Report of an Integrated Research
On 16-18 February 2000, the Telemedicine and Advanced Technology Research Center (TATRC) convened an Integrated Research Team (IRT) meeting for Medical Modeling and Simulation (MM&S), co-hosted by the U.S. Army Medical Research and Materiel Command (USAMRMC) and the U.S. Army Simulation, Training and Instrumentation Command (USASTRICOM). Given the complexity of the issues, TATRC chose to use the IRT process as a forum to build a series of technology road maps in this ever-burgeoning field. The conference outline was designed to enable materiel developers, combat developers and other government agencies to present their concepts about how modeling and simulation could - and should - be developed to meet military needs. From the outset, the participants recognized that MM&S would have a much wider application than the original intent to develop a training tool for medical readiness. It is inevitable that MM&S will provide a basis for training and education across the entire spectrum of future health care.
The program began with a vision statement from the Commanding General of MRMC, who outlined current deficiencies in military medical readiness training: an inability to train in peace for the needs of war; unique elements of combat medicine; the size of the force to be trained; and the eclectic nature of the force. Following the General's introductory comments, several speakers expanded the discussion of training inhibitors and recognized that the current use of animals to provide training was problematic and may be severely curtailed in the future. They contended that the efforts of the clinical community to provide alternative training in civilian trauma centers and pre-hospital EMS systems across the nation would prove inadequate to meet the demands of military medical readiness.
Representatives from government, academia and industry expressed the need for simulation training from their own vantage point. Military and federal agencies currently using Commercial Off-the-Shelf (COTS) simulators in medical readiness training gave their views of the value of simulation in training and their future needs. TATRC-funded investigators provided details of their ongoing research and highlighted emerging and inchoate science. In addition, a number of researchers not funded by TATRC but identified as on the leading edge of simulation modeling science were invited to present the latest work in their respective domains.
The conference culminated in an engagement of key stakeholders in the contemporary MM&S world who converted enlightened self-interests into agreement on conclusions and recommendations to the Commanding General, MRMC, as a basis for the development of a MM&S technology road map.
last updated on: February 26, 2001
The US military has
taken the first deliberate steps to launch simulation as the core of future
combat medical training. A Joint Trauma Training Center has been established
at the Ben Taub Hospital, Houston Texas. The Center capitalizes on the
extensive experience of the hospital staff and the high levels of trauma
typical in a major city and its environs to train military field surgical
teams prior to operational deployment. To meet this aim, the training staff
uses a combination of simulator training and "hands-on" real trauma
cases. A nascent simulation center is being developed on site, using a range
of simulators from existing Commercial Off The Shelf (COTS) technology.
Concurrently, the National Capital Area Medical Simulation Center has been
established under the aegis of the Uniformed Services University of Health
Sciences (USUHS) at the Forest Glen Annex of the Walter Reed Army Medical
Center. A number of other simulation centers are being developed, most
notably at the Army Medical Department (AMEDD) Center and School, San
Antonio, Texas and the Special Operations Medical Academy in Fort Bragg,
North Carolina. One of the first medical simulation centers, developed by the
Army National Guard at Fort Indiantown Gap Pennsylvania, has made great
inroads in training using a digitally enhanced mannequin simulator.
Each reported its experience with simulator trainers, evaluated their effectiveness, detailed their perceived advantages and disadvantages, and identified the need for specific improvements. Overall, the end users commonly agreed that simulator trainers are a vital and urgently needed tool. The aim should be to use simulators in place of animals for basic skills training and to use simulators to teach and hone other skills that are currently gained by practice on human patients. The end-user community also recognized that the current range of COTS simulators needs rigorous performance assessment, both to identify the skills and procedures most benefited by simulation and to provide a requirements basis for further research and development. The user community stated clearly that while they recognized the need for investment into the development of futuristic simulation envisaged as Total Immersion Virtual Reality (TIVR), they also needed enhanced versions of the current COTS range to meet today's needs. The consensus was a twin-track approach involving the purchase of current simulators and incremental enhancements to them while at the same time identifying and investing in the long-term strategy for TIVR. The key criteria for the current COTS technology were and would remain cost, ruggedness and logistic support. The user community made an urgent case for expanding the role of simulators to improve initial and sustainment training of far-forward care providers. The trainers of these combat medics felt that simulation training was needed to support the intense and time-critical demanding learning of combat trauma skills.
