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Design of a Serious Game for Handling Obstetrical Emergencies

Design of a Serious Game for Handling Obstetrical Emergencies Background: The emergence of new technologies in the obstetrical field should lead to the development of learning applications, specifically for obstetrical emergencies. Many childbirth simulations have been recently developed. However, to date none of them have been integrated into a serious game. Objective: Our objective was to design a new type of immersive serious game, using virtual glasses to facilitate the learning of pregnancy and childbirth pathologies. We have elaborated a new game engine, placing the student in some maternity emergency situations and delivery room simulations. Methods: A gynecologist initially wrote a scenario based on a real clinical situation. He also designed, along with an educational engineer, a tree diagram, which served as a guide for dialogues and actions. A game engine, especially developed for this case, enabled us to connect actions to the graphic universe (fully 3D modeled and based on photographic references). We used the Oculus Rift in order to immerse the player in virtual reality. Each action in the game was linked to a certain number of score points, which could either be positive or negative. Results: Different pathological pregnancy situations have been targeted and are as follows: care of spontaneous miscarriage, threat of preterm birth, forceps operative delivery for fetal abnormal heart rate, and reduction of a shoulder dystocia. The first phase immerses the learner into an action scene, as a doctor. The second phase ask the student to make a diagnosis. Once the diagnosis is made, different treatments are suggested. Conclusions: Our serious game offers a new perspective for obstetrical emergency management trainings and provides students with active learning by immersing them into an environment, which recreates all or part of the real obstetrical world of emergency. It is consistent with the latest recommendations, which clarify the importance of simulation in teaching and in ongoing professional development. (JMIR Serious Games 2016;4(2):e21) doi: 10.2196/games.5526 KEYWORDS serious game; obstetric emergencies; gynecology severe and urgent, a fast and efficient care led by a perfectly Introduction trained team is needed. In these cases, the training is mostly performed on real patients under the supervision of a senior. In most cases, pregnancy and childbirth are conducted without However, emergency situation does not facilitate the learning complications. However, when pathology occurs, sometimes process. http://games.jmir.org/2016/2/e21/ JMIR Serious Games 2016 | vol. 4 | iss. 2 | e21 | p. 1 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Jean dit Gautier et al The occurrence of certain situations is therefore random and actions enables the students to progress following a clinical depends on the maternity services with which the student is reasoning. Players can have access to various additional clinical affiliated. elements, for example, the possibility to perform an ultrasound, a biological assessment, consult medical records, or fetal The emergence of new technologies in the obstetrical field monitoring. Once the diagnosis is made, different treatments should lead to the development of learning applications, are offered to learners. specifically for obstetrical emergencies. Indeed, according to the latest 2014 Haute Autorité de Santé recommendations, We want to reach the most real-like situation by offering related to birth care quality and safety, simulation exercises are students the maximum dialog choices and additional tests. integrated into the team training for obstetrical emergencies [1]. In order to offer a certain freedom in action, a complex actions Many trainings using simulation were designed to teach medical diagram tree lead in-game actions and allows students to make students and to develop their capacity to perform surgeries in their own choices in the game. the future. Effectiveness of this form of learning is now well established [2,3]. Furthermore, using virtual glasses-headphones Both an educational engineer and a doctor have designed this coupling allows total immersion of the player in a 3D actions tree. It contains all the possible actions, which are given environment and affects both hearing and sight. This immersion to players in the game. Thanks to this method, the scenario is more complete as compared with a situation in which the moves away from a linear path, and allows students to learn player is just in front of a computer screen with keyboard and through attempts and errors. All these actions diagram trees are mouse control devices [4]. designed with a diagramming software, such as Ed Graph Editor, (see Figure 1). In the obstetrical field, many childbirth simulations have been recently designed for educational purposes [5]. However, to This actions diagram has been evaluated for its relevance by date, none of them have been integrated into a serious game, doctors with different knowledge levels. Thus, medicine allowing a global “virtual patient” approach. students, obstetrical residents, and hospital practitioners tested it. It was aimed to highlight possible misunderstandings or Our goal is to develop a new type of immersive, virtual reality inconsistencies, which may persist in the scenario realization. serious game using virtual glasses. We describe the design of This will also enable us to expand the range of options offered a new game engine, placing the student in some maternity to players. Some answers may not have been initially envisaged emergency situations and delivery room simulations. In-game and might be relevant in diagnostic or therapeutic procedures. decision-making should lead, in the second step, to an accurate obstetrical gesture realization on a physical manikin. The graphic universe has been fully 3D modeled and is based on hospital photographic references. Different views have been Methods taken in some strategic locations such as obstetrical emergencies unit, guardrooms, and delivery rooms (see Figure 2). So far, 2 For several years, our obstetricians’ team has been working in locations have been 3D modeled in order to compose the partnership with an educational engineer. environment of the 4 scenarios. “Spontaneous miscarriage” and “possible preterm birth” scenarios take place in the obstetrical Different pathological situations during pregnancy that have emergencies unit. “Forceps operative delivery for fetal abnormal been targeted are as follows: threat of early spontaneous heart rate” and “reduction of a shoulder dystocia” scenarios take