SeGTE: A Serious Game to Train and Evaluate Basic Life Support

Claudia Ribeiro

, Joana Tiago

, Micaela Monteiro

and Jo

ao Pereira

INESC-ID, Lisbon, Portugal

Instituto Superior T

ecnico, Universidade T

ecnica de Lisboa, Lisbon, Portugal

Servic¸o de Urg

encia Geral Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal

Keywords:

Basic Life Support, Cardiopulmonary Resuscitation, Serious Games, Finite State Machines.

Abstract:

Basic life support (BLS) is the level of medical care which is used for victims of life-threatening illnesses or

injuries until they can be given full medical care at a hospital. It can be provided by trained medical personnel,

including emergency medical technicians, paramedics, and by laypersons who have received BLS training.

BLS is generally used in the pre-hospital setting, and can be provided without medical equipment. The ability

to respond to an emergency situation can be the difference between life and death. Acknowledging this fact has

made decision-makers, governments and Non Government Organizations (NGO) to make a priority to spread

this knowledge and skills to the general population. Currently, BLS is taught in a standard course provided by

the Red Course or certiﬁed entities, where the pedagogical content given to the students is a mix of theoretical

and practical training where life-size mannequin are used. In this paper we argue that serious games could

help spread this knowledge through the general population and it could also be used to refresh the knowledge

of people that have been certiﬁed in BLS in the past. In order to test this hypothesis we have developed the

SeGTE game and performed an evaluation of its effectiveness on conveying such pedagogical content.

1 INTRODUCTION

In this new millennium, the prevalence of road acci-

dents is so frequent and fatal it is an issue uppermost

in the minds of individuals, decision-makers, govern-

ments and Non Government Organisations (NGOs)

worldwide (Fiander, 2009).

The Statistics of Road Trafﬁc Accidents in Eu-

rope and North America contains the basic statistics

provided by the Governments States members of the

United Nations Economic Commission for Europe

(UNECE). In this report is stated that for the ECE re-

gion in the decade 1999-2008 there were on average

150 000 persons killed and about 5.5 million persons

injured annually in more that 3.8 million road acci-

dents (UNECE, 2011). In the attempt of improving

both the consequences and well and the causes for this

statistics the International Federation of Red Cross

(IFRC) and Red Crescent Societies have issue sev-

eral reports where recommendations are proposed on

how to deal with this critical situation. Namely, one

of the central recommendations is to develop greater

ﬁrst aid knowledge amongst the general population

be they drivers, car-users or pedestrians involved in,

or bystanders to, road accidents (IFRC, 2009; IFRC,

2010).

Although ﬁrst aid is not a replacement for a emer-

gency services’ intervention, it is a vital initial step in

intervention that provides an effective and rapid con-

tribution. This both reduces the severity of injuries

and improves the chances of survival. In this manner,

the IFRC believes that everyone has the potential to

save lives. First aid is not just about techniques. It is

an act of humanity and therefore is a key responsibil-

ity of global citizenship (IFRC, 2009; IFRC, 2010).

The IFRC points out that the solution is not just

about making training compulsory. There is also a

need to improve the existing training practices and

quality. This is why people are called to attend ﬁrst

aid refresher classes. All skills must be practised

and upgraded. Refresher classes will bring the per-

formance of most interveners to a higher level than

that recorded after initial training (IFRC, 2009; IFRC,

2010). Continuing ﬁrst aid education is essential to

maintain providers’ knowledge and skills particularly

when they do not use their skills frequently.

An area where training can be improved is by in-

creasing the level of a course’s realism. It is one thing

to be in a training session but quite another to ap-

ply that classroom learning in a real situation. First

aid is not just about providing life-saving skills to a

438

Ribeiro C., Tiago J., Monteiro M. and Pereira J..

SeGTE: A Serious Game to Train and Evaluate Basic Life Support.

DOI: 10.5220/0004661504380444

In Proceedings of the 9th International Conference on Computer Graphics Theory and Applications (GRAPP-2014), pages 438-444

ISBN: 978-989-758-002-4

 2014 SCITEPRESS (Science and Technology Publications, Lda.)

manikin; the real situation means dealing with fac-

tors that can prevent the provision of efﬁcient ﬁrst aid,

such as coping with the terrifying presence of blood or

a person’s pale and sweaty appearance when having a

cardiac arrest. The person providing ﬁrst aid can also

be inﬂuenced by a crowd gathering around an acci-

dent. All these are important reasons for preparing all

ﬁrst aid providers for the stress that they will face. Im-

proving this aspect of training will avoid what should

never be seen: people trained in ﬁrst aid running away

from an accident scene simply because they are afraid

of blood or of the level of exposure.

