2005 Computerworld Honors Program

	Medical Readiness Trainer (MRT) Department of Emergency Medicine, University of Michigan Health System Ann Arbor, MI USA Year: 2000 Status: Laureate Category: Education & Academia Nominating Company: Lucent Technologies
	z»±L?ealistic virtual reality medical theaters immerse interns in the chaotic, fatigue-laden environment of a real-life emergency room, then test their ability to rapidly develop a plan of action and carry it out, significantly increasing their abiliti
	Since its beginning thousands of years ago, the teachers of medicine imparted upon their students the importance of recognizing the signs and symptoms of disease, the art of diagnosis, and of treatment leading, hopefully, to the full recovery of the patient. While the progress of biomedical sciences and technology vastly improved the lot of both the patient and the physician, imperfections of modern medicine are still an inherent part of medical practice. Some of these imperfections have roots in an inadequate understanding of the pathological processes whose combined effects manifest as sickness. Others, however, find their source in inadequate teaching of medical practice or in skills that are allowed to lapse, but are suddenly and unexpectedly needed. Mastering the art of healing is a difficult process. The future physician must diligently memorize a vast number of seemingly unrelated basic science "trivia", suffer through the laborious studies of human anatomy and physiology, convert the "normal" into pathology, then grasp its complex underpinnings. If this were not enough, pharmacology must be fitted into the entire, often not yet fully comprehended, structure. And then, when the ultimate moment of truth finally arrives, and the fledgling adept of the medical art faces the first ever patient Ü he or she frequently forgets it all! Constant study of medicine is an inseparable companion throughout every physicianÍs professional career. However, while continuous training is necessary to maintain undiminished clinical excellence, the access to such training is not equally available to all practitioners of medicine. This is particularly true for doctors working in rural and remote regions. The "global village" nature of the modern world underlines the ever increasing need for international education in medicine, and for training of multinational medical teams in working together while providing medical relief to people in poverty stricken parts of the globe, in times of natural disasters, and even war. The Medical Readiness Trainer (MRT) concept has been developed to provide comprehensive answers to the challenges of modern medical education and training of medical novices, senior clinicians, and multi-specialty medical teams. The highly realistic functions of the MRT incorporate the critical aspects of clinical medicine: integration of the observed clinical facts with the body of theoretical knowledge as the basis for appropriate diagnosis, diagnosis-based treatment of the illness, its modification based on its progression, complications, or unexpected events. Finally, the MRT is capable of introducing the elements of stress such as time limits, environmental distractions, fatigue, etc. The lack of the latter aspects makes current training in such disciplines as emergency or trauma medicine ineffective in any other environment than the working emergency department or operating room. However, training in such environment has inherent dangers caused by confusion, inadequate knowledge, or fear to ask that may have an adverse effect and affect the patient. Also, the "teach or treat dilemma" of training in the treatment of life-threatening disease may result in the inadequate exposure of the trainees (both senior students and residents) to an adequate level of the "hands-on" practice. In order to perform the highly complex functions and satisfy all requirements of the modern medical training, the MRT combines Human Patient Simulators (HPS) and fully immersive virtual reality (VR). Fusion of these superficially incompatible technologies recreates the "real life" world of clinical medicine and most of its "adrenaline discharging" challenges. In most cases, Human Patient Simulators are computer-operated, life-size manikins (FIG. 1) capable of physiologically faithful reproduction of human disease signs typically encountered by an emergency/trauma physician. The outputs of the device provide realistic chest and heart sounds, pulses, pupilary and laryngeal reflexes, and allow monitoring all vital signs (ECG, blood pressure, blood oxygen saturation, pulse, etc.) in a manner identical to that seen in the clinical setting. The latest HPS models are even capable of artificial bleeding. Fully equipped HPS permits execution of several procedures, e.g., maintaining airway even in medically very complex situations, insertion of drainage tubes and catheters, treatment of pneumothorax, or defibrillation of the heart. Successful implementation of the appropriate procedure is immediately reflected in the appropriate physiological response (e.g., relief of the pneumothrax restores chest sounds and chest movement on the affected side, and normalizes the ECG and blood gas levels). Moreover, virtually all drugs