Virtual Reality Simulator for Cardiopulmonary Resuscitation (CPR)

as Lifesaving Method in Many Emergencies Patients

Moh. Zikky

, Kholid Fathoni

, Ashafidz Fauzan Dianta

and Miftakhul Firdaus

Department of Multimedia Creative Technology, Politeknik Elektronika Negeri Surabaya,

Jl. Raya ITS Sukolilo, Surabaya, Indonesia

Joy Leap Studio, Game Developer Studio, Surabaya, Indonesia

Keywords: VR Simulator, Cardiopulmonary Resuscitation, CPR Virtual Laboratory, Virtual Reality, Virtual Laboratory.

Abstract: This Cardiopulmonary Resuscitation (CPR) simulator media is synchronized with Virtual Reality (VR) as

practicum media of medical student. Student or user of this simulator will act as a medical worker or volunteer

who helps patient with respiratory arrest or cardiac arrest by restoring his breathing and circulation functions.

This skill and competency are the basic need or the basic SOP procedure in the medical handling especially

in emergency room. However, this skill actually should be mastered by everyone if someday we meet a victim

person who needs the CPR handling. Several CPR procedures such as airway handling, compression, and

ambubag installation will be immersively simulated with the complete guidance, healthcare equipment, and

actual medical laboratory surrounding. Furthermore, this CPR virtual laboratory is expecting in guiding its

user to be more active, especially in his motor-sensor skill. At least, this approach hopefully could be like the

real condition how to handle with the right rules and understand the medical CPR procedures in the health-

laboratory. So, this VR is developed using Blender 3D modeler and programmed in Unity engine which

integrated to the SDK or plugin of Oculus Quest framework. The Oculus Quest device is used as the main

media of its VR simulator which is included head mounted display as the eyesight headset and two hand

controllers that allowed user to interact with virtual assets inside the immersively.

1 INTRODUCTION

Augmented Reality (AR) and Virtual Reality (VR)

technologies have been transformed to become the

most popular technology areas of the decade,

especially in simulation technology and game

development. Many technology companies change

the focus and support the devices-development of

both area, either the largest companies like Oculus,

Microsoft, Samsung, etc., or several startup

companies in this world with their unique products.

Thus, the Fourth Industrial Revolution (or

Industry 4.0) and the response of the current covid 19

pandemic made the impact of distance learning and

virtual simulations seem absolutely necessary. Some

laboratories in schools, or even physical devices in

various institutions and companies in the past year are

very difficult to access directly because of the WFH

(Work from Home) requirement and contact with

strict health protocols. Therefore, the challenge is

how to convert these laboratories into a virtual

simulator with immersive interaction like the real

physical device (or at least close to it).

Several VR simulators for internal campus

laboratories have been successfully converted into

virtual laboratories in previous studies, such as VR

for multimedia broadcasting laboratories,

Oscilloscope VR simulators, and several other

devices. Then, since the beginning of the pandemic,

the main challenge has been focused how to empower

medical institution that have become the frontline to

save humanity health today. Healthcare workers or

prospective healthcare (medical students) should still

be able to access their practicum in various ways as

they usually do in hospitals or health campus

laboratories.

Therefore, in this study, the Cardiopulmonary

Resuscitation (CPR) simulator was chosen as the main

virtual laboratory tool that developed in this research

and tried to implement the result on Semarang Health

Polytechnic Indonesia which has become a partner of

this research. Apart from its urgency, skill in CPR is

the main activity for healthcare workers in dealing

674

Zikky, M., Fathoni, K., Dianta, A. and Firdaus, M.

Virtual Reality Simulator for Cardiopulmonary Resuscitation (CPR) as Lifesaving Method in Many Emergencies Patients.

