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Resuscitation 80 (2009) 489–492
Contents lists available at ScienceDirect
Resuscitation
journa l homepage: www.e lsev ier .com/ lo
Short communication
Virtual hat
resusci
Federico cob
a Department o
b Percro, Scuola
a r t i c l
Article history:
Received 4 Au
Received in re
21 November
Accepted 1 De
Keywords:
Training
Cardiopulmo
Simulation
Virtual realit
Teamwork
as to
equin
n and
tSim
(VR) technologies with specially developed virtual reality software to increase the immersive perception
of emergency scenarios. To evaluate the acceptance of a virtual reality enhanced mannequin (VREM),
Introduct
Simula
care perso
experience
in a fully
acquire cl
through b
plex tasks
powerful t
the fidelity
as absence
and expre
dampness
� A Spanis
in the final o
∗ Correspo
E-mail ad
0300-9572/$
doi:10.1016/jnary resuscitation (CPR)
y
we presented it to a sample of 39 possible users. Each evaluation session involved one trainee and two
instructorswith a standardizedprocedure and scenario: theoperatorwas invitedby the instructor towear
the data-gloves and the head mounted display and was briefly introduced to the scope of the simulation.
The instructor helped the operator familiarize himself with the environment. After the patient’s collapse,
the operator was asked to check the patient’s clinical conditions and start CPR. Finally, the patient started
to recover signs of circulation and the evaluation session was concluded. Each participant was then asked
to respond to aquestionnaire designed to explore the trainee’s perception in the areas of user-friendliness,
realism, and interaction/immersion.
Results: Overall, the evaluation of the system was very positive, as was the feeling of immersion and
realism of the environment and simulation. Overall, 84.6% of the participants judged the virtual reality
experience as interesting and believed that its development could be very useful for healthcare training.
Conclusions: The prototype of the virtual reality enhanced mannequin was well-liked, without interfence
by interaction devices, and deserves full technological development and validation in emergency medical
training.
© 2009 Elsevier Ireland Ltd. All rights reserved.
ion
tion training has been applied to the training of health-
nnel to handle emergency conditions, as it replaces real
s with guided experiences by replicating the real world
interactive approach1,2 and allows medical trainees to
inical experience without involving real patients, both
asic procedural practice and through scenarios of com-
and team training.3 Available full-scale simulators are a
raining tool,which canbe further improvedby increasing
of the simulated patient by eliminating problems such
of overall body animation, particularly facial interaction
ssion, absence of skin changes (e.g., colour, temperature,
, sweating, etc.), which preclude the automatic acqui-
h translated version of the summary of this article appears as Appendix
nline version at doi:10.1016/j.resuscitation.2008.12.016.
nding author. Tel.: +39 03336592670; fax: +39 0516478867.
dress: rareseed@mclink.it (F. Semeraro).
sition of information from clinical signs or a reliable physical
examination.4 We hypothesized that the existing HeartSim 4000
mannequin (utilized for ALS training) could be improved by the
addition of a virtual reality (VR) system, increasing the involvement
and participation of the trainees and, thereby, the effectiveness of
the learning experience. To this end, we developed a prototype of
virtual reality enhanced mannequin (VREM).
Virtual reality may represent a powerful tool for allowing the
addition of plausible features of patient aspect, facilitating interac-
tion to mannequin simulators.5–7 The level of interaction between
the participant and virtual characters does not currently play an
important enough role, as demonstrated by the studies on sense of
presence experiences induced by the virtual environment.8,9 Inter-
action devices (data-gloves and head mounted display) represent
the necessary link to allow for physical interaction with virtual
objects but, although widely utilized for specific task trainers, these
have not been exploited for full-scale simulation.
The acceptance of such devices by trainees needed to be ver-
ified. The opportunity for such evaluation was offered by the
Italian Resuscitation Council 2008 annual congress, which gathers
– see front matter © 2009 Elsevier Ireland Ltd. All rights reserved.