used at the level of ER/OR can be administered either in the form of an intravenous drip or as syringe-injected bolus. Drug treatment of HPS causes correct response only if the dose, manner or duration of the injection are appropriate. Importantly, improper or delayed implementation of the required intervention may result in complications or even "death" of the simualtor. Hence, the student is simultaneously exposed to the realism of the medical event (severely ill patient), the demand for instantaneous marshalling of all intellectual resources required to perform the initial diagnosis, and to the demand for a rapid initiation of the appropriate treatment. The virtual reality component of the MRT provides all other aspects of the training environment (FIG. 2). It recreates the physical setting, e.g., a patient bay of an ER or an operating room. Virtual reality diagnostic devices such as "light boxes", ultrasound screens, or vital sign monitors provide diagnostic quality information on the patient that is compiled from the outputs of the HPS and the available patient data-bases. Floating VR billboards provide additional web-based information the trainee may need, such as the data on the relevant drugs and their dosage, videoclips of complex procedures that may be relevant to the trained medical scenario, or real patient data that are extracted from the available electronic data banks. Also, the trainee has access to purely educational tools such as anatomical cross sections, diagrams, abstracts to medical papers on line (MEDLINE), and even lectures provided by an expert on the topic. The billboards can be moved at will within the space of the MRT. When needed, the trainee can place them in the line of sight, treat the HPS "patient" following the guidelines, and then move the billboard and "tuck it away". Much of the initial treatment in emergency and trauma medicine takes place out in the field, and is often associated with severe stress that is never encountered in the emergency room. Poorly lit scenes of car wrecks at night, violently rolling decks of rescue ships, Medevac flights in severe turbulence, or treatment of wounded in the battle field are among the most classic examples of such settings. It is here that the virtual reality component of the MRT attains its full strength since it is responsible for recreating these environments. The tightly orchestrated interplay of the human patient simulation and virtual reality provides the ultimate teaching and training tool characterized by an unprecedented degree of flexibility. Depending on the training context, it may offer consistency or variability, repeatability and reproducibility, or a complete lack of predictable elements. Ultimately, the MRT provides an unlimited source of environmental and situational richness. Finally, the students can learn and practice what to do and how to do it in the environment of a deceptively real world, yet without actually being in it. The MRT concept has a global reach that is inherently built into its fundamental structure. The Next Generation Internet provides provides the pipe-line that can connect a world-wide network of inter connected MRT units. The network will allow medical students around the world to benefit from real-time, hands-on training in the practice of medicine provided through direct interaction with medical experts located thousands of miles away. For the first time ever, medical training will become truly international and provide opportunities to train together medical teams from different nations in virtual space, where all team members experience and interact with identical medical and environmental scenarios.
	The Medical Readiness Trainer opens a completely new way of teaching and training medicine. For the first time, the trainee has been liberated from a disjointed and dry exposure to the vast accumulation of medical facts that are seemingly devoid of any bridges to the true world of medical practice. Instead, the trainee is immersed in the reality of medical art, where facts that once might have seemed of little or no importance, assume new and often critical values that may affect the life of the patient. The MRT provides the thrill of fighting for the patient's life, where split second decisions often determine the outcome, where the sound of an irregular heart beat or weakening pulse impose urgency and tension, and a restored rhythm on the monitor's screen evoke the sense of a job well done. The environment of the MRT teaches the trainee to sift through the available data, select their relevant sets, analyze, and use the results of the analysis as a foundation for treatment. The MRT imposes stress, the urgency of time, the ever-present need to think and plan ahead, and always be ready for the unexpected (FIG. 3). The MRT creates the intrusive environment of a busy emergency room or a claustrophobic patient bay of a Medevac helicopter. It forces the trainee to control events rather than allowing the latter to control the former. Yet, the MRT produces the only environment where the unforgiving nature of fighting an acute illness has room for mistakes and blunders; where failures teach, rather than lead to scorn or even punishment. By offering a challenge, the MRT