Advanced Modular Manikin: It’s a Platform and More

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.

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

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

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

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

Indeed, as the Alpha demo unit is putthrough its paces, the AMM team will show a manikin made up of differentproprietary modules (both physical and virtual) delivered by different teammembers that are compatible with the operating system (platform). “What we’llbe doing is taking four or five different companies’ systems modules anduniting them in one system. Using the data standards, they are able toeffectively communicate the state of the patient to each other down to a greatlevel of detail,” Sweet forecasted and noted, “because they adopted thestandards 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 onesignificant return on investment on AMM, there is also a standardizedanatomical data set for the male and female. The data includes allanatomically-correct structures and select organs of the entire system. Sweetcontinued, “These are also available at no cost for the healthcare simulationdevelopment community to gain access to build modules within an anthropomorphicfootprint.”

And beyond the platform’s physicalattributes described earlier, AMM also supports and is successfully integratingand communicating with physiology engines, virtual reality simulators andvirtual patient platforms. “This is also really important,” Sweet pointed out.As an agnostic platform – physical or digitally derived modules can beconnected if they follow the standards. The digital platforms are, in a way, amore natural fit, as they automatically generate data. He continued, “Physicalmodules should really have sensors in them to really benefit from being part ofthe system. Modules can query information from the system, provide information tothe system and publish educationally relevant metrics to the system. This datacan 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.

Case in point: For example, a physical IVarm partial task trainer that is AMM compatible from one development group(CREST) queries the system what the heart rate is. The heart rate is generatedby Biogears, a different company’s (ARA) open source physiology engine. Whenthe IV arm receives this information, the pulse mechanism on the arm issynchronized with this rate. When an IV is successfully placed in a vein, themodule publishes the successful result as a learning outcome. It also notifiesthe system that an IV has been successfully placed. A different company’svirtual patient (Vcom3D) that is querying the system continuously for thepresence of an IV, automatically makes it appear on their virtual patient. Whenfluids are administered in the IV arm, the module provides this data to thesystem. The physiology engine, which is continuously querying for fluid/drugadministration, automatically recognizes this and the physiology changes whichcommunicates back to the pulse felt on the IV arm and the vitals displayed onthe virtual patient. If the standards are followed, development groups do notneed to know the inner workings of another group’s module.

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

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

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

A pilot of the AMM platform with theleadership and AMM STUDY WORKGROUP from the Division of Education for theAmerican College of Surgeons occurred March 23-24 at the University ofWashington WWAMI Institute for Simulation in Healthcare. An integratedinteroperable system performed across different learner groups (paramedic, anesthesiologist,surgeon) and different environments with swappable anatomic parts tailored tothe different groups. It will be compared to the task trainers on their ownwithout the connectivity of the platform. Discussions, reflections andsuggestions for refinements to the technology and research protocol were madewith the research development team, many of which will be implemented for themain study.

The Beta version demonstration is scheduledfor September, 2019. The event is expected to add additional modulecapabilities beyond the Alpha variant as additional development groupssuccessfully generate AMM-compatible modules.

AMM community members enrolling at theabove web site, will also have access to the open standards which are anotherfoundation of this project. This opportunity will enable members to write codefor their contributing platform materiel and complete other tasks. It has notbeen determined which organization will have maintenance and other oversightresponsibilities of AMM standards.

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

AMM will be also be a disruptor in theS&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.