SIMULATION-BASED MILITARY REGIONAL ANESTHESIA TRAINING SYSTEM
SIMULATION-BASED MILITARY REGIONAL ANESTHESIA TRAINING SYSTEMYi-Je Lim*, Tuan Le, Pablo Valdivia, Neil TardellaEnergid TechnologiesCambridge, MAKenneth CurleyTelemedicine and Advanced Technology Research Center (TATRC),U.S. Army Medical Research and Materiel Command (MRMC)Fort Detrick, MDbody, typically a limb, insensate and weak for a temporaryperiod of time, which allows for ‘painless surgery’ and anextended period of pain relief afterward. Nerve blockshave been associated with faster hospital discharge in theambulatory surgery setting, a reduction in thepostoperative usage of parenteral narcotics, and a potentialimprovement in patient functional recovery. Theplacement of an indwelling perineural or peripheral nervecatheter and continuous infusion of local anestheticsthrough the catheter allows for further extension of thepain-free period, and has been successfully employed inboth inpatient and outpatient settings.ABSTRCTDeployed American troops suffering injuries to theextremities are best treated with regional anesthesia, whichrenders only a portion of the body, such as a limb,insensate. However, it is possible for long-lasting damageto occur when regional anesthesia is improperly applied.Though nerve block procedures present fairly low risk in ahospital setting, the same may not be true on thebattlefield—where severe trauma cases are prevalent andfellowship trained pain management specialists are notalways available. There is a need for all militaryanesthesiologists to undergo training for the administrationof peripheral nerve blocks, yet currently no suitable masstraining curriculum or training system exists. The trainingsystem must be accurate, intuitive, and convenient. Undercontract with the Telemedicine & Advanced TechnologyResearch Center (TATRC), Energid Technologies isdeveloping such a training system. It includes instructionalcontent in a standard, configurable framework, andimmersive simulation of procedures to reinforce theinstructional content.Though nerve block procedures present a fairly lowrisk in a hospital setting, the same may not be true on thebattlefield—where severe trauma cases are prevalent andproperly trained pain management specialists are at apremium. In fact, although anesthesia residents arerequired to complete a minimal number of regionalanesthesia procedures in order to qualify for boardcertification, there is no “certificate of regional anesthesia”to prove competency. There is a need for all militaryanesthesiologists to undergo such training, yet, currentlyno suitable curriculum or training system exists.1. INTRODUCTIONWhat is needed is a training system that teaches allaspects of regional anesthesia. A system that not onlyincludes didactic content and an instructional framework,but also allows the anesthesiologist to practice in a virtualenvironment—with visual, haptic, and auditory feedback.And since the trainer needs to be accessible to allapplicable medical personnel (wherever they might bestationed), it should be small, rugged and portable.The majority of casualties in recent militaryoperations were superficial wounds or wounds to theextremities (Trunkey, 1983; Rush et al., 2007). This waspartly due to the advent of body armor—which reliablyprotects soldiers’ vital organs but leaves their limbsexposed. These types of wounds are well suited totreatment using regional anesthesia, with brings with it ahost of advantages over general anesthesia. As such,regional anesthesia management (such as administeringperipheral nerve blocks) has become a critical part ofcombat casualty care. Unfortunately, adequate training forsuch procedures is currently lacking.The virtual regional anesthesiology trainingsimulation system described in this paper is a cutting-edgeanesthesiology simulator and training system. It can beused for numerous training applications, such as traininganesthesiology residents, practice with new technology orinstruments, rehearsing anesthetic emergencies, andpossibly future testing, certification, or recertification ofanesthesiologists (Meislin, et al., 1997).Over the past decade, the utilization of peripheralnerve blocks for both intraoperative and postoperativeanalgesia, or pain control, has become increasinglypopular. A peripheral nerve block renders a portion of the1