miscarriage, threat of preterm birth, forceps operative delivery place in a delivery room. These different locations are 3D for abnormal heart rate, and reduction of a shoulder dystocia. modeled using “Autodesk 3ds Max” software. This serious game targets different categories of learners. Game development was carried out following 2 distinct phases. Indeed, “spontaneous miscarriage” and “possible preterm birth” First, it was necessary to develop a game engine. Indeed, once scenarios deal with 2 topics that are part of the French the actions tree design was completed, each actions branch had educational program of the medicine study second cycle [6]. to be linked to in-game actions. Each action contains, via the They also form a part of the midwife educational program. Thus, game engine, the action description, the previous actions these scenarios target a wide audience, composed of medicine (leading to this action), and the following actions (unlocked by students, obstetrical and gynecological internes and residents, this action). Some other information can also be set up, such as and apprentice midwives. The “forceps operative delivery for corresponding interactive objects, code names, and so on. abnormal fetal heart rate” scenario will permit the gynecology Second, indicated actions are connected with the graphic and obstetrics residents training. universe. For example, ultrasound actions type appeared by Obstetricians and midwives must know the “shoulder dystocia” clicking on the ultrasound equipment, respecting the timeline diagnosis and the related reduction gestures. The last 2 scenarios and the causes or consequences relationship established in the could be integrated as part of an ongoing medical training. actions tree diagram. An obstetrician initially wrote a scenario based on a real clinical Players are immersed in virtual reality thanks to the Oculus Rift situation. All scenarios were designed following the same technology, a virtual reality device designed by the Oculus VR method. The first phase put the learner in an action scene, as a Company. The device looks like a mask covering eyes and can doctor. The second phase lead to making the diagnosis of the be strapped to the face at the rear of the head. A digital screen pathology. An actions diagram tree referring to all the possible is placed a few centimeters in front of each eye, perpendicular http://games.jmir.org/2016/2/e21/ JMIR Serious Games 2016 | vol. 4 | iss. 2 | e21 | p. 2 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Jean dit Gautier et al to the sight line. This screen displays a stereoscopic picture, All these actions are then summarized at the end of the game digitally distorted by 2 lenses located in front of each eye, in in a score table (see Figure 3). The score table is divided into order to inverse the optical distortion. It expands the visual field 5 sections. On the top, the global player score is provided that and the definition in front of the fovea. The screen is placed in the player earned on the entire scenario. The first column the focal plane of these lenses. The created virtual picture is reminds each action he or she performed, the second shows the projected to infinity. Various sensors detect user head actions category, the third shows the score associated with this movements, which make a real-time picture adaptation on the particular action, and the last column often leads to additional screen possible and produce a total immersion into the rendered content (videos, articles, and courses). scene. Every time a session ends, a personal and downloadable A score, which can be either positive or negative, is set for every assessment of the player is edited through a spreadsheet software possible in-game action. A good action is positively rewarded, (Excel-like). Thus, the player can see his mistakes and successes and conversely, bad actions are negatively rewarded. Therefore, at the end of the game. A scoring system permits the player certain choices would be rewarded, and others would be assessment. The learning assessment is a two-step process. The penalized. Score points setting depend on the student diagnostic first step is made through the game based on the choices the process and its relevance. For example, if the student player virtually made and for which he or she has been given immediately led a biological assessment before interrogating points (positive and negative) assigning the player a final grade. or examining the patient, the student will be rewarded less score The second step occurs through the actual debrief at the end of points than a student who follows a correct approach, with a the learning session, with the teacher who will go through the medical logic (interrogation, followed by clinical tests, and blunt assessment given by the game. additional tests). In delivery room scenarios, a concept of penalty depending on the student’s decision time is added. Figure 1. Orange: environment changes and specific content display; blue: player decision making; purple: interaction with object; green: game automatic feedback; black: checkpoint. http://games.jmir.org/2016/2/e21/ JMIR Serious Games 2016 | vol. 4 | iss. 2 | e21 | p. 3 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Jean dit Gautier et al Figure 2. Elaboration of a graphic environment: (a) 3D modeled graphic universe, based on hospital photographic references: guard room and (b) obstetrical emergencies unit. Figure 3. Score table: personal and downloadable score table of the player. him with the necessary information on diagnosis. The learner Results can also consult the personal medical records in order to access various data such as patient history, allergies, and pregnancy All the scenarios mentioned above have been developed. monitoring. If the player wishes, he or she can perform an Two scenarios take place in obstetrical emergencies unit. The ultrasound, or consult the fetal heart rate and tocography. If so, 2 selected pathologies are frequent motives for consultations: he or she will have an access to ultrasound images we have spontaneous miscarriage and possible preterm birth [7]. included in the scenario (cervical length and estimated fetal weight). The purpose of these additional elements is to guide The player is in an emergency room. He or she has access to the learner toward a possible preterm birth diagnosis. However, all the necessary equipment in order to solve the clinical case: only the player can choose if he or she realizes (or not) a medical personal medical records, cardiotocography, lookup table, interrogation and additional examinations. He or she can then ultrasound device, tensiometer, thermometer, tubes for biological choose among several therapeutic