Ian Dunbar joined Cheshire Fire and Rescue Service in 1992 at the age of 17. He spent 19 years there and rose to the role of Watch Manager undertaking several operational and specialist roles.
In 2005 he became a road traffic collision instructor and spent the next 5 years training firefighters and other emergency personnel in the technical and medical aspects of vehicle extrication. In 2005 he became a faculty member of Anaesthesia, Trauma and Critical Care Group and also joined the United Kingdom Rescue Organisation (UKRO) as an assessor. He quickly qualified not only at regional and national level but in 2010 he assessed at the World Rescue Challenge in Ireland. Whilst at this event he was approached by Holmatro, the world leader in manufacture of hydraulic rescue tools and offered a position as their permanent consultant; He and his family made the life changing decision to leave the Fire and Rescue Service and the country of their birth and relocate to the Netherlands to take up their offer.
In the next 6 years Ian travelled to more than 100 countries to train and consult with emergency service organisations and also found time to write a critically acclaimed book; Vehicle Extrication Techniques. He also established a global extrication training concept known as Rescue Experience with the stated aim of delivering the latest, research led technical and medical rescue information to rescuers from all agencies.
Working closely with research and development colleagues, Ian also played a major part in the development of rescue products during his time with the company. In 2017 Ian and his family decided it was time to relocate back to the UK for family reasons and on February 28 th 2017 he left his position with Holmatro, taking with him many life changing memories and experiences.
As promised here is a very personal view of VR - from the outset I think VR has a few flaws - and much prefer AR strategies,,, We are still testing it though and trying to involve it in our mixed reality strategy....
Definition of Virtual Reality taken from the new SSIH Healthcare simulation dictionary.
VR = The use of computer technology to create an interactive three dimensional world in which the objects have a sense of spatial presence; virtual environment and virtual world are synonyms for virtual reality (M&S Glossary). • A computer-generated three-dimensional environment that gives an immersion effect.
Virtual reality (VR) takes the user to an entirely new environment, computer-generated or filmed, through a headset, whereas augmented reality (AR) shows a computer generated image interacting with the physical objects around it through a screen, a projection or headset. Or as we do - projected onto the walls ! (Reverse Augmentation)
For this post I’ll mostly be focusing on VR. and will cover AR in the next blog..
I am afraid I believe VR still has a few issues
Only one person at a time can usually see the image... because each headset is separate, this tends to reduce the opportunity to collaborate (an essential skill in most of healthcare.)
Think about it... A lot of our work is about us seeing the same thing, and communicating with our colleagues - conveying emotion and empathy with our eyes, body language etc.
With VR - its very difficult to see the same thing as your colleague.. its very difficult to share an experience with a completely blacked out headset attached to our eyes.
VR may have a use in exploring areas of anatomy - or environmental / situational awareness, but it may not be much use for group education / day to day education - compared with AR and Mixed reality strategies which better allow for collaboration.
As an educator I cannot see exactly what you can see - Each headset is not usually connected to another - so as educators we often struggle to control the student experience...
We don't really know that our student experienced what we wanted them to experience.
"I feel sick.. Nausea and wearing of Headsets is an issue
When you read all of the science associated with VR they try to explain how our eyes work - to see things well we need convergence and focus.
When we are wearing a VR headset we have an image just inches away from our eyes - which has been designed to look as though it is many feet away...
That causes confusion to our brains...
'Am I Hallucinating?'
I must have eaten a 'magic mushroom'
For the moment there are drawbacks with VR that maybe don't exist as much in Augmented Reality solutions - because we can often 'see through' the headset. But we shouldn't write off VR just yet.
What are the types of virtual reality products on the market at the moment?
The majority of devices available on the market come in the form of head mounted displays. Here are a few of the more commonly used ones:
A virtual reality headset with integrated headphones and rotational tracking, it is targeted at consumers and requires connection to a high-end PC in order to work.
I've used Oculus and it is effective for gaming...
For those wanting a more immersive experience and want to use VR without the aid of an expensive PC, this VR headset connects to your PlayStation 4 via a cable and isn’t phone-based.
I've recently invested in the PS4 in a hope of better establishing my educational use of VR
A VR headset that is connected to a high-end PC tower via a cable. So far it’s been used for mainly gaming but this is likely to change over the coming years.
