Plug and Play Architectures for Rapid Development of Medical Simulation Manikins
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Plug and Play Architectures for Rapid Development of Medical Simulation Manikins Peter Peters 1, Loe Feijs 1, and Guid Oei 2 1Department of Industrial Design, Eindhoven University of Technology 5600 MB Eindhoven, The Netherlands [email protected], [email protected] 2Máxima Medical Centre, 5500MB Veldhoven, The Netherlands [email protected] ABSTRACT Great-Britain more than 75% of newborns that had a bad start Medical simulation has become an accepted tool to support were exposed to suboptimal care [2]. Furthermore, medical team training and quality assurance of medical interventions. interventions that are uncommon, or too low in frequency for Successful examples include paramedic emergency crew regular real-life training, will have to be trained using non-real- training, anesthesia and delivery training. In this article we work life (i.e. simulated) training. A good example of the latter is on the two hypotheses that (1) simulation will gradually be breech delivery. After the publication of the ‘term breech trial’ introduced in other medical areas as well, and (2) that the in The Netherlands 2000 it seemed to be accepted that when a number of required functions and the level of required realism child was in a breech position a cesarean section is better for the in a given application will steadily increase. This has far- child. The number of cesarean sections in case of breech reaching technical consequences, notably a steep increase in position rose from 50% to 80% within 2 months after this technical complexity. We envisage specialized groups working publication [9]. Even although there was negative criticism in on specific functions, specific pathologies, and/or selected the years thereafter, the percentage remained 80%. interventions. The demand for managing this complexity asks for principles of open-source development. For the technical structure we translate the problem into the need for an open plug & play architecture. The article will discuss an exploration of three existing platforms originating from an intersection of the fields of embedded systems and design education. The focus of the work is on openness, which covers the nature of the plug and play mechanisms, scalability and extensibility. The three platforms are (1) Microchip PIC, (2) Lego NXT and (3) Phidgets MSP. As a case study we choose simple functions from the field of delivery and neonate simulations. Keywords: Healthcare, Simulation, Team training, Plug and Play, Architecture, Hardware platforms, Open source. Figure 1: Delivery simulation training session . 1. MEDICAL SIMULATION RELEVANCE & TRENDS As a consequence the number of natural breech deliveries decreased. Of the approximately 6000 breech deliveries per year Simulation-based training has shown its merits in aerospace, the in The Netherlands, around 20% is born naturally. Given the military, nuclear engineering and other professions where the number of gynecologists, the final result being 1.4 natural real situation cannot be used to do training. The medical breech deliveries per year per gynecologist, which is of course profession is a typical example where this frequently is the case not enough to stay well trained for this specific intervention. as well. Although a lot of training of medical personnel can be Since breech delivery is only one of the many examples where done ‘on the job’, a vast number of medical interventions lack of training applies, simulation-based training using cannot be practiced on patients. In 2005 the Máxima Medical appropriately designed manikins is a good way to get additional Centre (MMC) in Veldhoven, started simulation-based team training (see figure 1). Currently, the MMC is starting a trainings to train their multidisciplinary delivery teams, being simulation centre (headed by the 3 rd author) where teams of the first hospital in The Netherlands to do so. As an example medical personnel can be trained for specific situations. The why the MMC started doing these trainings consider the environment created will enable team members to practice the following. Of all safety problems in hospitals, 65-70% is caused near actual experience of performing specific interventions, not by human error [8]. Kohn et.al. describe that in the USA 98000 only from the purely medical point of view, but also evaluating people die probably as a consequence of human error [6]. In communication and cooperation within the multidisciplinary intervention teams. A complete environment that simulates the redistribution of modified open source designs can result in a total experience is a major condition for the success of these potentially large amount of developers and support, in the end trainings. leading to lower prices, faster development and opportunities 2. SYSTEM OVERVIEW for third parties to engage in production and commercial exploitation of service and support. Good examples of how this A manikin is only one of the elements of the complete system can lead to success is the Linux operating system [1] and many used for training. There will be several other elements (virtual other open source software projects. The effects of adhering to and/or physical) in the system; an important one of them will be the open design paradigm will however not be without a training scripting engine, controlling what actions should take consequence for the design of the manikin’s architecture. To place when, and how the manikin reacts upon these actions. support ease of change, redistribution and copying, it is This engine determines the scenario of the actual intervention advisable to use modular design in most disciplines involved. practiced, what sensors are of importance in the scenario and This approach aims to subdivide a system into smaller parts how the manikin reacts on the actions performed during the (modules) that can be independently developed, manufactured, training. The information exchange between the system and used in different systems to drive multiple functionalities. It elements will be done by message communication. Since the organizes a complex system as a set of distinct components that protocol used for message communication should not limit can be developed –or modified– independently and then future extensions it is important to consider this protocol in an plugged together. Although this may appear to be a simple idea, early stage of the system development. An over simplified experience shows that the effectiveness of the technique depiction of the system is shown in figure 2. The system shows depends critically on the way systems are divided into three possible system elements communicating: a training components and the mechanisms used to plug components scripting engine, a manikin and a video detection and together. augmentation system. The communication between these elements will not consist of raw sensor data messages but of messages on a higher semantic level (e.g. “change heart rate to 3.2 Architecture 100 bpm”, “display face312 at position x, y”). Two important obvious system elements that can be distinguished in the manikins are: hardware and software. For each of these elements early considerations for system architectures are necessary to prevent that the complexity of the Training system will in a later stage lead to the need for a complete Scripting redesign. Requirements that can be though of are: Engine • Scalability : Manikins will be equipped with a multitude of sensors and actuators, each of them requiring individual data transport. Although the early systems will start with a few sensors and actuators, the amount will quickly grow. • Video Expandability: The wish to enable open design, not being Manikin Detection & able to foresee all developments, requires that the systems Augmentation are expandable. It should be possible to add sensors and actuators not yet foreseen or not even existing yet. • Cost: A well thought of architecture reduces development Figure 2: System elements and communication cost. Decisions like clustering of sensors around one The remainder of this paper focuses on possibilities for the soft- controller or giving each sensor its own; choosing the right and hardware architectures needed to create the manikins used data transport mechanisms; Transmission media, buses, are in these simulation-based trainings. of major importance. • Lifetime/energy efficiency: Future manikins must be wireless. The manikin has to operate stand-alone for at 3. OPENNESS, ARCHITECTURE AND PLUG & PLAY least the amount of time a simulation will take. This constraints the power consumption of the electronics of the 3.1 Openness manikin. A well designed hard/software architecture will Current state-of-the-art medical simulation manikins are help to reduce power consumption. proprietary designs (hardware, software and body), usually only • Quality: The collected information has to be sufficiently available for usage and not available for exploration. Although accurate and delivery of the information should be in time. these manikins cater for a need very well, they do not allow for Time relations between events must be preserved when third party alterations or extensions. Any changes and/or translating them to event messages and delivering these. additions have to be implemented by the manufacturer and although they do a very good job, the development interests of The way to realize these requirements is to define clear software the manufacturer are not necessarily the same as those of the and hardware interfaces that do not pose unnecessary limitations user. The plug and play architecture proposed here is meant to on the actual implementation but also do not allow unnecessary enable development and extension of medical simulators by freedom. Things to consider are e.g. standardization of interested parties. The way this is enabled is by adhering to the sensor/actuator values and definition of a transmission protocol Open Source Initiative (OSI). We assume that the principles of that supports the above requirements. open design, amongst others applied in free software and open- source software [5], are re-usable in the medical simulation 3.3 Plug & play manikin context as well.