The Virtual Difference
Written by Regina Kerrigan
MMT 2010 Volume: 14 Issue: 1 (February)
Clinicians are using virtual reality software
for a variety of applications, including training
medics and emergency room personnel
and speeding patient recovery.
This experience makes for a safer environment for patients, even when their doctors and medics are rookies.
“Medication errors remain a serious issue for health care personnel, including military medics. Often, medication is being administered far forward in the battlefield under extreme duress,” said Laura Lovejoy, eLearning specialist for Medical Education Technologies Inc. (METI), based in Sarasota, Fla. Teaching trainees to correctly administer the right medication in the right amount at the right time, according to Lovejoy, is METI’s eDose.
The product is a Web-based learning tool designed to help health care students and professionals strengthen their drug dose calculation skills. According to the company, six different learning modules re-create a real-world clinical environment to allow trainees to develop their skills in areas such as medication dosages and IV infusion rates. Learners using eDose can also develop skills related to medication orders, medication administration vehicles, mathematical calculations and conversion of units.
Lovejoy said that eDose is fully narrated but that the learning solution does not stand alone as a replacement of traditional learning. Self-directed and instructor-directed evaluation and remediation are supported through built-in diagnostic practice assessments that use authentic representations of the medication to be administered. Individuals may practice at their own pace but don’t miss out on the assessment and evaluation that traditional learning offers.
“For example,” Lovejoy said, “to answer an injection dosage calculation question, a learner would choose an appropriate syringe and draw up the amount of medication to be administered.”
THE REAL WORLD
Virtual reality technology is not simply helping medical professionals prepare for their duties by allowing them to develop necessary cognitive skills. Today the medical field is witnessing the use of virtual reality to actually facilitate treatment of patients. BodyViz, a recent startup company based in Iowa State University Research Park in Ames, Iowa, developed software that allows surgeons and other medical personnel to view a patient’s MRI or CT scan data in 3-D images. The benefits of viewing 3-D images as opposed to the traditional 2-D images lead to saved time and saved money, and most importantly, more effective and efficient care for patients.
According to the company, pre-surgery planning customarily takes an hour, but with BodyViz software, that time can be cut down to four minutes. This means less time that patients are under anesthesia while their surgeons determine the best plan for surgery. In mid-2009, BodyViz introduced the use of an Xbox controller to its user interface. The controller further simplifies “creat[ing] ‘clipping’ planes and insert[ing] virtual surgical tools that can be maneuvered around internal structures of the anatomy in all directions,” according to the company.
The ability to view a patient’s anatomy is helpful for surgical purposes along with treatment purposes. Oncologists can use the software to see in detail a tumor and surrounding organs. With this detailed look inside the patient, there is less guesswork in the treatment plan.
With the concept still new, the BodyViz software has just begun to penetrate real-world medical settings. The Methodist Hospital in Houston, for example, is using BodyViz along with the company’s 16-by-9-foot silver screen.
The company stresses BodyViz’s affordability and ease of use. The software would be as mobile as a laptop, with the software designed to run on laptops and personal computers. How might this translate to a military setting? Portability is key for military deployment. With the system already extremely mobile, money could be saved in transportation, allowing deployed surgeons to use the software and provde better care for wounded servicemembers.
Organizations already offering virtual reality applications for training military medics include the Virtual Reality Medical Center (VRMC), based in San Diego with other locations in Los Angeles and Orlando. According to VRMC, one program that is being considered for implementation at the U.S. Army Medical Department Center and School at Fort Sam Houston, Texas, is virtual reality video gaming for combat medic training. The company said that during interaction with these “games,” medics’ knowledge and skills related to treating combat-related injury are tested. With the ability to retry the simulations, medics can learn from any mistakes until they complete the task satisfactorily.
Dr. Mark Wiederhold, president of VRMC, said there are two ways in which virtual reality can better prepare the combat medic. “The first part is recognition of injury and using appropriate skills for treatment. There is a cognitive aspect of identifying the type of injury,” he said. Medics who use virtual reality for training are also better prepared to perform the right set of steps in treatment, he said.
“The second advantage of virtual reality is that it psychologically prepares medics for what they’re going to be seeing,” Wiederhold said. “We use stress inoculation training, or stress hardening, to make training as realistic as possible.” Wiederhold said that feedback is positive regarding the realism of the training.
VIRTUAL REHABILITATION
VRMC is also using virtual reality to assist patients being treated for post-traumatic stress disorder (PTSD) and traumatic brain injury.
In virtual reality treatment system that VRMC developed for PTSD in Iraq under the Office of Naval Research, the system gradually introduces distressing stimuli while still allowing the patient to practice such skills as regulating breathing. VRMC said that after enough treatment sessions, a patient’s distress will be relieved or eliminated when exposed to the distressing stimuli.