Form ApprovedOMB No. 0704-0188Report Documentation PagePublic reporting burden for the collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data sources, gathering andmaintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information,including suggestions for reducing this burden, to Washington Headquarters Services, Directorate for Information Operations and Reports, 1215 Jefferson Davis Highway, Suite 1204, ArlingtonVA 22202-4302. Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to a penalty for failing to comply with a collection of information if itdoes not display a currently valid OMB control number.1. REPORT DATE2. REPORT TYPEDEC 2008N/A3. DATES COVERED-4. TITLE AND SUBTITLE5a. CONTRACT NUMBERSimulation-Based Military Regional Anesthesia Training System5b. GRANT NUMBER5c. PROGRAM ELEMENT NUMBER6. AUTHOR(S)5d. PROJECT NUMBER5e. TASK NUMBER5f. WORK UNIT NUMBER7. PERFORMING ORGANIZATION NAME(S) AND ADDRESS(ES)8. PERFORMING ORGANIZATIONREPORT NUMBEREnergid Technologies Cambridge, MA9. SPONSORING/MONITORING AGENCY NAME(S) AND ADDRESS(ES)10. SPONSOR/MONITOR’S ACRONYM(S)11. SPONSOR/MONITOR’S REPORTNUMBER(S)12. DISTRIBUTION/AVAILABILITY STATEMENTApproved for public release, distribution unlimited13. SUPPLEMENTARY NOTESSee also ADM002187. Proceedings of the Army Science Conference (26th) Held in Orlando, Florida on 1-4December 2008, The original document contains color images.14. ABSTRACT15. SUBJECT TERMS16. SECURITY CLASSIFICATION OF:a. REPORTb. ABSTRACTc. THIS PAGEunclassifiedunclassifiedunclassified17. LIMITATION OFABSTRACT18. NUMBEROF PAGESUU619a. NAME OFRESPONSIBLE PERSONStandard Form 298 (Rev. 8-98)Prescribed by ANSI Std Z39-18
We have been developing a realistic regionalanesthesia training simulator. The main goal of ourregional anesthesia training simulator is to create a natural,immersive virtual environment unlike any developedbefore, incorporating haptic, visual and auditory feedback.Both stimulator-based and ultrasound imaging guidedregional anesthesia procedures are simulated in the trainingsystem. The innovative devices capable of generatinghaptic feedback during needle insertion, needle injectionand palpation can be applied through a modular design forvarious procedures and curriculums. The simulationsystem provides initial training for students, as well ascontinuity training for seasoned anesthesiologists requiringongoing training for procedures that require significanttechnical skill. Our design is configured using theExtensible Markup Language (XML). Each of the modulesand systems shown in Fig. 1 can be exchanged throughXML. The design is well suited to interface with SCORMcompliant contents (Sharable Content Object ReferenceModel at www.adlnet.gov/scorm/index.cfm).system will graphically, textually, and verbally describethe procedure from beginning to end. Students are able tocycle through the pages describing the block. Fig. 2 belowshows an example of the introductory content for anfemoral nerve block procedure.Fig. 2: Didactic Instructional Trainer; an interactive userinterface for an anesthesia procedure.Fig. 1: Core training modules and systems.2. CORE TRAINING MODULESFig. 3: SCORM-based authoring tool.Energid’s regional anesthesia simulation (RAS)system includes four core training modules:1) Didactic Trainer,2) Anatomy Viewer,3) Technique Trainer, and4) Scenario-Based Trainer.These four components will together provide trainers witha comprehensive and effective training for teaching nerveblock procedures.Energid has developed a SCORM Authoring tool tocompose training packages in the form of a ReusableLearning Object (RLO). This tool can currently be used tocreate and edit SCORM packages where training contentsconsists of HTML text, images, and video clips.We create an easy-to-use approach that allows theMedical Content Authors (MCAs) with little or advancedknowledge on the SCORM to author RLOs. Our approachis a content-based method in which the user first focuseson developing course content and structure using a wizardlike GUI (Graphic User Interface). The subsequentoptional steps are creating and organizing resources (e.g.html files, images, videos etc.) that support the content andstructure. We also support course structure templates andHTML templates for rapid training package development.Once the MCA selects a course template, the wizard2.1 Didactic TrainerThe design of this module is centered on a SCORM compliant core for authoring and delivering trainingcontent. The interactive SCORM-compliant didacticinstructional trainer facilitates the development of reusablelearning content within a common technical framework.The instructional narrative component of the training2
allows the user to select a predefined HTML template thatrepresents the presentation of a training page. A GUI willdisplay the selected course structure (see Fig. 3) and allowthe MCA to edit the content and structure. This will bedone using a Resource Editor and Activity Editor.operative techniques, specifically needle insertion andsyringe injection (Lim, 2008). An additional embedded inour trainer is the performance measurement that assessesthe user’s Task Performance Levels (TPLs). Fig. 5 showsthe needle insertion trainer session through the techniquetrainer GUI.2.2 Anatomy TrainerThe anatomy viewer allows trainees to explore richlydetailed anatomy in a 3D graphical environment whileselecting anatomical features of interest for visualenhancement. Users can view anatomical structures fromany perspective, and create ‘flythroughs’. The AnatomySelector Dialog traverses the model and creates a tree ofanatomy components (see Fig. 4). The user may select agroup of anatomical features (e.g. the nervous system) orsub-regions