The vive has many links to haptic feedback devices - a big plus.
As a wearer of glasses, and having recently trialled the Vive, this device does not allow for focus adjustments, making the experience blurry since my glasses need to be removed prior to use.
One of the most lo-fi VR options, Google Cardboard is a foldout VR viewer made of cardboard that a user slots their smartphone into. It is intended to encourage development in VR applications given its low cost.
Google cardboard camera allows users to make their own VR videos.
I love the concept of google cardboard and cardboard camera - affordable fun experiences - easy to build content and give a simple experience. A big tick!
Samsung Gear VR
Uses your smartphone and has been promoted as a never seen before entertainment experience, offering 360 degree videos, photos and gaming.
How could virtual reality be used in different industries?
VR and AR have potential to change the way we live, often promising a future straight out of a sci-fi novel. But will that promise ever be fulfilled?
Well, I guess excitement over the future of VR/AR is certainly still going strong: it is said that 65% of UK businesses planned to use VR in the future.
Learning and development professionals in particular, are excited about it’s application to learning. For a sector that can often move quite slowly, products like VR/AR offer new and exciting ways to deliver learning; early use suggests that technical training, events, health and safety and on-boarding/induction could all be possible areas to consider when it comes to VR. Virtual walk around your new environment.
In paramedic education we use VR for checking scenes and for aspects of our anatomy teaching, but at the Academy of Professional Development we prefer to work with content that can be cross platform - VR Headset, AR Classroom, IPad or computer / phone review.
We are developing interactive elements and ways of capturing affordable experiences from VR.
VR holds possibilities for other sectors of Healthcare too, let’s have a look at just a few of them:
There are many ways VR is being used in healthcare, but some of the most interesting fall into the remit of : practicing
You don’t normally get practice runs when it comes to healthcare, or at least the practice runs aren’t especially realistic.
This especially true when it comes to surgery, or invasive procedures - which is tricky when students need to have a thorough understanding of standard procedures and experienced professionals need to learn new or high-risk procedures regularly. This is where VR comes in: using virtual models of humans and VR surgeons are able to get a much more realistic experience of what it might be like to work on a real person.
First do no harm... Perfect practice makes perfect VR also presents new ways for healthcare to become more connected. For instance VR has been used to offer window into surgery, which allows you to view surgery live from all over the world – almost as if you’re in the room. Live VR streaming has been successful recently - by Dr Shafi Ahmed
VR and CPD / Statutory and Mandatory training
Work training all too often is dull for employees: it involves clicking through some dodgy animations and trying to trick the timing system into thinking you’ve spent the right amount of time doing an exercise. It has become a tick box exercise rather than a real world learning opportunity.
This is a shame...
Some E'learning / Training it might involve sitting through an out of date video or series of lectures. And for employers it can often be expensive and difficult to organise.
We've been busy experimenting with addressing all of these concepts for Paramedic education, and I guess the constraints of VR make it a strategy that we don't use very often. We are still experimenting and developing VR content - but for cross platform delivery.
VR is being studied for its use in PTSD, VR is being used as a distraction therapy for pain relief and many other clinical uses are being trialled - these will be subject to a separate blog post.
Thanks to mr Will Cranmer for his Technical Support and knowledge. And David Salt and Chris Porter for their ability to generate amazing content.
The next article will look at some of the AR / Mixed reality methods - how they are employed, and how these can be used for simulation / Paramedic education.
I will be in Orlando at IMSH next week - so lets see what the new world of simulation can offer.
The advantages of simulation?
Note... As I write this blog I am trying to keep the simulation theories to a high level before we delve into the individual strategies such as In-situ simulation, Augmented Reality and Virtual Reality simulation, Mixed Reality simulation, Computer Assisted simulation, and Immersive Interactive education.
In the previous blog post we have discussed the main academic arguments surrounding fidelity and suggested that within simulation fidelity is a subjective matter.
We also reviewed the 3 MAIN COMPONENTS or aims of medical simulation - Equipment - Environment and Psychology.
A couple of useful papers have outlined the benefits of simulation in healthcare and are summarised briefly below
Advantages (Moorthy, Vincent, & Darzi, 2005), (Brooks, Moriarty, & Welyczko, 2010)
Simulation allows participants to purposely undertake high-risk activities or procedural tasks within a safe environment without dangerous implications to themselves or their patients.