In this paper we present SeGTE, a serious game

designed to train and evaluate Basic Life Support,

with the aim to teach the procedures described by the

European Resuscitation Council (ERC, 2012). This

game exploits video game technology to link in a

framework computer-based case with e-learning func-

tionalities. Some computer graphics techniques are

used to reproduce different situations where basic life

support is required and also the procedures that have

to be applied. SEGTE includes two game modes,

training mode and evaluation mode. In training mode,

the user can train the different medical procedures

provided in the ERC’s protocol (ERC, 2012). In the

evaluation mode the users can assess their knowledge.

The remaining sections of this paper are com-

posed as follows: Section II present the state of the

art of serious games for teaching and training of Basic

Life Support. Section III presents SeGTE architec-

ture and the main characteristics. Section IV presents

Evaluation, how the solution was validated with real

users. Section V presents the conclusions and future

work.

2 BACKGROUND

Basic life support (BLS) is a sequence of attitudes and

procedures aimed at recognizing a patient in cardiac

arrest, calling specialized help and meanwhile estab-

lishing blood circulation and oxygen supply in order

to keep the victim alive. In 2010 The European Resus-

citation Council (ERC, 2012) published new guide-

lines that precisely redeﬁned the algorithm of proce-

dures for BLS. Every citizen should ideally be trained

in BLS as most cardiac arrests happen with layper-

sons as ﬁrst helpers and brain death usually occurs

within 5 minutes of cardiac arrest if no help is pro-

vided. Traditionally BLS is taught and trained with

dummies in special courses of several hours.

Recently simulation software programmes have

been developed where the BLS algorithm can be

trained. ”Staying Alive” by iLumens

creates a 3D

environment where the user has to assist a collapsed

victim by following the BLS rules. ”AedChallange”

by Insight Instructional Media

is a video game for

refreshing already acquired skill. It presents several

clinical cases where the player can train BLS. The

player scores when he/she proceeds according to the

BLS algorithm. At the end there is a debrieﬁng and

errors are explained.

3 SeGTE: A SERIOUS GAME TO

TRAIN AND EVALUATE BASIC

LIFE SUPPORT

SeGTE is a serious game, designed in collaboration

with healthcare professionals, to train and evaluate the

general public (lay persons) in basic life support. The

main objective of the game is to teach the procedures

described in the ERC’s protocol (ERC, 2012).

The sequence of procedures is determined by the

current condition of the patient. Speciﬁcally, if a pa-

tient is responsive it will not be necessary to execute

the procedure that corresponds to preform 2 rescue

breaths and 30 compressions. Actually, it would be

dangerous to perform such a procedure in a respon-

sive patient. In order to achieve this ﬂexibility both in

specifying game cases as well as in game mechanics,

we used a ﬁnite state machine to guide the simulation

underlying the game logic. This ﬁnite state machine

was deﬁned interactively with the help of healthcare

professionals. It was necessary to guaranty that every

path through the ﬁnite state machine was a valid one

and also that the feedback given during game play was

correct both in terms of content as well as the simu-

lation execution step. In the next subsections it will

be further elaborated how the ﬁnite state machine was

deﬁned, as well as the game play, clinical cases deﬁ-

nition and implementation details.

3.1 SeGTE Finite State Machine

The use of ﬁnite state machines in video games is pro-

moted by many developers due to their robust nature

as they are easy to test and modify. They are typically

used to model the behaviour of computer-controlled

game characters, also called no-player characters

(NPC), to make NPCs react to game events seem as

intelligent and natural as possible, (Hu et al., 2011;

Saini et al., 2011).

http://ilumens.fr/numerique/serious-games/

http://aedchallenge.com/

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439

A ﬁnite state machine is a system with a set of

states and a collection of transitions, which represent

some kind of actions for each state. It has a initial

state, and one or more ﬁnal states. In practice, it’s a

description of how an object can change its state over

time in response to the environment and events that

occur. Each state represents a behaviour, resulting in

the behaviour changing as states change from one to

another, (Saini et al., 2011).

In Figure 1, is depicted the Finite State Machine

of our serious game.

Figure 1: The Finite State Machine representing the proce-

dures of ERC’s protocol.

