How Augmenting Reality Changes the Reality of Simulation: Ethnographic Analysis

BACKGROUND

Simulation-based medical education (SBME) provides key medical training for providers to safely and ethically practice high-risk events. Augmented reality (AR)-enhanced simulation projects digital images of realistic examination findings into a participant's field of view, which allows nuanced physical examination findings such as respiratory distress and skin perfusion to be prominently displayed. It is unknown how AR compares to traditional mannequin (TM)-based simulation with regard to influencing participant attention and behavior.

OBJECTIVE

The purpose of this study is to use video-based focused ethnography-a problem-focused, context-specific descriptive form of research whereby the research group collectively analyzes and interprets a subject of interest-to compare and categorize provider attention and behavior during TM and AR and provide suggestions for educators looking to delineate these 2 modalities.

METHODS

Twenty recorded interprofessional simulations (10 TM, 10 AR) featuring a decompensating child were evaluated through video-based focused ethnography. A generative question was posed: "How do the attention and behavior of participants vary based on the simulation modality?" Iterative data collection, analysis, and pattern explanation were performed by a review team spanning critical care, simulation, and qualitative expertise.

RESULTS

The attention and behavior of providers during TM and AR simulation clustered into three core themes: (1) focus and attention, (2) suspension of disbelief, and (3) communication. Participants focused on the mannequin during AR, especially when presented with changing physical examination findings, whereas in TM, participants focused disproportionately on the cardiorespiratory monitor. When participants could not trust what they were seeing or feeling in either modality, the illusion of realism was lost. In AR, this manifested as being unable to physically touch a digital mannequin, and in TM, participants were often unsure if they could trust their physical examination findings. Finally, communication differed, with calmer and clearer communication during TM, while AR communication was more chaotic.

CONCLUSIONS

The primary differences clustered around focus and attention, suspension of disbelief, and communication. Our findings provide an alternative methodology to categorize simulation, shifting focus from simulation modality and fidelity to participant behavior and experience. This alternative categorization suggests that TM simulation may be superior for practical skill acquisition and the introduction of communication strategies for novice learners. Meanwhile, AR simulation offers the opportunity for advanced training in clinical assessment. Further, AR could be a more appropriate platform for assessing communication and leadership by more experienced clinicians due to the generated environment being more representative of decompensation events. Further research will explore the attention and behavior of providers in virtual reality-based simulations and real-life resuscitations. Ultimately, these profiles will inform the development of an evidence-based guide for educators looking to optimize simulation-based medical education by pairing learning objectives with the ideal simulation modality.

Improving CPR Quality by Using a Real-Time Feedback Defibrillator During Pediatric Simulation Training

OBJECTIVE

The aim of this study was to assess the effectiveness of a defibrillator with real-time feedback during code team training to improve adherence to the American Heart Association (AHA) resuscitation guidelines.

METHODS

This is a retrospective cohort study designed to compare pediatric resident adherence to the AHA cardiopulmonary resuscitation guidelines before and after use of real-time feedback defibrillator during code team training simulation. After institution of a real-time feedback defibrillator, first-year resident's adherence to the AHA guidelines for chest compression rate (CCR), fraction, and depth during code team training from January 2017 to December 2018 was analyzed. It was then compared with results of a previously published study from our institution that analyzed the CCR and fraction from January 2015 to January 2016, before the implementation of a defibrillator with real-time feedback.

RESULTS

We compared 19 eligible session preintervention and 36 postintervention sessions. Chest compression rate and chest compression fraction (CCF) were assessed preintervention and postintervention. The depth of compression was only available postintervention. There was improvement in the proportion of code team training sessions with mean compression rate (74% preintervention vs 100% postintervention, P = 0.003) and mean CCF (79% vs 97%, P = 0.04) in adherence with the AHA guideline.

CONCLUSIONS

The use of real-time feedback defibrillators improved the adherence to the AHA cardiopulmonary resuscitation guidelines for CCF and CCR during pediatric resident simulation.

Code Team Training: Demonstrating Adherence to AHA Guidelines During Pediatric Code Blue Activations

OBJECTIVE

Pediatric code blue activations are infrequent events with a high mortality rate despite the best effort of code teams. The best method for training these code teams is debatable; however, it is clear that training is needed to assure adherence to American Heart Association (AHA) Resuscitation Guidelines and to prevent the decay that invariably occurs after Pediatric Advanced Life Support training. The objectives of this project were to train a multidisciplinary, multidepartmental code team and to measure this team's adherence to AHA guidelines during code simulation.

METHODS

Multidisciplinary code team training sessions were held using high-fidelity, in situ simulation. Sessions were held several times per month. Each session was filmed and reviewed for adherence to 5 AHA guidelines: chest compression rate, ventilation rate, chest compression fraction, use of a backboard, and use of a team leader. After the first study period, modifications were made to the code team including implementation of just-in-time training and alteration of the compression team.

