3D Printing

Summary

3D printers are tools to help bring 3D models or scans into the real world. While the technology has been present for numerous years, it has only been in the past few years that this technology has been available to the consumer market. Becoming more affordable, accessible, and applicable to almost every industry (e.g., local libraries, schools, and even individuals owning a 3D printer for as little as a few hundred dollars). In the healthcare setting, these machines have near limitless use potential from simply being a fun "toy factory", unique end product for an art/design project, resource for adaptive and medical education equipment, a personalized keepsake from a bereavement experience or several other uses your team or adjacent departments can dream up.

The most common steps involved with 3D printing, from start to finish, is the creation of a 3D model, conversion into a sliceable model, printing, and post processing. For each step, there are a variety of options, and subsequent learning curve that makes picking a printer, software program, and 3D model an important decision. Which is why it is a tool that perfectly fits the role of Game Techs, as most other hospital programs may not have the flexibility or bandwidth to tackle the education needed to fully utilize a 3D printing initiative within the healthcare settings.

Best Practices

3D Models

A 3D model is a digital representation of a three-dimensional object, surface, or scene created using specialized computer software. 3D models can be used for a variety for purposes, such as animation, gaming, prototyping, simulation, and visualization. Computer-aided design (CAD) is the primarily type of software application used to design, modify, analyze, and optimize designs in a virtual environment. 3D models are integral in 3D printing, it is the digital instructions that a 3D printer needs in order to create a physical object.

FDM vs SLA in Healthcare Settings

There are a wide variety of commercially available 3D printing processes, that utilize a variety of techniques and materials to create a physical object from a digital model. In the non-clinical pediatric healthcare settings, there are two suitable technologies that standout: fused deposition modeling (FDM) and stereolithography (SLA).

FDM is the most widely used and works by extruding thermoplastic filaments, through a heated nozzle to rapidly heat and cool plastic, building up the physical model layer by layer. FDM is the most popular process because offers the most simplicity, low cost, and versatility. Through FDM, a printer uses string-like plastic (known as filament) to print parts with layer height accuracy of 100-200 microns (0.1-0.2 mms) and minimal post-processing needs.

SLA uses a UV layer to selectively cure a liquid resin, creating a physical object layer by layer out of a pool of liquid plastic. SLA primary difference from FDM, is that it uses light and liquid technology to develop parts with layer height accuracy as small as 25 microns (0.025mm), offering more detailed and complex geometries with finer features and smoother surfaces. However, this requires a much more in-depth and timely post-processing procedure in order to safely handle the final product. Known as curing and washing, these steps use potentially harmful liquid solutions that require ventilation, gloves, and other protective equipment.

Overall FDM is likely the best initial fit for use in the non-clinical healthcare setting, as it has a simplified workflow process and does not require extensive safety accommodations. However, every program is different in needs and accommodations, so it is helpful to know if your hospital program has alternative locations/workshops/etc - potentially opening the door to the variety of 3D printing technologies available.

Models/Scans as PHI

(This section will be a general rule of thumb, please remember to always check with your specific hospital's guidelines and rules for topics on PHI/HIPAA)

PHI concerns primarily come in the following form:

3D Scans

The primary concern with scans regards the act of photographing and converting 2D images of the patient (whether it be partial body, full body, with/without family members, etc) into 3D renders. From facial scans to fingerprints, there are many identifiable features that may or may not fall under PHI/HIPAA concerns.

Printing Patient Data

Many programs display the 3D printer and ongoing printing process to patients, families, and guests. When printing personalized data/models (e.g., patient scans, bereavement/legacy items, etc) please keep in my who may be able to see the end product.

Storage of Patient Data

The largest concern lies in how data is stored, what is stored, and who has access to it. Metadata used to label the 3D model/file should always be anonymized (e.g., patient name, date of birth, etc). Other considerations, many 3D printing slicers, programs, and companies are moving to a cloud storage solution, which increases the security risk for data leaks and the need for the cloud service providers on behalf of healthcare providers to ensure confidentiality, integrity, and availability of PHI stored. For more information on HIPAA cloud-computing and general HIPAA security guidance.

While many hospitals have various operating procedures and standards, consent forms are always a safe step in ensuring and protecting staff and the hospital in a similar capacity as to when photography and videography is used.

[Consents needed? File labels? Cloud usage?]

Recommended Uses

Normalization/Play

A 3D printer can simply be a fun way to engage and play with a patient while they are hospitalized. The "wow" factor is typically enough to ice break most interactions and there are numerous fun and free models available on the internet to print favorite characters, and fun fidgets. It is also can be a great expression tool where a patient can create a 3D model in Tinkercad or in a VR sculpting program and then have the physical end product. This can be great for extended admissions or "frequent fliers" to have long term projects to work on while hospitalized. Patients and families will often come up with fun and unique ideas once they wrap their head around what a 3D printer can do, so ask away! Below are some examples shared by numerous programs:

• A 3D scan of a siblings face was added to a generic game piece and used in numerous games the patient and sibling would play over video chat.
• A patient explored options for IV line management, as they were often frustrated as things would get tangled and independently found carabiner clip models to print.

