Dr. Bob Underwood (Host): Welcome to Pediatrics in Practice, a CME podcast. I'm Dr. Bob Underwood. And today, we are joined by Dr. Mark Ryan, pediatric surgeon at Children's Mercy Kansas City and Assistant Professor at the University of Missouri, Kansas City to explore how virtual reality is beginning to change pediatric surgical care from planning and communication all the way to patient experience and training. Dr. Ryan, thank you for taking the time to talk to us today.

Dr. Mark Ryan: Sure. Thanks for having me on.

Host: Yeah. Well, let's start at the bedside. So, how are you currently using virtual reality in pediatric surgery, and where does it add the most value to your day-to-day practice?

Dr. Mark Ryan: So, my primary use for this stuff is for preoperative planning and for education of residents or medical students or fellows. But I rarely use it at the bedside or in the operating room. I've done limited use in the operating room, but I'm trying to do it in a way that doesn't disrupt the flow of the operation, because OR time is a precious resource. So, I don't want to waste it.

Host: Yeah, it absolutely is. So from your perspective as a pediatric surgeon, when you're working closely with pediatricians or families, how does using VR change the way your surgery is planned or explained to children and their caregivers?

Dr. Mark Ryan: Usually, what I'll do is the 3D imaging tools that I use are all free. So, the file reader that I use for CTs and MRIs and things is called 3D Slicer, and it's a program that's been around for probably I want to say 15 years. It was made up at Harvard, at Beth Israel Deaconess, I think.

And so, in clinic, it's hard to tote around a pair of VR goggles. So if I have something that's complicated enough to need, that kind of imaging, then I can share it on my screen or whatever and just show them sort of a roadmap for what the plan is. And it's the same process I use for me, because I just need to have a detailed plan for where I'm going to go and what to look out for.

Host: Yeah, absolutely. So, how do families react when they see these images?

Dr. Mark Ryan: They think it's cool. It helps with understanding. For them at least, nobody's trained on CT scans or MRIs or anything. So, it can be sort of intimidating to try and figure out where things are or what I'm doing. And so, this just sort of simplifies it a bit and makes it easier for them to wrap their head around

Host: Yeah, I think that that's got to be absolutely true. I think that our training, we know that it's a two-dimensional slice of a three-dimensional object, but that's hard to explain to patients or a lay person, I think, sometimes.

Dr. Mark Ryan: And even for me, like, I know how to read a CT or an MRI for surgery planning. But that's all kind of mental work that you're putting in as part of the process. And so, this just sort of frees up that part of your brain to sort of look at other things rather than try and reconstruct the thing in your head.

Host: Yeah, absolutely. Does it help those patients with the anxiety levels perhaps too, in terms of trying to understand, you know, especially the patient I'm thinking and what their surgery may entail? It really helps them kind of gain an understanding of it.

Dr. Mark Ryan: I mean, it's tough for them no matter what. Like, I don't know if I can make it go away, but at least that part of the deal is that I'm not sort of dictating what they should and shouldn't do, but it helps them understand sort of why I'm recommending what I am so that way they can get on board, and be a part of the plan a little bit more.

Host: Yeah. So, shared decision-making is much easier in that kind of circumstance because you know that they kind of have a better understanding.

Dr. Mark Ryan: Yeah, I just tell them I'm not a dictator. This is a group project. I could just give them the best information I have and we figure it out together.

Host: Yeah. Absolutely love it, group project. That's a wonderful terminology. So, are there, you know, specific conditions, procedures, patient populations where this is especially helpful?

Dr. Mark Ryan: So, I see a lot of kids who come in with pectus excavatum, which is where they have a large dent in the center of their chest, and it's due to abnormal cartilage growth from the sternum. And so, in terms of putting into perspective, "This is where your heart is. This is what the orientation of your chest is," because they're all somewhat different.

