“Why not abandon the simulations, with their actors and boxes full of pig’s intestines, and recreate surgery in virtual reality?“
Picture the scene: it’s your first night in A&E as a junior doctor. You’ve done your training. You know which bits go where in a person and how much they can be jumbled around before someone revokes your medical licence. You know how to stop people bleeding, start people breathing and generally how to keep people from dying, because you’ve watched surgeries, read books and practised on surgical dummies. But then your first real-life victim comes crashing through the doors on a gurney.
“I found when I went through my medical training, doing all this fake simulation training, that certainly as a junior doctor the first time I was on the scene with someone who’d stopped breathing I froze,” says Alex Magnussen. “I knew what I needed to do, but because I wasn’t used to that pressure, I didn’t really know how to start. That’s what we’re aiming to combat.”
Magnussen is an orthopaedic surgeon at Imperial College London, where he regularly tutors the medical students. But the realities of teaching medicine are, he says, that you’re frequently lecturing 200 students at once, each of whom only gets to limited hands-on time to practise their surgical skills. And even when they do, the situation doesn’t feel real.
“[We use] those little plastic torsos that have a mouth that you breathe into, and the plastic chest that has a spring in it,” he says. “And then you have someone standing in the corner saying, ‘OK, you’ve found Bob here, and he’s unconscious, tell me what you’d do.’ That’s a very fake scenario. It teaches you the basic skills, but it doesn’t put you in a real-world scenario, it doesn’t account for how normal people react when faced with these emergencies. If you’ve got someone who’s dying, if not dead, in front of you, what are you going to do?”
According to Magnussen, the cutting edge tool for medical students learning surgery today is the simulation suite. Essentially an Ikea window display if Ikea did operating theatres, the experience is designed to be as close as a medical student can get to surgery without having to sit in on an actual operation. But the drawbacks are substantial:
“Let’s say you’re going to simulate taking someone’s appendix out in one of these big simulated theatre suites,” says Magnussen. “You have to have the room, you have to have actors to play your anaesthetist, to play the nurse who assists you, and you need all the equipment there in real life, including the instruments that you use.
“And then you need your plastic box with, I don’t know, a pig’s intestines in there, so you’re actually going to remove the appendix of a pig.” He pauses. “Obviously the pig is long dead. But they’ve preserved the relevant bits. Then you would remove that in a real-time, real-life-esque scenario. But as you can imagine, the time, the logistics and the cost involved to do that are vast.”
Part of the path to becoming a medical consultant, says Magnussen, is making meaningful contributions to your field. Lab work didn’t appeal (“I had no desire to spend all my daylight hours in a laboratory somewhere, trying to grow cells or whatever it would be… I’ll be honest: that stuff really bores me.”). A gamer since the age of seven (he’s 29 today), PS4 player and regular reader of gaming sites, it was while reading up on the Oculus Rift that Magnussen had what he calls his “eureka moment”: why not abandon the simulation suites, with their actors and surgical tools and boxes full of pig’s intestines, and recreate the experience of surgery in virtual reality?
“They would put the headset on and they would be within a fully filmed HD scenario that would be immersive,” he says of the project, which he is now co-developing with colleague Crispin Wiles at Imperial. “So whether that would be out on the street, or in a hospital or whatever – the whole point is to use the immersion that these technologies give, so they feel like they’re actually in the scenario, to get them to act like they would.
“Let’s say it’s an advanced life support scenario. You put the headset on, and you’re in the resuscitation bay of any A&E department. If you look straight ahead, you see the patient in front of you; if you look to the left, you see screen with the patient’s vital signs on it; if you look to the right, you’ll see the nurse you’re working with. You get to witness exactly what goes on and see how the team interact with each other, not with a real patient but with an actor playing a patient who is getting their life saved.”
What Magnussen is describing sounds like passive VR projects we’ve seen before – experiences that put the ‘player’ into the role of an observer. But the real goal is to make the experience interactive – to test students’ ability to make life or death choices under the realistic pressures of the operating room.
“As we build on the technology and make it more complete, we will introduce a level of interaction where you have to make choices, almost RPG-style,” Magnussen says. “What do you do now? Do you make sure their airway’s OK? Or do you try and stop the bleeding first? And then a different branch of the scenario would play out depending on what your choices would be.
“That’s what we’re aiming to achieve with what I’d call the ‘live action’ scenarios – something that’s been filmed with either two GoPros to create a stereoscopic 3D effect, or with a fisheye lens to allow a 360-degree environment that you can look around using the Oculus.”
One hurdle for the early iteration of Magnussen’s ICL project is that, to receive additional funding, Magnussen and Wiles have to be able to prove that the project is worthwhile (“[if] surgical trainees who spent hours and hours and hours in this virtual reality were then just as useless when it came to operating as people who’d never done that, then the whole thing would be a waste of time,” he says, candidly). But the possibilities for the future and a much, much wider scope are already taking form.
“All it would take would be to add in another program to change the scenario and throw curveballs to the poor candidate,” he says of the project’s ultimate goal. “The scenario I always return to in my mind, being an orthopaedic surgeon, is fixing a broken hip, which involves X-rays in theatre and drills and saws – you know, proper carpentry. You’d have to bring the X-ray machine in yourself and press a button to fire a virtual X-ray across the virtual bone, then you’d look to your left and see the X-ray screen and you could see what you needed to do to get the bone back to where it should be, and then choose the correct screw or plate or whatever, and then fix it, and learn the steps of this operation from start to finish all in virtual reality.
“And then of course you could get the anaesthetist up at the head of the patient to pipe up, ‘their heart’s stopped beating!’”
Of course, the goal of the project isn’t just to have things go catastrophically wrong – despite the obvious, crass comparison, this really isn’t Surgeon Simulator. But if the project is going to work at all, Magnussen is adamant that it does need to be entertaining.
“It’s very difficult to engage with medical students sometimes,” he says. “[But] if you can plop VR tech in front of them, or turn on a PS4 and hand them a Project Morpheus and two of the PlayStation Move controllers, and say, ‘right, you’re going to be put into a theatre scenario and I want you to do your best to take out the appendix without causing too much blood loss. Go,’ it doesn’t matter if they completely can’t do it or if they screw up or if they kill the patient. They’re going to have fun. They’re going to engage with it. And they will learn something from it.”