DOI: 10.5220/0010950900003260

In Proceedings of the 4th International Conference on Applied Science and Technology on Engineering Science (iCAST-ES 2021), pages 674-680

ISBN: 978-989-758-615-6; ISSN: 2975-8246

 2023 by SCITEPRESS – Science and Technology Publications, Lda. Under CC license (CC BY-NC-ND 4.0)

with patients. Then, we choose Oculus Quest as the

VR device which is relatively very cheap and capable

enough to build this VR CPR Laboratory. Its

controller can direct the eye and imitating hand

movements into a virtual form both in position and

orientation, thus the buttons on the device act as

interactions in the hand, such as finger movements,

grasping, pointing, and so on.

2 LITERATURE REVIEW

2.1 Cardiopulmonary Resusitasi (CPR)

Procedure

Cardiopulmonary resuscitation (CPR) is a method to

restore respiratory and circulatory function in patients

experiencing respiratory and cardiac arrest

(Ganthikumar, 2016). CPR is an effort created by

healthcare worker for patients who are in emergencies

or critical condition to prevent a death. This condition

is usually happened in patients, either in condition

related to certain diseases such as heart attacks, being

exposed to viruses such as covid 19 virus, in accident

such as drowning in water, choking on the respiratory

tract, drug or alcohol poisoning, inhaling a lot of

smoke to shortness of breath, or the other life-

threatening conditions. For handling those patients,

healthcare person or maybe all of people if they face

this situation should be familiar with the basic

techniques of CPR, therefore, CPR practicum is

basically required to be mastered in all medical fields

There are many stages of CPR in patient

treatments, starting from basic medical checkup until

the specific advance handling likes respiratory tubes/

ventilators installation or direct handling with

healthcare’s hands (when the accident suddenly

happened far from the hospital). This action in

medical handling is formulated with three parts, it

used to call ABC: (a) A for airway, (b) B for

breathing, and (c) C for circulation. Before

performing these three actions, healthcare personnels

are advised to make an approach likes touch and talk,

both methods can be simulated like waking up a

sleeping person or stimulating the victim to react,

while talking to him or calling him in a loud voice

(American Heart Association Guideline

Resuscitation (CPR) and Emergency Cardiovascular

Care (ECC) of Pediatric and Neonatal Patients, 2006),

if there is no reaction then check his pulse, and the

last if still no reaction and that patient is in cardiac

arrest, now the CPR procedure can be carried out as

soon as possible as these procedural steps:

a) Airway

This process is handled by opening the airway using

the Head Tilt–Chin Lift Maneuver method, this

method is processed by placing one hand on the

patient forehead and push it down, and another hand

just placing its fingers on the bone under the chin then

open the patient's airway, thus the next method can be

performed by maneuvering his jaw thrust, it is called

by the mandibular thrust maneuver. This method is

performed by holding both sides of the jaw while

slowly moving it to the front position and keeping the

patient's mouth open. This process is simply as

illustrated in Figure 1

(a) (b)

Figure 1: Airway Process: (a) head tilt chin lift method and

(b) jaw thrust maneuver procedure (SA, 2010).

b) Breathing

This method can be performed after ensuring that the

patient is not breathing or breathing problems occur,

this situation can be analyzed by seeing the

movement of the chest, hearing the presence or

absence of breath sounds, and feeling his breath by

bringing the healthcare's ear closer to the patient's

mouth and nose, while keeping the airway open. If

the respiratory have not been shown, then the patient

can be given respiratory support. Perform 5 rescue

breaths if its patient is not breathing until he can

breathe effectively by expanding the chest wall, if the

chest does not expand, reposition the victim's head in

order that the airway is open. This breathing

assistance can be installed by ambubag pump or

directly (mouth to mouth and mouth to nose) of its

patient. Figure 2 is an example of a direct breathing

method and using an ambubag installation

(a) (b)

Figure 2: Breathing Assistance; (a) direct breathing

assistance and (b) breathing assistance using an ambubag

Virtual Reality Simulator for Cardiopulmonary Resuscitation (CPR) as Lifesaving Method in Many Emergencies Patients

675

c) Circulation

The next help if there is no re action after performing

artificial respiration, it can be continued by giving a

chest compressions 30 times. The position of chest

compressions starts from locating pressure on the

processus xyphoideus and take a path of line to the

cranial 2 fingers above it and just do it in that place.