The trainers assessed current versions of computer-based training programs as needing more accurate portrayal of medical conditions, outcome-oriented feedback from intervention measures, and greater realism in scenarios. Similarly, improvements were recommended for digitized mannequins, including better assessment tools, such as pulse differentiation, skin color changes, temperature differentiation and representations of bodily fluids.
End users tended to regard virtual-reality type training simulators as being more relevant to trauma care at areas behind the combat zone. There was consensus that the IRT should recommend continued research on virtual-reality type training simulators, but there was general acknowledgement that much work had yet to be done in the development of enabling technologies.
of Simulation Training
Area 1 - PC-Based
There are many of these systems already on the market and in wide use in
military medical training. They have much merit, particularly in learning and
rehearsing processes in clinical care. The costs of this technology make it
ideal for individual use. The major limitation it currently faces is the lack
of quality assurance, particularly in the verification of clinical
curriculums and program protocols.
Area 3 - Virtual Workbenches. The first steps in utilizing virtual reality for medical skills training have taken the form of so-called virtual workbenches. The technology and sophistication is growing rapidly. At one end of the scale are relatively simple, inexpensive but highly effective PC based systems that enable the teaching and practice of an array of clinical and diagnostic procedures such as catheterization and bronchoscopy. At the other end, there are complicated and expensive simulators that enable the user to practice complex laparoscopic surgery. The state of the art makes them ideal for practicing minimally invasive procedures, but the limitations in haptic feedback restrict their utility. Cost is dependent upon complexity.
Area 4 - Total Immersion Virtual Reality. The technological challenges to developing Total Immersion Virtual Reality are many and varied. However, without advances in true virtual reality it will not be possible to meet the demands of training for combat casualty care and other forms of clinical training will be severely limited. Among the challenges to overcome is complete haptic feedback that enables a user to "feel" a wound and for tissue to react to touch. The development of a virtual physiology to match the existing anatomy is also a great scientific test. Work is underway in all these areas but success will be contingent upon the level of investment in the future.
Each area had relative value in either availability or cost, and each required research investment to attain effectiveness. Deliberations produced the framework of a broad-based investment strategy - both near and far term - for MM&S research support. Similar discussion highlighted the need for a single entity to integrate the many and diverse research efforts related to MM&S.
Technology Currently Funded by DOD
Category 1 - PC-based Decision Teaching Tools. The Simulation Technologies for Advanced Trauma Care (STATCare) project, conducted by Research Triangle Institute, Research Triangle Park, North Carolina, is a PC-based, interactive CD-ROM simulator system. The program focuses on skills required to assess multi-trauma incidents, to provide command and control and initial first aid. The objective is to practice rapid assessment decision-making skills. The system includes a variety of scenarios and a spectrum of the most commonly encountered trauma conditions. Each scenario requires response to both the overall scene and the physiological condition of the individual patients.
Category 2 - Digitally Enhanced Mannequins. The Combat Trauma Patient Simulator (CTPS) project, conducted by Medical Education Technologies Inc, Sarasota, Florida, consists of digitally enhanced mannequins that demonstrate signs and symptoms of injury and that react to clinical intervention.
Category 3 - Virtual Workbench Technology. The virtual workbench simulation technology is exemplified by the range of COTS simulators produced by HT Medical Systems Inc., Rockville, Maryland. They provide a high level of realism for training and practice of a number of minimally invasive procedures. The latest simulator, the virtual ureteroscope, was funded by TATRC.
Category 4 - Total
Immersion Virtual Reality. The Center for Integration of Medicine and Innovative Technology
(CIMIT) Boston, Massachusetts, has begun a series of research projects
designed to provide the enabling technologies for Total Immersion Virtual
The University of
Houston is using its experience in simulation research related to the space
program, to develop a test bed for so-called "checkpoint"
scenarios. This enables individual or team training in enriched environments
that provide " challenges to the training experience".
Ethereal Technologies, Ann Arbor, Michigan, is utilizing an image rendering system to develop a work station that displays in real time, in front of the observer, the ethereal model that the computer generated, which is in full color and which also has acoustic and haptics interface.
Virtual Presence LTD, Lynnfield, Massachusetts, is combining mathematical modeling and interactive computing to produce better minimally invasive therapies.