treatments. To some extent, samples, or even urine sample bottles for urinalysis strips uses. the player can constantly access the ongoing diagnosis before Each element has a specific role in the scenario. choosing the appropriate treatment and modify it if he or she The threat of preterm birth scenario is a simple situation in wants. However, there are points of no return: Once he or she which a patient comes to obstetrical emergencies unit for pelvic reaches one, the player cannot go back would he or she want to pain at 30 weeks of gestation. We have created a virtual dialogue obtain additional information and modify his diagnosis. The between the patient and the learner or player in order to provide diagnostic process is estimated at 20 minutes, which is the time http://games.jmir.org/2016/2/e21/ JMIR Serious Games 2016 | vol. 4 | iss. 2 | e21 | p. 4 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Jean dit Gautier et al amount allotted to the player to solve the case. With this midwifery students by offering the possibility to face frequent countdown system, we want to recreate the stressful conditions emergency situations, which require quick management answers of emergency services (average consulting time). and are based on essential knowledge. The “spontaneous miscarriage scenario” takes place in the same Some commercial or nonprofit platforms already exist but have environment and is based on the same game action engine, with not been totally adapted to the medical training needs. For a similar diagnostic approach. A patient, at the first trimester instance, these game engines do not support the Oculus Rift of pregnancy, comes for metrorrhagia. The player can realize technology. Based on our training needs, we created our own detailed examinations, ultrasound, and biological check-up specific tool. It allows the incorporation of a complex diagram (pregnancy blood test, complete blood count). He or she should tree, based on a real clinical situation, which offers a multiple eventually make a spontaneous miscarriage diagnosis and choose action combination and leads to a realistic and immersive game. the adapted therapy. Regarding the scenarios taking place in Moreover, the project must lead to the integration of a medical the delivery room, we needed to create a new graphic training manikin, be sensor-equipped, and link to the Serious environment. Game, to allow obstetrical gesture training with real-time An obstetrical unit midwife calls the player and asks him to feedbacks. Our game engine should therefore be custom come into the delivery room. He or she can consult the personal designed in regard with this evolution. Serious games medical records, the monitoring (showing an abnormal fetal developments in the medical field are often very specific to each heart rhythm and expulsive efforts), ultrasound, and has access project. Few of them use a game engine, which allows creating to various obstetrical tools. new scenarios with minimal efforts, especially in the gynecologic field. Our work led to the development of a new Regarding “forceps operative delivery through forceps for game engine, which allows integrating, quickly and easily, new abnormal heart rate scenario,” the player can lead a patient and scenarios, both in the gynecologic and obstetric fields, as well a midwife interrogation, perform a vaginal examination, an as in other medical fields, without requiring the intervention of ultrasound, and collect some information about fetal head a programmer. Each scenario can be integrated into a new engagement and orientation. The goal is to achieve as soon as graphic environment, corresponding to various hospital possible the abnormal fetal heart rate diagnosis requiring forceps locations, using already created graphic assets. Moreover, few operative delivery. The decision must be taken within 10 serious games offer a complete immersion in the medical field minutes in order to represent the urgency of this type of currently. Immersion, through the Oculus Rift, can increase the situation. realism of a clinical situation and the involvement of the player The “reduction of a shoulder dystocia scenario” takes place in [9]. the same way. The same additional examination possibilities Learning by playing seems to be a solid method to gain better are offered to the player. Most of them are useless, and even appropriation for the learner [10]. Serious games, mostly have a negative impact and result in a waste of time because developed for surgical skills, have been tested to prove their the shoulder dystocia diagnosis is purely clinical. The player validity [11-13]. Serious games seem to better enable the learner goal is to reach this diagnosis as soon as possible and choose to feel immersed, to improve their confidence, and to enhance among various proposed gestures. their clinical skills [12]. Serious games offer an innovative approach and seem more attractive than the “old fashioned way” Discussion of learning. Nevertheless, in order to do so, it is important to cooperate in designing and validating a serious game for a Principal Findings specific educational problem [14,15]. That is why we combined We designed a new type of immersive serious game, using a both the work and the skills of a pedagogic engineer, a game new game engine. It supports the Oculus Rift technology, allows designer, a medical doctor, and a medical professor. the integration of new scenarios with minimal effort, especially Our educational method aims at learning various common in the gynecologic field, and could be linked to the medical gynecological pathologies through realistic virtual situations. training manikin. It has been designed so that it is The game provides the learner with the opportunity to think and sensor-equipped to allow gesture realization. to follow a patterned diagnosis approach. Thanks to the The use of new simulation technologies has been widespread postgame score analysis, the learner can evaluate himself and in the obstetrical field for the last ten years. However, to our get debriefed about the mistakes he or she committed during knowledge, there is no publication about serious games used the game session. as pedagogic tools for learning in obstetrical emergency Naturally, this tool has to be properly tested on a student’s situations. sample in order to validate its performances and demonstrate Nowadays, learning through simulation mostly concerns its pedagogic potential, and also evaluate the good learning trainings related to breast and pelvic clinical examination as acquisition. Thanks to the game and to the learning session with well as to postpartum hemorrhage management [8]. This the debrief-time. learning form is commonly