.resuscitation.2008.12.016reality enhanced mannequin (VREM) t
tation experts�
Semeraroa,∗, Antonio Frisolib, Massimo Bergamas
f Anaesthesia and Intensive Care, Ospedale Maggiore, Bologna, Italy
Superiore Sant’Anna, Pisa, Italy
e i n f o
gust 2008
vised form
2008
cember 2008
a b s t r a c t
Summary: The objective of this study w
type of virtual reality enhanced mann
to participate in the evaluation sessio
Methods: A commercial Laerdal Hearcate / resusc i ta t ion
is well received by
, Erga L. Cerchiari a
test acceptance of, and interest in, a newly developed proto-
(VREM) on a sample of congress attendees who volunteered
to respond to a specifically designed questionnaire.
4000 mannequin was developed to integrate virtual reality
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490 F. Semeraro et al. / Resuscitation 80 (2009) 489–492
participants interested in the issues of CPR and related training,
among which a large number of CPR instructors. The goal of this
study was to test the acceptance of and interest in a VREM pro-
totype among a sample of congress attendees who volunteered to
participate in the evaluation session and to respond to a specifically
designed questionnaire.
Materials and methods
The VREM was developed at the PERCRO laboratory, Scuola
Sant’Anna of Pisa, utilizing a commercial Laerdal HeartSim 4000
mannequin connected with VR technologies (data-gloves, head
mounted display and tracking devices) specifically designed for
this application.10,11 The VREM prototype tested was able to ren-
der the main clinical signs and patient’s reactions in an immersive
VR scenario and with a first person perspective. The detailed
description of VR technologies is available in the e-version of the
article.
The subject was able to touch the patient, hold the head of
the patient in his hands, and check the carotid pulse. Real-time
animations were implemented in order to simulate some of the
typical clinical findings indicative of a cardiac arrest, including pro-
gressive skin colour changes and mydriasis. These reverted once
the manoeuvre of the external cardiac compression was success-
ful.
The evaluation session involved one trainee and two instructors
with a standardized procedure and scenario (Figure 1):
1. The operator was invited to wear the data-gloves and the head
mounted display and was briefly introduced to the scope of the
simulation.
2. The instructor helped the operator become familiarized with the
virtual environment in relationshipwith himself and the patient.
3. The patie
“I am not
4. The oper
5. After beginning CPR, the patient started to recover signs of circu-
lation (acute pallor was reverted and the pupils became myotic).
6. The evaluation session was concluded.
Each participant was then asked to respond to a questionnaire.
Thequestionnaire, formulatedbasedona7-point Likert scale (LS),12
was designed to explore the trainee’s perception in the areas of
user-friendliness, realism, and interaction/immersion.
Results
The VREM was tried by 39 users. The sample consisted of
27 (69.2%) men and 12 (30.8%) women, with an average age of
41.9±10.8 years. Only 20.5% had previous experience with Virtual
Reality, 51.3% had a previous experience of training in simulation
centres. The sample included 54% medical doctors, 23% nurses and
23% lay rescuers. Sixty-seven percent were CPR instructors. The
evaluation for each question is reported in detail in Table 1 and
questions are grouped according to three areas: user-friendliness,
realism, and interaction/immersion.
User-friendliness
The difficulty in using and wearing the devices (Q5) was judged
variably with 8 participants judging it difficult (LS >4), 2 judging it
neither easy nor difficult (LS =4), and 29 judging it easy (LS <4). The
difficulty in practicing the cardiac compression (Q8) was judged
as difficult by 11 participants (LS >4) and easy by 28 participants
(LS <4).
Realism
The overall feeling that the patient was present in front of the
person (Q6) and that the virtual hands were moving like the real
(Q7,
signs
dged
IRC 2nt’s voice was then heard in the room. The patient said
feeling well, really bad, I think I’m fainting.”
ator was asked to check the patient’s clinical signs.
hands
arrest
was ju
Figure 1. Two evaluation sessions, NaplesQ10) were both high. The overall realism of cardiac
was judged well (Q9) and the hospital environment
as good (Q11, Q12).