( Often referred to as the canary in mineshaft theory).
Rather than sitting through a training lecture, trainees can practice what they have learnt, and quickly learn from any mistakes without serious implications.
Simulation based curricula have been developed in Nursing education and many traditional EMS education programmes have moved towards a blend of strategies - steadily seeing a removal of the traditional lecture based - force fed type of learning.
Simulation is not always able to completely re-create real-life situations. And if the fidelity drops for just one second it can be very difficult to get the student back into the moment of suspended belief!
Not all students / situations being created / tested by simulation are suitable for this methodology.
Some Simulators can be very expensive and require constant updates and maintenance.
It takes effort - 'lots of effort' to create meaningful experiences.
Many pieces of simulation equipment (Simulators, Monitors and other props) are reliant upon directly plugged in power sources, and are often not waterproof or easily transported, some are fragile.
Not every situation can be simulated. Most importantly we can only really simulate things that we know...
We cannot use simulation for example to test a new drug - still under trial... Never yet tested on humans - since such a simulation would not be able to predict every side effect to an unknown drug in an unknown patient population. We could of course simulate the delivery and other aspects of drug delivery.
The results and feedback are only as effective as the actual training provided, and the person / persons running the simulation: this is important since often too little emphasis is put onto the personal reflection, and peer review elements of a simulation event.
Our Staff running the simulator need to be trained on how to use the software and/or hardware and this takes up time and costs money. (Magician and Wand) They need to be clinically competent and able to understand the aspects of technical accuracy in order to feed back.
Gray (2002) suggests that "all simulation is pretend".. And students are never really subjected to the consequences for mistakes which may result in students under performing and not being fully engaged in the training, thus producing inaccurate results.
Some students / participants can be unwilling to learn from their mistakes, whilst other students/ participants can be unwilling to engage, or may-not possess the ability to imagine.
Some students / participants get better at being tested - and some students/ participants learn how to play the 'simulation game' rather than how to treat real patients.
........As an overview - hopefully all of the content above obvious to everybody who runs a simulation...
So lets go a little further with how things are developing in the 21st century
3d printing and new technologies have enabled the development of tissues and bones and the creation of affordable home made manikins and models.. these allow for clinicians themselves to become the ones building the models for simulation...
Some of the most challenging manikins are being built in peoples garages... the recent "wooky" intubation model and emisis system - The so called "Salad" system... are superb examples of how clinicians have made their own manikins - built because the lessons they can create are better than with they can achieve with more traditional tools.
It is becoming socially unacceptable to use human cadevers if other tools are available, and, it is becoming unacceptable to use animal models if other models are available.
We rarely see many of the "unusual" events that we used to see - Healthcare is improving to such in ways that some conditions are now rare - simulation can enable us to practice for the more unusual as well as the every day essentials to clinical practice.
The list of reasons to try and develop our simulation based strategies appears never ending, although the evidence that education via simulation really effects delivery of better care is still unfortunately lacking.
One key thing that many of the Modern Educators have learned is to make the learning event a fun but challenging process
Within the SMACC community we see amazing innovations presented every year - designed to teach the practical lessons essential to clinical practice.
In the next 'foundation of simulation' blog article - we will discuss Virtual and Augmented Realities - reviewing the technologies themselves and why 'headset and goggle based simulation' may have problems for healthcare education.
Sorry....I am heading off to the Middle East to review an amazing simulation facility - so next blog wont be until this time next week...
Brooks, N., Moriarty, A., & Welyczko, N. (2010). Implementing simulated practice learning for nursing students. Nursing Standard, 24(20), 41. Retrieved from http://go.galegroup.com.ezproxy.ecu.edu.au/ps/i.do?id=GALE%7CA219374229&v=2.1&u=cowan&it=r&p=AONE&sw=w&asid=46732320b5d0a6aec241ece3377893c9
Gray, W. D. (2002). Simulated Task Environments: The Role of High-Fidelity Simulations,Scaled Worlds, Synthetic Environments,and Laboratory Tasks in Basic and Applied Cognitive Research. Cognitive Science Quarterly, 2, 205-227.
