Augmented reality game-related injury

Abstract

There are an increasing number of injuries associated with ambulatory mobile phone use. Pokémon Go is one of the first widely used mobile phone augmented reality games and generated substantial media interest. We present a case of electrical burns in a Pokémon Go player and review literature on ambulatory mobile phone injuries.

Background

There are now more mobile devices than people worldwide, with statistical website Statista documenting 4.77 billion people who are in possession of a mobile phone. Concurrently, the number of injuries associated with mobile phone use is rising, particularly among pedestrians. Pokémon Go is one of the first popular mobile augmented reality games and attracted explosive media attention within its first weeks. This included adverse incidents. Here, we report a unique case of electrical injury resulting in significant disability which arose in association with the phenomenon of Pokémon Go. We discuss how this case highlights the impact of developing technology on healthcare and society.

Case presentation

A fit and well young man presented to the emergency department having sustained high-voltage electrical burns from falling onto a railway track while playing Pokémon Go. On examination, he had 7% full thickness burns involving his right anterior thigh and knee (figure 1), left anterior thigh, right lateral elbow, chest and right mandible. There was associated loss of movement in his right foot. He had severe pain on palpation of his right thigh, raising suspicion of compartment syndrome.

Figure 1.

Full thickness burn to right anterior knee and fasciotomies to right thigh.

Investigations

ECG demonstrated no abnormalities. Plain radiographs and CT scan were negative for associated injuries. His creatine kinase was 79 000 units/L, with normal renal function.

Treatment

He was taken to theatre for emergency exploration and debridement. He required early fasciotomies of his right thigh and later extensive debridement of the anterior thigh skin, fat, fascia and muscles until healthy bleeding tissue was reached. The distal half of vastus lateralis, vastus medialis, vastus intermedius and rectus femoris muscles were all excised (figure 2). His right patella was also necrotic. Exploratory fasciotomies of his right leg showed no compartment syndrome. Debridement of his right elbow was also performed at this time.

Figure 2.

Right anterior knee and thigh postsurgical debridement. Demonstrates loss of muscle and necrosis of patella.

Postoperatively, he was managed in a high-dependency bed. Rhabdomyolysis was managed with intravenous fluid. Cardiac monitoring was continued for a 72-hour period.

The patient returned to theatre at 48 hours for reassessment and debridement of the remaining full thickness burns and patella.

Outcome and follow-up

He required a right above knee amputation due to extensive tissue loss and damage to his common peroneal nerve from the initial injury.

Discussion

Media coverage has reported on safety incidents involving Pokémon Go, including people becoming stranded, risky behaviour at the sites of known minefields and the unfortunate death of a teenager.^{1 2}

Pedestrian injuries due to mobile phone use increased 35% between 2010 and 2014.³ In 2010, the estimated number of injuries among pedestrians using mobile phones in the USA was 1506.⁴ However, the number of injuries that could be attributed to distraction is likely higher due to under-reporting. It has been suggested that distraction could account for 1 in 10 pedestrian injuries and deaths.⁵ Injuries associated with pedestrian mobile phone use are increasing more rapidly than those associated with driver use.⁴

When considering knowledge of the impact of augmented reality games on personal safety, evidence is limited. Multitasking causes attention and performance on each task to decline. Taking ‘selfies’ is demonstrated to cause a lack of situational awareness and distraction.⁶ Controlled studies to look at the impact of mobile phone use on pedestrian activity have focused on perception or gait pattern. Visual cues were not perceived by 48% of subjects when using a mobile phone while walking on a treadmill compared with control conditions.⁷ Gait pattern also shows more medial to lateral excursion of the pelvis. Individuals also demonstrate higher levels of risk taking behaviour when engaged on mobile devices.⁸

However, the impact of distraction associated with mobile phone use is not restricted to pedestrians. With greater data available, motor vehicle incidents provide a useful insight into safety concerns, including in relation to Pokémon Go. The American Automobile Association (AAA) reports that 59% of accidents among young drivers were associated with distraction within 6 s of the accident.⁹ American research extrapolating from data available through social media suggested 113 993 incidents involving distraction of a driver, passenger or pedestrian by Pokémon Go in a 10-day period.¹⁰ Finally, Faccio and McConnell analysed the impact of the release of Pokémon Go to estimate a contribution to 150 000 traffic accidents and 256 deaths in the first 148 days.¹¹