Medical Play/Education

Medical play and education is large aspect of how a Child Life Specialists can help a patient and their family cope with being in the healthcare environment. Utilization of real medical materials is particularly helpful as it gives a concrete experience for the child and allows them to explore what actually be used for their care, thus making it less surprising/scary. However medical items are typically expensive and unique items such as trachs or g-tubes are in limited supply for teaching and typically the patient is not able to keep said item after an education session. Using 3D printing, models of these items can be printed to real life specs and used in sessions with patients who in turn can keep them at bedside to continue medical play even after the CCLS has left the room. Models can also be scaled up to explore aspects in greater details or scaled down to fit teddy bears or medical dolls. While the exact textures and colors may be different then the real models, 3D printed models will still provide a positive impact. Meet with your child life team to explore what items would be most utilized and explore modeling the item yourself or use program curated collections list below.

• Models created at Ann and Robert H Lurie Children's Hospital of Chicago
• Models created at Riley Hospital for Children

Adaptive Equipment

Adaptive equipment is often expensive and at time difficult to obtain in the health care setting. While some devices are complex and tailored to the individually, others can be fairly simplistic and universal. 3D printing allows a quick/cheap resource for patients and can help them participate in other distracting/normalizing activities while hospitalized. These devices may be only needed temporarily if a patient is simply weak from treatment/recovery or preeminent due to a diagnosis or injury. It will likely be beneficial to consult your child life, rehabilitation, or orthotics teams to explore current needs/deficits. That being said simple tools like grips can be helpful in art or music therapy sessions and there are numerous options that can be utilized with gaming and other tech that would be utilized gaming focused bedside sessions. Here are a few models or curated collections that may be helpful.

• Models created at Ann and Robert H Lurie Children's Hospital of Chicago
• Models created at Riley Hospital for Children

Legacy/Bereavement Items

3D printing can provide unique and powerful keepsakes in memory making for a family. This is a difficult and nuanced experience which often has social workers, Chaplins, or child life specialists being the main emotional support during these experiences. Touching with these teams or your hospital palliative care department is a good first step to explore how 3D printing can help during the experiences. From there it is important to establish a referral system, realistic time lines, and print limits for this process to be sustainable. Often one may be tempted to be over accommodating due to weight of these interactions, but having clearly defined and upheld limits is important. We have listed some common model type/techniques that programs use in Legacy Building/Bereavement referrals.

Policies & Procedures

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Models of Printers

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Makerbot Method

Brand: Makerbot

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Ultimaker S5

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Dremel DigiLab 3D45

Brand: Dremel

Current Programs Using: Hassenfeld Children's Hospital at NYU Langone

Build Volume: 255 x 155 x 170 mm (10 x 6 x 6.7 in)

Features: Enclosed, heated glass bed, direct drive extruder, bed leveling, filament detection sensor, touch screen UI

Limitations: Proprietary filament (0.5kg and adapter needed for other filament), nozzle tolerance is peculiar

Default Slicer: Cura

Cost: $2,000 (May 2023)

Designed for Consumers

Flash Forge Adventurer 4

Adventurer 4

Brand: Flashforge

Current Programs Using: Ann & Robert H Lurie Children's Hospital of Chicago

Build Volume: 220 x 220 x 250 mm (8.7 x 7.9 x 9.8 in)

Features: Enclosed, heated bed, quick swap nozzles, flexible/removable build plate, build-in camera, filament detection sensor, touch screen UI

Limitations: Proprietary nozzles, misleading bed leveling (uses average based on 9 points, not mesh), limit opportunities for user mods/adjustments

Default Slicer: FlashPrint

Cost: $700 (March 2023)

Creality Ender 3

Ender 3 Pro

Brand: Creality

Current Programs Using: Riley Hospital for Children

Build Volume: 220 x 220 x 250 mm (8.7 x 7.9 x 9.8 in)

Features: open frame, heated & removable build plate, fast, customizable, open source, well documented, pretty big build area

Limitations: some assembly required, manual bed leveling, exposed print area

Default Slicer: Prusa Slicer

Cost: <$200 (March 2023)

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Prusa MK3S+ (template)

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Flashforge Creator Pro 2

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Bambu Labs Carbon X1

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Slicers

Slicers are programs that take 3D models and "slice" them into horizontal layers for the 3D printer to print. This is also where you will be adjusting layer height (affects detail/time of print), supports (needed to print overhangs), print speed/temperature (slight adjustments needed depending on the filament being used), and other settings. Most printers have a default slicer but some are better supported and most can be used with any printer.

