Virtual Medical Simulation

In the hushed silence of the OR, broken only by a beeping monitor, an interventional cardiologist expertly inserts a pacemaker wire to the right ventricle of a patient’s heart as physicians, nurses, and medical students observe. Suddenly, the heart monitor screeches an alarm signaling that the patient’s heart is under stress; the physician has accidentally applied excessive pressure to the wire. But the cardiologist remains unconcerned.

The OR is actually a sophisticated computer simulator housed in an 80-foot truck, the MedtronicTherapy and Procedure Training Center Mobile Unit. Everything in the OR, from the monitor showing the patient’s vital signs to the screen displaying his open chest cavity, is a computergenerated image. For two days, more than 250 medical personnel experience high-tech virtual medical simulations on a variety of cardiovascular procedures as the Medtronic simulator sits in a central Florida retirement center’s parking lot. Then, the truck and its high-tech cargo rumble on to another destination filled with physicians participating in 21st-century medical training.

Hospitalists wanting interesting CME options, acquisition or retraining of skills associated with a procedure, or practice in teamwork and communication need look no further than the virtual world. They can check their alma maters, the nearest major hospital, or the Internet for convenient medical simulation centers off ering a safe environment in which to master medicine’s latest and greatest, virtually. They’ll participate in medical simulation—an IT marvel that uses computer-generated images, video cameras, models, and sensors—for practice in lifelike circumstances. Medical simulation allows learners to review and practice procedures and situations as often as required to reach profi ciency without involving live patients. Computer-based medical simulations, or virtual reality, enhance learning by utilizing visual, auditory, and haptic feedback that helps the learner feel that he or she is practicing medicine in real life.

Teaching medicine

For the majority of hospitalists who are board-certified in internal medicine, and the smaller contingents from pediatrics and family medicine, medical simulation has increasingly been incorporated into medical training. Ross Scalese, MD, FACP, director, Gordon Center for Research in Medical Education, University of Miami Miller School of Medicine, has seen a recent shift toward medical schools incorporating virtual simulation into physician training. For example, family medicine residents at the University of Kansas School of Medicine boost their skills and confidence in critical care and procedures through simulations in respiratory emergencies, management of shock, and advanced cardiac life support. Pediatricians who go on to be hospitalists now include medical simulation in their curricula.

The Cincinnati Children’s Hospital Medical Center’s Division of Emergency Medicine, for example, has residents use high-fidelity pediatric patient simulators to test their skills in administering medications and reactions to residents’ ministrations. “There is still too much variability in medicine. We need to reduce medical errors, and patients’ rights and safety shield them from some interaction with medical students. Virtual medical simulation (VMS) solves many of the medical educational issues that we face. True, the costs and the stakes are high for quality simulations, but simulation improves outcomes. Medical simulation is real, people are spending money on it and it is having a high level of impact on the practice of medicine,” says Scalese.

Scott & White Hospital/Texas A&M’s Clinical Simulation Center, a state of the art minihospital using high-fi delity human patient simulators, allows medical students, residents, and practicing physicians in internal medicine, family medicine, hospital and emergency medicine, and pediatrics to sharpen their skills in virtual reality. They can chose from off erings such as OB/GYN simulation workshops in family medicine, internal medicine clerkship and residency simulations, and emergency medicine residency simulations.

Simulation requires a mind-boggling change in mindset and practice for medical educators and students, both new and those receiving additional training. For centuries, medical students have been apprentices to senior physicians. For centuries, “Do one, see one, teach one” has epitomized the predominant medical school teaching style. The doctor initiates used lab animals, cadavers, and real patients to practice, and hopefully, to attain skill mastery as demonstrated by their teachers. But animal anatomy is problematic, cadavers don’t answer questions, and today’s patients are shielded from medical students by copious regulations.

All three traditional learning modalities present ethical, cost, and practical barriers to eff ective learning. VMS, on the other hand, facilitates training by providing easily modifi able, life-like settings in which the learner can use time, repetition, and feedback to improve skills.