linked to the technical skills Even today, serious game is not a well-defined concept. So far, reinforcement, especially with postexercise debriefing. Through it has many definitions, which differ from author to author the game, our educational tool can help stimulate the motivation [16-20]. Our work matched with the definition of Julian Alvarez of medicine students, obstetrical interns, residents, and http://games.jmir.org/2016/2/e21/ JMIR Serious Games 2016 | vol. 4 | iss. 2 | e21 | p. 5 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Jean dit Gautier et al that defines serious games as any “computer application whose Thereafter, we would allow the learner to realize these technical initial intention is to combine, with consistency, both serious gestures on a sensor-equipped obstetrical anatomic manikin, aspects with fun spring from video game” [18]. We have which tracks each learner’s gestures. described a system that meets this definition by using scoring We are working on a virtual simulator of the pregnant woman’s system, action and decision tree, stressful and immersive graphic pelvic system in order to allow gestures on a digital model. The environment narrative systems, and game mechanics based on game action engine of our serious game can also integrate new flow and game design theory (especially from point and click future scenarios such as ectopic pregnancy, operative delivery adventure game type). This Serious Game is developed as a part for obstructed labor, and/or vacuum extraction. of a continuing medical training, funded by Lille2 University. It is used within the framework of learning sessions, managed Conclusion by a professor. A medical teacher carries out the briefing and Simulation teaching offers active learning, conducted by the the debriefing. In this context, the game is only a support, used learner, immersed in an environment recreating all or part of to initiate a dialogue involving the player’s own knowledge. the real world, promoting knowledge integration and technical However, this game can be also used as a “standalone game.” and behavioral skills in a short time. The final report screen allows nonetheless a basic assessment, Our serious game is part of this type of educational training, even without learning sessions. The scoring system, initially and offers a new perspective for obstetrical emergency learning. designed by a doctor, allows the player to visualize his mistakes, We need to test it on a student sample to validate its pedagogic and to get the “correct answer” related to the clinical situation potential in order to justify its integration into an obstetrical he or she just experienced. Prior to any training, we will use learning program. these sessions as an opportunity to make A-B testing (with and without the game) and evaluate its usability, through a form We want to develop it by creating some new scenario in the filled by the student at the end of each session. gynecologic and obstetrical fields to extend its pedagogical impact. So far, delivery room scenarios end at the obstetrical gesture choice. Acknowledgments The authors would like to thank the University of Lille for the financial support. Conflicts of Interest None declared. References 1. Granry JC, Moll MC. Rapport de mission État de l'art (national et international) en matiere de pratiques de simulation dans le domaine de la sante: Dans le cadre du developpement professionel continu et de la prevention des risques associes aux soins. Haute Autorité de Santé. 2012 Jan. URL: http://www.has-sante.fr/portail/upload/docs/application/pdf/2012-01/ simulation_en_sante_-_rapport.pdf [accessed 2016-08-30] [WebCite Cache ID 6k9DApsIO] 2. Cook DA, Hatala R, Brydges R, Zendejas B, Szostek JH, Wang AT, et al. Technology-enhanced simulation for health professions education: a systematic review and meta-analysis. JAMA 2011 Sep 7;306(9):978-988. [doi: 10.1001/jama.2011.1234] [Medline: 21900138] 3. Graafland M, Schraagen JM, Schijven MP. Systematic review of serious games for medical education and surgical skills training. Br J Surg 2012 Oct;99(10):1322-1330. [doi: 10.1002/bjs.8819] [Medline: 22961509] 4. Starner T. Fundamentals of wearable computers and augmented reality. In: Wearable Comput Meetting Chall. France: CRC press; 2015. 5. Dupuis O, Moreau R, Pham MT, Redarce T. Assessment of forceps blade orientations during their placement using an instrumented childbirth simulator. BJOG 2009 Jan;116(2):327-32; discussion 332 [FREE Full text] [doi: 10.1111/j.1471-0528.2008.02004.x] [Medline: 19076965] 6. Ministère de l'éducation nationale et ministère de l'enseignement supérieur et de la recherche. Deuxième partie du deuxième cycle des études médicales. Bulletin officiel. 2007 Jun 07. URL: http://www.education.gouv.fr/bo/2007/22/MENS0753287A. htm [accessed 2016-08-30] [WebCite Cache ID 6k9DfNadw] 7. Alouini S, Mesnard L, Coly S, Dolique M, Lemaire B. Urgences gynécologiques : nature et degré de gravité. J Gynécologie Obstétrique Biol Reprod 2012;41(1):48-54. 8. Daniels K, Parness A. Development and use of mechanical devices for simulation of seizure and hemorrhage in obstetrical team training. Simul Healthc 2008;3(1):42-46. [doi: 10.1097/01.SIH.0000290632.83361.4b] [Medline: 19088641] 9. Csikszentmihalyi M. Toward a Psychology of Optimal Experience. In: Flow and the Foundations of Positive Psychology. Netherlands: Springer; 2014:209-226. http://games.jmir.org/2016/2/e21/ JMIR Serious Games 2016 | vol. 4 | iss. 2 | e21 | p. 6 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Jean dit Gautier et al 10. Al-Smadi M. Assessment in serious games: An enhanced approach for integrated assessment forms and feedback to support guided learning. 2012 Presented at: 2012 15th International Conference on Interactive Collaborative Learning (ICL); September 26-28, 2012; Austria. [doi: 10.1109/ICL.2012.6402089] 11. Youngblood P, Harter P, Srivastava S, Moffett S, Heinrichs W, Dev P. Design, development, and evaluation of an online virtual emergency department for training trauma teams. Simul Healthc 2008;3(3):146-153. [doi: 10.1097/SIH.0b013e31817bedf7] [Medline: 19088658] 12. Heinrichs W, Youngblood P, Harter P, Kusumoto L, Dev P. Training Healthcare Personnel for Mass-Casualty Incidents in a Virtual Emergency Department: VED II. Prehosp Disaster Med 2012 Jun 28;25(05):424-432. [doi: 10.1017/S1049023X00008505] 13. LeRoy HW, Youngblood P, Harter P, Dev P. Simulation for team training and assessment: case studies of online training with virtual worlds. World J Surg 2008 Feb;32(2):161-170. [doi: 10.1007/s00268-007-9354-2] [Medline: 18188640] 14. Schijven M, Jakimowicz J. Validation of virtual reality simulators: Key to the successful integration of a novel teaching technology into minimal access surgery. Minim Invasive Ther Allied Technol 2005;14(4):244-246. [Medline: 16754170] 15. Gallagher A, Ritter E, Satava R. Fundamental principles of validation, and reliability: rigorous science for the assessment of surgical education and training. Surg Endosc 2003 Oct;17(10):1525-1529. [doi: 10.1007/s00464-003-0035-4] [Medline: 14502403] 16. Abt CC. Serious games. Lanham, MD: University Press of America; 1987. 