Expanding the Virtual EnvelopeExpanding Envelope

DOD MEDICAL COMMUNITY EYES VIRTUAL ENVIRONMENT FOR TRAINING AND HEALING.
 

The DoD uses a rich mix of virtual technologies to train its health care providers. More capable simulators and simulations allow the military medical community to learn and then improve its healing and treatment skills for an expanding array of routine and emergency procedures.

As this technology matures and becomes more affordable, the services expect to use the virtual environment to treat post traumatic stress disorder (PTSD) and other psychological trauma.

TRAINING IN REALISTIC ENVIRONMENTS

Medical simulators and devices allow the service man or woman to learn perishable skills and practice them until they are mastered without touching a real patient.

Jack Norfleet, lead science and technology manager, Medical Simulation Technologies, Research Development and Engineering Command-Simulation and Training Technology Center, provided insight on this capability. “For the pre-hospital caregiver, such as the medic or the combat lifesaver, simulation often provides the only patient contact he or she will receive prior to deployment,” he pointed out.

With simulation, medics also gain the opportunity to treat patients with the same types of severe injuries they may encounter in the contemporary operating environment. “By training in realistic environments with simulated patients, the caregiver hones his or her skills, but more importantly, gains the confidence that comes with encountering a difficult situation and handling it,” added Norfleet.

The services are building innovative products and applications to support medical training and education, including wireless simulation, devices which more accurately replicate body organs or systems, and training centers whose curricula combine virtual systems.

TWO SAMPLE PROGRAMS

Personnel simulators have been a foundation of medical provider training for decades. Recent developments in the standalone patient simulator (SAPS) will bolster the fidelity in these devices.

The SAPS is the first wireless, rugged, physiologically-based patient simulator, and was designed to address specific Army training requirements. The simulator “gives the Army a new capability to train patient care in realistic combat environments. With this capability, medics are trained to provide care in destroyed vehicles, buildings, and on the battlefield while operating as part of a combat team. For the first time, fully simulated patients with the capability of dying must be assessed, extricated and evacuated from the line of fire,” said Norfleet.

SAPS prototypes are currently undergoing user tests with the Army, Navy and Marine Corps. Funding is being sought for a rapid fielding of an initial capability at Army medical simulation training centers (MSTCs) in 2008, with the eventual replacement of all legacy MSTC-tethered simulators by 2012.

A second virtual application, the tactical combat casualty care (TC3) simulation, assists in teaching and refreshing those skills from the tactical combat casualty care-combat medic advanced skills training course.

TC3 is a computer-based training program that uses the Gamebryo engine to create an environment for practicing critical decision-making skills. “The simulation gives the trainee experience in handling single and multiple patients while operating as part of a combat team,” opined Norfleet.

The TC3 simulation was delivered to the Department of Combat Medic Training, Fort Sam Houston, Texas, in May 2007.

DoD is also seeking simulators that more accurately replicate the body’s systems and organs.

A SPECIALTY TRAINER

Ingmar Medical’s ASL 5000 adult and neonatal breathing simulator provides highfidelity lung simulation from basic skill training up through ventilator management training and disease state modeling.

The ASL 5000 meets the full spectrum of breathing simulation challenges, including apnea, snoring and active exhalation, and provides hands-on training for respiratory care providers.

The training package includes playback of actual patient recordings, and other components of an instrumentation package. A simulation editor and scripting interface permits the instructor to change parameters while the system is operating.

“We just received an order for six ASL 5000 units from the Army,” recalled Nick Coniglio, company spokesperson. “The Air Force has recently placed an order for 10 of our midrange lung simulators. Currently Lackland [Air Force Base] is previewing the ASL 5000 for use in research and training,” he added.

In addition to training, the ASL 5000 supports respiratory system research and development, quality control and testing applications.

The ASL 5000 is also interoperable with manikins. “What we do is take the trachea off the manikin head. The manikin lungs are usually just bags with little ability to simulate pulmonary dynamics. We hook up our servo lung and can create a customized high-fidelity lung that greatly augments the manikin’s capabilities,” explained Coniglio.

An expanded suite of virtual devices is also being sought for one service’s training centers.

PUTTING IT ALL TOGETHER

Eighteen Army MSTCs worldwide conduct classroom instruction to validate medical skills proficiency training based on new programs of instruction. “Medical simulation is integral in all of the training at the MSTCs,” noted the service’s Norfleet.

The stand-alone patient simulator discussed earlier is expected to be joined by other virtual trainers after it arrives in 2008.

Another representative MSTC program on the close-in horizon is the Severe Trauma Simulation (STS) Army Technology Objective. This research effort will increase the fidelity of wound simulations used for training. The program’s research is looking at new skin, tissue, blood, fluids, bone, smells and other attributes that more accurately simulate severe trauma. “The intent is to desensitize the medical providers so they can concentrate on the tasks at hand,” said Norfleet.

The STS project is expected to be delivered to the MSTCs starting in Fiscal Year 2009.