teaches. By being demanding, the MRT extracts the best performance the trainee can muster. By being distractive, the MRT enforces self-discipline and control of the situation. The result is a complete immersion in the reality of medical practice, and the unprecedented continuum of the brain and hand. These very unique attributes of the MRT helped students and junior residents to master airway management in a critically ill patient. They assisted medics in ships to refresh their skills in dealing with injury, and now the help flight nurses to deal with the sudden emergencies in the tight cabin of a Medevac helicopter aloft. The medical events within the MRT can be controlled by an expert teacher located hundreds or even thousands of miles away. Thus, training can be global and the medical mastery of the few can be simultaneously shared with a world-wide audience. The advent of the MRT has fundamentally changed the way medicine will be taught in future by giving the student an intimate view of the dynamics of medical treatment through the subliminal fusion of theory and practice into the continuum of ever-increasing experience. The MRT elevates the process of learning from a passive accumulation of facts followed by the plunge into the world of medical realities, to a gradually escalating degree of active interaction with that world. The progress of learning and the rate with which the practical proficiency is acquired assume a steeper but also much smoother curve, producing dramatically enhanced post-training expertise. Thus, despite the artificial capsule of the medical world created by technology, those clinicians exposed to the MRT are more secure in their approach to the seriously ill patient, and their confidence in manual and intellectual skills is significantly higher. Consequently, the MRT serves as the challenge that offers the most comprehensive preparation for the final step Ü treatment of the injured or critically ill patient.
	The entire concept of the MRT is fueled by advanced information technology. While still at their comparatively early stages of development, Human Patient Simulators are a modern marvel of technical mastery and mechanical achievement. Likewise, the immersive virtual reality is an emerging technology, still in its infancy as a medium for communication and for providing new ways to visualize data. Unquestionably, an HPS is an ideal tool for teaching a specific set of medical skills. However, the immersive VR environment offers a mechanism to gain a completely different and new perspective. It also provides a shattering demonstration of what comes next after the worldwide web. It is an entirely new world of new realities - the world of "virtual reality". HPS machines are currently limited by what can be incorporated into the mechanical functionality of the manikin. On the other hand, one of the most difficult challenges for virtual reality and a major obstacle to its practical, daily implementation is the lack of the sense of touch, known as the "haptic" component. By combining these two technologies for the common purpose of medical education, we have harnessed the attributes of both and overcame the limitations of either. Within the Medical Readiness Trainer capsule, the HPS provides the integral element of touch, and recreates the physical aspect human anatomy "enlivened" by computer models of human physiology. The environment of immersive virtual reality surrounds the HPS and provides the external shell, i.e., the physical environment of each medical setting, rich communication possibilities, and the ability to virtually overlay the HPS with advanced attributes, such as burns or virtual surgical fields. The extremely powerful combination thus created grows exponentially when connected into an interacting network. Now, the existing information resources can be both incorporated and distributed within the higher level environment. The network permits teletraining of individuals, teams, or even groups of teams physically separated by very large distances from the teaching expert. Finally, the network permits sharing of educational experiences and learning to collaborate smoothly as a very large entity. The latter aspect allows efficient training of medical deployment teams that need to work together in multinational environments encountered during disaster or humanitarian relief operations undertaken with ever increasing frequency by the USA, UN, or private organizations. Medical training that includes realistic sources of stress, real-life cues, and immediate feedback has not been possible in the past except when performed in the setting of actual patient care. Since the latter approach is fraught with significant problems, there is little doubt that medical caregivers will quickly embrace the new concepts presented by the MRT, especially because the low-level simulation wins rapid acceptance within the medical community already. The rest of society is equally ready to embrace the new form of medical training. After all, it is an easily convincing argument that teaching and training using simulation entails fewer risks, less morbidity and mortality, and efficiently assuages the ethical dilemmas of using animals for both teaching and biomedical experiments.
