Samuel Rodriguez, MD, Pediatric Anesthesiologist at Lucile Packard Children’s Hospital Stanford talks about new technology designed to put anxious young patients at ease before surgery.
Interview conducted by Ivanhoe Broadcast News in May 2017.
Could you explain what the bedside entertainment therapy is?
Dr. Rodriguez: We have a big program here called the CHARIOT Program, it stands for Childhood Anxiety Reduction through Innovation and Technology; and as part of that we have a portable video projection system, which is called BERT, which stands for Bedside Entertainment and Relaxation Theater. What that does is it’s basically a portable movie theater for kids to watch movies while they are waiting for procedures to happen, while they are wheeling through the hospital, and we use them while they are going off to sleep with anesthesia.
How long has this device been implemented?
Dr. Rodriguez: The first interactions we implemented, probably over two years ago, and we started very simply; we only had one or two units that we would initially just hold in our hands at the head of the bed and we would actually projected to some of the residents. They were holding up sheets right in front of the stretcher as they were walking down the hallway and we slowly got better. We started to mount the projectors onto the beds themselves and we eventually built screens that we could mount on the bed. We went through a couple of interactions with the screens and the projectors, and we finally got to a place, probably about a year or a year and a half ago where we launched it throughout the preoperative department and even in some of the other departments, like radiology and some of our satellite locations.
When you used it what did you notice with the patient?
Dr. Rodriguez: The need was we have children who were very anxious, very stressed about having surgery; about being in a different environment. Sometimes about being away from their parents and physicians are very clever; we started using iPhones and different mobile devices, tablets, there are some TV units in the preoperative area, but we found that there were frequent interruptions in their experiences, especially when they were watching a video in the preoperative area and then they would get wheeled to the operating room or get wheeled to a different part of the hospital. There were interruptions in their experiences and sometimes that was when they are the most nervous; sometimes that was at the times and separated from their parents. So we wanted something we could create a continuous experience without interruptions, basically from the time their meeting the surgical anesthesia team in the preoperative area all the way to the point where they are completely asleep under anesthesia.
What did you notice with the patients?
Dr. Rodriguez: We noticed that when there were fewer interruptions, any experiences they were calmer, and they were laughing more. We noticed that the parents were happier because now all of a sudden they were engaged in the experiences as opposed to someone just watching a little video on a mobile device where everyone else can not necessarily see what is going on. We noticed that because the screen is so large, it is about three feet wide, that it consumes a lot of the child field of view, so as opposed to a eight inch mobile phone; now they actually could not even see the operating room equipment as they were walking in because the screen was actually big enough to be blocking it. They could not see a lot of the strange faces that they might encounter as they are being wheeled through these new environments. We found that an uninterrupted experience, the novelty of it, because it is something new for them, as well as the immersive nature of the unit all helped to kind of create this fun, theatrical environment that the kids really, really enjoy.
Since you are the one who came up with this idea, and you developed it and implemented it, and you saw that it works, how did that make you feel?
Dr. Rodriguez: I would say it is very exciting but it is a lot of work. For one person to do it, it is not that difficult. For me to just have my own projection unit and use it on my patients was not a significant amount of work, but when we are talking about launching that to an entire department or an entire hospital the amount of work multiples exponentially. We first had been piloting the projector for somewhere about six months to a year, before we actually started letting other staff use it. We had no issues with them breaking, our set-up times were super quick when it was a couple of people using it, but when we started to let other people use it we noticed that projectors were breaking, the cases were breaking, stuff was going missing, stuff was not charged, there was nowhere to keep things, people were breaking the screens, people did not know how to use the clamps; so there was all these systems based issues that created a ton of challenges for us when we started launching it on a hospital wide level.
Tell me about how you developed this in your garage?
Dr. Rodriguez: Yeah initially we started off very small. I had a single unit, the first projection screen that we were using was actually a photographic reflector that you could collapse down and expand; and it was super fun. I bought a bunch of clamps basically from photography stores that we eventually pieced together to mount them onto the bed, but the collapsible screens we ran into infection control issues; they were very difficult to clean. Eventually we went to corrugated plastic board model, but even the corrugation in the plastic boards needed to be sealed for infection control reasons so they could easy be cleaned. I had to work out a lot of the infection control issues by sealing up the corrugations, creating brackets that can be easily mounted onto the bed and taken apart quickly if there was an emergency or for when kids have to move from one bed to another and most of the units that are currently in use right now were actually built in my garage.
What has the reaction been from most of the parents?
Dr. Rodriguez: The parents really enjoy it, sometimes the parents enjoy it more than the kids, and it is very interesting they enjoy the novelty. One of the most common things we hear is, what the parents would say, oh I wish I had this one if I had a procedure, or why don’t you guys do this on adults, or this is so much different than when I was a kid and when I had anesthesia. They really, really enjoy it and especially when they see their kids very engaged with the movies, or in one of the games. I think it is very calming for the parents too and when I think that the parents are calm and the kids see that the parents are having fun and calm they feed off of each other, so I think it is kind of a reciprocal response between the kids and the parents.