Then, the patient should be given breathing assistance

twice anymore. If the pulse still has no reaction, then

that process can be repeated until 5 times looped with

a compression speed of 100 times per minute. Figure

2.3 is an example of healthcare’s giving compression

to improve blood circulation with reference to the

large arteries (carotid artery and femoral artery).

Figure 3: The process of chest compressions for patient's

rescue in CPR method.

2.2 Several CPR Simulators

C.-H. Yang et al. (Cheng-Hong Yang, 2020) made

interactive VR-CPRs for health education using

Arduino and VR headset or usually called Head

Mounted Display (HMD). Both devices are paired

using Bluetooth module. In this research, they

blended physical mannequin (real mannequin) with

virtual reality and guidance. Also, they add force-

sensor to measure the pressure of user’s hand. So,

with this simulator, Cardiopulmonary Resuscitation

(CPR) process is felt like a real sensing. User

simulates a rescue to the patient (which substituted by

mannequin) looks like doing to the real person, as he

touches the patient’s body and sees a 3D patient’s life-

character on his HMD display. Their equipment

totally spent about $200 for one simulator cost;

includes Arduino, Bluetooth module, force-sensitive

resistors, and VR headset. It was relatively cheap and

affordable to duplicate in several laboratory classes of

medical school or the other medical institutions.

On another research, Greis F. M. et al made a CPR

mannequin training use 3D-printable equipment with

monitor head up display to measure the success

performance of healthcare user (Greis F. M. Silva-

Calpa, 2018). They use Nintendo Wii Balance Board

for measuring CPR compression and weight. Thus,

these data are sent to the device, either computer or

android using a Bluetooth connection. So, as

mentioned before, this device shows the graphs of

user performance with a real-time. Including force,

frequency, and the angle of mannequin posture when

compression is applied. 3D-printable with Wii

devices are chosen because a low-cost reason and the

efficiency of its device. As we know, Nintendo Wii

Balance Board can be used for several measurement

purposes.

Thus, the simple CPR simulator also performed

by Neil Vaughan et all (Neil Vaughan, 2019). They

made a simple VR simulator for CPR training. They

built this VR simulator for training school children

uses. They use Oculus Rift as head mounted display

(HMD) which attached by Leap Motion controller to

detect the user’s hand movement and orientation.

They use a simple 3D object which scanned from

Torso mannequin. Although it can’t be effective

procedure of CPR, at least children understand the

procedure sequence in CPR performance as the

general perspective of CPR competencies.

3 METHODOLOGY

Based on several previous research, we want to build

the low-cost CPR simulator with immersive

interaction and lively surroundings environment,

either in human mannequin, ambubag, detail

procedures, counter display (when compression

implemented), and the other instructions need.

Technically, this simulator designed with the

concept of interactive animation based on Virtual

Reality (VR). VR simulation is currently still

considered as the low-cost simulator, both in terms of

equipment and development costs. This simulator

device will be developed using the Oculus Quest

SDK and Steam VR Plugin which is available on their

official website. As we know that Oculus Quest is one

of the low-cost HMD devices, but it covered complete

interaction, either in displaying picture on its HMD

with IMU sensor, speakers, and detecting the hand

orientation. Furthermore, software and programming

will be carried out in the Unity game engine, while

modeling assets, mannequins, and all the needs of 3D

objects environments built using Blender 3D. These

stages can be illustrated in Figure 4.

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Figure 4: Several milestones in CPR simulator development.

3.1 Simulator Equipment

Head Mounted Display used on this VR simulator is

the Oculus Quest. Oculus Quest runs under an

Android OS. It is different with the older one; either

Oculus Rift (Oculus Quest is totally wireless), and

Oculus Touch which is still needs a computer as the

main server for installing the application. In Oculus

Quest, we can play with it just after porting VR

application to this device, because it can run with

stand-alone device. The most important thing that

Oculus Quest is simpler and cheaper than both

previous devices, so it is very affordable to duplicate

for several classes or multiplayer users. As shown in

Figure 5, the sensors used on the Oculus Quest as

usual sensors on HMD, there are IMU sensor and

motion tracking where tool will detect x, y and z axis,

provides a room-scale tracking, accommodates until

64 GB internal storage, and capable in transferring

user’s hands into the HMD while their hand’s

gestures appear with realistic precision (Facebook

Technologies, n.d.). So, this device is the main

equipment in this CPR simulator. The VR application

is ported into it, so that a user will see VR perspective

on its display, then he will perform several CPR

procedures using those two stick handlers.