	The most striking innovative aspect of the MRT is its combination of the Human Patient simulation and immersive virtual reality technologies. Despite the fact that both technologies existed in separation, their combination into a new entity elevated their practical utility to a much higher level. In a sense, such fusion may be compared to the development of FordÍs Model "T". The engine, the gear box, the suspension elements, etc., existed for quite a while. Even the concept of the car was already there. However, the ingenious fusion of all existing elements resulted in a car that could be built rapidly and in large numbers. Innovation created an automobile for all, and its consequent popularity changed the face of the world. Another highly original aspect of the MRT is that it provides medical training under the conditions of extreme realism resulting from the simultaneous stimulation of all relevant senses: touch, sight, sound, and smell. The MRT project is the first to bring these elements together for the specific purpose of both medical education and preparation. Criticism may be offered that MRT is nothing but another version of a flight simulator whose principles are, at least on the surface, identical. Modern, highly sophisticated flight simulators combine tactile and visual environment (interior of the cockpit and flight controls) and virtual reality (flight environment such as airports, clouds, other aircraft). Flight crews are exposed to the stress of sudden flight emergencies, difficult operational environments, etc. The essential difference between the flight simulator and the MRT rests in the extreme scenario richness provided by the latter, and its ability to provide education to a widely dispersed community of trainees. Finally, the range of outcomes that demand a complex but rapid "cross-indexing" of different areas of knowledge is much greater in the MRT than in the flight simulator. The inevitable consequence of poor flight management (i.e., destruction of the aircraft) does not mean that poor patient management must end in an equally inevitable death. Instead, it may lead to long term disability and serious collateral consequences. For example, incompetence in airway management may lead to substantial brain damage resulting in paralysis, lowered mental performance, perpetual coma, etc. The pilot is trained in mastering unpredictable behaviors of a machine where the range of outcomes, while large, is still significantly smaller than in medicine. Thus, every aircraft of the same type is essentially similar, and its response to major system failures are (essentially) predictable. On the other hand, each patient is characterized by a set of individual variables whose recognition represents a new challenge, and the failure to do so may result in a less than optimal outcome. Hence, the MRT allows equally effective training in routine skills (e.g., listening to the sounds of the heart) and in the mental and practical readiness for the unpredictable (e.g., sudden collapse caused by the allergic response to the latex examination gloves preceded, however, by the original complaint of cardiac instability). Some medical events, such as exposure to some types of toxins, may be quite uncommon. Others, do not take place frequently enough to offer enough learning exposure. Hence, todayÍs training of appropriate responses to several illnesses is accomplished primarily through the classical lectures on "how to" or, if one is lucky enough, a chancy real-life exposure with the tutor conveniently present at oneÍs side. The MRT transcends these difficulties and permits practical exposure to many of the infrequent but very life threatening conditions. The medical industry is inundated with computer based training tools, web based educational content, amazing three-dimensional visible human anatomical models, expert demonstrations of clinical procedures, etc. However, until the advent of MRT, no common framework existed that aligned all these parts into one educational platform where the hands-on skills, the traditional "book" skills, and an instructor (remote or local) were all readily available. Efficient orchestration of all these discrete, and at times even incompatible, elements into one smoothly functioning whole represents yet another significant facet of MRTs originality.