To create this ﬁnite state machine, we transform

the basic life support algorithm, presented by the Eu-

ropean Resuscitation Council 2012 (ERC, 2012), to

a set of states and actions, and deﬁne how they are

connected. The process starts with the transformation

of each medical action in a element of the ﬁnite state

machine. For this purpose, it was necessary to under-

stand what is an action, a state or a transition.

Each state of the ﬁnite state machine corresponds

to the current state of the patient during a game

play. In each state the player can decide which action

she/he should take but only the valid transitions of the

ﬁnite state machine are considered correct. Therefore,

every action taken which is outside the set of actions

permitted or considered correct will have a negative

feedback. Depending on its level of severity, the game

can either end, resulting in the death of the patient or

a warning is issued to the player. More details about

the game play and different elements that make-up

the game SeGTE are described in the following sub-

sections.

3.2 SeGTE Game Play

The game play starts with a brieﬁng screen where the

player is introduced to the pedagogical goals of the

game. Also, in this screen the player can access in-

formation concerning the basic life support algorithm

and how the user interface works. In this phase a facil-

itator that has background knowledge of the game and

the basic life support algorithm, provides extra infor-

mation and clariﬁes any necessary doubts that might

be posed by the player.

Once this phase is terminated, the player can

choose either to play in training mode or in evalua-

tion mode. In training mode, the player can train the

different game cases. If the player chooses the wrong

procedure a warning appears. This warning con-

tains information about what procedure should have

be done. After this, the player can correct her/his er-

ror and continue the game. Furthermore, some in-

formation is given on how to make certain actions

(e.g. compressions and ventilations). In evaluation

mode, the players can assess their knowledge, there-

fore no type of information or help is provided during

the game. If she/he makes a mistake, the patient’s life

is at risk and some decisions can lead to prematurely

ending the game resulting in the patient death.

Independent of the game mode, after each game

case the player is presented with the debrieﬁng screen.

On this screen the player is given an explanation of

what were her/his mistakes and how they can be cor-

rected. This phase of the game play is critical for

knowledge retention. By reﬂecting on the game af-

ter playing it, debrieﬁng helps the player make mean-

ingful connections between the game experience and

the ”real world” (Crookall, 1990; Crookall, 1992),

thereby likely enhancing transfer of knowledge and

skills. Debrieﬁng can promote active learning by de-

constructing the experience, exploring alternatives re-

sponses, and linking observations and experiences in

the virtual world to those in the real world (Gaba

et al., 2001). It is still not clear how debrieﬁng

can be most effectively incorporated in serious games

(Thompson et al., 2010). Therefore, during the evalu-

ation of different releases of the game informal inter-

views were made to users in order to better understand

if our choices were both aligned with the expectations

of the users and, as well as the pedagogical goals of

the game.

3.3 Clinical Cases

In SeGTE several game cases were set up in order to

allow the player to have the opportunity of exploring

the application of the algorithm in patients with differ-

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440

ent health conditions. Therefore, each game case cor-

responds to what we have denominate a clinical case.

Basically, a clinical case is a description of several at-

tributes that make up the patient’s current condition

and the environment were he is currently in. Such at-

tributes are for example, if the patient is secure or if

the patient is breathing.

Currently the game cases are conﬁgured inside the

game application, but extending this solution to sup-

port adding new clinical cases is trivial and is one of

the top priorities of the next release of the SeGTE

game. Structuring this information in an XML ﬁle

would not just facilitate the process of adding new

game cases, it would also admit to translate the game

into different languages. Apart from this and most

important it would allow healthcare professionals to

add this information without the intervention of a pro-

grammer. This is very relevant, both because it would

ideally motivate the use of this game by healthcare

professionals but it would also make this game less

fragile to new updates of the basic life support algo-

rithm.

3.4 User Interface

The interface was create with the goal of making the

player’s interaction as simple and efﬁcient as possible.

With this purpose we have use a navigation based on

point-and-click. This greatly facilitates the navigation

inside the virtual world for players that are not used

to play games or to navigate inside 3D environments.

For the reminder of the user interface, the standard

style of interaction such as buttons, boxes and win-

dows were used.

The environment is outside of a hospital. Most

of this cases deal with the basic life support, i.e. the

primary skills in cardiopulmonary resuscitation and

include basic mouth-to-mouth resuscitation and chest

compressions to circulate blood. No medical equip-

ment is required and there are no invasive procedures.

The player interface simulates the unexpected

emergency incident and allows the player to rescue

the victim.

The scene starts with the emergency situation,

when a victim falls in the street. The player plays

the role of the helper that tries to save the victim. Af-

ter ﬁnishing the clinical case the debrieﬁng menu is

shown and the player can assess her/his performance.

