Published in January 2007

Nurse Training Goes 'Virtual'
By Jim Stokes

VCU's anesthetist program provides tech-centric facility.

There are two teaching labs that feature lifelike computer-controlled manikins, ranging in human development from infant to adult, that simulate real world operating-room scenarios.

    The anesthetist providing anesthesia care is in deep concentration, as are the surgeon and other medical staff in the operating room. Suddenly the patient’s blood pressure drops. Multiple camera angles pick up the scene. The control room operator views the situation with intensity, as well. What’s to be done? Music up and cut to commercial? Well, the scenario is somewhat like a TV show. In this case, however, it could be a simulation lab exercise.
    The AV facility that supports the Nurse Anesthesia Graduate Program at Virginia Commonwealth University (VCU), Richmond VA, was updated recently. The training course has the distinction of being ranked the #1 Nurse Anesthesia Program in the United States since 2003 by U.S. News & World Report, and has been preparing Certified Registered Nurse Anesthetists (CRNAs) for more than 30 years. Because AV support is crucial in supplying realistic training, the program’s simulation center consists of three operating room (OR) labs, which are all equipped with lifelike, computer-controlled manikins.
    In a typical “sim” (simulation) lab teaching scenario, a patient simulator manikin is connected to a monitoring system, which displays the “patient’s” vital signs. From a control room, a professor can manipulate such variables in the manikin as breathing and heart rate, plus communicate via headset mics with OR/sim lab personnel. In turn, the nurse-anesthetist-in-training seated behind the simulator has to respond appropriately to critical situations. Furthermore, sim lab exercises can be recorded, and there’s AV connectivity among the labs, classroom and conference center. The facility is set up for distance videoconferencing, as well.

Credits
    VCU AV project credits include Dr. Michael Fallacaro, DNS, CRNA, professor and chairman, Department of Nurse Anesthesia, School of Allied Health Professions; in Media Support Services: department manager Carol Haley; senior design consultant John Bogan and project manager Sharon Whitley. On the integrator side: en- gineer David Wolf, The Whitlock Group.
    The Whitlock Group, Richmond VA, completed the final systems engineering, programming and integration. We spoke with Fallacaro, Bogan and David Wolf.
    The project, which took a year to complete, is estimated at around $200,000. The bulk of the install was finished in Summer 2006. Bogan pointed out that his department provides media consult and design for the university, and that “most of the time we have an integrator such as Whitlock provide the hard equipment design.” Bogan’s job involves overseeing the engineering and planning side.
    He noted that, once the budget was allocated, Media Support Services and the Department of Nurse Anesthesia “came up with a plan of how the facility should function. Then we brought The Whitlock Group on- board, and they came up with a great design and we were off and running. It’s a very cool facility. Very modern looking. It’s almost like a production facility as far as the sim lab goes.”
    “We do a lot of work for VCU,” explained Whitlock’s Wolf. “They’re one of our best clients. We support Media Support Services heavily and we enjoy working with them. And they seem to enjoy working with local integrators.” We’ll offer more personal perspectives and insight into challenges later.

Virtual OR
    The simulation center consists of one lab each for an adult, a child and an infant. Each of the three labs can be used separately or combined, depending on training needs. “What we’ve created is a virtual operating room,” declared VCU’s Fallacaro, Thus, the OR has been recreated down to every minute detail, from the OR table to storage and supplies. Authenticity includes the anesthesia delivery system, support carts and materials you’d find in any operating room. “Our simulation activities do not replace hands-on patient care. But they supplement it.”
    Fallacaro noted that anesthesia is very safe. It’s a rare event when something goes wrong. “I could teach someone how to properly manage a patient with a heart attack under anesthesia. But he or she may not see that occurrence until many years into the practice, and knowledge is fleeting. However, in a simulation lab, we can make the rare event commonplace. So we can program the simulation to be that patient that has the heart attack, stroke or allergic reaction. And we can have students practice proper management over and over again.”
    He compared the anesthesia sim lab to the simulation environment in aviation training, where pilots experience engine flameout, hydraulic pressure loss and electrical system loss, which are very rare occurrences in an aircraft. When such an event happens in real life, they’d be better able to manage it through simulation training.