	During its very brief history, the MRT project achieved remarkable success. It combines existing tools into an immediately useful, completely new, and functional entity. The MRT took head-on the challenges of modern medical education and connects those who need education with those who are preeminently suited to provide it. Just-In-Time and Tele-training exercises with the U.S. Navy and the U.S. Coast Guard proved that the MRT successfully spans the gap of time and space. It allows a remote paramedic or physician to acquire new skills under the direction of a previously inaccessible expert. As a summary of success, a University of Michigan flight nurse, Chris Nelson best describes the usefulness and functionality of the MRT after a brief exposure to it: "UnbelievableƒIt was like being thereƒThis would more than fill a need, it would blaze a trailƒ". The immediate future plan is the continuation of the development and improvement of the MRT scenario contents. The virtual reality "burned patient" already under development will be refined and integrated with the VR environment of the cave in order to allow extreme realism in training the treatment of thermal injuries. At the time of writing, Jim Freer is devising a series of HPS-derived physiological responses that correlate with the intensity of burns and the total area affected. Once developed, the output will be displayed on the VR vital signs monitor, while the HPS computer will be used to manipulate treatment paradigms (such as administration of I.V. fluids, pain killers, etc.) Another imminent project whose conceptual definition has been completed, and which will soon enter its initial development under the direction of Jim Freer and Dave Treloar is the virtual reality airway management trainer. Insufficient skills are the primary source of poor execution of the critical airway support during medical crises. Consequent injuries and even death are frequently reported. The airway management component of the MRT will create a virtual reality tool allowing full manipulation of the airway even under the most difficult conditions. The haptic (touch) component of the "AIRWAY" project will use tools developed for the "burned patient" with the addition of VR-based instruments such as laryngoscopes, tubes, ventilation bags, etc. The airway management trainer will allow the trainee both to practice the procedure and also look at the position and movement of the used instruments (for example the laryngoscope) in relation to the relevant anatomical structures. In its final version, the airway management trainer will be capable of creating abnormal conditions such as obstructions by foreign bodies or tumors, spasms of musculature, or burns and physical injuries. Simultaneously, Eric Wolf and Howard Levine will continue to solve the problems of remote control of large simulator federations, and develop gateway mechanisms to allow control of simulators of different manufacture and capacity. The first exercise investigating such control will be conducted under the leadership of Bill Wilkerson, and is planned for the end of February and beginning of March 2000. During the test, simulators manufactured by the two leading national companies (MedSim/Eagle and METI) will be deployed to locations approximately 8000 miles apart and remotely controlled by the training physicians from Bethesda, MD, or Ann Arbor, MI. We also plan to investigate the challenge of shifting from central to mobile and remote multi-simulator control. Two ships, one located in the Atlantic and the other in the Pacific will be used for this purpose. By using such complex structure, the exercise will provide the basis for the subsequent MRT-based preparation and training for medical activities during the international relief operations following major natural disasters such as the recent earthquakes in Turkey or the cyclone in India. As the Next Generation Internet (NGI) or Internet 2 becomes increasingly pervasive, the MRT Team at the University of Michigan intends to develop close collaboration with other institutions already possessing the virtual reality caves. The collaboration will allow us to share our software and solutions to problems in order to create a nationwide MRT network. The advent of an MRT network provides a singular advantage for training the very complex issues of stratified medical operations. The network allows several activities to take place at the same time, without the need for translocation of the affected personnel (FIG. 8). At the bottom of the training pyramid, and within each individual MRT, several individual trainees can be trained in providing appropriate medical treatment. At this level, team interactions and leadership skills can also be practiced. Several teams, each located within their individual MRT and, most likely, separated from each other by hundreds or even thousands of miles, can be directed by the supervising specialist physician. The role the latter would be similar to that of a senior physician in charge of a department of emergency medicine or a field hospital. Finally, the latter, together with a number of other department supervisors, may be connected to the "regional command physician" and his/her staff. The "command center" staff receives information concerning the number and type of victims from all individual "departments", their materiel status (e.g., need for supplies, additional staff, etc.), evacuation needs (transport of patients to specialized facilities located elsewhere), etc. The staff of the command center will analyze these data and coordinate them with all other available information relevant to the conduct of the operation. The "confounders" such as weather (which may prevent helicopter operations), state of the roads (bridges may be washed away by floods), or the availability of supplies (massing up at harbor heads due to the hurricane damaged infrastructure) can be randomly generated or recreated using the past events as a guide. The command decisions can be then passed downstream to regulate activity at all subordinate levels, such as the necessity for long-term stabilization of victims due to temporarily unavailable transport to the higher-level treatment centers, rationing of supplies, or even