Is VR the Future of MH Training?

Staff Training and Education Patient Safety Healthcare IT Anesthesia

By: Joe Paone | Senior Editor

Published: 8/16/2022

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Virtual reality can enhance the response of OR teams during practice sessions and — if the time comes — in real life.


In a world turned upside-down by COVID and dizzying rates of staff turnover, live, team-based training on how to quickly respond to an instance of the rare but potentially fatal phenomenon of malignant hyperthermia (MH) is more difficult than ever. Luckily, the emergence of virtual reality (VR) simulation training is making it easier for facilities to bridge that gap.

Jacqueline Sumanis, DNAP, CRNA, assistant director of nurse anesthesia services at Memorial Sloan Kettering Cancer Center in New York City, began training her facility’s staff on MH response in 2016 and has seen a lot of major changes in the educational sessions her facility conducts — particularly during the pandemic. Dr. Sumanis, who joined the board of the Malignant Hyperthermia Association of the U.S. (MHAUS), sees potential in VR as a training tool. “Many hospitals are moving toward VR because it’s so hard to have the space as well as all the participants in one area to conduct team training,” she says.

Although Dr. Sumanis has yet to use MH VR training at her facility, she and her colleagues at MHAUS, along with the Association of periOperative Registered Nurses (AORN), served as content experts during the creation of a new VR app for MH training from Health Scholars, a software company. “A lot of MH education is didactic — people looking at PowerPoints or reviewing slides,” says Pam Martin, MD, medical director at Health Scholars. “Using VR puts you in the OR setting as the user so there’s an element of real life, of anxiety and emotion.”

5 Key Issues to Address With MH Training
CORE COMPONENTS
ERROR ELIMINATOR Closed-loop communication is vital during an MH event to confirm the performance and accuracy of necessary tasks.

Jacqueline Sumanis, DNAP, CRNA, assistant director of nurse anesthesia services at Memorial Sloan Kettering Cancer Center in New York City and board member of the Malignant Hyperthermia Association of the U.S. (MHAUS), advises facility leaders to focus  on these areas of malignant hyperthermia (MH) training.

• Designate a team leader. “It seems really basic, but a member of the surgical team should take charge of the response efforts,” says Dr. Sumanis, adding that every non-leader should know their roles, such as mixing medications.
• Prepare the dantrolene. According to Dr. Sumanis, this is a three-person job, with proper dosage being calculated based on the weight of the patient, and then numerous vials being mixed quickly and accurately. “Minutes matter during an MH event, and reconstituting dantrolene is very time-consuming and labor-intensive. It always surprises people how long it takes,” she says. “It takes time and negative pressure to pull up the saline, inject it into the vial, shake it to make sure it dissolved, put the needle back in and draw it back out. And you’re usually pushing it in and pulling it up three times.” Having multiple providers mixing the medications spreads the physical labor out and allows each provider to focus on doing the job as quickly as possible.
• Prioritize communication. Dr. Sumanis says closed-loop communication is vital for effective MH response, but some providers, particularly veteran staff, might not be aware of the concept. “Closed-loop communication is a way of ensuring a message is heard and carried out. An order needs to be given, received and confirmed, and then once it’s carried out, you confirm it’s been done,” — for instance, confirming the proper dosage of dantrolene is being prepared and administered.
• Use visual aids. “Checklists are a proven guide to help teams function better together, because it’s a shared mental model of what needs to be done and where the resources are,” says Dr. Sumanis. Additionally, a drug dosage chart should be available on the MH cart or digitally, so providers don’t need to use a calculator when reconstituting dantrolene.
Dr. Sumanis favors both paper and tech for her checklists and charts. “We can pull up our MH checklist on computers in the ORs and in the PACU, but we also have paper copies on our MH cart,” she says. When using paper checklists, keep in mind that those documents are frozen in time. “Paper always runs the risk of becoming outdated, and if you have it in multiple places, you need to make sure you replace it in all of those places every time you update it,” she says.
• Gather feedback. Dr. Sumanis typically surveys participants after MH simulations. Her queries include asking staff if they feel better prepared to treat an emergency, if they now know where the necessary equipment is and whether they feel they have learned skills that will help the team function. “Make sure the participants come out feeling better prepared and more confident in their decision making, as well as where resources and equipment are,” she says. 
—  Joe Paone

Beyond acquiring Oculus Quest 2 VR headsets and paying for application “seats” for each user, there’s no back-end work a facility must do to use and maintain the company’s cloud-based app, which is accessible via Wi-Fi and receives updates automatically. The app features a standardized virtual OR team, with the user acting as team leader, assigning roles and using their voice to talk the rest of the team through the crisis. “You’re standing there talking to the avatars like you’d interact with staff in a normal OR,” says Dr. Martin. “The user says, ‘We need to give the dantrolene’ and calls out the correct dose, and the avatars mix the drug and administer it.”

The current version of the app is a one-player module, with no ability to collaborate with other real users as a team during an MH scenario. That could be a drawback — but there’s an inherent benefit to it as well. “It allows you to practice as often as you want,” says Dr. Martin. “You can hop on the headset on your own time, at your own pace and as often as you’d like to hone your muscle memory to react to the signs and symptoms of MH.”

After simulation, the app debriefs users on what they got correct and where they require improvement. Educators can also see how users are performing and where they might be struggling. They can even gamify the VR education by recognizing the provider with the highest score. The concept of gamifying VR training is something that is very intriguing to Dr. Sumanis. “We all have a tendency to become a bit addicted to games, so why not use that for something good?” she asks, adding that gamifying the scores has the potential to improve effectiveness.

The Health Scholars app was Dr. Sumanis’ first experience with VR. “I really like that you can run a simulation on your own, on your own time, from home or wherever you are,” she says. “One of the challenges with live simulation is that you need the whole team present,” she says.

VR modules that are collaborative can be game-changers when it comes to surgical training, according to Dr. Sumanis. “With these apps, you can interact with providers all over the country,” she says. “You’re having real interactions and learning off each other. It can help you optimize how your team functions together.” Dr. Sumanis is quick to point out that VR technology is not a substitute for live simulations or tabletop training. “It’s not a replacement, but it serves a purpose,” she says. “MH events are high-risk, low-frequency emergencies. Knowing how to treat MH doesn’t mean you can do it under pressure, that you can mobilize your resources. What and where is your equipment? Who do you call? How do you page them? Who comes when you press the code button?” OSM

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