Teleconferencing, including installed video projector and screen, microphones, speakers and LCD monitor in the classroom and conference room, enables observers to interact live with students in the simulated operating room.

Sim Lab Operation
    The sim ORs, classroom and conference room are all Crestron-controlled. The control room, which is equipped with one-way glass, overlooks the three labs.
    One large, 18-inch screen Crestron DTT-18 touchpanel and one smaller, 10-inch screen TPS-4000 touchpanel allow flexibility in using one or variously combined ORs.
    In addition, a room divider can be set up to separate the ORs during instruction. An example of maximizing the space and AV resources would have labs #1 and #2 combined for a larger simulation exercise. A faculty member/operator would run the DTT-18. Then another faculty member would use the TPS-4000 for an infant simulation in lab #3. The sim labs are equipped with a generous supply of Extron AAP interface wall boxes to accommodate AV equipment because beds often are moved to several locations.
    Now let’s set up a simulation lab scenario in detail. A Laerdal patient simulator (manikin) is laying on an operating table. The trainee, seated behind the patient, has to respond to dramatic changes. The manikin’s vital signs showing on a bedside monitor are PC-controlled from the control room. Via touchpanel access, a Roland EDIROL video effects mixer allows the vital signs to be overlaid over the operating room’s multiple ceiling-mounted Vaddio video cameras’ views. The resulting audio and video can be recorded to a Sony DVD deck for review in the classroom and archived.
    Audiowise, the faculty member/operator has the flexibility of addressing all medical personnel in the OR via a QSC wall speaker outside the control room, or privately via Shure headset/mics worn by OR staffers. Clockaudio ceiling boundary mics provide overall room pickup in the labs. Control room monitoring is via two Tannoy speakers, one for each side when labs are divided for separate operations. When the labs combine, the speakers combine, as well.

Role Playing
    According to Fallacaro, the trainee actually administers anesthetic to the manikin. “And then in the lab, we have faculty play roles such as surgeon and scrub nurse while the trainee delivers the anesthetic. The patient simulators are very high fidelity [realistic] systems that include intravenous access, heart and breath sounds, and palpable pulses.” Meantime, in the control room, the faculty member/operator can manipulate vital signs, such as having the blood pressure drop suddenly or even simulating cardiac arrest. In turn, the trainee has to respond to these events as he would during a real situation. The manikin has a built-in speaker from which the faculty member in the control room can verbally respond to the anesthetist as would a real patient.
    As mentioned, AV technology allows recording the trainee’s OR exercise via multiple cameras for later review. “We can go into a quiet room and replay the event with different camera angles, so we can debrief the anesthesia providers as to what happened and how and why they responded to the situation,” explained Fallacaro. “Hopefully, if outcomes were poor, after reviewing their performance, they may choose to respond differently. The goal is to create a reflective provider: someone who will look at their actions, see what the outcome was and make adjustments to improve performance, should the situation befall them again.”
    In addition to recording, the sim labs are AV-linked to the classroom, conference room and offsite areas for live viewing, as well. There’s a 32-inch LCD in the labs for far-site videoconferencing. The training area and the classroom are run off one rack-accessed Tandberg 6000 codec.

Classroom AV
    All the rack equipment for the classroom, three training labs and the lab control room are housed in Middle Atlantic racks in one separate room. The classroom, per se, has a ceiling-mounted Sony LCD projector firing on a 100-inch Da-Lite screen. There’s a PolyVision Interactive Whiteboard and a WolfVision document camera as well, for presentations. During videoconferencing using the Tandberg codec, far-end video is displayed on a Sony 42-inch LCD. For interactive distance learning, Vaddio cameras pick up the presenter and participants in the classroom, while audio is picked up via eight Shure ceiling mics.
    At the lectern, the presenter uses a Shure gooseneck. Audio is processed in a ClearOne XAP-800 matrix mixer, and QSC ceiling speakers are driven by QSC amplifiers. At the lectern, the presenter can access all equipment from a Crestron 4000 touchpanel. The SMART Sympodium annotator sits on top of the lectern and connects to a PC. There’s also an Extron AAP for laptop interface, so users can bring in another video source.

The Nurse Anesthesia Graduate Program is part of the vast complex at Virginia Commonwealth University in Richmond VA.