17. Michael D, Chen S. Serious Games: Games That Educate, Train, and Inform. Boston, MA: Course Technology PTR; 2005. 18. Alvarez J. Du jeu video au serious game: approches culturelle, pragmatique et formelle. Games. URL: http://ja.games.free.fr/ These_SeriousGames/TheseSeriousGames.pdf [accessed 2016-08-25] [WebCite Cache ID 6k1jmaIyV] 19. Sawyer B. The “Serious Games” Landscape. Biu. 2007. URL: http://u.cs.biu.ac.il/~ariel/download/mm664/resources/ digital_games/Serious%20Games%20Landscape.ppt [accessed 2016-08-30] [WebCite Cache ID 6k9FTgirk] 20. Djaouti D. Serious Game Design: considerations theoriques et techniques sur la creation de jeux video a vocation utilitaire. Ludoscience. URL: http://www.ludoscience.com/files/these_djaouti.pdf [accessed 2016-08-25] [WebCite Cache ID 6k1kClCEs] Edited by C Boyer; submitted 14.01.16; peer-reviewed by P Staccini, D Katz, C Boyer; comments to author 30.03.16; revised version received 25.05.16; accepted 08.08.16; published 21.12.16 Please cite as: Jean dit Gautier E, Bot-Robin V, Libessart A, Doucède G, Cosson M, Rubod C JMIR Serious Games 2016;4(2):e21 URL: http://games.jmir.org/2016/2/e21/ doi: 10.2196/games.5526 PMID: 28003175 ©Estelle Jean dit Gautier, Virginie Bot-Robin, Aurélien Libessart, Guillaume Doucède, Michel Cosson, Chrystèle Rubod. Originally published in JMIR Serious Games (http://games.jmir.org), 21.12.2016. This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Serious Games, is properly cited. The complete bibliographic information, a link to the original publication on http://games.jmir.org, as well as this copyright and license information must be included. http://games.jmir.org/2016/2/e21/ JMIR Serious Games 2016 | vol. 4 | iss. 2 | e21 | p. 7 (page number not for citation purposes) XSL FO RenderX http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JMIR Serious Games JMIR Publications

Design of a Serious Game for Handling Obstetrical Emergencies

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Abstract

Background: The emergence of new technologies in the obstetrical field should lead to the development of learning applications, specifically for obstetrical emergencies. Many childbirth simulations have been recently developed. However, to date none of them have been integrated into a serious game. Objective: Our objective was to design a new type of immersive serious game, using virtual glasses to facilitate the learning of pregnancy and childbirth pathologies. We have elaborated a new game engine, placing the student in some maternity emergency situations and delivery room simulations. Methods: A gynecologist initially wrote a scenario based on a real clinical situation. He also designed, along with an educational engineer, a tree diagram, which served as a guide for dialogues and actions. A game engine, especially developed for this case, enabled us to connect actions to the graphic universe (fully 3D modeled and based on photographic references). We used the Oculus Rift in order to immerse the player in virtual reality. Each action in the game was linked to a certain number of score points, which could either be positive or negative. Results: Different pathological pregnancy situations have been targeted and are as follows: care of spontaneous miscarriage, threat of preterm birth, forceps operative delivery for fetal abnormal heart rate, and reduction of a shoulder dystocia. The first phase immerses the learner into an action scene, as a doctor. The second phase ask the student to make a diagnosis. Once the diagnosis is made, different treatments are suggested. Conclusions: Our serious game offers a new perspective for obstetrical emergency management trainings and provides students with active learning by immersing them into an environment, which recreates all or part of the real obstetrical world of emergency. It is consistent with the latest recommendations, which clarify the importance of simulation in teaching and in ongoing professional development. (JMIR Serious Games 2016;4(2):e21) doi: 10.2196/games.5526 KEYWORDS serious game; obstetric emergencies; gynecology severe and urgent, a fast and efficient care led by a perfectly Introduction trained team is needed. In these cases, the training is mostly performed on real patients under the supervision of a senior. In most cases, pregnancy and childbirth are conducted without However, emergency situation does not facilitate the learning complications. However, when pathology occurs, sometimes process. http://games.jmir.org/2016/2/e21/ JMIR Serious Games 2016 | vol. 4 | iss. 2 | e21 | p. 1 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Jean dit Gautier et al The occurrence of certain situations is therefore random and actions enables the students to progress following a clinical depends on the maternity services with which the student is reasoning. Players can have access to various additional clinical affiliated. elements, for example, the possibility to perform an ultrasound, a biological assessment, consult medical records, or fetal The emergence of new technologies in the obstetrical field monitoring. Once the diagnosis is made, different treatments should lead to the development of learning applications, are offered to learners. specifically for obstetrical emergencies. Indeed, according to the latest 2014 Haute Autorité de Santé recommendations, We want to reach the most real-like situation by offering related to birth care quality and safety, simulation exercises are students the maximum dialog choices and additional tests. integrated into the team training for obstetrical emergencies [1]. In order to offer a certain freedom in action, a complex actions Many trainings using simulation were designed to teach medical diagram tree lead in-game actions and allows students to make students and to develop their capacity to perform surgeries in their own choices in the game. the future. Effectiveness of this form of learning is now well established [2,3]. Furthermore, using virtual glasses-headphones Both an educational engineer and a doctor have designed this coupling allows total immersion of the player in a 3D actions tree. It contains all the possible actions, which are given environment and affects both hearing and sight. This immersion to players in the game. Thanks