Moorthy, K., Vincent, C., & Darzi, A. (2005). Simulation Based Training. British Medical Journal, 330, 493-494. doi:10.1136/bmj.330.7490.493
Beaubien JM, Baker DP. The use of simulation for training teamwork skills in health care: how low can you go? Qual Saf Health Care. 2004;13: i51
For great Video Resources - follow Dr Tim - http://kidocs.org/talks-vids/
Previous article on paramedic competence - published online http://healthysimulation.com/2858/designing-prehospital-medical-simulation-scenarios/
2016 has been a year of product development and greater understanding of the simulation world on a global scale... I have started to write a new theoretical outline for immersive education since my personal belief is that the traditional educational pedagogies are being left behind by the technologies now available to us.
I propose to try and write an article each week during 2017 explaining the key theories of medical simulation in the hope that those of you who follow these ramblings can apply these to your own practise. I will explain how we can use new technology and why and how these technologies add to the saving of lives in healthcare education.
Simulation is a fast growing global healthcare business and within healthcare we are just starting to understand the benefits of using our new found educational techniques and technologies to enhance patient care.
Integrating the virtual, holographic and augmented worlds into immersive experiences we will have to design new ways of thinking and ensuring engagement is linked to patient benefit.
The basic pretexts of a medical simulation haven't changed but the technologies available to educators goes way beyond those found in most "high fidelity" simulation facilities.
Many people use a simulator to try and establish deficiencies in student performance... To identify training needs... To test systems and find fault...
The simulator has become " the canary in the mineshaft" a phrase used by Gallagher and Isenberg in their book Simulation in Anaesthesia ( 2007)
Back in the nineteenth century, when coal mining was a very dangerous profession (even more dangerous than it is today), miners took a caged canary down into mines, and watched them with anxious eyes. If the canary suddenly dropped dead, that meant that the deadly gas, carbon monoxide, was slowly seeping into the shaft, and it was time to run like hell.
Medical Simulators are often used in a similar manner to the Canary - to warn us of skills deficits in our students, or just as commonly - our Teaching!
But Why do people use simulators ?
This is where we will begin our 2017 journey... With a simple Question...
What is a simulator? Is it a manikin? Is it a room? Is it a strategy? Is it a technique?So many tools can now be used - that go way beyond the traditional manikin and defibrillator strategies. Many techniques use low technology to achieve incredibly high reality! And it is this fundamental question that I would ask you to explore...
At my teaching institution ( the academy of professional development) we use a number of tools to encourage the student to go beyond the traditional simulation strategy...
#Simbodies - medical manikins that look and feel like real people... Designed in the UK and now being sold worldwide
Using tools such as the #simbody we see better and more immediate suspension of belief within our students, we can see true emotion and caring that we would not have seen with more traditional ( plastic) manikins. These tools are used by military and HEMS teams and have a multitude of features that enable clinicians to experience " new things".
We have reduced the relaince upon cadevers and animal models...
At the Academy we use iSimulate - an iPad based clinical monitor - used on real people or manikins to recreate vital signs which require human interaction and clinical assessment / decision making. These vital signs are manipulated to force decision making in the mind of the clinician, and the vital signs and subsequent information is presented to the clinician in a manner that matches the reality of the "real" world.
But at the academy of professional development our over riding belief is that Simulation goes way beyond the Manikin or actor - It also requires the interaction with the clinical environment as well... since we know that the environment shapes our behaviours
We specialise in the use of Interactive environments - using 360 degree Video and Projection technology combined with lasers which map human interaction
We use Smell machines, to recreate Vomit and Faeces - Up to 300 smells available
We are in the process of redesigning many "traditional" academic programmes to cater for the learning preferences, styles and expectations of our learners. And we have written a research strategy to look at the effect of immersive education directly on patient outcomes.
I hope that you will encourage others involved in medical simulation to follow these posts and that in a 12 months time we will have developed a greater understanding of the whole new "science of simulation."
SO - Back to the Question - What is a Simulator?
Dave Halliwell is a researcher and educator who delights in asking the bigger questions. His clinical work includes supporting Middle East agencies to test their healthcare systems, and supporting military medical developments worldwide. He is a fan of new technologies and can be found lecturing on his passions of simulation and resuscitation in a number of international conferences in 2017. ( USA, Australia and Europe)