Figure 5: Oculus Quest Display CITATION Fac21 \L 1033

(Facebook Technologies, N.D.).

Figure 6: Head Mounted Display of Oculus Quest and its

features.

Figure 7: Flowchart of procedure in performing CPR based on Basic Life Support Health Service according to AHA 2015

(Robert W Neumar, 2015).

Virtual Reality Simulator for Cardiopulmonary Resuscitation (CPR) as Lifesaving Method in Many Emergencies Patients

677

One of the features that really very useful to support

immersive environment is attached speakers. As

displayed on Figure 6, Oculus Quest has embedded

two active speakers on the left and right side, even it

can be paired to the external headphone or bigger

active speaker with 3.5 mm audio jacks. For the

further interaction, it also has an integrated

Microphone, compression, and so on. So, the

summary of the cardiopulmonary resuscitation (CPR)

procedure as shown at the flowchart on Figure 7.

3.2 Scenario Simulation

In this section, the VR simulator will be designed so

that the user can perform the procedures as described

before, starting from preparing the equipment,

checking the pulse in the carotid artery, until

performing several actions .

Thus, based on this CPR procedure, in this

development simulator, the main assets needed in

performing pulse and breath checkup are 3D visuals

of the hands as the virtual user/ healthcare interaction

and human mannequin as the virtual victim or

patient Some examples of CPR assets are shown in

Figure 8.

Figure 8: Assets for the early process in checking pulse and

breathing of CPR procedure.

After checking the pulse and found to be

abnormal, the next scenario is compression rescue as

described before in the discussion and flowchart of

CPR procedure. At this stage, the position of

healthcare’s two-hands positioned together in the

middle of the sternum and push the chest with a

compression depth for about 5-6 cm and 100-120

times/minute of speeds. Furthermore, if there is no

reaction, continued the compression process 30 times

(see the patient’s complete recoil or the return of the

chest wall). After these 30 times of compressions, this

healthcare or user must give twice rescue breaths

(ventilations) using an ambubag. After performing 1

cycle of CPR (30 compressions and 2 ventilations),

user should recheck the carotid pulse. If still there is

no reaction on carotid pulse, repeat the CPR process

for another 1 cycle. Perform this CPR until finding

carotid pulses and breathing returns. So, to perform

this process, at this stage we need an additional asset

of the ambubag to be attached to the patient, the

ambubag and its installation as shown in Figure 9.

Figure 9: Ambubag and its installation to the virtual

mannequin after compression process.

As the last step, after the CPR process is finished and

the last evaluation results that the pulse has been run

and breathing is back, the VR user should position the

patient in the recovery position, which is tilted his

body to relieve its airway, as shown in Figure 10.

Figure 10: The patient's recovery position after giving the

CPR.

3.3 SDK and Plugin Programming on

Unity Engine

After building all assets in 3D models and establish

the scenario procedures, the Unity programming can

be developed. This development process can be

integrated to the VR SDK or Plugin for Unity Engine

in order the result can be displayed and integrated to

the proposed VR-headset device.

On this development, we used the Steam VR

SDK, SteamVR works as an SDK for Virtual Reality

in universal devices which can be downloaded freely

in Unity Asset Store (Unity, n.d.). With this SDK, the

application output of Virtual Reality can be installed

in several VR devices such as Oculus, HTC Vive, or

the other various HMD devices that compatible with

SteamVR. So with this SDK package, we can install

for several devices without configurating the specific

device anymore. Figure 11 is the thumbnail picture of

Steam VR which is displayed on Unity Asset Store.