for display. A transparency level can bespecified for non-selected components which helpshighlight the structure of interest. The Anatomy Vieweralso allows the user to zoom in and zoom out of the 3Dmodel and adjust the 3D model’s position and view angle.Fig. 5: Technique Trainer.2.4 Scenario-Based TrainerScenario-based simulation has the potential torevolutionize surgical training. Training with scenarioswill result in better performance than general training in avariety of manual skills (Noble, 1970). Another obvioussupporting argument for scenario-based training is theissue of developing surgical judgment, that is, clinicaldecision making. Energid’s scenario-based trainer takesstudents through an entire simulated procedure from startto finish, allowing for multiple paths to completion withboth common and rare complications built in. Theauthoring tool also allows for creation of new scenarios.Decision making is scored providing direct feedback tostudents about the appropriateness of their choices. Fig. 6presents the scenario-based trainer GUI design. The GUIdesign include better training content outline, imagescaling, vital sign display and Q&A selection and display.(a)(b)Fig. 4: Anatomy Viewer. (a) A 3D patient model shownwith a transparency level specified by the user through theanatomy selector and (b) a patient model with a mangledlower extremity.2.3 Technique TrainerThe technique trainer is used to practice specifictechniques within the simulator. The user can select aparticular technique within the selected procedure. Onecomponent of the trainer, for example with the MagnetoRheological (MR) - fluid based haptic device (discussed insection 3.1), allows for simulated practice of specificFig. 6: Scenario-Based Trainer.3
nerve block procedures in order to properly train painmanagement specialists.3. NOVEL SKILL TRAINERSThe Energid RAS trainer includes innovative devicescapable of generating haptic feedback during needleinsertion, injection and palpation through MR fluid controland tactile display systems - controllable actuator arrays enhanced with the development of modular software andalgorithms, configurable procedures and scenarios, andintegrated training modules. Anesthesiologists will holdand manipulate tools, interact visually with the virtualpatient model and simulated ultrasound images, andinteract verbally with patients, just as they would in a realprocedure.For simulation of the syringe injection process, aregular syringe is filled with MR fluid. By controlling theintensity of the electromagnetic field composing anelectromagnetic field winding the viscosity of the MRfluid can be controlled in a way that mimics syringeinjection force. The needle injection flow speed isdetermined by the regional anesthesia procedure beingsimulated and the tissue models involved in the procedure.3.1 MR Haptic DeviceMR fluid is a type of controllable “smart material”whose rheological properties may be rapidly varied by theapplication of a magnetic field (Magneto-RheologicalTechnology at http://www.lord.com). This interestingproperty has brought the possibility to use the MR fluid todevelop haptic devices (Scilingo, et al., 2003; Li, et al.,2004; Liu, et al., 2006).In this research, we develop a pair of MR fluid basedhaptic systems for simulating needle insertion and syringeinjection procedures. We use the essential characteristic ofMR fluid, a controllable yield strength (changeable inmilliseconds under a magnetic field), to impose simulatedforces on a nerve block needle used in regional anesthesiaprocedures. We employ our customized needle trackingalgorithm to determine the position and orientation of theneedle. (a)MR fluid-based Needle Insertion Haptic DeviceThe haptic system for needle insertion consists of anelectromagnetic field winding and an MR fluid chamber.(see Fig. 7) By controlling the magnetic field strengthinside of the MR fluid chamber, the viscosity of the MRfluid can be changed in such a way that the needle resistiveforce is created mimicking the actual muscle/tissueviscosity of the human body. Hence, the controllablehaptic feedback is generated in the system. Theperformance of the MR fluid haptic system may bedetermined by the MR fluid (the base density andviscosity) and winding unit (the strength of magneticfield). (b)(c)Fig. 7: MR fluid-based needle insertion Haptic device; (a)An illustration of the flux flow, (b) the exploded systemcomponents, (c) the MR haptic device with a force sensor.3.2 Tactile Palpation DeviceThe tactile understanding of anatomy is of enormousimportance during nerve block procedures. This calls forthe development of a novel tactile feedback technology tolocate anatomic structures with palpation.A welldesigned palpation haptic device can improve the trainee’sinteractive perception of the patient’s anatomy structure.Energid’s tactile palpation device aims to achieve highfidelity tactile feedback through a configurable platform.MR fluid-based Syringe Injection Haptic DeviceAnesthesiologists normally rely on a subjectiveevaluation of possible abnormal resistance to injectionwhile performing a nerve block. A greater force requiredto perform the injection is believed to associate withintraneural injection. Therefore, simulation of the syringeinjection process with controllable pressure is crucial to4
