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A lifesaving role for virtual reality

Department of Defense photo by Tech. Sgt. Cherie A. Thurlby, U.S. Air Force

How well can simulation training prepare combat medics for the real thing? U of M leads the team that will find out

By Dan Haugen


At Fort Sam Houston in San Antonio, Texas, the Army trains about 7,000 combat medics each year. Most arrive with no medical experience whatsoever. They’re usually in their early 20s with maybe a high school degree or some college under their belt. By the time they leave just 16 weeks later, they’ll be trusted to take on one of the most stressful and important jobs on the battlefield.

Good training pays off in lives saved — and more than 90 percent of troops wounded in action do survive. But is combat medic training the best it can be? To find out, the Department of Defense has awarded an $11 million grant to the University of Minnesota Medical School to lead a consortium that will develop metrics to measure training effectiveness, identify gaps in simulation technology, and come up with the best methods for preparing our military’s first responders.

“I feel very patriotic about what we’re doing,” says the project’s principal investigator, Robert Sweet, M.D., an associate professor of urology and director of the University’s SimPORTAL.

Short for Simulation PeriOperative Resource for Training and Learning, SimPORTAL is the Medical School’s interactive training center where medical students and other trainees participate in situations brought vividly to life by virtual reality, simulation, and 3-D.

What started out as the pursuit of a major grant has turned into something more powerful, says Sweet, a world-renowned expert in medical simulation training. “It’s become more than just a research project. I really feel like we have the opportunity to make a substantial contribution to the future of our men and women in uniform and to the missions they serve.”

Judging preparedness

More than 45,000 service members have been wounded in action in Iraq and Afghanistan. For many troops, the first medical attention they receive in the critical moments following an injury comes from a combat medic. This “golden hour” is when most lives are saved, Sweet says.

At Fort Sam Houston, the medic training begins with a basic emergency medical technician course — the same one civilian first responders need to pass before becoming paramedics. Next, they move on to more specific battlefield first aid and trauma training.

It all culminates with a two-week simulation during which trainees perform tasks on mannequins while the sights and sounds of combat are re-created around them.

“Even though the mannequin never dies, we can still make it relatively nerve-racking,” says Don Parsons, the U.S. Army’s deputy director of combat medic training.

The experience serves as the last test of students’ skills — there is no formal final exam. That isn’t the case with some Special Forces, which require medic trainees to pass an evaluation at the end of their training.

The Army does not have a universal assessment tool to judge the preparedness of combat medic trainees. Part of the MEDSIM Combat Training Consortium’s mission is to develop one.

The three-year project has had Sweet and his team traveling to multiple military sites, including Fort Sam Houston and Special Forces locations, to observe training and interview leaders about the essential skills a combat medic requires. They’ve gathered existing assessment tools, both military and civilian, and they’ll use this information to develop a single test for the military to use across all service branches.

Robert Sweet, M.D., and Troy Reihsen are two members of a University team leading a national consortium that's evaluating simulation training for combat medics. Also on the team are coinvestigators Greg Beilman, M.D., Jeffrey Chipman, M.D., Joseph Clinton, M.D., François Sainfort, Ph.D., Connie C. Schmitz, Ph.D., and Julie Jacko, Ph.D. (Photo: Scott Streble)

From CPR dolls to virtual reality

Medical simulation has come a long way since the days of Resusci Anne. Today’s simulation mannequins might resemble yesterday’s CPR dolls, but that resemblance is only skin deep. The insides of modern simulators are packed with sensors and electronics that let them be programmed for and respond to a variety of situations.

Sweet’s medical simulation career started around the time technology was beginning to reinvent the field. He first became interested while completing his residency at the University of Washington in the late ’90s. He was watching a faculty member demonstrate a procedure in which he held a controller in one hand and viewed the tip of the tool through a video monitor.

“It just sort of clicked,” says Sweet: This wasn’t all that different from the video games he had played as a kid.

As part of his lab project, Sweet proposed building a virtual-reality video game for training prostate surgeons. He convinced his chairman of the merits and then not only found funding to build the tool, but also successfully spun it into a commercial product. Sweet stayed in Seattle to help cofound Washington’s simulation center before being recruited back home to the Twin Cities in 2005 to start a program in Minnesota.