Conference Room
    The conference room is down the hallway from the other spaces we’ve covered. Because of space limitations, the equipment rack is located within the same room. The main purpose of the room is a meeting space for staff professors. It’s used for videocon- ferencing and other high-level staff meetings because the classroom is booked most often for student use. Aside from that, the conference room and the classroom have similar configurations. The conference room can take feeds and route sources from the sim lab control room. And the conference room has a separate Tandberg codec for videoconferencing and a ClearOne for audio conferencing.
    A Sony LCD projects onto a Da-Lite 84-inch screen for room presentations. During videoconferencing, far-end site video can be viewed on a 42-inch Sony LCD monitor. An Extron AAP table interface accommodates a plug-in laptop and other video sources. Then an Extron twisted pair receiver/transmitter can send RGB and video to the conferencing locations. Video is controlled by an Extron 12x8 video matrix switcher. Rack equipment is accessed by a Crestron TPS-4000 touchpanel.

Other Equipment
    Other conference room equipment includes two Sony ceiling cameras that are used during videocon- ferencing. A DVD records the event. There’s a VHS player, as well. For audioconferencing, a ClearOne XAP-800 eight-channel matrix mixer is used in conjunction with a ClearOne telco hybrid. All conferencing room audio goes through a QSC power amplifier, which drives QSC ceiling speakers. Four Shure ceiling mics capture audio within the conference room.
    David Wolf pointed out that, from the integrator’s perspective, the research and development of the audio distribution system, “where the rooms can talk to each other without any unwanted noise, was probably our biggest challenge. We also worked hard to get touchpanels that would work well for the user to come in and understand what really happens when they push a button, because there’s a lot going down. We give them a lot of function. They have to preview and control multiple DVD recorders and multiple cameras on the same touch- panel. So we really worked hard to give them an interface that was easy to understand and easy to use, but very complex and very feature-heavy. So they’re able to do almost anything they want with these rooms.”
    Regarding custom GUI and programming, he explained that Whitlock does that work in-house. “There’s a lot of interaction with the teachers. The professors would come in and work through the system. Then we’d have to come back a couple times. But part of what we offer is a full, user-friendly GUI interface that allows professors to train other professors. And there are other aids provided to help them effectively teach. There’s also RGB and video that goes back and forth through the system through the Extron twisted pair solutions.”
    VCU’s Bogan said about the technology, “There’s a classroom that’s tied to the labs, AV-wise. Students can be watching the [trainee] doing the simulation from the classroom as it happens. They can also be watching him in the conference room, because all of these rooms are tied to the same switchers.”
    He related his experience viewing a sim lab exercise. “I was in the control room. They had a latex catheter in a scenario in which the [patient] was allergic to latex. Every time they put the catheter in [the patient], his vital signs started going on. The nursing student had to figure out what was the problem. The simulations are very real. It’s like a real-world OR situation. They’re using all the technology: The manikins breathe, their eyes move around, their arms and legs move.”
    Finally, Fallacaro explained that this simulation-based applied learning approach to CRNA graduate education, employed in his department at VCU, is relatively new. “It’s not universally embraced in the profession because it’s expensive and labor intensive. Over the last five to 10 years, more and more educational programs are starting to incorporate human simulation. We certainly are one of the pioneers out there. And the technology in our simulation center is, indeed, state-of-the-art. There is only a handful of facilities nationwide that have the resources we have here in our lab.”

 

The Whitlock Group
    Based in Richmond VA, systems integrator The Whitlock Group, a national audio and video integration firm, focuses on the design, procurement, engineering, installation and service of audiovisual, videoconferencing, video-streaming, digital signage, video-production and broadcast solutions. The Whitlock Group delivers complete solutions that seamlessly integrate the audio, video, display and system controls to create unique and compelling multimedia solutions.
    The Whitlock Group represents more than 400 manufacturer product lines, which allows it to be fully prepared to design and deliver systems tailored to best fit customers’ specific needs and applications.
    Projects include turnkey broadcast and production facilities, presentation systems, network operations centers, business videoconferencing centers and electronic boardrooms.
    For more information, go to www.whitlock.com.