personnel rotation. Until now, exercises involving very high degree of complexity similar to the one described above could be performed only by the armed forces using large numbers of troops, equipment, and at a very significant cost. The network of MRTs (especially when some of the MRTs are created in virtual space and, while physically non-existent, provide the required output) reduces these requirements. More importantly, however, the civilian personnel will finally have the same access to advanced and complex levels of training in medical operations and logistics that presently is only available to the military. The MRT provides a common frame of reference for completing the cycle from research to education to patient care and reinforces of the need for additional research again. A pilot study instrumental in the creation of an independent branch of the MRT project, the SMAL (Simulation and Modeling for Animal Life) Project demonstrate this additional role. The experiments indicate MRTÍs applicability in clinical practice and in basic biomedical sciences by helping both researchers and clinicians visualize simulated information in, for example, certain types of pharmacological research currently conducted on animals. These preliminary results showed that the number of animals needed would be significantly reduced. Thus, pre-testing of experimental design in the MRT may help address the ethical issues of the excessive use of animals in research. Moreover, the cost of the planned full-scale experiments was reduced by approximately $ 180,000 and the bench research workload shortened by approximately 14 months. In the future the SMAL project will use the most advanced techniques of simulation and modeling to develop functional and scientifically viable animal models suitable for preliminary hypothesis testing, narrowing of experimental parameters, definition of technical approaches, etc. It will make the latter faster, cheaper, and better defined by allowing the easy manipulation of experimental variables, fast rejection or acceptance of concepts during experimental hypothesis development, and the initial hypothesis testing. Today, all these functions can be performed only by using the slow, laborious and, at times, questionable process of animal experimentation. Thus, the success of the MRT rests in its open-ended potential, where new thoughts and techniques can be developed, tested, iterated and recycled. With the addition of SMAL to the MRT project, the potential for facilitating the interactions among clinicians and researchers becomes even more exciting. In much the same way Teletraining bridges the physical distance between two clinicians, the SMAL component breaches the intellectual barriers that often prevent research from being translated to clinical practice.
	The single most difficult obstacle that affects all other issues is the problem of conveying its nature. Seeing the MRT, particularly when it is used in training, proves the only way to understand what the MRT really is, and how it differs from anything that people have experienced before. Not many have had the opportunity to stand immersed in a virtual reality setting. Even if one had seen the Holo-deck aboard the Star-TrekÍs "Enterprise" (still very much science fiction), the frame of reference for the possibilities and limits of such environment is missing. Some day, it will be common for all physicians to use human patient simulators to refine their talents. Today, first hand exposure of these advanced devices remains novel and rare. Therefore, it is difficult to effectively communicate what the Medical Readiness Trainer is capable of. Most of our audiences find it hard to imagine. Curiously, it is the same aspect that makes the potential of the MRT so extremely exciting - there are still many unexplored uses that wait yet to be discovered. The MRT project has no other funding but that provided by the Chairman of the Department of Emergency Medicine at the University of Michigan, Bill Barsan, and the Head of the Information Technology at the University of Michigan Health System, Jocelyn DeWitt. Both immediately saw the potential of the MRT and supported the project to their full capacity. Still, the resources at their disposal are exceedingly limited. The University of Michigan College of Engineering unhesitatingly put their massive technical and intellectual resources at the disposal of the project each time they were needed. The MRT seems to be too bold, it aims too far, and does not want to walk but insists on flying right away. And it is not understood. Hence, funding remains the absolutely leading challenge. Constrained resources limit the rate of progress. Nonetheless, help arrived from the most unexpected sources. The Coast Guard offered the ship and passage from Portsmouth to Roosevelt Roads. Without applications, without masses of paper, without fuss and without delays. Two weeks after the initial contact with Commander Sikorski (the captain of the "FORWARD"), the Team was at sea. The Navy offered their hospital, its personnel, and their work. Without applications, without masses of paper, etcƒJust a few officers who saw the potential, and who, with the truly sea-going notion of taking initiative into their own hands and ACTED rather than waited for the paper trail to form. The results are "history" and a series of the "first evers". We learned to be to be both persistent yet patient. Solving complex technical problems, developing and doing things never done before have their own rewards. We KNOW that MRT is the way of the future. And in the process, we learn, experience thrills of the travelers of the past, where each step was a discovery, and each step Ü another world. It is a thrill, it is the most glorious feeling that nowhere on the planet a device exists that is similar to ours, and we have created it! We KNOW that in not too distant future the very same device will be as common as once FordÍs Model "T" has been. More humbly, however, we know that ours is one of the greatest privileges Ü we have a chance of changing the face of medical training and by doing that, a chance of making others safer, happier, and less desperate. There is no better feeling for a physician or a scientist.