Perfecting patient care through virtual reality
It's late afternoon in a hospital trauma receiving room. Three young doctors-in-training talk with a patient as they prepare him for surgery. Stan D. Ardman, a 55-year-old truck driver, is complaining of chest pain following an accident. Suddenly, the monitors go wild — the patient's blood pressure falls precipitously as his heart begins beating erratically.
The young doctors snap into emergency mode. One takes charge, beginning chest compressions, shocking the patient with a defibrillator and instructing her impromptu team to inject epinephrine and deliver oxygen. Another team member documents each step in the resuscitation process.
The quick response and procedures are evidence of a well-trained team working together. The three physicians assessed the patient's condition, made critical medical decisions, and stabilized the patient — a life saved!
But nothing in this scenario was unexpected. In fact, it was all programmed into a computer. That's because “Stan,” also known as Standard Man, is a sophisticated instructional simulator used to provide training to health-care students and professionals.
Stan is one of several high-tech simulation systems and state-of-the-art training tools now being used at the Center for Virtual Care, a facility and program established by the UC Davis School of Medicine at its teaching hospital in Sacramento.
Simulation systems have come a long way since the introduction of rubbery mannequins upon which many people learned CPR. Like a real patient, Stan, can be injected with medication and have tubes inserted into his throat or abdomen to open up an airway or relieve fluid buildup. Developed by Florida-based Medical Education Technologies, Inc., the unit has a pulse, normal and abnormal breath and heart sounds, pupils that are sensitive to light, and an airway that swells when exposed to a medication to which he's programmed to be allergic.
Sophisticated programming allows students to practice a variety of medical situations in a supervised learning environment so that by the time they are assigned a real patient, they are more skilled, experienced and confident. In this way, students can safely learn to start an intravenous drip, inject medications, perform CPR and put in a catheter. They not only become proficient in airway management and respiratory therapy, they learn to work as a team, because knowing each person's role and responsibility in an emergency can be as crucial as choosing the right medication. Just like the real hospital, every medical outcome in the virtual center depends on a trainee's actions and decisions.
For example, Stan may suffer a heart attack or have a severe breathing problem. With a few adjustments and some computer keystrokes, Stan the mannequin can even be transformed into an expectant mom and experience labor difficulties. In addition, instructors can easily change a training situation in progress, pause the action to point out something that has just happened with the patient. and provide immediate guidance to trainees.
“The use of simulators in medical education is the equivalent of flight simulator training for pilots,” said Judith Hwang, an associate professor of anesthesiology who teaches classes at the center. “Students, as well as physicians, can benefit from simulation training regardless of their level of expertise. Simulators allow users to try new procedures, make errors and, more importantly, learn how to recover from them. Since their 'patients' are never at risk, trainees become more confident and more proficient in their skills.”
New way to learn
The UC Davis Center for Virtual Care is in the forefront of a national trend in medical education to supplement the traditional "see one, do one, teach one" approach. The old system of training doctors is now regarded as insufficient in a world of increasingly complex medical intervention and patient management. Peter Moore, chair of the Department of Anesthesiology and Pain Medicine, is medical director of the center and a longtime advocate of simulation training in medicine. He points out that the new technology is sophisticated enough to train health personnel of all levels, ensuring that all team members understand their roles and interact effectively.
“The use of simulators in medical education is the equivalent of flight simulator training for pilots.”
— Judith Hwang
"We can provide a realistic setting to develop critical thinking and practice a variety of techniques that play out in real time," Moore said. "This is of enormous benefit not only for students to learn new skills, but for more experienced professionals to perfect their roles as part of a smoothly running medical team.”
With four full-sized mannequins, which include an infant model, trainers can simulate a busy intensive care unit, multi-vehicle crash or terrorist attack to allow paramedics, nurses and physicians to practice their roles in tandem.
From aviation to medicine
David Dawson, an associate professor of vascular surgery, has had years of experience with simulators in other settings. Before coming to UC Davis, he served 10 years in the Air Force, including a stint as a senior NASA manager and aerospace medicine specialist at the Johnson Space Center in Houston. At NASA, he "flew” airplanes that developed engine fires and “landed” the space shuttle — on flight simulators, that is.
"Simulators mimic the entire airplane and create situations that a pilot may see only once in a lifetime," he said. "But traditionally, when a physician wants to learn new techniques or handle emergencies, the 'simulator' is the actual patient. There is no transition between 'read' and 'do.' Physicians learn through their experiences, but in clinical training we have very little control over what problems trainees get to see and manage."
Dawson also noted that the way doctors treat patients is changing, with some of the conventional tools for surgery giving way to high tech interventions that are almost like a video game.
“Doctors need to develop a new skill set that is image-driven, which is why we set up our virtual care center to offer a variety of training tools," he said.
Virtual heart catheterization
The risk-free environment of a simulator is ideal for learning such complex skills. Down the hall from Stan, a cardiac interventional team is practicing on "Simantha,” which was developed by the Medical Simulation Corp. of Denver.
The video game analogy is apt. This is virtual navigation through the heart! Just like in a real procedure, the cardiologist's hands are manipulating a catheter inserted in Simantha's leg; his feet are operating pedals that help deliver radiation and inject contrast dye, enabling him to better see blood flow. Of course, the real action is taking place in the mannequin's coronary arteries, so all eyes follow the monitor screen as the surgeon moves the catheter, inflates and deflates a balloon, and snaps a slender tube called a stent into place, relieving the blockage.
Similar to Stan, a variety of real-life scenarios are available to test student physician skills and produce certain outcomes depending on the user's choices. In this case, Simantha may have a variety of blockages in major arteries and other vascular problems. Advanced training can be set up to allow experienced surgeons to practice for situations where patients might have quirks in their blood vessels or unexpected reactions to a drug.
After completing a scenario, which includes the simulated patient's drug and radiation dosage levels, each trainee finds out how he or she handled their case compared to national guidelines and standards.
Robotic surgery simulator
Virtual navigation practice also gets a real workout in another room at the center, where a surgical robot is set up exclusively for training. This machine allows surgeons to develop and hone their skills at controlling robotic arms for incisions and suturing before taking that experience and ability into the operating room.
“You can't beat a surgical robot for accuracy,” said Will Fuller, a gastrointestinal surgeon at UC Davis. “But learning to manipulate robotic arms safely and efficiently really takes practice. Having this training unit available is a wonderful benefit for surgeons like myself who always are looking to acquire new skills or sharpen the ones they have.”
Physician trainers like Moore emphasize that simulation practice is meant only to supplement, not replace, traditional medical training. Simulation and mannequins offer unique opportunities to learn new skills in a controlled setting before going on to the care for patients in a medical environment. The Center for Virtual Care is one of only a handful of sites in the United States offering such a comprehensive array of virtual training experience for people working at all levels in medicine.
UC Davis officials are excited about the simulation tools now in use and plan to offer even more opportunities in the future. Plans call for taking training to a whole new level by potentially expanding facilities to include individual virtual units in pediatrics, mental health and trauma.
"The bottom line is patient safety and improving care," said Moore. "When health-care professionals have the chance to practice skills as well as work together as a team, patients benefit from the experience gained. Improving the health and care of patients is the reason why we're taking such a leadership role in creating this type education center.”