Figure 2 shows the sequence of procedures for a

cardiopulmonary resuscitation situation from (a) ini-

tial state with the patient on the ﬂoor; (b) Check is

Secure; (c) Check conscience; (d) Check is breathing;

(e) Initiate Compressions and Ventilations. Helper

choose mouth-to-mouth or mask; (f) Helper starts

compressions and Ventilations.

Figure 2: Sequence of Procedures in SeGTE.

Some of the animations and actions lack realism

as avatar performance is limited. However, for this

ﬁrst prototype the main objective is that the player

learns the order of each procedure.

In the future work, we can improve some of these

animations and procedures. The possibility of player

collaboration with other characters (e.g. a person for

help in compressions and ventilations)will also be in-

cluded.

3.5 Implementation Details

SeGTE architecture is divided into two main com-

ponents, the serious game component and the Finite

State Machine component. The serious game com-

ponent is generically responsible for managing the

game logic, graphic assets, interfaces and players in-

teractions. It’s based on Unity3D

game engine and

follows a script based architecture, that encapsulates

functionality as C# scripts.

In the serious game component there are four main

modules, the HUD manager, the Camera Manager,

the FiniteStateMachine Manager and the Game Man-

ager. The HUD manager is responsible for manag-

ing all the interfaces of the game, namely all the

menus, feedback information messages and brieﬁng

screen menu. The Camera manager is responsible

for managing the navigation inside the game. This

is accomplished by methods and routines that dy-

namically change the camera position in order to al-

low the player to explore the 3D virtual environment.

The FiniteStateMachine manager is responsible for

instantiating the ﬁnite state machine with the current

clinic case and also managing its execution with the

http://unity3d.com/

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441

Finite State Machine component. The game man-

ager is responsible for managing all the game me-

chanics, interfaces and player interactions. Finally,

the Unity3D kernel is responsible for managing the

graphical pipeline, graphic asset and scene graph.

4 EVALUATION

One important differentiating factor between serious

games and entertainment games is the importance

of assessment. Measuring, discussing and reasoning

about the game play effectiveness is very important in

this domain. This can lead to reﬂection and there-

fore improved learning (Lopes and Bidarra, 2011).

Chen and Michael have identiﬁed some of the main

challenges that assessment in serious games is facing,

namely effecting and improving player experience.

The authors suggest that log information and teach-

ers/instructors knowledge should be fully explored

and, in some way, incorporated back in the game, to

guide its course (Chen and Michael, 2005).

Pamela Kato (Kato, 2012) has also argued that the

few research studies published on the validity and ef-

ﬁcacy of health games are often poorly designed and

that their conclusions cannot be considered valid evi-

dence to support or refute efﬁcacy. In this respect, she

has suggested a set of guidelines for conducting high

quality efﬁcacy studies on games for health. These

guidelines include grounding the game design in well

deﬁned theories, conducting randomized trials that in-

cluded adequate control groups and number of partic-

ipants, and also incorporating standardized measures

to facilitate comparisons across studies.

The authors agree with the recommendations pro-

vided by the previous cited authors and they have

been considered both during the development of the

game as well as when designing and planning the

evaluation of game play effectiveness. During game

design, both experts and lay people were involved in

deﬁned check-points to validate that both the peda-

gogical goals as well as the user interactions were ac-

cording to the expectations of the end-users. Also,

the inclusion of pedagogical content in the game

had into account previous studies of similar games

and approaches such as design patterns (Bj

ork and

Holopainen, 2005) and ﬁnite state machine diagrams.

It was then important to evaluate if the game actu-

ally taught what it had been designed to. This was the

hypothesis of our study. In order to conﬁrm or dis-

card this hypothesis, we designed a qualitative study

based on pre-experimental design research method

(Creswell, 2008), which includes three speciﬁc mo-

ments: brieﬁng, where the player is introduced to the

pedagogical goals of the game; a pre-test, where the

user responds to the questionnaire; game experience,

where the user plays the different game modes (train-

ing mode and evaluation mode); and, a pos-test where

the player responds to the questionnaire. The pre-test

and pos-test questionnaire are one and the same, and

consist of a set of questions related to the ERC’s pro-

tocol and some demographic information related to

the player. In the reminder of this section, we detail

how the study was conducted and the achieved results.