Tell me about Sevo?
Dr. Rodriguez: Yes, so Sevo the Dragon is a fun game that we developed for the projection unit. It is also available for tablets and phones. We’re primarily watching videos on the projection unit, on the BERT unit and we wanted to take it to the next level, we wanted to make it more interactive, so we created it. Our first game is Sevo the Dragon, where kids get to pretend they are a dragon and then they pick a color of a dragon, and they pick a different food for the dragon to cook, and what they actually do is we use it to not only to distract the kid with the game but we also get them to be more cooperative and to take deep breaths, we train them to take deep breaths in preparation for inhalation for induction of anesthesia when they are going to sleep with a mask.
How did you come up with this idea?
Dr. Rodriguez: We all played video games as kids and we noticed that watching videos was very fun for the kids but what we did was we actually took a lot of the techniques that we used without technology such as distractions, engaging kid’s imagination, and in order to get them more cooperative we started incorporating those into technology. For years I had been doing something that is called a dragon induction with kids and this is with no technology where I have kids pretend like they were dragons and they would breathe into the mask, and then they would roar into the mask, and we would even take a red bike light and we would shine that all over the room so it looked like they could pretend that they were breathing fire to different parts of the room. All we did was take these fun and imaginative games and started to incorporate them with some of the emerging technologies that we have an abundance of here in Silicon Valley and the two the imaginative game play that we were doing with the kids, merging with the technology resulted in these super fun games like, Sevo of the Dragon.
With all that kind of VR technology, have there been any nay-sayers?
Dr. Rodriguez: I think from the BERT unit, the video projection, I do not know if we have had any negative feedback from that one. Because it is more of a theater experience, it is kind of requires almost nothing from the patient. All they have to do is sit there and either play a game or watch a movie; it does not require them to wear anything so it is a very little investment from the patient. So we have had almost no negative feedback from that, we have been doing virtual reality here for several months now since last year, the results from that have been remarkable. We have had extremely positive feedback but with virtual reality every now and then we do get some parents asking questions about what our potential side effects from that, or we get kids who are a little bit hesitant to have goggles, or to put something on their face, but I would say, overall the feedback and the response to all of these technologies have been remarkably positive. Futhermore, we have had far more success than most of us had anticipated.
What is your hope for the future, how this would be used?
Dr. Rodriguez: We want to design a model program that is a beacon for other places to emulate where kids come in and we have an entire tool set of technologies that we can pick from. When a child comes in we can compare the appropriate intervention with the appropriate kid to suit their age, their personality, their preferences, and potentially help to decrease the amount of sedative medicines that we have to give them and provide them with an overall better experience. Especially, since we see a lot of children over and over again in pediatrics; especially kids with chronic diseases and having a positive experience for them is very, very important because it help decrease a lot of the emotional trauma that is very common with our chronic ill children.
Okay, and who is Dr. Caruso?
Dr. Rodriguez: Dr. Tom Caruso is a crucial part of the program. He is the Director of Operations; he is the one who take these technologies, adapts them and scales them in a hospital system. Because again having one projection unit is not that hard to implement, but when you are talking about 10 or 50 of these units there are a lot of challenges in implementing them in what I call the hostile hospital environment because technology, just as all of our equipment gets broken and we have infection control issues that we need to address. We have storage issues, security issues, all of those components that when you start to scale become a large barrier between getting what we know the technologies that we know that are affective, actually to the children on a large scale.
Is there anything else you want to add?
Dr. Rodriguez: We do have a couple of other games coming out; Sevo the Dragon game has been very popular. It seems to be very effective with certain kids, but we are also working on a bubbles game, where kids would be able to blow virtual bubbles, because we can’t blow actual bubbles in the operating room for infection control reasons. We will be doing virtual bubbles for them and they would be able to blow through the mask and they will project all over the wall, all over the ceiling, wherever they want them and um we are working on several custom virtual reality games. One of them is called, Space Burgers, where you get to zap a virtual hamburgers floating in space that is being co-developed with a group called Juno that we are partnering with. We are working with several other companies who have developed commercial games for virtual reality for the public that do have potential healthcare applications with only slight modifications and we have received great feedback and great willingness from the gamer software developing community to be involved in helping children by customizing their games and even creating news games for the hospital environment.
You’re doing all this really cool stuff and helping all of these kids here, do you have any plans to be like distributed to other hospitals throughout the country?
Dr. Rodriguez: So we do have plans. We are working on that right now, some of the software is much easier to scale and disperse across the country than others, because we can do things like put that on the Android or Apple store and those will be available in other hospitals. We have already started establishing relationships with some other institutions in terms of letting them test out some of the software. The hardware requires a little bit more expertise and customization, we are sending one of our projection units to Barcelona, Spain this month because we had the some interest from there and they want to try one out. We will be doing a workshop at the Society for Pediatrics and Anesthesia our national conference and we actually will be demonstrating some of this equipment and showing other hospitals how to use them.
END OF INTERVIEW
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