to this method, the scenario is more complete as compared with a situation in which the moves away from a linear path, and allows students to learn player is just in front of a computer screen with keyboard and through attempts and errors. All these actions diagram trees are mouse control devices [4]. designed with a diagramming software, such as Ed Graph Editor, (see Figure 1). In the obstetrical field, many childbirth simulations have been recently designed for educational purposes [5]. However, to This actions diagram has been evaluated for its relevance by date, none of them have been integrated into a serious game, doctors with different knowledge levels. Thus, medicine allowing a global “virtual patient” approach. students, obstetrical residents, and hospital practitioners tested it. It was aimed to highlight possible misunderstandings or Our goal is to develop a new type of immersive, virtual reality inconsistencies, which may persist in the scenario realization. serious game using virtual glasses. We describe the design of This will also enable us to expand the range of options offered a new game engine, placing the student in some maternity to players. Some answers may not have been initially envisaged emergency situations and delivery room simulations. In-game and might be relevant in diagnostic or therapeutic procedures. decision-making should lead, in the second step, to an accurate obstetrical gesture realization on a physical manikin. The graphic universe has been fully 3D modeled and is based on hospital photographic references. Different views have been Methods taken in some strategic locations such as obstetrical emergencies unit, guardrooms, and delivery rooms (see Figure 2). So far, 2 For several years, our obstetricians’ team has been working in locations have been 3D modeled in order to compose the partnership with an educational engineer. environment of the 4 scenarios. “Spontaneous miscarriage” and “possible preterm birth” scenarios take place in the obstetrical Different pathological situations during pregnancy that have emergencies unit. “Forceps operative delivery for fetal abnormal been targeted are as follows: threat of early spontaneous heart rate” and “reduction of a shoulder dystocia” scenarios take miscarriage, threat of preterm birth, forceps operative delivery place in a delivery room. These different locations are 3D for abnormal heart rate, and reduction of a shoulder dystocia. modeled using “Autodesk 3ds Max” software. This serious game targets different categories of learners. Game development was carried out following 2 distinct phases. Indeed, “spontaneous miscarriage” and “possible preterm birth” First, it was necessary to develop a game engine. Indeed, once scenarios deal with 2 topics that are part of the French the actions tree design was completed, each actions branch had educational program of the medicine study second cycle [6]. to be linked to in-game actions. Each action contains, via the They also form a part of the midwife educational program. Thus, game engine, the action description, the previous actions these scenarios target a wide audience, composed of medicine (leading to this action), and the following actions (unlocked by students, obstetrical and gynecological internes and residents, this action). Some other information can also be set up, such as and apprentice midwives. The “forceps operative delivery for corresponding interactive objects, code names, and so on. abnormal fetal heart rate” scenario will permit the gynecology Second, indicated actions are connected with the graphic and obstetrics residents training. universe. For example, ultrasound actions type appeared by Obstetricians and midwives must know the “shoulder dystocia” clicking on the ultrasound equipment, respecting the timeline diagnosis and the related reduction gestures. The last 2 scenarios and the causes or consequences relationship established in the could be integrated as part of an ongoing medical training. actions tree diagram. An obstetrician initially wrote a scenario based on a real clinical Players are immersed in virtual reality thanks to the Oculus Rift situation. All scenarios were designed following the same technology, a virtual reality device designed by the Oculus VR method. The first phase put the learner in an action scene, as a Company. The device looks like a mask covering eyes and can doctor. The second phase lead to making the diagnosis of the be strapped to the face at the rear of the head. A digital screen pathology. An actions diagram tree referring to all the possible is placed a few centimeters in front of each eye, perpendicular http://games.jmir.org/2016/2/e21/ JMIR Serious Games 2016 | vol. 4 | iss. 2 | e21 | p. 2 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Jean dit Gautier et al to the sight line. This screen displays a stereoscopic picture, All these actions are then summarized at the end of the game digitally distorted by 2 lenses located in front of each eye, in in a score table (see Figure 3). The score table is divided into order to inverse the optical distortion. It expands the visual field 5 sections. On the top, the global player score is provided that and the definition in front of the fovea. The screen is placed in the player earned on the entire scenario. The first column the focal plane of these lenses. The created virtual picture is reminds each action he or she performed, the second shows the projected to infinity. Various sensors detect user head actions category, the third shows the score associated with this movements, which make a real-time picture adaptation on the particular action, and the last column often leads to additional screen possible and produce a total immersion into the rendered content (videos, articles, and courses). scene. Every time a session ends, a personal and downloadable A score, which can be either positive or negative, is set for every assessment of the player is edited through a spreadsheet software possible in-game action. A good action is positively rewarded, (Excel-like). Thus, the player can see his mistakes and successes and conversely, bad actions are negatively rewarded. Therefore, at the end of the game. A scoring system permits the player certain choices would be rewarded, and others would be assessment. The learning assessment is a two-step process. The penalized. Score points setting depend on the student diagnostic first step is made through the game based on the choices the process and its relevance. For example, if the student player virtually made and for which he or she has been given immediately led a biological assessment before interrogating points (positive and negative) assigning the player a final grade. or