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In a revolutionary approach to medical simulation a centre, that uses a bespoke digital video solution to closely monitor medical teams under stress, has been installed at a Munich university. Anna Mitchell explores the unique facility.
Simulation in medicine has a tradition that dates back thousands of years,” explains Christian Hinske, a medical doctor and MIT graduate. “Most simulation is used to practice medical procedures but what we’re doing here is very different.”
Hinske is talking about the Human Simulation Centre at The Ludwig-Maximilians University (LMU) in Munich, Germany. The centre was designed and built to monitor medical teams’ reactions in stressful situations. Marc Lazarovici, medical doctor and an informatics graduate, leads the centre that is situated within the university’s Institute of Emergency Medicine. He explains the centre’s purpose is two-fold.
Firstly emergency medicine teams, mostly from Germany, pay to train at the centre. They particularly focus on the stressful handovers that occur as any emergency is dealt with. This could be the transfer of a patient from the scene of an accident to an ambulance or their admittance to the emergency ward in a hospital. The centre is also used for research.
The individuals taking part in the simulations are carefully monitored not only for their own development, but in an effort to pinpoint problematic areas that could have an impact on how medical response is carried out.
Training is for experienced medical professionals and both Dr Lazarovici and Dr Hinske stress the importance of training teams that usually work together to avoid people “playing roles”. Teams are usually made up of between three and five people. Three teams usually rotate during any one simulation with two watching.
Dr Hinske says: “We’re looking at team interfaces and interaction in emergencies. In an emergency you have a tight timescale. Classical simulation focuses on static situations. You’ll have a patient in an operating theatre and you’ll monitor their life signs as you perform a procedure.
“This is fluid. It moves through four environments because real patients have to be moved. They don’t just lie in a bed and when they are moved things happen. Patient health can decline before you notice and under pressure people forget certain procedures.”
The four environments that Dr Hinske mentions are simulated within four linked rooms. The first can be set up as the scene of an accident, the second deals with the patient transportation and the last two both simulate hospital environments. All four rooms surround a central monitoring area.
Seventeen regular surveillance cameras, Ganz YCH- 30Ps, and six controllable Panasonic dome cameras can be moved between and installed installed in each of the four rooms to discreetly monitor the simulations. Video and audio signals are encoded by 37 Teracue ENC 100 MPEG-2 Transport Stream encoders and streamed into a Gigabit network using multicast broadcasting. A mobile unit, with six encoders and four RF audio channels is also provided to extend simulations out of the centre.
“When you simulate the interfaces between medical teams you start to see what errors can occur,” explains Dr Lazarovici. “For example when you hand over a patient you may forget to transfer certain pieces of information. This simulation allows you to see what will happen when certain things are not done. You learn the impact of errors by building the chain of events that leads to the final problem.”
As the centre largely focuses on handovers the Teracue system was essential to allow supervisors to quickly and easily switch from one video stream to the next. Furthermore it was important to be able to do simulations simultaneously so two video feeds can be transmitted at the same time. “Regular simulation will usually take place in one room,” says Dr Hinske. “Here it takes place throughout four. This is where the complications with the video can come across. When you transfer from one room to the next then the system has to be capable of following. It must be fast and easy.”
It was seven years ago that the team originally had the vision to be able to simulate these situations. The centre as it is today was a process of evolution and what was originally planned was somewhat different to what is in place now. As the project evolved the equipment was changed with a major impact on the video system. The initial idea was to use a hardware solution to split the video signal but the team realised the project needed far more flexibility and Teracue came on board with a digital solution.
“Teracue wanted to provide video distribution over IP to make the feeds easily available,” continues Lazarovici. “And when Christian [Hinske] arrived the idea of monitoring software began to be discussed. The recording solution could not be off the shelf.”
Hinske programmed the system for viewing live video on the monitors. This system is also used for recording and debriefing. It was decided that a classical surveillance set up would not provide what the team needed. The streams can be played and switched very easily so observers can flit from room to room. Trainers have to edit and show live video as well as performing certain tasks during and after the simulation when it is played back for de-brief.
“Live watching proved to be an extremely important part of our work,” says Lazarovici. “The viewing software was developed very quickly, Christian essentially designed it in one weekend. But, it turned out it was one of the most important aspect of the whole project.”
The feeling of reality for the participants is also essential. Therefore audio throughout the rooms had to be loud to make communication difficult. All participants wear wireless TOA microphones and audio is also picked up from installed AKG mics in each room. A Yamaha digital mixer handles 16 microphones, which have to be dynamically grouped according to the activities of the team going through a simulation.
“During the simulation you have to keep on top of the audio quality but you cannot interfere or you will ruin the illusion,” explains Lazarovici. “The digital solution means all microphones can be switched throughout the four rooms.”
The first room of the centre is used to simulate the scene of an accident or emergency. Three NEC beamers are used to project scenery on the white walls of the room. Common accident scenarios include a road accident (the centre even includes a car for this simulation) or a home birth, where the room is configured as a domestic setting.
Moving through to the second room participants enter the transport phase of the simulation. A real, out of service helicopter and a real ambulance are situated side by side. The helicopter is equipped with a ceiling speaker that generates enough noise to make it essential for the participants to use supplied communication headsets or helmets.
The final two rooms cover the hospital part of an emergency response. They are well equipped with the medical equipment that would usually be found in hospitals. These two rooms can be separated or used as one space and can be configured to simulate an accident and emergency department, operating theatre or intensive care unit.
All rooms surround a central control area that overlooks each space through one-way glass. The control room uses NEC monitors and each room is managed by its own control place. Two staff, which are specialised trainers and medical professionals, are required to monitor a simulation.
Life signs of the realistic human manikins are continually monitored and layered on the video stream for use in the simulation de-brief. Hinske’s software allows the trainers to assign five types of markers to highlight issues as they arise during a session. This allows the trainer to easily jump to marked points when taking the medical teams through the simulation afterwards.
The simulation footage is also studied for research purposes and trainers can assign a varying colour – from green to red – to note how severe a mistake or outstanding an action is. Whilst the training provides revenue for the centre, it is this research that is central to the HSC’s existence at LMU. Its funding was partially based on research requirements. Initially the centre was presented as a concept with a paper titled ‘The Human Factor in Medical Emergency Simulation’. Now, the team is working on quantative research that will be related in a paper exploring how varying factors reflect the perception of different roles.
German integrator Ippi handled the hardware installation for the project. But it was the team of doctors that first envisioned the centre seven years ago that was central to selecting, installing and managing the equipment.
It is their vision, dedication and technical know-how that is instrumental to the centre’s valuable work. The core of the project is the video management and the trainers that work at the HSC had very specific demands about what they needed. The resulting installation was truly bespoke with the software that Dr Hinske developed and direct involvement from encoder manufacturer Teracue.
AKG C562CM microphones
Sonus APG2008 audiomixer
TOA WM4300 wireless microphones,YW4500 UHF antennae
Yamaha DME-24N digital mixing engine
AMX room controller
Ganz YCH-30P cameras
Guntermann & Drunck KVM matrix switch
NEC WT-610 parabolic beamer and monitors
Panasonic WV-CS095 dome cameras, VJ-MP204 camera controller
Teracue ENC 100 MPEG-2 transport stream encoders, FR-2000 19”racks