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Figure 11: Downloadable SteamVR Plugin on Unity Asset

Store (Unity, n.d.).

4 RESULT

A. Checking a Patient’s Pulse on his Neck

Figure 12: Left side showed the process of pulse checking

and right side is user’s question board displayed about

patient situation.

In this scene, as shown in Figure 12, user is provided

the patient in lying position. User as the healthcare

person, firstly must check him up the pulse with

touching patient’s neck. Note will appear beside it

and its result must be synchronized to the question

board. User must choose “yes” answer if the result

showed the pulse, and vice versa. Which means pulse

tick in the neck indicates the patient is still alive.

Purple line appears in front of user virtual hands to

pointing and answering multiple choice button in the

board question.

A system will random this condition, if user didn’t

get a neck pulse, then he must repeat until he get it,

otherwise the next procedure can’t be processed,

which means the patient can’t be helped anymore.

B. CPR Compression Action

Figure 13: Compression Procedure which is showed by

instruction board on the left side and process snapshot on

the right side.

After user got the patient’s pulse, system will

continue to the main procedure of CPR, namely

compression. As the instruction showed in Figure 13

on the left-side, user should stack his hands (both of

hands) on patient’s chest to apply the pressure-

procedure 10 times in 5 minutes, then it must be

repeated until 3 set (three times). In this case, actually

on every set, user should check a patient’s breathing.

If the patient has been breathed just with one set or

twice, compression can be sufficient, and the

procedure can be continued directly to the ambubag

installation.

C. Ambubag Installation

Figure 14: Ambubag installation steps and instruction.

Ambubag installation can be performed after

compression process. In this scene, user should take

the ambubag which is placed on the table beside the

patient. Thus, he must pump it twice as the instruction

showed on virtual board-instruction as Figure 14.

D. Recheck Patient’s Pulse

Figure 15: Ensuring process of patient breaths after

compression and ambubag installation.

For ensuring the patient has been breathed and his

pulse are running normally, user should check his

carotid artery on the neck one more time as the

procedure shown in Figure 15. Then, if its pulse is

running well, everything has been done. User just

need to reposition his resting position in recovery

position as the last procedure.

E. Rescue the Patient in Recovery Position

Figure 16: Recovery position.

Virtual Reality Simulator for Cardiopulmonary Resuscitation (CPR) as Lifesaving Method in Many Emergencies Patients

679

As the last procedure, the patient should be left with

the right resting and recovery position. Recovery

position means a user should push the patient body

until tilted to relieve the airway as shown in Figure

16.

F. Experiments and Testing

In several events and exhibitions, it has been

performed to the public and related institutions. We

interviewed them the experiences when performing

this CPR VR simulator. Most of them are feeling with

immersive interaction and follow the instruction and

procedure properly. Figure 17 showed several

documentations of this simulator exhibition and

coverage on the JawaPos newspaper (Indonesian

popular newspaper), when simulated by General

Director of Vocational Education of Education and

Culture Ministry of Indonesia.

Figure 17: Experiment on the exhibition and newspaper

coverage.

5 CONCLUSION

Based on the result of this VR simulator prototype,

we can conclude the following points:

This simulator was built to convert a physical

laboratory into a virtual laboratory with the aim of

minimizing risk, reducing the cost, easing in media

duplication for student practicums, but still feeling

with immersive interaction approaching a real

physical-simulator.

Virtual laboratory or virtual simulator have many

opportunities to be developed, especially during

today’s pandemic and industrial revolution 4.0

challenges. So that, distance learning or practicum

will be very easy to be implemented with virtual

laboratory idea.

Based on these experiments, user just feel pure

virtual experience and doesn't interact wiyh

collision immersivity. So, for the next

development, it will be better if this simulator is

mixed with the real mannequin.

ACKNOWLEDGEMENTS

This work was supported by Postgraduate Program of

Semarang Polytechnic of Health as the partner and

resources supporter in developing this virtual

laboratory. Hopefully, with this memorandum of

understanding, we can support each other and develop

the other several health-laboratory devices for

supporting the adaptable recent education media.

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