examining the patient, the student will be rewarded less score The second step occurs through the actual debrief at the end of points than a student who follows a correct approach, with a the learning session, with the teacher who will go through the medical logic (interrogation, followed by clinical tests, and blunt assessment given by the game. additional tests). In delivery room scenarios, a concept of penalty depending on the student’s decision time is added. Figure 1. Orange: environment changes and specific content display; blue: player decision making; purple: interaction with object; green: game automatic feedback; black: checkpoint. http://games.jmir.org/2016/2/e21/ JMIR Serious Games 2016 | vol. 4 | iss. 2 | e21 | p. 3 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Jean dit Gautier et al Figure 2. Elaboration of a graphic environment: (a) 3D modeled graphic universe, based on hospital photographic references: guard room and (b) obstetrical emergencies unit. Figure 3. Score table: personal and downloadable score table of the player. him with the necessary information on diagnosis. The learner Results can also consult the personal medical records in order to access various data such as patient history, allergies, and pregnancy All the scenarios mentioned above have been developed. monitoring. If the player wishes, he or she can perform an Two scenarios take place in obstetrical emergencies unit. The ultrasound, or consult the fetal heart rate and tocography. If so, 2 selected pathologies are frequent motives for consultations: he or she will have an access to ultrasound images we have spontaneous miscarriage and possible preterm birth [7]. included in the scenario (cervical length and estimated fetal weight). The purpose of these additional elements is to guide The player is in an emergency room. He or she has access to the learner toward a possible preterm birth diagnosis. However, all the necessary equipment in order to solve the clinical case: only the player can choose if he or she realizes (or not) a medical personal medical records, cardiotocography, lookup table, interrogation and additional examinations. He or she can then ultrasound device, tensiometer, thermometer, tubes for biological choose among several therapeutic treatments. To some extent, samples, or even urine sample bottles for urinalysis strips uses. the player can constantly access the ongoing diagnosis before Each element has a specific role in the scenario. choosing the appropriate treatment and modify it if he or she The threat of preterm birth scenario is a simple situation in wants. However, there are points of no return: Once he or she which a patient comes to obstetrical emergencies unit for pelvic reaches one, the player cannot go back would he or she want to pain at 30 weeks of gestation. We have created a virtual dialogue obtain additional information and modify his diagnosis. The between the patient and the learner or player in order to provide diagnostic process is estimated at 20 minutes, which is the time http://games.jmir.org/2016/2/e21/ JMIR Serious Games 2016 | vol. 4 | iss. 2 | e21 | p. 4 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Jean dit Gautier et al amount allotted to the player to solve the case. With this midwifery students by offering the possibility to face frequent countdown system, we want to recreate the stressful conditions emergency situations, which require quick management answers of emergency services (average consulting time). and are based on essential knowledge. The “spontaneous miscarriage scenario” takes place in the same Some commercial or nonprofit platforms already exist but have environment and is based on the same game action engine, with not been totally adapted to the medical training needs. For a similar diagnostic approach. A patient, at the first trimester instance, these game engines do not support the Oculus Rift of pregnancy, comes for metrorrhagia. The player can realize technology. Based on our training needs, we created our own detailed examinations, ultrasound, and biological check-up specific tool. It allows the incorporation of a complex diagram (pregnancy blood test, complete blood count). He or she should tree, based on a real clinical situation, which offers a multiple eventually make a spontaneous miscarriage diagnosis and choose action combination and leads to a realistic and immersive game. the adapted therapy. Regarding the scenarios taking place in Moreover, the project must lead to the integration of a medical the delivery room, we needed to create a new graphic training manikin, be sensor-equipped, and link to the Serious environment. Game, to allow obstetrical gesture training with real-time An obstetrical unit midwife calls the player and asks him to feedbacks. Our game engine should therefore be custom come into the delivery room. He or she can consult the personal designed in regard with this evolution. Serious games medical records, the monitoring (showing an abnormal fetal developments in the medical field are often very specific to each heart rhythm and expulsive efforts), ultrasound, and has access project. Few of them use a game engine, which allows creating to various obstetrical tools. new scenarios with minimal efforts, especially in the gynecologic field. Our work led to the development of a new Regarding “forceps operative delivery through forceps for game engine, which allows integrating, quickly and easily, new abnormal heart rate scenario,” the player can lead a patient and scenarios, both in the gynecologic and obstetric fields, as well a midwife interrogation, perform a vaginal examination, an as in other medical fields, without requiring the intervention of ultrasound, and collect some information about fetal head a programmer. Each scenario can be integrated into a new engagement and orientation. The goal is to achieve as soon as graphic environment, corresponding to various hospital possible the abnormal fetal heart rate diagnosis requiring forceps locations, using already created graphic assets. Moreover, few operative delivery. The decision must be taken within 10 serious games offer a complete immersion in the medical field minutes in order to represent the urgency of this type of currently. Immersion, through the Oculus Rift, can increase the situation. realism of a clinical situation and the involvement of the player The “reduction of a shoulder dystocia scenario” takes place in [9]. the same way. The same additional examination possibilities Learning by playing seems to be a solid method to gain better are offered to the player. Most of them are useless, and even appropriation for the learner [10]. Serious games, mostly have a negative impact and result