Just two years later, the SimPORTAL program had already received level-1 accreditation from the American College of Surgeons, putting it in an elite class. Since then, the program has hired directors and researchers, developed training and curriculum, and pulled in federal research grants.

Medical simulation is still an emerging field with relatively few sources of research grants. The U.S. Department of Health and Human Services has funded some projects, but the biggest source of dollars by far has been the U.S. Department of Defense. “DoD gets it, and they have for years,” says Sweet. DoD has either funded or developed the majority of medical simulation products currently in use. And so building a premier medical simulation center practically depends on winning work from and partnering with the military.

The University of Minnesota-led consortium beat out bids from strong teams across the country to win the $11 million grant — the military’s largest-ever award for training effectiveness and medical simulation research.

“It’s a really great statement about what our school can do and how broadly recognized it is,” says Aaron Friedman, M.D., dean of the University’s Medical School and vice president for health sciences. “A grant like this allows us to not only be recognized for what we’ve done, but to continue to remain at the forefront of how this kind of technology and training can be used going forward.”

Showcasing strengths

The award is an endorsement of the University’s trauma research and medical simulation program, as well as its long history of training and innovation in critical and trauma care. Grant collaborators include University of Minnesota scientists Greg Beilman, M.D., and Richard Bianco, who have developed new therapies and tools for treating trauma and hemorrhagic shock.

“We’ve done trauma research for years. We’re very experienced at training people, whether it’s doctors or technicians, or in this case, medics,” says Bianco, director of experimental surgery at the University.

Another of the program’s assets is its director of operations, Troy Reihsen, First Sergeant Joint Force Headquarters with the Minnesota National Guard. Trained as a combat medic at Fort Sam Houston in 1991, he brings a unique perspective to the project.

“Currently, there is no tool out there that can [fully] prepare you for wounds seen on the battlefield,” says Reihsen, recalling his own combat experiences.

Achieving the realism necessary to properly train combat medics is SimPORTAL’s goal. Its DoD grant is focused solely on developing metrics to measure training effectiveness by examining the current curricula and evaluating existing simulation technology, but Sweet and his team are working on a variety of novel simulation tools through separate grants from other sources. The program has been developing a database of human tissue properties, which it’s using to create synthetic tissues that look and act like the real thing. It’s also developing iPad apps for teaching procedures, and it’s partnering with an Austin, Texas, company called Zebra Imaging on three-dimensional holograms. “It’s like an anatomical Star Wars,” Sweet explains.

The SimPORTAL team spent the fall and winter reviewing the literature, collecting information on current training programs, researching existing simulation tools, and designing an initial version of the assessment tool. It will spend the spring and summer refining that tool and testing the design of the training course in a half-year pilot study.

“Our facilities will simulate the sights, sounds, and smells of the battlefield, and our human factors team will be monitoring medics’ stress responses to the situation as they perform these lifesaving maneuvers,” says Sweet. “We want them to feel like it’s real so that they don’t freeze up the first time they have to perform these skills in combat.”

By the end of summer, the SimPORTAL team plans to have its new medic assessment tool validated and ready for use. The military will be able to incorporate the finished tool into combat medics’ final exams to measure skill acquisition. The tool will also be central to an 18-month comparative study that will begin in September. SimPORTAL staff will travel to Fort Sam Houston and compare the effectiveness of a training course based on simulation with other approaches.

The project’s final six months will be spent on data analysis, publication, and presentations.

Becoming a world leader

Sweet frequently hears comments from people who compare his field to the airline industry, which has used flight simulators for decades. “People say, ‘Why don’t you just do that for medicine?’” says Sweet.

The problem: a 747 is simple compared with the human body. We know exactly what an airplane is made from and how those parts and materials will react to any force they encounter in the air, says Sweet. Meanwhile, we still haven’t unlocked enough mysteries of our model of the human body to know precisely how any individual will respond to different procedures.

Simulation technology is evolving, but more funding would speed it up — which is what makes the Department of Defense grant so significant, positioning Minnesota to play a lead role in the field.

“We want Minnesota to be known as the place to come to for medical simulation,” says Sweet. “We won the biggest grant ever to study medical training effectiveness — a completely new approach to medical education. We’re at the right place at the right time. I feel like we’re ready to begin building the golden gate to a new era in simulation-based training in health care.”

Dan Haugen is a Minneapolis-based freelance journalist who writes about energy, business, and technology.

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