And so, in terms of helping them sort of wrap their head around like the way we fix it is with a bar that pushes the sternum outward and rests on the outside of their chest. And so, it can be tough to wrap your head around that. Part of the bar's inside and part of the bar's outside, but neither one is poking through the skin. And so, in terms of what goes where, it's helpful for them to conceptualize the operation.

Host: Absolutely. And so, you mentioned earlier that you work with residents. So, how is virtual reality being used in training, in education for new surgeons, residents care teams, things like that?

Dr. Mark Ryan: So, there are a bunch of anatomy applications for just the cadaver labs. And the anatomy labs are helpful, but they're tough to access and tough to maintain. And it's helpful for them to see. But at least for the virtual reality software that I use, it's called the medical holodeck, but it comes with a cartoon version, like a 3D anatomy diagram type thing. But it also has sort of scanned cadavers with different levels of dissection so they can have a similar experience. But main thing is all the structures are tagged and so you just point your hand to this muscle or this nerve, and it'll tell you what it is. And so, you can wrap your head around where these things are in space. And you can have all these things open at the same time. And then, you have your cartoon diagram thing and you have your cadaver model and you can synthesize it a bit better. And I didn't have it when I went through medical school. Because I remember it being sort of painful, reconstructing everything from drawings and time in the anatomy lab. But the kids these days, they got a lot of tools that they can use to figure this stuff out. And hopefully, it makes life a little easier for them.

Host: Yeah. And I think in the long run, it'll make meaningful differences in terms of quality, patient safety, being prepared for surgery because you've got these model training elements.

Dr. Mark Ryan: Thankfully, I don't need the cartoon or the cadaver ones anymore. I kind of know where I'm going. But at least the software also allows you to view a CT scan or an MRI in a similar way. And if you want to, like if I'm teaching the students, I can take an anonymized CT or MRI from somebody with a particular condition, and then put it next to a normal anatomy model so they can see what in particular is not normal or have a sort of reference. So, it's pretty cool.

And before I came to Kansas, I had a couple computers in my office. And it allows for group work so everybody sees the same thing. And so, I can draw on stuff, and I can tailor the images so that it's basically just like a little classroom in there. And I can highlight objects of interest and communicate with them about it.

Host: I mean, just amazing to be able to do that and see in gross representation, the pathology on an anatomical scale. Again, things that didn't exist when you and I were in our training.

Dr. Mark Ryan: Yeah, it can get weird and I can make it room size if I want. Just walk around in there. You can do all kinds of weird stuff. And mostly, it's just lining up my shot for when I'm going to remove something or knowing what to look out for. And so, it's pretty helpful for that stuff.

Host: Sure. So, all new technology comes with a hype curve. So when you step back from the enthusiasm of virtual reality, how strong is the evidence right now? Are we seeing measurable clinical outcomes because of this? What's your experience and perception?

Dr. Mark Ryan: It's not a medicine. It's a tool. It's like saying if your needle driver changes the outcome. And I'm sure if I looked at a regular scan long enough, I'd probably make a good plan. But this just takes some of the mental load off and helps me to have a better understanding of where I'm going.

And some of these structures are very complicated. So, for things like tumors that have a lot of blood vessels that don't have a name and are full of these things that can be really helpful to have a reference in terms of where things are in three-dimensional space.

But also even the same kind of tumors, not necessarily apples to apples, they vary in complexity and things they're stuck to and all that stuff. So, trying to prove that this thing is better than that thing. I think, at the end of the day, a lot of it's just your decision-making process and the ORs.

So I don't know if it's going to show that the best data I've seen on using it is just on the patient side. So, it does distract you pretty well, terms of doing a painful procedure or doing something where kids are really nervous, like it's a good tool for occupying their mind a bit and reducing their anxiety so that they can tolerate it, or even just in pre-op if they're nervous, before a procedure, it's sort of a thing to do for them. And actually, Child Life here at Mercy brought it for a kid who I was doing some wound debridement for a leg bite. And the guy was in virtual space the whole time and just talking about that, and it was pretty painless. And so, on that end, it's pretty impressive. But I don't know if you'll ever see like, "My surgery is X amount better because I did the goggles beforehand."