The multi-million-dollar question is whether advocates of simulation can document improvement in skills. Several scientifi c studies have compared medical simulation positively with traditional training. Neal Seymour, MD and Anthony Gallagher, PhD, performed a prospective, randomized, blinded study on the skills of 16 surgical residents on laparoscopic cholecystectomy. They concluded that VR-trained residents worked 29% faster on gallbladder dissection and were six times less likely to make errors such as injuring the gallbladder or burning the non-targeted area as traditionally trained residents. A study by Grancharov showed similar results; surgeons with simulator training made signifi cantly fewer errors, worked faster, and displayed greater economy of movement. Further signaling the acceptance of virtual medical simulation, in 2007 the Society of American Gastrointestinal Endoscopic Surgeons established profi ciency levels for laparoscopic surgeons using the Minimally Invasive Surgical Trainer-Virtual Reality System.

Virtual platforms

Like their brick and mortar counterparts, virtual medical environments rest on foundations. In the latter’s case, the foundation exists in cyber-space, as do the doctors and nurses that populate them. The Second Life Grid, for one, is a popular, open-source, fl exible platform for educators around the world using distance learning, computer-supported cooperative work, and simulation. Medical educators have embraced it for its low cost, adaptability, data storage capability, teaching tools, and video game-like simulations.

John Miller, RN, a nurse educator for 32 years, uses Second Life for distance learning nursing instruction at Tacoma Community College. A recent video shows an emergency room with a patient undergoing a massive heart attack, beeping monitors, an oxygen canister that needed to be replaced, and other real-life events calling for a nurse’s or doctor’s attention. Each student is an avatar (a person in virtual reality) in the virtual ER. “It appears as a game, but it isn’t. I can program variables so the scenario is interactive. I test my students’ collaboration and teamwork to observe how they react in emergency situations,” he says. He enjoys giving students something beyond lectures and textbooks, balancing online and classroom learning.

In the classroom, Miller’s students use mannequins with prepackaged simulations. “Mannequins are great for high acuity, low frequency events, such as massive MIs or a pulmonary embolism,” he says. He has also programmed a pneumothorax, a grand mal seizure, and a crash cart with paddles that records students’ responses. Second Life is also a first choice for virtual hospitals, places where health professionals, citizens, vendors, politicians, and deep-pocketed donors can visit years before the actual hospital is built. Palomar Pomerado Health’snew hospital in San Diego won’t be completed until 2011, but the hospital, partnering with Cisco, allows stakeholders to kick the tires right now. For example, an avatar exploring Palomar Pomerado can wear a bracelet with embedded sensors that monitor his movements, guiding him to the fl oor that houses the treatment area he needs.

Where medicine meets games

Virtually all medical simulation product champions bemoan the lack of funding for their pet projects. Most piggyback on their universities’ computer facilities and scrounge for charitable and government grants. But the mother lode for augmenting medicine simulation’s puny funding pool—only $105 million in 2007 according to Advanced Initiatives in Medical Simulation—is the video game industry. The $18 billion video game industry is helping fledging medical virtual reality. Innovators around the country—from anesthesiologist John Willis, MD, at the University of New Mexico, to vascular surgeon Mark Obrellaro, MD, of Bellevue, WA, and nurse Claudia Johnson, PhD, at Texas A&M Corpus Christi—are partnering with video game fi rms and other funding sources to produce quick-moving, tension-producing medical simulation games.

At Duke University, Jeffrey Taekman, MD, Director of the Human Simulation and Patient Safety Center, puts physicians in training, including fourth-year anesthesiology residents, in simulated emergency situations using a prototype video game. He can raise or lower a virtual patient’s blood pressure or cardiac oxygen saturation level, seeing how his residents respond to adverse sentinel events. The game’s fast pace throws doctors in training into real-life adrenaline-pumping situations.

That exposure, says Taekman, helps with the 70% of emergencies that head south because of botched teamwork or communication and clinical mistakes. Texas A&M health professionals have teamed up with BreakAway, a game startup company in Hunt Valley, MD, and the Office of Naval Research on a $12 million video game platform called Pulse!!

In recent field testing, Pulse!!’s immersive, three-dimensional experiential environment proved satisfactory in sharpening diff erential diagnostic thinking and clinical skills in 82% of end users.

Looking ahead

In short, virtual reality medical simulation is a force to be reckoned with. Today. Problems with access to live patients, animals, and cadavers, coupled with emphasis on patient safety and outcomes-based medicine, enhance medical simulation’s appeal. As more specialty and sub-specialty boards follow SAGES’ lead by including VR benchmarks into the physician certifi cation process, hospitalists will become as comfortable with avatars as with live patients.

Marlene Piturro, PhD, MBA, is a freelance medical writer.