Devices for tactile display systems we are developingemploy arrays of independently controllable actuatorelements that are able to exert forces in normal direction tothe user’s skin surface. By adequate control of theactuators, an impression, similar to the direct touch of anobject, can be artificially generated.produced a significant improvement of nerve detectionunder direct visualization (Peterson, et al., 2002). Flexibleand real-time image acquisition requires that ultrasoundimaging be able to translate and rotate without restriction.One of the important objectives of the anesthesia trainingsystem is to provide virtual ultrasound images from thetransducers at arbitrary locations and angles. We employan interactive clipping plane algorithm to create dynamiccross sections of anatomy structures on the ultrasound scanplane with a synthetic noise processor and Blob analysisalgorithm (see Fig. 9). The simulated ultrasound image isrendered graphically on the display based on the probeposition and angle.As shown in Fig. 8, the main components in thissystem are a high-density pin array, a deformable skinlayer to mimic virtual human model, a positioning system,and an actuator to reconfigure skin profiles by preciselycontrolling the pin array. The advantage of this design isthat it can mimic touch sensing of virtual objects in a highresolution, high fidelity and high force level thatconventional haptic systems lack.4. RESULTSEnergid’s regional anesthesia simulation systemdelivers the total integrated spectrum of medical trainingmodalities, including didactic instructional course,anatomy viewer, technique trainer, and scenario-basedtrainer. Our system modules have achieved reusability andinteroperability by the SCORM specification. TheSCORM-compliant didactic trainer browses didacticcurriculum which embed text, images, and video clips. TheSCORM-based authoring tool allows instructor to developand edit training contents.Energid develop a pair of MR fluid based hapticsystems for providing accurate haptic feedback for needleinsertion and needle injection. The MR haptic systemswill provide accurate haptic feedback and help the traineeeffectively learn the psychomotor skills necessary forregional anesthesia procedures. A novel tactile palpationdevice will provide touch sensing of virtual objects in ahigh resolution, high fidelity and high force level thatconventional haptic systems lack. The use of ultrasoundguidance offers significant benefits to perform regionalnerve blocks. The simulated ultrasound image guidessimulation is integrated into our comprehensive trainingsystem. A schematic illustration of the RAS system for thenerve block is shown in Fig. 10 below.Fig. 8: A prototype design of a tactile palpation device.5. CONCLUSIONSEnergid Technologies made great strides toward ourgoal of creating a comprehensive, state-of-the-art regionalanesthesia simulation system. Through a modular designand innovative components, such as the anesthesia trainingmodules, the palpation haptic feedback device, the MRfluid based needle insertion devices, and the simulatedultrasound image-guided training module, our system willsupport multiple training procedures and will beparticularly beneficial to battlefield regional anesthesiatraining. The RAS training system uses a natural,Fig. 9: A synthetic ultrasound image3.3 Simulated Ultrasound Image Guided Nerve BlockWith the aim of verifying the block and increasing thecorresponding success rate, the use of ultrasound (US) has5
immersive virtual environment, incorporating haptic,visual and auditory feedback in the simulation.ReferencesLi, W.H., Du, H., Guo, N.Q., and Kosasih, P.B., 2004:Magnetorheological fluids based haptic device, SensorReview, 24(1), 68-73(6).Lim, Y.-J., Valdivia, P., Chang, C.-Y., and Tardella, N., 2008:MR Fluid Haptic System for Regional Anesthesia TrainingSimulation, Proc. of Medicine Meets Virtual Reality(MMVR) 16, 132:248-53.Liu, B., Li, W. H., Kosasih, P. B., and Zhang, X.Z., 2006:Development of an MR-brake-based haptic device, SmartMater. Struct., 15, 1960-66.Meislin, H., Criss, E. A. et al., 1997: Fatal Trauma: The ModalDistribution of Time to Death Is a Function of PatientDemographics and Regional Resources, Journal of TraumaInjury Infection & Critical Care, 43(3), 433-440.Noble, C., 1970: Acquisition of Pursuit tracking skills underextended
Energid’s regional anesthesia simulation (RAS) system includes four core training modules: 1) Didactic Trainer, 2) Anatomy Viewer, 3) Technique Trainer, and 4) Scenario-Based Trainer. These four components will together provide trainers with a comprehensive and effective training for teaching nerve block procedures. 2.1 Didactic Trainer
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