Orlando is at the Center of Re-Inventing Medical Training
By Terri Bernhardt
The pressure is on. You are handed a five-member family with a strong medical history ranging from illnesses like diabetes, high blood pressure, breast cancer, depression, celiac and gout. They need constant attention and research; their ages range from 1 to 64 and they are considered the “sickest family in Orlando.” Your job is to heal them in one semester, and the realism is enough to make a medical student break into a sweat.
This technology, called Virtual Patient, is a game that was developed in conjunction with Dr. Juan Cendan at the UCF College of Medicine, which can be programmed with a variety of illnesses to which the student must learn to respond. For example, the virtual patient can leave a fictitious voicemail after-hours that actually factors into the case study simulation. The student must listen to the message, order the right tests and make a diagnosis – all in a game-like simulation. “The virtual patient may call you at 2 a.m. and go into deep distress about what is bothering them,” said David Metcalf, Ph.D., senior researcher and director, Mixed Emerging Technology Integration Lab (METIL) at the Institute for Simulation & Training at UCF. “Your job is to listen to the patient, assess what they are saying and look up their medical record to assist them.”
These cognitive and metacognitive processes result in highly educational experiences, and this type of medical simulation is but one example of what is going on in Orlando for training future health care professionals. Ultimately, medical simulation is the experiential learning every health care professional will need, but cannot always be experienced in real-life patient care.
No commercial airline pilot or military aviator ever takes off in a multi-million dollar aircraft without logging countless hours in a flight simulator. Military and commercial aviation learned long ago it was not only much cheaper (one tenth the cost of live training), but it was far more effective to train personnel in lifelike scenarios where failure was an option. In fact, it was part of the learning experience.
The transition from simulating jets, tanks and helicopters to simulating patients in emergency or clinical situations faced by combat medics, nurses and doctors has been quickly evolving, in an industry that has called Central Florida its home for over 40 years.
This inventive group combines science, engineering and art to make fake blood that feels, smells and clots just like real blood. They turn a high-fidelity mannequin into a groaning, twisting man with congestive heart failure that is so realistic that the trainee sweats while trying to stabilize him. These same people develop serious games that take nurses through triage and combat medics through tying tourniquets in real time with life-like scenarios, followed by an after action review for effective memory retention.
With all eyes on Lake Nona’s Medical City, breakthrough simulation technologies, medical research and medical training are able to converge. Harry Robinson is the national program manager of the Veterans Health Administration’s Simulation Learning Education and Research Network, “SimLEARN.” For the retired Navy aviator, the ability and potential of simulators to duplicate real life scenarios was obvious. “Just like when I was a squadron commander, we are able to replicate an actual situation, in this case a medical procedure or medical emergency situation, in a safe environment, where there is no danger or inconvenience to a human patient. Also, trainees are able to both develop the skills (in diagnosis and in muscle memory) and then have a meaningful debrief, where we actually watch the training exercise.”
The VHA did a nationwide search to determine where the SimLEARN program would be located. Because of the advanced simulation resources – including Team Orlando, a collaborative alliance of the various military simulation commands – along with academic and industry leaders, Orlando was chosen.
More Real and More Available
Beth Pettitt, branch chief of the Medical Simulation Research Branch, Simulation & Training Technology Center, and Jack Norfleet, their chief engineer, have spent their careers endeavoring to make what once were astronomically expensive mannequins, more lifelike and more affordable, thus more available for training. Like actual patients, robotics in these mannequins are able to mimic the movement of limbs; air passages exhale, simulating pulmonary function; and small embedded speakers provide the sounds of heart beats, respiration and digestion. Everything is designed to enable the trainee to see, feel, hear and even smell the types of situations faced in combat, a natural disaster, a terrorist attack or in the emergency room of a local hospital.
The early simulators dealt with two of the most common scenarios: how to stop bleeding or open a clogged air passage and the shock that would result if these conditions weren’t corrected. “Our focus is always on the educational need. What is the Army trying to teach (referred to as ‘fidelity’) or adherence to the specific training requirements, and (‘resolution’) how accurate and humanlike will the technology enable us to make it? And then to bring these two together by building the technology that matches their training expectations,” Norfleet explained.
“Our first work was building trauma capabilities, while bringing the price down. The technology that resulted from that was actually fielded and resulted in what was commercially known as the ‘Emergency Care Simulator’ that has been used around the world, in military and civilian training,” he said.
There are four areas of medical simulation training: full environment simulation, task trainers, computer-based trainers and simulated/standardized patients. Fundamentally, these break down simulation into two tracks, though more and more of these two tracks have and will overlap. One is a digital training scenario, where the student is in a video game type of experience. The second is a full emersion with a mannequin or more accurately android-like patients.
Greg Welch, Ph.D., the Florida Hospital Endowed Chair in Health Care Simulation at UCF, has been working in the field in one form or another for decades, but his current work is taking medical simulation to a whole new level. Currently, medical personnel are sometimes trained using actors that emotionally and physically imitate the behavior of someone with a particular condition, but there are limits to what an actor can mimic. What is more, there are limits to the number of actors and frequency of times these scenarios can be simulated.
Welch is working not to simply duplicate the movements, the feel or the anatomical authenticity of a medical android, but its mental and emotional behavior. “Part of the diagnostic procedure is really an interrogation of sorts, to actually determine what symptoms the patient is experiencing. To successfully do that you have to understand how to communicate with the patient and empathize with their condition; you have to learn what questions to ask, along with developing the patience that is necessary to succeed in that process.
“My area of expertise and my passion over the last 20 years has been about simulating human interactive experiences. This is a physical/virtual reality, which simulates human behavior with the goal of building a computer-controlled system that mimics human responses for medical or health care related training,” continued Welch. “To do that you have to study human interaction and transfer that knowledge to a patient/clinician experience that is lifelike and authentic. We want to simulate the fear, pain, discomfort of a patient and help the clinician learn to be comfortable interacting and doing what is sometimes awkward or socially inappropriate to do.”
Medical simulation is another facet of the burgeoning modeling, simulation and training industry that calls Orlando home. Like other aspects of this economic juggernaut, collaboration, cooperation and partnership seem to be hallmarks, and the possibilities for expansion and diversification seem limitless. It is comprised locally of more than 150-plus industry companies, in addition to UCF, the acquisition commands for the Army, Navy and Marine Corps, the Air Force Agency for Modeling & Simulation, plus 10 other federal government agencies and joint commands.
“There is a huge opportunity to transfer proven simulation technology from defense to a number of other sectors of the economy to include medical simulation,” said Lt. Gen. (Retired) Tom Baptiste, CEO, National Center for Simulation. “The paradigm used to train fighter pilots is directly applicable to the way we train, certify and re-certify doctors, nurses, anesthetists and countless other specialties. And simulation is a key portion of the overall training curriculum. In fact, the Department of Defense has been and remains a leader in leveraging simulation technology to satisfy the training requirements of America’s combat medics and other military medical providers. Today, Orlando is well postured to drive the future of medical simulation.”