The Augmented Emergency Department

How virtual and augmented reality could change the way we practice.

Over in Bed 2, a metabolic kid is waiting for his infusion to finish. You’ve seen him before and he’s normally a handful, but today he’s wearing a Virtual Reality (VR) headset and has been no problem at all – compliant and immersed in his own digital world.

VR is a technology that, in its current form, uses head mounted displays and stereoscopic images to create the illusion of depth. Combined with motion sensors to provide a moving image, it can trick one’s brain into feeling physically present in a virtual environment. It’s making headlines now as the first high-end headsets hit the consumer market, and people realize even the low-budget Google Cardboard unit can turn their smartphones into an immersive experience.

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Of course, VR has been around for decades, used in niche markets with expensive headsets and sometimes body suits to provide visuals, auditory, and tactile feedback. But, over the past couple of years, VR has transformed – from lab experiment to real consumer product [1]. What’s exciting about this revival is the breadth of interest the technology is generating. Beyond the classic use case of video games, companies and VCs are investing millions in film, architecture, tourism, education, data visualization and other fields [2,3].

And VR’s potential in medicine is now becoming apparent.

In Bed 5, your burn patient is awaiting transfer to the academic center. He’s strapped into his VR set, too. Fluids are running, as is morphine – but you’re surprised how little morphine he’s required so far.

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VR, it turns out, can be so immersive as to provide measureable pain relief [4,5]. A number of researchers, app developers and device manufacturers have rushed in to explore VR in medicine. Over 200 peer-reviewed studies on VR have been published over the last 10 years. Some of the recent clinical work has been centered around ophthalmology to correct strabismus [6] and for example, identifying glaucoma patients at risk for falls [7]. Also, psychiatry has been a focus, as VR provides a safe but immersive path to providing exposure therapy to fight phobias and Posttraumatic Stress Disorder [8,9].

But there’s a role for VR in the Emergency Department (ED), as well.

Next to bed 7, your elderly patient who fell is getting a PT consult, through her VR headset [10]. The device is coaching her through various maneuvers while a physical therapist looks on. If she scores well enough in the ED, she’ll be taking the headset home to continue the regimen – and PT will be able to monitor her adherence and progress.

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Beyond using VR headsets for direct patient care, one obvious application is training [11]. Simulation training in the ED is now common place, but physical manikins remain expensive and are limited in the scenarios they can simulate. While haptics of procedures are still likely best simulated with physical equipment, cognitive – and team-based skills can be simulated in VR – like running a trauma resuscitation [12]. With significantly lower entry prices, there will be many opportunities to incorporate modern day VR into the mainstay of simulation training [1,13].

Despite its new popularity VR may find itself leapfrogged by yet another emerging technology: Augmented Reality (AR). Similar to VR, AR uses head mounted technology to display virtual images. However, as oppose to VR, it does not obscure the user’s field of vision, and allows the wearer to continue to interact with their surrounding, while a computer system augments the environment with overlayed images or text. Microsoft has recently release a developer version of their first generation AR glasses, HoloLens, and many other companies, including the Google-backed Magic Leap, are following suite.

Having made your scan of ED patients, you take off your AR goggles. The floating information disappears and you’re back to using just your old-school, un-augmented eyes. When you look t each bed, you no longer see the name of the patient, his or her complaint, recent vitals and test results. You think back to the large LCD trackboard you used to have, with its confusing collection of icons nd colorful boxes. And you reflect on the makerboard before that, with its scribbles that required constant updating. The AR unit’s display gives you only the information you need, when you need it-the ED is a lot more calm and less cluttered.

This future may be a few years away, or never come to pass – but what’s clear is that VR and AR are advancing rapidly and the technology is set to disrupt industries well beyond gaming. Some are comparing it to the early days of the internet: excitement, experimentation, and a sense of opportunity. But to really understand all the attention, VR and AR should be experienced. Strap on a headset and see for yourself what everyone’s talking about.

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STARTER PACK
Want to give virtual reality a try? Here’s where to start.

1. Google Cardboard can be ordered for $15 and fits most current smartphones:
2. Download free or inexpensive apps like AnatomYou and Bard VR (iOS only), or Recovery Position (Android only).
3. For a more advanced experience, look to the more expensive Oculus Rift or HTC Vive, although most apps for these headsets are currently for games.
4. Try out augmented reality via smartphone apps like StarWalk, Layar, Google Translate (which can read and translate street signs), and even Yelp (look for the Monocle feature under “More”)

REFERENCES

1. Riva, G., and B. K. Wiederhold. “The New Dawn of Virtual Reality in Health Care: Medical Simulation and Experiential Interface.” Studies in health technology and informatics 219 (2014): 3-6.
2. <http://fortune.com/2015/11/30/investment-hot-virtual-reality/>
3. http://www.bloomberg.com/news/articles/2015-06-19/how-oculus-and-cardboard-are-going-to-rock-the-travel-industry
4. Hoffman, Hunter G., et al. “Feasibility of articulated arm mounted Oculus Rift Virtual Reality goggles for adjunctive pain control during occupational therapy in pediatric burn patients.” Cyberpsychology, Behavior, and Social Networking 17.6 (2014): 397-401.
5. Schmitt, Yuko S., et al. “A randomized, controlled trial of immersive virtual reality analgesia, during physical therapy for pediatric burns.” Burns 37.1 (2011): 61-68.
6. https://www.diplopiagame.com/
7. Diniz-Filho, Alberto, et al. “Evaluation of Postural Control in Patients with Glaucoma Using a Virtual Reality Environment.” Ophthalmology 122.6 (2015): 1131-1138.
8. Botella, Cristina, et al. “virtual reality exposure-based therapy for the treatment of post-traumatic stress disorder: a review of its efficacy, the adequacy of the treatment protocol, and its acceptability.”
9. Neuropsychiatric disease and treatment 11 (2015): 2533.
10. Glantz, Kalman, et al. “Virtual reality (VR) and psychotherapy: Opportunities and challenges.” Presence: Teleoperators and Virtual Environments 6.1 (1997): 87-105.
    http://vrecover.com/
11. Cha, Y. W., et al. “Immersive Learning Experiences for Surgical Procedures.”Studies in health technology and informatics 220 (2016): 55.
12. Youngblood, Patricia, et al. “Design, development, and evaluation of an online virtual emergency department for training trauma teams.” Simulation in Healthcare 3.3 (2008): 146-153.
13. Kleinert, Robert, et al. “3D immersive patient simulators and their impact on learning success: a thematic review.” Journal of medical Internet research 17.4 (2015).