008 Congress.
Page 3
F. Semeraro et al. / Resuscitation 80 (2009) 489–492 491
Table 1
User responses to VREM manikin. Participants rated the following statements using a 7-point Likert scale (1 = completely disagree, 7 = completely agree).
N Mean S.D.
User-friendliness
Q5: 5. It has
Q8: It has be
Realism
Q6: I had the
Q7: I had the
Q9: The pati
Q10: I had th
colour, w
Q11: I had th
Q12: The en
Interaction/im
Q13: The pe
Q14: It was d
Q15: The int
Q16: The inv
Interaction
The perc
as high (Q1
(Q15), and
(Q16).
The diffi
evaluated v
action/imm
Overall,
interesting
for healthca
TheVRs
of immersio
Discussion
This stud
nology wit
emergency
to enhance
cal respons
mannequin
The 39 s
use of devic
interaction/
ation of VRE
as very usef
The add
improve dia
duction of c
the effect o
help task pe
The exte
reviewed.13
training dec
accuracy, an
dard laparo
training.
Emergen
training, wh
resource ma
‘providing f
The effec
ing the hyp
signs of virt
assisted deb
limi
diac
ped
still
syn
effe
al re
tions
unte
st th
s stud
pme
blen
eve o
sion
onclu
nd r
pe o
iasti
s and
move
nt cli
t of
relat
l ent
ent abeen very difficult to wear and use the helmet and the gloves
en difficult to perform external cardiac compressions
feeling that the patient was really present in front of me
feeling that my hands were positioned and oriented as the virtual ones
ent presented the classical signs of cardiac arrest (mydriasis, pale skin)
e feeling that the virtual hands began to look like the real ones, in terms of shape,
rinkledness and other visual features
e impression to be in a real hospital room
vironment of the operation room was very realistic
mersion
rception of the three-dimensional space was very high
ifficult to reach and touch the patient
eraction with the patient was very realistic
olvement in the resuscitation procedure was high
/immersion
eption of the three-dimensional space was evaluated
3), interaction with the patient was judged realistic
the involvement in the intervention manoeuvres high
culty in reaching and touching the patient (Q14) was
ery variably, but the overall answers judged the inter-
ersion to be high.
84.6% of the sample evaluated the VR experience as
and believed that its development could be very useful
re training.
ystemwas found tobeverywell-liked, aswas the feeling
n and the realism of the environment and simulation.
y demonstrates the feasibility of combining VR tech-
h a traditional training mannequin for use during
care training. The resulting VREM prototype was able
the perception of realism and extend the physiologi-
e to treatment beyond that available with traditional
s used during resuscitation training.
ubjects who participated in the session reported the
es to be acceptable, the realism to be very high, and the
immersion realistic, leading to a positive overall evalu-
M. Subjects judged the development of this technology
ul for healthcare training.
ition of VR to traditional emergency care training may
gnostic orientation by adding information by the repro-
linical signs in the virtual patient, provide feedback on
f treatment (e.g., skin colour as index of perfusion) and
The
the car
develo
width)
not yet
The
iologic
evalua
tor vol
among
Thi
develo
VREM
to achi
Conclu
In c
sible a
prototy
enthus
device
finger
differe
ing.
Conflic
No
mercia
represrformance training.
nsive use of VR for surgical training has been recently
The review concluded that for laparoscopic surgery, VR
reased the time needed to complete a task, increased
d decreased errors compared to no training and stan-
scopic training, and was more accurate than video
cy care training, in addition, needs team performance
ich has been shown to be effectively achieved by crisis
nagement (CRM) with high-fidelity simulation,14 with
eedback’ being the most important feature.1
t of the addition of VRwill need to be tested also explor-
othesis that feedback provided by changes in clinical
ual patientsmay improve the effectiveness of the video-
riefing.
Acknowled
We than
for providin
Laerdal Ital
for the tech
Appendix A
Supplem
the online v
References
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39 5.08 1.634
39 5.08 1.282
39 5.71 1.037
39 2.79 2.002
39 5.53 1.133
39 5.66 1.146
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