Group Editor Marty Kauchak provides an update on the Advanced Modular Manikin (AMM) project.

The Advanced Modular Manikin (AMM) project is a collaborative effort between the US Defense Department, the University of Minnesota (prime) and the University of Washington CREST (Center for Research in Education and Simulation Technologies). The American College of Surgeons Division of Education, Army Research Laboratory, Vcom3D, Entropic Engineering, Applied Research Associates and industry producers round out the rest of the collaborators on this innovative program.

Advanced Modular Manikin

The project, proceeding as DoD Award #: W81XWH-14-C-0101, is on schedule to complete its three-year Phase 2 contract this September.

The AMM program is creating open-source standards which will allow healthcare simulation and training development groups to build training devices and enabling systems, which are interoperable and unified by the operating system. Dr. Robert Sweet, the AMM Phase 2 Principal Investigator, reflected on the genesis of AMM and noted, “It was a brilliant and timely move by JPC-1. I think it will allow the healthcare simulation industry to mature and evolve more rapidly as far as leveraging the capabilities of the greater community, rather than being ‘siloed’ – within companies or academic labs that have fixed configuration options, different standards and limited functionality.”

When Dr. Sweet spoke with MTM this January, his team was completing its Alpha demo unit.

And this is where terminology becomes critical to understanding the underpinnings of AMM. “You have to think of the system as a platform – I am aware this is called Advanced Modular Manikin,” Sweet emphasized and added, “The platform is what is being funded and the manikin is merely a demonstration of the capabilities of that platform – this nuance is extremely important to understand.”

Indeed, as the Alpha demo unit is put through its paces, the AMM team will show a manikin made up of different proprietary modules (both physical and virtual) delivered by different team members that are compatible with the operating system (platform). “What we’ll be doing is taking four or five different companies’ systems modules and uniting them in one system. Using the data standards, they are able to effectively communicate the state of the patient to each other down to a great level of detail,” Sweet forecasted and noted, “because they adopted the standards and they adopted the platform to work on.”

The Alpha demo unit platform has digital components, clinical components and a physical structure. “It has a standard unified toolless connector that pops organs and body segments on and off with a click of a button, which automatically connects air, fluid, power and data all in one connector” the simulation community expert added. “This was a monumental task in and of itself”. Universal connectors are used throughout the platform for the head, torso, lower extremities and at other points. The computer-assisted design (CAD) for the connector will be available February 2019 and provided at no cost for individuals or groups who register to be a member of the AMM community.

While the universal connector is one significant return on investment on AMM, there is also a standardized anatomical data set for the male and female. The data includes all anatomically-correct structures and select organs of the entire system. Sweet continued, “These are also available at no cost for the healthcare simulation development community to gain access to build modules within an anthropomorphic footprint.”

And beyond the platform’s physical attributes described earlier, AMM also supports and is successfully integrating and communicating with physiology engines, virtual reality simulators and virtual patient platforms. “This is also really important,” Sweet pointed out. As an agnostic platform – physical or digitally derived modules can be connected if they follow the standards. The digital platforms are, in a way, a more natural fit, as they automatically generate data. He continued, “Physical modules should really have sensors in them to really benefit from being part of the system. Modules can query information from the system, provide information to the system and publish educationally relevant metrics to the system. This data can be interpreted by other unrelated modules.”

Robert Rush (general surgeon, retired colonel, right) and Dr. Robert Sweet (PI of the AMM grant, Urologist, left) are seen conducting a laparotomy on the manikin, as David Hananel (PI on the AMM subcontract at UW) and Hazel Williams (part of the CREST anatomy team) observe in the background. Image credit: University of Washington CREST.
Robert Rush (general surgeon, retired colonel, right) and Dr. Robert Sweet (PI of the AMM grant, Urologist, left) are seen conducting a laparotomy on the manikin, as David Hananel (PI on the AMM subcontract at UW) and Hazel Williams (part of the CREST anatomy team) observe in the background. Image credit: University of Washington CREST.

Case in point: For example, a physical IV arm partial task trainer that is AMM compatible from one development group (CREST) queries the system what the heart rate is. The heart rate is generated by Biogears, a different company’s (ARA) open source physiology engine. When the IV arm receives this information, the pulse mechanism on the arm is synchronized with this rate. When an IV is successfully placed in a vein, the module publishes the successful result as a learning outcome. It also notifies the system that an IV has been successfully placed. A different company’s virtual patient (Vcom3D) that is querying the system continuously for the presence of an IV, automatically makes it appear on their virtual patient. When fluids are administered in the IV arm, the module provides this data to the system. The physiology engine, which is continuously querying for fluid/drug administration, automatically recognizes this and the physiology changes which communicates back to the pulse felt on the IV arm and the vitals displayed on the virtual patient. If the standards are followed, development groups do not need to know the inner workings of another group’s module.

The Alpha version of the system, whose scenario has been designed to demonstrate its capabilities to train a broad swath of learners including first responders, emergency care providers, anesthesiologists, OR nurses and surgeons, just underwent a successful and engaging pre-pilot this week. A formal pilot test will then follow with AMM partner American College of Surgeons’ Division of Education in March. “A formal trial of our Alpha unit will occur at sites selected by the ACS, really looking at usability, acceptability and capabilities of the system,” Sweet added.

While the initial pilot scenario goes across different military healthcare provider roles, they can be readily applied to the adjacent civil sector, with the one system accommodating different environments and different learner groups – from first responders to emergency room physicians. Sweet noted the versatility in this instance of AMM, saying that while one group could respond to the same system and doing different manipulations, “by quickly swapping out body parts you can take the system to the operating room and do a full surgery on that same patient, with anesthesia – and that’s the demonstration for the scenario – all on the same system and patient with different modules easily swapping in and out.”

At the ACS Surgical Simulation Summit held in Chicago, March 15-16 several meetings were held to discuss the advances in AMM and a Project Meeting was held with all vendors attending ACS who were participating in the program. One meeting, Developing Simulators and Simulations in an Open Standards, Open Source Environment discussed the AMM Project in detail and talked about expanding and enhancing the core platform and the developing standards and invited those attending to participate in the program.

A pilot of the AMM platform with the leadership and AMM STUDY WORKGROUP from the Division of Education for the American College of Surgeons occurred March 23-24 at the University of Washington WWAMI Institute for Simulation in Healthcare. An integrated interoperable system performed across different learner groups (paramedic, anesthesiologist, surgeon) and different environments with swappable anatomic parts tailored to the different groups. It will be compared to the task trainers on their own without the connectivity of the platform. Discussions, reflections and suggestions for refinements to the technology and research protocol were made with the research development team, many of which will be implemented for the main study.

The Beta version demonstration is scheduled for September, 2019. The event is expected to add additional module capabilities beyond the Alpha variant as additional development groups successfully generate AMM-compatible modules.

AMM community members enrolling at the above web site, will also have access to the open standards which are another foundation of this project. This opportunity will enable members to write code for their contributing platform materiel and complete other tasks. It has not been determined which organization will have maintenance and other oversight responsibilities of AMM standards.

Forthcoming, will also be a series of user manuals to accompany the system, to better explain what can and cannot be done.

AMM will be also be a disruptor in the S&T sector.

Dr. Sweet, himself a practicing surgeon, noted AMM will be a “stimulant” for the industry and the market, not a threat. “What it will allow companies to do is take their limited resources and apply those resources toward expanding their market and capabilities, rather than recreating core. They will be able to leverage this investment by the DoD, broadening their healthcare simulation product portfolio, leveraging others’ strengths and ultimately enhancing the training for healthcare providers.” 

Originally published in Issue 2, 2019 of MT Magazine.