Host: Gotcha. So, what are some of the barriers you see to broader adoption? I know there's money, workflow integration, training, demands. You kind of took a number of different applications, kind of put them together on your own. What are the barriers to other people using this, you think?

Dr. Mark Ryan: The main one is that you got to wear these big dumb goggles to do this. And I tell them part of the reason I won't wear them in the or is because you look like a jerk when you do it. But also, I have actual reasons.. But the main thing is just having this big headset, which, you know, if you're wearing glasses or any sort of eye condition makes that difficult for you.

 And if you haven't done it before, there's a learning curve associated with it. But I mean, my kid plays goggles longer than I'd like him to. And he is playing games with his friends and swinging around to pretend trees. So, the 10-year-olds can wrap their head around it. I think it's the older guys that have a rough time with it. But also, it's not a convenient thing to put on most of the time. And so, the workflow that I came up with was I can be in and out in four or five minutes, but it requires some work to sort of replicate that.

Host: I'm sure it does. All right. So, there are pediatricians who are listening today. What do they need to understand to be prepared for how this technology may evolve in terms of virtual reality being used in surgery? What are your thoughts around that?

Dr. Mark Ryan: I think the procedures themselves are pretty unchanged. I think some of the tools that we use are similar. So, the Da Vinci robots and the way the robot works is similar to the goggles. It's got two cameras and it's got two screens and you see a 3D picture when you're using it.

But for me at least, if I use it at all in the operating room, it's to have a loop of my imaging in the background. So that if I need to, I can pause and take a quick look at it and then resume the regular operation. But in terms of using it during the operation to sort of guide you or change what you do, there's still a ways to go to make that sort of accessible or practical, because I get excited about this stuff, but I have, people that I use as a wet blanket that will sort of temper that. It's all through the window as this practical. Is it the best thing for the kid? Most of the time, the answer's no. Mostly, it's helpful to have sort of reference imaging available. And my main interest for the OR itself is there are actually sort of glasses-free, three-dimensional displays that do things like project an image or they have eye-tracking cameras. There's a bunch of neat stuff that allows you to disregard the goggles altogether and just continue operating as you normally do, but provide a better roadmap to reference while you're doing it.

Host: Yeah, absolutely. And really just wonderful application that you've been able to come up with yourself. So, anything you'd like to conclude with as we close down today?

Dr. Mark Ryan: I think that the equipment is cheaper than it's ever been. So, I mean, there's a decent headset for 400 or 500 bucks. And even the imaging software that I use, they have subscriptions—and it's not the only one. There's a variety of applications out there. So, It doesn't necessarily have to be these giant contract medical grade things. I think it's different if you're diagnosing a tumor or if you're staging something I don't have the radiology piece of paper that says I took the classes and did the residency. So, I don't pretend I can do that. But it's more just me just lining up my shot. And so, the barrier to do that is not very high. So, I'd say that it's worthwhile pursuit if that's something that somebody's interested.

Host: Sure. That's awesome. Dr. Ryan, thanks for being with us this morning.

Dr. Mark Ryan: Oh, you bet. No, again, it is fun. I could bore people with this stuff all day. So, anytime.

Host: It's fascinating. I think to most of us to see what you've been able to put together. So, thank you.

Dr. Mark Ryan: You bet. Any questions or anything, I'm happy to answer anytime.

Host: To our listeners, as a reminder, claim your CME credits after listening to this fascinating episode today. You could do so by visiting cmkc.link/cmepodcast And then, click the Claim CME button. If you enjoyed this podcast, please share it on your social channels and check out the entire podcast library for topics that may interest you. I'm Dr. Bob Underwood. And this has been Pediatrics in Practice, a CME podcast.