The MSTC program proponent is the Service’s Medical Command, with management provided by Program Executive Office for Simulation Training and Instrumentation. CTC is the MSTC prime contractor.

The virtual domain is also being examined as an enabler of other higher-order learning.

BUILDING HIGH-END SKILLS

The Office of Naval Research (ONR) has provided funding for Pulse!!, a research project at Texas A&M University-Corpus Christi, to show whether high-level medical clinical education can occur in a virtual environment.

Claudia L. Johnson, PhD, associate vice president for special projects, A&M-Corpus Christi is principal investigator for Pulse!!. Hunt Valley, Md.-based BreakAway Ltd. is producing the software as part of an international development team headquartered in an on-campus studio at A&M-Corpus Christi.

The first Pulse!! cases are set in a detailed, 3-D virtual replication of the intensive care unit at National Naval Medical Center Bethesda. Pulse!! users navigate an immersive, 360-degree environment, interacting with nurses, orderlies and complex virtual patient that responds to treatment in real time. The learning platform calls upon users to assume the role of primary physician in each of id Navy Commander Russell Shilling, Ph.D., Pulse!! program manager, ONR. “Our goal is developing critical decision making and clinical thinking skills, not procedure-related, handson tasks,” he added. Pulse!! also drives learners to show that they have mastered the diagnostic process by demonstrating critical thinking skills.

The full version of Pulse!! will provide feedback on users’ performance, not step-by-step as in most training simulators, but at the end of each case once a user’s treatment has produced an outcome. The platform’s automatic feedback enables training at remote locations, but it also may form the basis for debriefing by an attending physician. In this case, “a physician-instructor will sit down with the trainee and go through the responses step-bystep,” explained Shilling.

The Pulse!! development team is planning to establish evaluation and validity criteria with field tests at Yale University School of Medicine, the Johns Hopkins University School of Medicine, and the National Naval Medical Center, Bethesda. This multiple site testing also will address platform playability and usability.

Another of the program’s quantum leaps forward is its focus on simulating the entire body, which allows medical learners to conduct physical examinations in virtual space.

In a scenario demonstrated for MMT, the rigor and fidelity of the platform was evident as the user completed stethoscopic and ultrasonic diagnostic procedures while continuously checking a real-time monitor for vital signs. The demonstration also included a series of clinical procedures from increasing the oxygen flow through a ventilator and listening to thoracic sounds, to noting the patient’s physiological responses.

Authoring tools and other capabilities will allow future scenarios to be developed for combat corpsmen and other health care providers, and for cases beyond complex combat injuries.

Beyond Pulse!!, another opportunity awaits the promise of virtual reality (VR) as a tool to heal psychologically traumatized patients.

VR THERAPY FOR PTSD

The U.S. Veteran’s Administration recently reported that 39,243 veterans out of 686,000 who have served in Iraq or Afghanistan since 2002 have been diagnosed with PTSD. ONR is spearheading VR Iraq to build upon earlier efforts to use VR to treat chronic PTSD.

Since 2005, ONR has funded three separate studies looking at the usefulness of VR therapy scenarios for treating combatrelated PTSD or acute stress reaction. All three systems allow patients to use a head-mounted display to become fully immersed in a combat scenario. The therapist carefully controls what that patient sees, hears and even smells as he or she relives simulated combat in a low threat environment and faces psychological trauma. This step is often the stimulus for PTSD patients—who traditionally do not talk about or remember their trauma-inducing experience—to talk to the therapist.

“This is an extension of cognitive therapies, including cognitive behavioral therapy already in standard use by clinicians,” explained Shilling. He continued, “What this does is give the therapist a tool to carefully evoke sensitive memories that may be associated with psychological trauma. The therapist can place the patient in a generic city or roadside environment in Iraq and insert a rocket-propelled grenade detonation, a helicopter attack, or whatever is appropriate to occur in the environment while discussing the patient’s feelings and memories, and monitoring physiological responses to these stimuli.”

A prior study conducted in 1998 demonstrated this technique to be highly effective in Vietnam veterans who had not responded well to other types of therapies.

Current studies supported by VR Iraq include scenarios to treat warfighters exposed to the rigors of combat, as well as scenarios to treat psychological casualties among medics and corpsmen.

Like Pulse!!, VR Iraq relies heavily on game-based technologies. One of the tools being developed at University of Southern California’s Institute for Creative Technologies is using assets from the video game Full Spectrum Warrior. “But this is not a video game. This is a highly developed clinical tool that has to be used carefully,” emphasized Shilling.

Ongoing testing and validation of the VR Iraqi treatment is in progress at Naval Hospital San Diego, Marine Corps Base Camp Pendleton, and Tripler Army Medical Center, Hawaii.

Other project team members are Virtual Reality Medical Center, San Diego, University of Washington, Pacific Telehealth and Technology Hui, and Virtually Better, Decatur, Ga. ♦

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