Virtual calming

Easing anxiety in young patients using immersive technology

Every Tuesday and Thursday after school, for about a month, Zack Dwyer, then 17, would settle into a reclining chair in the family room of his San Mateo, California, house and strap on a pair of goggles.

Illustration by Greg Clarke

Attached to the eyewear was a smartphone containing an app that ran a virtual reality experience. It was designed by clinicians at Lucile Packard Children’s Hospital Stanford to calm nervous teens like Dwyer, who was facing surgery to correct supraventricular tachycardia — rapid heartbeat caused by abnormal electrical impulses.

The virtual trip took him through the steps of the procedure, starting at the entrance to Packard and ending in the recovery room. He saw it all as if he was at the hospital — checking in at a desk, lying in a bed in the operating room, talking to a surgeon.

When the day of his surgery arrived, Dwyer took it all in stride, even when he was in the procedure room surrounded by a cadre of scrubs-clad physicians and nurses and a bunch of scary-looking machines. “It definitely would have been super overwhelming if I didn’t know that was coming,” he says.

Adults usually know what to expect from a visit to the hospital. If they haven’t undergone a medical procedure themselves, they’ve accompanied family members or heard about them from friends. To children and young adults, however, being in the hospital can be terrifying. “Procedures and the hospital can be stressful for everyone,” says Lauren Schneider, PsyD, a pediatric psychologist at Packard Children’s. “But for children, it’s unfamiliar, a new life experience.”

The app Dwyer used is designed for teenagers, who make up the majority of pediatric patients undergoing the cardiac catheterization he had. Younger children present other challenges. They squirm when an intravenous line has to be inserted, scream during vaccinations and pull off anesthesia masks.

For these children, Packard doctors, nurses and child life specialists are employing technologically enhanced distraction techniques: virtual reality goggles that hide equipment and engage kids in games, and video screens that feature characters who trick youngsters into breathing anesthesia gas.

Packard physicians are also tapping the three-dimensional aspect of virtual technology to educate patients and their parents by showing them 360-degree images of organs. The systems illustrate medical problems in a way that drawings or verbal explanations never can and help young patients and their parents become more invested in their care.

More effective calming techniques

For years, psychologists have talked fearful children and teens through frightening procedures, nurses have offered stickers to appease preschoolers receiving shots and cardiologists have opened plastic heart models to show parents a congenital defect. But they are finding that new technologies including virtual reality and portable video systems are far more effective in calming, distracting and educating patients — easing the jobs of care teams while also reducing trauma for kids.

Schneider works with the pediatric cardiology division to treat children who are suffering from the emotional side effects of heart disease, such as fear of dying during a procedure or anxiety about palpitations. She provides in-person tours of the hospital and uses exposure therapy to help relieve their anxiety. She also teaches them relaxation techniques such as guided imagery, in which patients close their eyes and imagine waves crashing on a beach, for example. But she’s not able to work with every patient, whether because they don’t have time or because they live far from the hospital.

So she joined pediatric electrophysiologist Anne Dubin, MD, professor of pediatrics at the Stanford School of Medicine, in designing a simulation experience in which two teen actors, playing former surgery patients, walk young patients through the process (Emily addresses girls; Akilee, the boys).

"Medical procedures can traumatize kids. Later in life, they may not be willing to undergo procedures they need."

Once they don the virtual reality goggles and start the program, patients see the entrance to Packard; if they turn their heads, they can see what’s behind them. They move through the pre-and post-operative stages, viewing each room, complete with equipment and the care team. They also see the actors and physicians, standing off to the side, who explain what will happen at each stage. At two points in the experience, the real-life video of the hospital switches to a tranquil, animated scene.

In one, the imagery becomes a nighttime valley, surrounded by mountains, under a sky filled with stars. With subtle shifts of their heads, patients can move dots of light around the scene; if they place the dot on the ground, it grows into a new tree. They can spend as much time as they’d like in the scene, building a forest, changing the color of the sky and meditating on the serene landscape.

“At key moments, when they’re waiting, for example, and may start to feel nervous, they can bring up the memory of the forest-building,” says Schneider, a clinical assistant professor of psychiatry and behavioral sciences. They can also practice breathing exercises, which are described at another point in the virtual program. Simply familiarizing themselves with the physical hospital reduces some patients’ anxiety, she adds.

“Medical procedures can traumatize kids,” Dubin notes. “Later in life, they may not be willing to undergo procedures they need. It colors their entire medical involvement and interactions.”

A virtual ounce of prevention

While Packard’s simulation apps are helping teenagers like Dwyer relax before a scheduled surgery, younger patients benefit from the distraction provided by virtual reality goggles. Stephanie Chao, MD, turned to the technology when she needed to remove fluid from a cyst on the neck of her 9-year-old patient without any pain medication. She numbed his neck with ice, then had him put on the goggles before she produced the needle.

“Most kids, just seeing the needle, would start crying,” says Chao, an assistant professor of surgery. But her patient, engrossed in a 3-D animated underwater world of dolphins, shipwrecks and schools of fish, didn’t even flinch when she poked him — twice: “He was so immersed in the virtual reality, he had absolutely no anxiety.”

That immersive quality of the virtual experiences is what makes it so successful as a distraction tool: When they’re looking into the goggles, patients can’t see the equipment, blood or other frightening aspects of an exam room. They’re also so taken by the novelty of it, they barely notice the needle pokes.

"We can provide a cool experience in a setting that is not cool at all."