Cura

The default slicer for the UltiMaker devices, but the arguable favorite in the 3D printing community. Actively being developed with updates coming out several times a year, often with industry changing advancements. Can be a bit more complex in advance settings, but nothing that isn't learnable through watching a few YouTube videos. Also has an option for community add-ons which offer several quality of life improvements.

FlashPrint

The default slicer for the Flashforge devices. Works well with these devices and can be used with other brands of printers, but nothing flashy or special that puts it above other slicers.

Modeling Software

To edit or clean up 3D models, there are several different programs one can use. Each has different levels of complexity and limitations.

Tinkercad

A web based design program that allows the user to create 3D models using predefined shapes. Shape dimensions can be modified free hand or inputting precise measurements. Users combine normal and "ghost" shapes to delete portions of objects. While it will load already created STL files, it does have a set limit on file size/triangle account. This is a great introduction into 3D modeling and a good resource to introduce to a patient to create their own project.

Blender

A free program revolving around 3D modeling and animation. A bit more in depth then other software, requiring time spend watching tutorials or simply messing around to get a feel for the process. Users can modify models on the mesh level by adjust vectors and face or use the sculpting mode for a more artistic approach. Will load most complex STL files and is a great way to combine two models into one (e.g. a lithophane and a stand).

Fusion360

Fusion 360 is a cloud-based 3D CAD program that utilizes the cloud storage for easier use in collaboration on complex projects. Another advantage of the cloud platform is that Fusion stores the entire history of the model including the changes to it. Numerous design options are available, including freeform, solid, and mesh modeling. The software is free for personal and noncommercial use, but has limitations on the number of projects stored on the cloud.

Meshmixer

While it is no longer being developed, Meshmixer provides straight forward and unique tools in editing mesh models including planner cuts, filling/hollowing models, and creating tubes. While likely not the first choice in creating models from scratch, these tools can be helpful in end stage processing.

Filament

Fused deposition modeling (FDM) printers use rolls of filament as their material source andare several different types that each have ideal usages, strengths, and limitations. Below are some of the most common types used, but advancements are made each year, so other unique products may be available/best fit for your needs.

PLA

PLA (Polylactic Acid) is the most common 3D printing material because it is easy to use and is made from renewable resources and thus, biodegradable. Some companies have PLA+ or Silk variants that mix additives into the base PLA to increase strength, smoothness, texture etc. This will often modify print temperature or other setting, so make note on what is listed on the package.

Typical Temp Range: 205±15 °C

Heated Bed: Not Required

Ventilation: Not Required

Pros: most cost effective, easiest materiel to work with

Cons: not super strong, can warp in high heat, degrades with UV exposure over time

ABS

ABS (Acrylonitrile Butadiene Styrene) is another commonly used 3D printer material. Best used for making durable parts that need to withstand higher temperatures.

Typical Temp Range: 230±10 °C

Heated Bed: 90±10 °C

Ventilation: Likely, fumes aren't toxic but do smell

Pros: strong heat/UV resistant prints, can be post process with acetone for a glossy finish

Cons: prone to warping so may require an enclosure, stinky fumes

PET (PETG)

PET (Polyethylene terephthalate) is almost a combination of the ease of use of PLA with the durability of ABS.

Typical Temp Range: 245±10 °C

Heated Bed: Not required

Ventilation: Not required

Pros: stronger then PLA, barley warps, no odor, more transparent then other materials,

Cons: harder to clean during post-processing, can get stuck to print bed, very hygroscopic so requires a dry box for storage or drying before use

TPU

TPU (Thermoplastic Polyurethane) is an elastic, oil/grease resistant, and abrasion-resistant material with a shore hardness of 95A. This materials is great for grips, cases, and other item that require more flexibility

Typical Temp Range: 220±10 °C (can depend on brand)

Heated Bed: 40±10 °C

Ventilation: Not required

Pros: elastic/soft material, low warp-age/shrinkage,

Cons: difficult to print, prone to clogging particularly with systems using a bowden extruder, difficult to post-process especially support removal, hygroscopic so requires a dry box for storage or drying before use

ASA

Acrylonitrile styrene acrylate (ASA) was developed as an alternative to ABS. With a number of additional features, like improved weather resistance and resistance to yellowing from UVs, making it an excellent choice for parts or prints meant for outdoor use.

Typical Temp Range: 250±10 °C

Heated Bed: 90±10 °C

Ventilation: Likely, fumes aren't toxic but do smell (less then ABS)

Pros: strong heat/UV resistant prints, post processed with acetone,

Cons: prone to warping so may require an enclosure, stinky fumes, hygroscopic so requires a dry box for storage or drying before use

Compatible Accessories

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Adaptive & Inclusive options

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Additional Resources

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