 

VCU Center for Research in Human Simulation
    The Center for Research in Human Simulation is located on the second floor of West Hospital on the MCV Campus of Virginia Commonwealth University, and was built in Summer 1998. The faculty occupies more than 1300 square feet of space and the department’s program leads to a CRNA (Certified Registered Nurse Anesthetist) graduate (MSNA) degree.
    Features of the Center include two full-body Laerdal patient simulators, which can be used in operating rooms, critical care or emergency medical services settings. The recent addition of the Medical Educational Technologies, Inc. (METI), Pedia-Sim ECS patient simulator provides the unique opportunity for clinical interventions and drug administration relevant to the administration of anesthesia in the pediatric population. The Pedia-Sim ECS generates realistic and automatic responses to student interventions.
    The Department of Nurse Anesthesia also has acquired the Immersion Medical PreOp Endoscopy Simulator, which delivers realistic, procedure-based training of fiberoptic intubation and bronchoscopy cognitive and motor skills. The Immersion simulator hardware interfaces with a personal computer that demonstrates 3D interactive models.
    The Center for Research in Human Simulation offers tours and information for groups interested in simulation training and education.
    For more information, go to www.sahp.vcu.edu/nrsa.

 

EQUIPMENT

Training Lab 1
    5 Clockaudio C0007E ceiling boundary mics
    1 EDIROL by Roland V-4 video effects mixer, V-4RM V-4 rack mount
    2 Extron MPA 122 mini power amps
    4 Extron blank single AAPs*
    8 Extron HD15/mJack AAPs
    2 Extron DB9 female AAPs
    2 Extron dual USB AAPs
    4 Extron RJ45 punchdown AAPs
    1 Middle Atlantic DVD-R rack mount
    4 NTI USB-C5-LC USB extenders
    5 Shure UC14/51 wireless lav packs
    2 Shure UA500 1/2 wave remote antennas
    1 Tandberg 6000MXP VTC

Nursing School Training Lab, Classroom
    1 QSC AD-S52T wall speaker
    1 QSC AD-YM5 yoke mount
    1 Sony RDR-HX900 DVD recorder
    1 Tandberg Natural Presenter Package**
    5 Vaddio CeilingVIEW 70 PTZ in-ceiling PTZ cameras

Training Lab 2
    3 Clockaudio C0007E ceiling boundary mics
    1 EDIROL by Roland V-4 video effects mixer, V-4RM V-4 rack mount
    1 Extron AAP104 plate
    1 Extron MPA122 audio amp
    2 Extron blank single AAPs
    4 Extron HD15/mJack AAPs
    1 Extron DB9 female AAP
    1 Extron Dual USB AAP
    2 Extron RJ-45 punchdown AAPs
    1 Middle Atlantic DVD-R rack mount
    2 NTI USB-C5-LC USB extenders
    1 QSC AD-S52T wall speaker, AD-YM5 yoke mount
    1 Sony RDR-HX900 DVD recorder
    3 Vaddio CeilingVIEW 70 PTZ in-ceiling PTZ cameras

Training Lab 3
    1 Altec Lansing CF204-8A bed speaker
    1 Clockaudio C0007E ceiling boundary mic
    1 EDIROL by Roland V-4 video effects mixer, V-4RM V-4 rack mount
    1 Extron AAP104 plate
    1 Extron MPA122 audio amp
    2 Extron blank single AAPs
    4 Extron HD15/mJack AAPs
    1 Extron DB9 female AAP
    1 Extron Dual USB AAP
    2 Extron RJ-45 punchdown AAP
    1 Middle Atlantic DVD-R rack mount
    2 NTI USB-C5-LC USB extenders
    1 QSC AD-S52T wall speaker, AD-YM5 yoke mount
    1 Sony RDR-HX900 DVD recorder
    1 Vaddio CeilingVIEW 70 PTZ in-ceiling PTZ camera

Classroom
    1 Chief CMA-100 ceiling mount**
    1 Chief PDS-2095 LCD mount**
    1 Chief RPA-085 projector mount**
    1 Crestron accessories
    1 Crestron TPS-4000B 10.4" touchpanel
    1 Extron AAP104 frame w/accessories
    2 Extron HAS AC Net AAPs
    3 Extron RGB192 interfaces
    3 Extron under-desk mounting kits
    1 Furman TWG-PC8 power conditioner
    1 Middle Atlantic DVD-R rack mount
    1 Middle Atlantic VHS rack mount
    8 QSC AD-C52T ceiling speakers
    2 Shure UA500 1/2 wave remote antennas
    1 Sony FWD-42LX1/B 42" LCD monitor**
    1 Sony RDR-HX900 DVD recorder**
    1 SSL-250 Sympodium interactive**