4.1 Pre-test and Pos-test

Before each game experience each player was asked

to answer the questionnaire in order to have feed-

back about their knowledge of basic life support. The

main goal of the pre-test was to evaluate the previous

knowledge the user had about the different procedures

provided in ERC’s protocol.

The questionnaire was composed by ten ques-

tions. The ﬁrst three questions concern demographic

information about the player. According to this infor-

mation, the participants are between 20-30 years; 23

are male and 8 are female, in a total of 31 participants,

without any speciﬁc previous knowledge about Basic

Life Support.

The remaining questions, were related to the ERC’s

protocol and they were validated by healthcare pro-

fessionals.

After playing, each player was asked to answer

the questionnaire again in order to evaluate the knowl-

edge the player had acquired during the game session.

The pos-test was exactly like the pre-test except for

the ﬁrst three questions concerning demographic in-

formation. The main goal of this pos-test was to eval-

uate if the game teaches the sequence of procedures

described in the ERC’s protocol. In other words, vali-

dated the evolution of the user’s knowledge after play-

ing the serious game SeGTE.

After all the participants were evaluated, the data

collected were analysed and the results of the pre and

pos-test were compared.

5 DISCUSSION

Comparing the results of the pre-test with the pos-test,

we obtain better results in all of the questions in the

pos-test. This positive trend may show that the seri-

ous game has some impact in the user’s knowledge,

as presented in Figure 3.

These results are very positive which give us a certain

conﬁdence that the game fulﬁls its educational goals.

Furthermore, the participants in general demonstrated

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442

Figure 3: Comparison between Pre-test and Pos-test.

to have enjoyed playing the game and they considered

it very interesting. Some participants also got a lit-

tle sad when the victim died. This is an interesting

point, because it demonstrates her/his emotional in-

volvement in the game and their motivation to save

the victim.

Nevertheless, there are also some limitations that

should be mentioned. Namely, although the game was

designed to teach the ERC’s protocol procedures it

can’t be neglected that certain aspects of these pro-

cedures can’t be entirely simulated in a virtual envi-

ronment. For example, in a real-world situation per-

forming compressions requires strength and a certain

level of physical condition to sustain until assistance

arrives. This is why Basic Life Support should ideally

be performed by two helpers instead of just one.

Therefore, it is not intended that this game substi-

tutes training with a life-sized doll with replicated air-

ways and anatomy, used in CPR training to simulate

the performance of rescue breathing and cardiac com-

pressions. Instead, this game should be used as a com-

plement of this training, as it has proven to help mem-

orize the Basic Life Support procedures and some of

its speciﬁcities. Also, it can be used as a tool to re-

fresh the knowledge previously acquired in a proper

Basic Life Support Course.

6 CONCLUSIONS

In this paper the serious game SeGTE has been de-

scribed. This game was design to teach the ERC’s

protocol to laypeople, speciﬁcally focusing on the

speciﬁcities of each procedure and also how it should

be applied according to the current condition of an

adult victim. SeGTE has been developed in collabo-

ration with healthcare professionals, that participated

both in validating the pedagogical content of the game

and the correct simulation of the ERC’s protocol. To

simulate the ERC’s protocol we have used Finite State

Machines, were the states represent the current state

of the patient and the possible actions of the player

are the transitions between states. This representation

also allowed us to set up different clinical cases by in-

stantiating accordingly different ﬁnite state machines.

A study based on pre-experimental design was also

conducted in order to assess if SeGTE fulﬁl its ped-

agogical goals. For that purpose a questionnaire was

devised in collaboration with healthcare profession-

als. This questionnaire was used to evaluate both the

previous and prior knowledge regarding the basic life

support. In between answering the questionnaire the

participant played each clinical case once in training

mode and once evaluation mode. This study involved

31 participants and the analysis and comparison of the

results was presented in section 4. The number of cor-

rect answers increased after the participants played

the game which provided us with some conﬁdence

that the game could be used as a tools to teach or

refresh the procedures of the ERC’s protocol. Nev-

ertheless, as future work this study needs to be ex-

tended to a bigger and more diverse audience in order

to assess its statistical signiﬁcance. Also, further de-

velopments are being included in the current version

of the game with the goal of integrating it as a learn-

ing tool in the Portuguese Red Cross courses, which

have already shown an interest in SeGTE.

ACKNOWLEDGEMENTS

This work was supported by FCT (INESC-ID

multiannual funding) under the project PEst-

OE/EEI/LA0021/2013. The authors also would

like to acknowledge to the European funded Project

Games and Learning Alliance (FP7 258169) the

Network of Excellence (NoE) on Serious Games.

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