not watch movies, he participates in them himself.

And the more reliable our simulator, the more the specialist will believe in what is happening. This emotional response, which a person receives, albeit in virtual reality, also affects digestibility.

Are there any side effects when using simulators?

Someone may feel dizzy, and orientation in space is lost. We suggest you give it a try - you can just take off your helmet at any time. But, as practice shows, almost everyone completes the task to the end.

Especially to reduce the "side effects" in our simulators, we completely got rid of dashing teleportations. In life, we walk with our feet. If you need to go to the foot of the gurney, then we really go to it - no instantaneous movements. This, according to my feelings, leads to less stress on the vestibular apparatus.

Where are the simulators of your design already used?

In the RNRMU itself, many departments use the simulator as one of the educational elements in advanced training programs for doctors. During the training, the teacher is at the computer and sees all the indicators on the screen, can view the protocol of the specialist's actions, and analyze all the mistakes made. The training of teachers is planned in the form of a professional development program at the Department of Organization of Professional Education and Educational Technologies of the FDPO under the guidance of the head of the department, Olga Fedorovna Prirodova.

The VR simulator does not replace the teacher but becomes another innovative tool for experienced hands.

Under the guidance of Professor, Doctor of Medical Sciences Olga Sharhun, an advanced training program for primary care physicians of all specialties “Development of an algorithm for providing emergency and emergency medical care in case of sudden acute diseases and conditions” was developed. The program includes a theoretical part, training in assisting in a VR simulator, and practicing assisting skills on mannequins.

At the Peoples' Friendship University of Russia and at the Moscow Regional Scientific Research Clinical Institute. M. F. Vladimirsky uses our developments. Colleagues themselves chose and purchased equipment that was suitable for them in terms of price and convenience, while we helped and advised with the installation of the program. Now virtual reality equipment is available. Installing the simulator does not require a special computer, a regular, medium power one will do.

Healthcare professionals and medical organizations can download RNIMU VR simulators from the Continuing Medical and Pharmaceutical Education Portal of the Russian Ministry of Health. It's free, but you only need to buy the hardware to use it.

How is it planned to develop the project further?

Firstly, we have plans to finalize the rest of the urgent (urgent) situations that are included in the accreditation scenarios. Secondly, we develop not only VR simulators. Now we are developing a 3D simulator that can be run both on a computer and on the screens of mobile devices.

The 3D simulator contains real clinical situations, scenarios of which were written by experts from leading universities and National Medical Research Centers in seven narrow specialties.

These are complex clinical cases, polymorbid patients, and situations based on real medical practice, and much more. On the Portal of Continuing Medical and Pharmaceutical Education, you can already try this simulator.