A team at Packard, working with game developers and using funding from the Lucile Packard Foundation for Children’s Health and private donors, also created virtual games for precisely the kinds of situations Chao faced. Besides creating scenes like the one Chao used with her patient, the team created games that allow kids to play by moving only their heads. The games aren’t likely to cause nausea, they aren’t violent and they’re continuous play, so they won’t end just when a needle is about to enter a vein. In one of the games, patients zap burgers flying in space; in another, they steer penguins down a snowy hill.

“We can provide a cool experience in a setting that is not cool at all,” says Veronica Tuss, who, as a child life specialist helps children cope with treatments in the hospital. “It really helps us get the child through the procedure.”

Using adapted goggles that are readily sanitized, Tuss and the other child life specialists can choose games based on the patient’s request: Some want to hear the game, some don’t. Some are fine with a relaxing scene, while others require a high-activity distraction. The game developers are building a library of experiences — they have about 10 now — so Packard clinicians can choose the best one for each patient, based on age, personality and the procedure he or she is facing.

Making sense of care

Sam Rodriguez, MD, a pediatric anesthesiologist who is part of a team developing these games, stresses that someone doesn’t simply hand the kids a pair of goggles, then proceed with treatment. “We’re still interacting with the patient,” says the clinical assistant professor. “We ask them what they’re seeing so we can gauge how they’re doing. The interpersonal skills of the child life specialist, or the physician or the nurse are still very important.”

For 3-to 4-year-olds who need to undergo general anesthesia, the Packard team has created a game, Sevo the Dragon, to convince them to breathe in the gas through their anesthesia masks. With a video screen showing the Barney-like dragon attached to their beds, the tots learn that Sevo needs to cook pizza using fiery dragon breath, and they need to help! They blow into their masks, the child life specialists or the anesthesiologists surreptitiously tap a button, and Sevo blows fire onto the pizza slice.

“As soon as they blow out, they have to take a huge breath in,” causing them to inhale the anesthesia, Tuss says. Soon they’re asleep.

Without a distraction like Sevo, younger children often pull the masks off their faces, forcing anesthesiologists to hold them down, “which can be a traumatizing experience for them.”

“Having a terrifying clinical experience can change behavior for weeks,” says Tom Caruso, MD, clinical assistant professorof anesthesiology, perioperative and pain medicine, also part of the Packard team developing the games. “We see sleep disturbances and regression in children’s behavior.”

The team is studying the effectiveness of Sevo and other games. From what they’ve seen so far, Rodriguez says, the games appear to make a “profound difference” among the most anxious children. “For some of these patients who’ve had a horrific experience in the past, it takes the fear from a 10 out of 10 to a 2 out of 10.” No patients have yet shown any negative side effects from the goggles or the games, he says: “The worst case is the kid doesn’t like it and takes it off.”

Skyler Rodriguez, who is not related to Sam Rodriguez, liked her experience. Earlier this year, she had an osteoblastoma tumor on her spine that required surgery. Using virtual technology, her physician, Gerald Grant, MD, was able to show her and her parents a 3-D image of the tumor. “He literally gave us a tour of my spine,” the Hollister, California, 17-year-old says. “He showed me every possible angle, and what he would do during the surgery. It helped me understand what was going on, and what they would do. It made it less scary.”

The system combines imagery from patients’ CT, MRI and PET scans to create 3-D renderings through which patients can “travel,” starting outside their skulls then proceeding all over their brains and into their spinal cords. Patients as young as 4 can see their tumors or a set of tangled arteries, or skull deformations. The brains and spinal cords appear in animated form, like three-dimensional textbook illustrations they can step into. They can also visually follow the steps surgeons will take to remove tumors, correct deformations or place electrodes to treat epilepsy.

Before the virtual experience, says Grant, young patients are often disengaged and frightened. “It’s hard to connect them with what’s going on,” he says. “They’re scared of pain, they’re scared of waking up during the surgery, they’re scared of dying.” But when they view the 3-D imagery, “You see the kid light up. They start asking questions. Especially the teenagers. It reduces the fear, the anxiety, the mystery.”

While there is no data to show that educating young patients about their medical situation leads to improved results, “They feel more stable; their approach is more relaxed. It enhances their trust,” says Grant, an associate professor of neurosurgery. Without the imagery, he adds, they can’t fully understand the problem and how the surgeon will correct it.

'You see the kid light up. They start asking questions. Especially the teenagers. It reduces the fear, the anxiety, the mystery.'

Pediatric cardiologists are also using the technology to educate: David Axelrod, MD, is building a library of virtual imagery that illustrates congenital heart defects. Unlike the neurology cases, these defects tend to fall into categories, so he can pull up virtual experiences to explain a specific condition or defect and what the surgeons will do to fix it, all in 3-D. “It’s really important for families to know what’s going on with their child’s heart defect,” says Axelrod, a clinical associate professor of pediatrics. “The 3-D images give them a much better understanding.”

The program that calmed Zack Dwyer’s nerves is being used in a pilot study that Schneider and Dubin are conducting to see if it reduces anxiety for 8-to 25-year-old patients who are undergoing cardiac catheterization surgery. If it does, Packard plans to produce virtual programs for young patients who require different cardiac treatments and, eventually, any stress-inducing procedure.

Dwyer, who first noticed his racing heart during basketball practice at San Mateo’s Hillsdale High, was back on the court 10 days after his surgery, the rapid heartbeat just a memory. He says he would strongly recommend the app experience to other teens. Taking the virtual tour led by Akilee, “a kid my age,” helped him a lot. “It’s crazy to think you have to have heart surgery,” he says. “But I had something that made it seem like it was no big deal.”

Mandy Erickson is a freelance writer and editor.

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