RESULTS

Thirty-eight sessions were completed, with 31 eligible for video analysis. During the first study period, 1 session adhered to all AHA guidelines. During the second study period, after alteration of the code team and implementation of just-in-time training, no sessions adhered to all AHA guidelines; however, there was an improvement in percentage of sessions adhering to ventilation rate and chest compression rate and an improvement in median ventilation rate.

CONCLUSIONS

We present a method for training a large code team drawn from multiple hospital departments and a method of assessing code team performance. Despite subjective improvement in code team positioning, communication, and role completion and some improvement in ventilation rate and chest compression rate, we failed to consistently demonstrate improvement in adherence to all guidelines.

Mild fumarase deficiency and a trial of low protein diet

We report clinical findings in a 12-year-old girl with a mild case of fumarase deficiency who continues to make progress. She has two novel mutations of the fumarase gene [c.521C>G (p.P174R) and c.908T>C (p.L303S)]. A trial of low protein diet did not reduce fumaric aciduria.

Frequency of sustained glaucomatous-type visual field loss and associated optic nerve cupping in Beaver Dam, Wisconsin

PURPOSE

To determine the prevalence of persisting glaucomatous-type visual field loss in a Midwestern American adult population, in association with four grades of disc cupping.

METHODS

On two separate occasions (1988-1990 and 1993-1995) 2955 predominantly Caucasian adults aged 43-84 provided medical history, underwent applanation tonometry, slit-lamp examination, quantitative suprathreshold perimetry and stereoscopic disc analysis as part of the National Institutes of Health-sponsored Beaver Dam Eye Study. Those demonstrating evidence of glaucomatous-type visual field loss at both visits were the subject of the present analysis. Among these individuals, associations were determined for four categories of optic disc cupping (vertical cup/disc < 0.5, > 0.5, > 0.6, > 0.8), intraocular pressure, blood pressure, cardiovascular pathology and prior glaucoma diagnosis.

RESULTS

Of the 2955 subjects assessed, 120 (4%; 57 women, 63 men) demonstrated glaucomatous-type visual field defects at each visit. Fifty-five of these 120 (2% of the tested population) also exhibited some degree of disc cupping in a related eye at both visits. Among these 2%, positive associations relating the extent of field loss, cupping and intraocular pressure were confirmed, but the majority in each cupping category had normal eye pressures. Only seven of the 120 were aware of the presence or suspicion of eye disease prior to the screening.

CONCLUSIONS

A majority of those found to have visual field loss and optic nerve cupping persisting together in the same eye after 3-5 years had normal pressures in each eye at both visits. Despite good access to medical care, very few who demonstrated persisting cupping and field loss (even among those with elevated eye pressure) were aware of their ocular condition through prior contact with an eye care professional.

Effects of pergolide on sensorimotor gating of the startle reflex in rats

RATIONALE

Prepulse inhibition (PPI), a cross-species measure of sensorimotor gating, is impaired in certain neuropsychiatric disorders, including schizophrenia. This study was designed to assess the effects of the D2-family agonist pergolide in rats, in anticipation of human studies of the dopaminergic regulation of PPI.

METHODS

The effects of pergolide (0.0001-0.5 mg/kg) on PPI of the acoustic startle reflex were studied in rats using a wide range of prepulse intensities [1-15 dB(A) over background] and prepulse intervals (5-100 ms, onset to onset). Studies also examined the effects of the D2 antagonist haloperidol on pergolide-induced changes in PPI.

RESULTS

Pergolide exhibited dose- and stimulus-dependent effects on PPI. Pergolide increased PPI when startle stimuli were preceded by weak prepulses [1-5 dB(A) over background] at the longest prepulse interval (100 ms), or intense prepulses [15 dB(A) over background] at short prepulse intervals (5-20 ms). Pergolide (0.5 mg/kg) also decreased PPI elicited by intense prepulses at long intervals (60-100 ms). Both PPI-enhancing and PPI-disruptive effects of pergolide were reversed by the D2 antagonist haloperidol.

CONCLUSIONS

These effects of pergolide suggest that D2 substrates mediate opposing influences on PPI under different stimulus conditions. The dopaminergic regulation of sensorimotor gating appears to interact with stimulus characteristics such as relative intensity and temporal separation, allowing for dynamic shifts in both the quantity and quality of "gated" information.

Sensitivity to the dopaminergic regulation of prepulse inhibition in rats: evidence for genetic, but not environmental determinants