Lectern (6RU)**
    1 Da-Lite 100" projection screen w/low voltage control**
    1 PolyVision TS800 4’x8' interactive whiteboard
    1 QSC CX302V 2-channel audio amp
    1 Shure MX418/S gooseneck mic
    2 Shure UC24/58 wireless HH packs
    8 Shure MX202WP/C ceiling mics
    1 Sony SLV-N900 VHS player
    1 Sony VPL-CX85 LCD projector
    2 Vaddio CeilingVIEW 70 PTZ in-ceiling cameras
    1 WolfVision VZ-9 document camera

Control Room
    1 Crestron TPS-4000B touchpanel
    1 Crestron DTT-18 18" touchpanel system**
    1 Crestron UPX-2 touchpanel system processor**
    2 NTI USB-C5-LC USB extenders
    1 Shure MX-418D/C gooseneck PTT mic
    2 Tannoy CMS50 ICT-30 ceiling speakers

Rack Room
    1 ClearOne XAP-800 8-channel matrix mixer**
    1 ClearOne XAP-TH2 telco hybrid**
    2 ClearOne XAP-800 8-channel matrix mixers
    1 Crestron C2ENET-1 Ethernet card
    1 Crestron PRO2 control processor
    2 Crestron CNPWS-75 power supplies
    3 Crestron CNX-MIDI MIDI expansion cards
    6 Crestron C2COM-3 RS232 expansion cards
    1 Crestron C2IR-8 IR expansion card
    1 Crestron RACK2 control processor
    1 Crestron ST-PC power control module
    3 EDIROL by Roland V-4 crossfader option
    5 Extron VSC900 scan converters
    1 Extron CP2424HVA matrix switcher
    1 Extron MAV3232VA matrix switcher
    2 Extron TPRBNCAV receivers
    2 Extron TPT15HDAV transmitters
    2 Furman TWG-PC8 power conditioners
    2 Middle Atlantic WRK-44SA-32 44RU equipment racks, accessories
    1 QSC CX204V 4-channel audio amp
    5 Shure UC4 wireless mic receivers**
    2 Shure UA220 passive combiners
    3 Shure UA845US antenna DAs

Conference Room
    1 Chief CMA-100 ceiling mount
    1 Chief RPA-085 projector mount
    1 ClearOne XAP-800 8-channel matrix mixer
    1 ClearOne XAP-TH2 telco hybrid
    1 Crestron C2COM-3 RS232 expansion card
    1 Crestron C2ENET-1 Ethernet card
    1 Crestron PRO2 control processor
    1 Crestron RMK-4000L rack mount
    1 Crestron ST-PC power control module
    1 Crestron TPS-4000LB 10.4" touchpanel
    1 Da-Lite 84297R 84" projection screen w/low-voltage control
    1 Extron RGB168xi interface
    1 Extron CP88HVA matrix switcher
    2 Extron RGB192 interfaces
    1 Extron MAV128AV matrix switcher
    1 Furman TWG-PC8 power conditioner
    1 Middle Atlantic WRK-37SA-27 37RU equipment rack w/accessories
    2 NTI USB-C5-LC USB extenders
    6 QSC AD-C52T ceiling speakers
    1 QSC CX302V 2-channel audio amp
    4 Shure MX202WP/C ceiling mics
    1 Sony RDR-HX900 DVD recorder
    1 Sony SLV-N900 VHS player
    1 Sony VPL-CX85 LCD projector
    1 Tandberg 113545 6000MXP VTC codec
    1 Tandberg 113828MS multi-site package
    1 Tandberg 113828NPP natural presenter package
    2 Vaddio WallVIEW 70 PTZ cameras

Wire, Cable
    Belden low-voltage control Cat5
    Extron RGB, video, audio cabling

*Architectural adapter plate
**Owner furnished equipment
List is edited from information supplied by The Whitlock Group.


Sound & Communications Contributing Editor Jim Stokes has been involved in the AV industry for more than 30 years as an AV technician and writer.

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