in a waste of time because developed for surgical skills, have been tested to prove their the shoulder dystocia diagnosis is purely clinical. The player validity [11-13]. Serious games seem to better enable the learner goal is to reach this diagnosis as soon as possible and choose to feel immersed, to improve their confidence, and to enhance among various proposed gestures. their clinical skills [12]. Serious games offer an innovative approach and seem more attractive than the “old fashioned way” Discussion of learning. Nevertheless, in order to do so, it is important to cooperate in designing and validating a serious game for a Principal Findings specific educational problem [14,15]. That is why we combined We designed a new type of immersive serious game, using a both the work and the skills of a pedagogic engineer, a game new game engine. It supports the Oculus Rift technology, allows designer, a medical doctor, and a medical professor. the integration of new scenarios with minimal effort, especially Our educational method aims at learning various common in the gynecologic field, and could be linked to the medical gynecological pathologies through realistic virtual situations. training manikin. It has been designed so that it is The game provides the learner with the opportunity to think and sensor-equipped to allow gesture realization. to follow a patterned diagnosis approach. Thanks to the The use of new simulation technologies has been widespread postgame score analysis, the learner can evaluate himself and in the obstetrical field for the last ten years. However, to our get debriefed about the mistakes he or she committed during knowledge, there is no publication about serious games used the game session. as pedagogic tools for learning in obstetrical emergency Naturally, this tool has to be properly tested on a student’s situations. sample in order to validate its performances and demonstrate Nowadays, learning through simulation mostly concerns its pedagogic potential, and also evaluate the good learning trainings related to breast and pelvic clinical examination as acquisition. Thanks to the game and to the learning session with well as to postpartum hemorrhage management [8]. This the debrief-time. learning form is commonly linked to the technical skills Even today, serious game is not a well-defined concept. So far, reinforcement, especially with postexercise debriefing. Through it has many definitions, which differ from author to author the game, our educational tool can help stimulate the motivation [16-20]. Our work matched with the definition of Julian Alvarez of medicine students, obstetrical interns, residents, and http://games.jmir.org/2016/2/e21/ JMIR Serious Games 2016 | vol. 4 | iss. 2 | e21 | p. 5 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Jean dit Gautier et al that defines serious games as any “computer application whose Thereafter, we would allow the learner to realize these technical initial intention is to combine, with consistency, both serious gestures on a sensor-equipped obstetrical anatomic manikin, aspects with fun spring from video game” [18]. We have which tracks each learner’s gestures. described a system that meets this definition by using scoring We are working on a virtual simulator of the pregnant woman’s system, action and decision tree, stressful and immersive graphic pelvic system in order to allow gestures on a digital model. The environment narrative systems, and game mechanics based on game action engine of our serious game can also integrate new flow and game design theory (especially from point and click future scenarios such as ectopic pregnancy, operative delivery adventure game type). This Serious Game is developed as a part for obstructed labor, and/or vacuum extraction. of a continuing medical training, funded by Lille2 University. It is used within the framework of learning sessions, managed Conclusion by a professor. A medical teacher carries out the briefing and Simulation teaching offers active learning, conducted by the the debriefing. In this context, the game is only a support, used learner, immersed in an environment recreating all or part of to initiate a dialogue involving the player’s own knowledge. the real world, promoting knowledge integration and technical However, this game can be also used as a “standalone game.” and behavioral skills in a short time. The final report screen allows nonetheless a basic assessment, Our serious game is part of this type of educational training, even without learning sessions. The scoring system, initially and offers a new perspective for obstetrical emergency learning. designed by a doctor, allows the player to visualize his mistakes, We need to test it on a student sample to validate its pedagogic and to get the “correct answer” related to the clinical situation potential in order to justify its integration into an obstetrical he or she just experienced. Prior to any training, we will use learning program. these sessions as an opportunity to make A-B testing (with and without the game) and evaluate its usability, through a form We want to develop it by creating some new scenario in the filled by the student at the end of each session. gynecologic and obstetrical fields to extend its pedagogical impact. So far, delivery room scenarios end at the obstetrical gesture choice. 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URL: http://www.ludoscience.com/files/these_djaouti.pdf [accessed 2016-08-25] [WebCite Cache ID 6k1kClCEs] Edited by C Boyer; submitted 14.01.16; peer-reviewed by P Staccini, D Katz, C Boyer; comments to author 30.03.16; revised version received 25.05.16; accepted 08.08.16; published 21.12.16 Please cite as: Jean dit Gautier E, Bot-Robin V, Libessart A, Doucède G, Cosson M, Rubod C JMIR Serious Games 2016;4(2):e21 URL: http://games.jmir.org/2016/2/e21/ doi: 10.2196/games.5526 PMID: 28003175 ©Estelle Jean dit Gautier, Virginie Bot-Robin, Aurélien Libessart, Guillaume Doucède, Michel Cosson, Chrystèle Rubod. Originally published in JMIR Serious Games (http://games.jmir.org), 21.12.2016. This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Serious Games, is properly cited. The complete bibliographic information, a link to the original publication on http://games.jmir.org, as well as this copyright and license information must be included. http://games.jmir.org/2016/2/e21/ JMIR Serious Games 2016 | vol. 4 | iss. 2 | e21 | p. 7 (page number not for citation purposes) XSL FO RenderX

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JMIR Serious Games – JMIR Publications

Published: Dec 21, 2016

Keywords: serious game; obstetric emergencies; gynecology

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