Wiederhold said the system has been used successfully for over one year, and there is also a system in South Poland being used by Polish troops. He also said VRMC facilitates rehab in about 15 veterans hospitals.
“The system is completely ruggedized and mobile, and fits entirely in one case,” he said, so that treatment for PTSD can begin during deployment. These methods are relatively new, but “for PTSD [the use of virtual reality] is becoming more mainstream,” Wiederhold said.
At Walter Reed Army Medical Center (WRAMC) in Bethesda, Md., the Computer Assisted Rehabilitation Environment (CAREN) Laboratory has been assisting combat-wounded servicemembers since September 2007. Sarah Kruger, biomedical engineer/WRAMC CAREN operator, said that from the time of its installation to December 2009, CAREN assisted 235 wounded warriors with varying injuries: amputations; brain injuries (traumatic, anoxic, stroke, etc.); visual deficits; orthopedic injuries; neurological disorders; vestibular deficits; conversion disorder; PTSD; and general pain and weakness.
The CAREN system is a six degree-offreedom motion platform that contains an instrumented treadmill and synchronizes in real time with a virtual environment projected onto a large, 120-degree curved screen. Patient motions are captured using a 14-camera motion capture system by tracking the movement of reflective markers placed on specific anatomical positions.
Kruger said many patients using the walking applications of the CAREN report “improved balance and confidence in everyday walking activities” like hills and slanted sidewalks.
The system was developed by Motek Medical, a company based in Amsterdam. Motek also developed the first three applications that WRAMC used when the CAREN was installed, but WRAMC has since developed over 50 of its own unique graphics and CAREN environments to best suit the needs of its patients.
Erwin Albers, manager of customer support and services for Motek Medical, said, “The clinician or therapist decides what the game should look like, what the clinical task is and what the user experience should be.”
What are the biggest benefits of CAREN? Kruger said the repetition of applications in the CAREN allows patients essentially to train for activities they may not be ready for in the real world. With complete control over the exercise, operators can make “subtle changes” to gradually increase difficulty. And Kruger routinely sees patients pushing themselves to move up to higher levels of difficulty.
“Our patients want to get better and are vocal about changes we can make to the virtual environments in order to challenge them more. While the CAREN can be viewed as a more game-like approach to rehabilitation, each application has a therapeutic benefit,” Kruger said.
Because the CAREN displays and records times, scores, speeds and other result data, patients see a tangible level of progress that they find themselves wanting to beat again and again. The values allow the patients and therapists to see progression from one session to the next.
“These values also act as motivators,” Kruger said. “Our patient population constantly wants to improve and push themselves to beat previous times and scores.”
Albers said that immersion in a virtual environment creates a kind of positive experience that fully distracts the patient from the actual rehabilitation.
“The patient experiences this as a game whereas the game is based on therapeutic principles,” he said. “You can not only challenge the patient better, you can also distract them from their fears and pain.” Patients at WRAMC are not the only servicemembers taking advantage of the benefits that CAREN can offer. The first facility in the United States to install the CAREN was the Center for the Intrepid near Brooke Army Medical Center in San Antonio in January 2007. The most recent facility in the United States to install the CAREN was the Naval Health Research Center in San Diego. Albers said that 10 other CAREN systems have been installed throughout the rest of the world, including the Netherlands, Canada, the United Kingdom, Israel and Singapore. He added that seven more have already placed orders for the system for next year, with four of those in the United States: the National Intrepid Center of Excellence in Bethesda, two at Ottawa University in Ottawa, Kan., and another system for WRAMC in Bethesda.
As far as the future goes for the CAREN, it is apparent that many more facilities will show interest in installing their own systems. The CAREN may even one day be used to measure the severity of and treat PTSD.
“Next to rehabilitation of motor skills, we’re currently investigating if we can use the software for measuring and treatment of PTSD,” Albers said. “This is a development we’ll be doing in close cooperation with experts in the field. Based on their guidelines, we can develop applications for them. However, this is just in the initial phase.”
BETTER PATIENT CARE
With all of the benefits of using virtual reality applications for military medical training and military-related rehabilitation, it could be easy to forget about the benefits to taxpayer dollars and defense budgets. When virtual reality is used for training, for example, these resources are used and reused, and more funds are not wasted on new training tools. Virtual reality applications that can run on PCs and require little extra hardware are especially affordable.
Regardless of the extra monetary benefit, however, the most important advantage remains a better end result: improved medic preparation and more effective patient care. Walter Reed’s Kruger pointed out that virtual reality “allows for the incorporation of visual and auditory feedback, which can promote motivation and in turn improve compliance and performance.” ♦