Prepulse inhibition (PPI), a measure of sensorimotor gating, is reduced in schizophrenia patients and in rats treated with dopamine (DA) agonists. Reported strain and supplier-based differences in sensitivity to PPI-disruptive effects of DA agonists presumably reflect the differential impact of genetics and/or environment on DAergic substrates regulating PPI. In 2000, Harlan Laboratories established a Texas Sprague-Dawley line (SDHt; facility 211) using breeders from Indianapolis (SDHi; facility 202A). SDHi rats had been used, approximately 11 years earlier, to establish a colony in San Diego (SDHsd; facility 235). SDHt and SDHi rats are thus genetically similar, but raised in distinct environments; approximately 11 years of genetic "drift" separates SDHsd rats from both SDHi and SDHt rats. Harlan Long-Evans hooded rats (LEH; Madison, WI; facility 207) are genetically distinct from albino SDH. All except SDHsd rats were shipped to our facility by air freight. We used SDHt, SDHi, SDHsd, and LEH rats to assess genetic and environmental contributions to the DAergic regulation of PPI. Acoustic startle/PPI were assessed in rats treated with the D1/D2 agonist apomorphine (APO), the D2 agonist quinpirole, or the D1 agonist SKF 82958. The relative sensitivities to the PPI-disruptive effects were: APO: SDHt=SDHsd=SDHi>>LEH; SKF 82958: SDHt=SDHsd=SDHi (LEH not sensitive); quinpirole: SDHt=SDHsd=SDHi; SDHi>LEH. Strain/supplier differences in sensitivity to drug effects on startle magnitude did not correspond to patterns of PPI sensitivity. In these rats, strain differences in the DAergic regulation of PPI are most easily explained by genetic, rather than environmental influences that differentially impact both D1 and D2 substrates. This finding is consistent with published reports in other strains. Pharmacogenetic studies of PPI in rats may identify a genetic basis for a model of deficient sensorimotor gating in schizophrenia.

Preventing the misuse of microorganisms: the role of the American Society for Microbiology in protecting against biological weapons

The American Society for Microbiology's (ASM) involvement with issues surrounding biological weapons began during World War II and continues to the present time. The Public and Scientific Affairs Board (PSAB) of the ASM has played an important role in monitoring and responding to legislative and regulatory issues involving biological weapons. As this review makes apparent, there is no consensus of opinion among scientists on their role in biological defense research, or is it likely that there will ever be complete agreement. There is consensus that steps should be taken to prevent biological warfare and that openness of scientific research and global surveillance of disease outbreaks can significantly increase transparency for detecting development of biological weapons. The ASM recommends increased attention to and efforts directed toward global surveillance of disease outbreaks, not only to aid public health organizations in improving human health, but also to establish baseline data against which unusual disease outbreaks can be assessed. Issues of how best to increase global security and to achieve a scientifically based verification protocol of the Biological Weapons Convention are important and continue to be addressed by the ASM.

A Bayesian characterization of Hardy-Weinberg disequilibrium

A Bayesian method for determining if there are large departures from independence between pairs of alleles at a locus, Hardy-Weinberg equilibrium (HWE), is presented. We endorse the view that a population will never be exactly in HWE and that there will be occasions when there is a need for an alternative to the usual hypothesis-testing setting. Bayesian methods provide such an alternative, and our approach differs from previous Bayesian treatments in using the disequilibrium and inbreeding coefficient parameterizations. These are easily interpretable but may be less mathematically tractable than other parameterizations. We examined the posterior distributions of our parameters for evidence that departures from HWE were large. For either parameterization, when a conjugate prior was used, the prior probability for small departures was itself small, i.e., the prior was weighted against small departures from independence. We could avoid this uneven weighting by using a step prior which gave equal weighting to both small and large departures from HWE. In most cases, the Bayesian methodology makes it clear that there are not enough data to draw a conclusion.

Prospective comparison of the Heine retinometer with the Mentor Guyton-Minkowski potential acuity meter for the assessment of potential visual acuity before cataract surgery

Various techniques and devices have been developed to aid in the assessment of potential visual acuity prior to cataract surgery. We report a prospective comparison of two such assessments, one made using a new instrument, the hand-held Heine retinometer (HR) (Heine Instruments, Germany), and the other using the Mentor Guyton-Minkowski potential acuity meter (PAM) (Mentor, Inc, Norwell, Mass). A total of 37 eyes were assessed using both instruments just before cataract surgery. Three eyes were excluded from analysis due to postoperative complications affecting visual acuity that could not have been predicted with either instrument. The false-negative rate was 44% for the PAM and 32% for the HR. There were no false-positive results with either instrument. Neither instrument was particularly accurate in predicting actual final visual acuity (r2 = 0.290 and 0.144 for the PAM and HR, respectively). The HR was deemed easier to use.

Dynamic testing of hypothalamic-pituitary function in abnormalities of ovulation

A review of 26 unusual patients indicates that a combined luteinizing hormone-releasing hormone (LRH)-clomiphene test in conjunction with an estrogen provocation test not only was helpful in identifying underlying pathophysiology of anovulation but also proved useful in the clinical management of the patients. Dynamic testing per se does not establish a diagnosis but, in conjunction with history and other laboratory findings, it does make possible further subdivisions of groups of patients who otherwise appear similar, both clinically and from routine laboratory evaluations. It, therefore, tends to pinpoint a lesion and establish the area in which further tests should be made. It is concluded that the value of such investigations will be more evident as gynecologic endocrinology moves into investigation of the supratentorial control of hypothalamic function and as hypothalamic LRH becomes available as a therapeutic agent.