If we wish to postulate as to the effect of mobile phone augmented reality games on public health and cost to society as a whole, we must also start by looking at the impact of mobile phone use in motorists. By far one of the most balanced assessments of this was published by the Harvard Centre for Risk Analysis and School of Public Health.¹² Their review of the literature found that use of a mobile phone did result in decrement in performance. They struggled at the time of publishing in 2000 to show an association of mobile phone use with traffic fatalities, but did suggest that there was an increase in overall risk. This information is in line with that which we have seen reported for 2007–2015 by the AAA.⁹ Harvard then moved on to estimate the cost of accidents caused by cellular phones to be US$3000/collision or US$2 billion/year. This can be compared with the estimated cost from Faccio and McConnell’s analysis of accidents associated with Pokémon Go, which was an economic cost of between US$2 billion and US$7.3 billion for the 148 days following release.¹¹

Estimating the cost to individual and society of associated injuries is challenging, as each accident will be unique. Death from electrical burns is estimated at 3%–5%.¹³ High-voltage injuries can lead to widespread necrosis under apparently healthy skin. Tissue destruction is often severe due to vascular injury and thromboxane production. In high-voltage injuries, further studies have identified a correlation of serum creatine kinase level with risk of limb amputation and mortality.¹⁴ This would be consistent with the significantly raised creatinine we witnessed and the consequence of above knee amputation. Major limb amputations in high-voltage electrical injuries have been reported at 35%, with significant long-term neurological deficits in 73%.¹⁵ Limb salvage was not possible in this patient, and therefore, in addition to his acute care, the disease burden will include the long-term costs associated with an above knee amputation in a young man. Tools are available to predict outcome in this patient including LIAMs score for rehabilitation and BLARt score for use of prosthesis. Determining the patient’s level of impairment could then be done using the American Medical Association Guides to the Evaluation of Permanent Impairment. Mackenzie et al in their paper estimated the lifetime cost of amputation following trauma to be US$509 275 (£384 548).¹⁶ Meanwhile Chung et al estimated the cost for the first 5 years following amputation to be £69 000.¹⁷

In those countries where health insurance is required, players may be left considerably out of pocket if an injury is sustained. In addition to this it may be noted that a claim for an injury associated with the game could result in an increase in not just an individual’s insurance premium, but also more widely a change in the way insurance premiums are calculated. In response to those injuries publicised, it is now possible to buy insurance specifically to cover accidents, which may occur while playing. Insurance companies could in the future being taking into account participation in augmented reality games to calculate insurance or refusing cover for those events in which a game was implemented.

The Harvard review also considered what benefits may be produced from using a mobile phone while driving. They identified factors such as reduced unnecessary travel, reduced speeding, security and expanded productivity. Societal benefits were identified as improved information available to emergency services, decreased emergency response time and apprehension of criminals. Positive media coverage reflects on the increased time spent outdoors when engaged in playing Pokémon Go. Niantic proposes this, along with increased social interaction, as benefits in their comments on game safety.

In a healthcare setting, there is the potential for the beneficial use of augmented reality. One example considered to be on the horizon is its use in the training for professionals, through simulating the impact of a disability or recreating a challenging communication scenario. Augmented reality games have, before the advent of Pokémon Go, already been used in patient care. In 2008, they were being used to significantly reduce pain during dressing changes on paediatric burns patients.¹⁸

The impact of pedestrian mobile phone use is an important public health concern. This will become an increasing focus with the further development of augmented reality activities. Pokémon Go warns of the risk posed by distraction and accept reports of Gyms and Poke stops located in dangerous areas to enable them to take action. They have also agreed that characters will not be placed in certain no go areas, including nuclear plants in Japan and railways in Taiwan. However, these warnings are unlikely to be sufficient to reduce all risks associated with augmented reality games. Measures to reduce the more general risks associated with distraction are therefore crucial. This includes speed-calming measures, changes to sidewalks and fines for distracted pedestrians.³ The use of mobile phones causes both auditory and visual distraction, and this should be considered when developing measures to reorientate users to hazardous situations.

Learning points.

• Use of mobile devices impairs situational awareness and coordination.

• Reporting of injuries associated with device use is important in informing the public and healthcare providers.

• There needs to be increased awareness of the risks and injuries associated with ambulatory mobile phone use.