cybertherapy & rehabilitation, issue 4 (2), summer 2011

Issue 2 / 2011

Stress InoculationTraining forCombat Medics

and much more...

T h e O f f i c i a l V o i c e o f i A C To R

ISSN 2031 - 278

FEATURES:Modeling and Simulation to SupportTraining of Combat Medicsp 14

New Applications for High Fidelity Patient Simulationp 20

COVER STORY:

ASK THE EXPERTRobert Madelinp 33

COUNTRY FOCUS:Germanyp 42

Visually Realistic - Comfortable - Easy to UseDurable - Reusable - Tactilely Realistic

INJURY CREATION SCIENCEThe Next Generation of Injury Simulation Today

Prosthetic tissue, wounds, and life saving skills training devices used in the training of medical professionals • Cricothyrotomy Skills Trainer • Needle Decompression Skills Trainer • Bleeding Wound Skills Trainer • Amputation Skills Trainer • Burn Wound Skills Trainer • Odor Wound Skills TrainerMerging latest special effects technology with medical and material sciences research to replace live tissue and training.Physiologically based research and development program focused on providing enhanced training capabilities for medical professionals to include: • Basic Life Support • Patient Assessment • Hemorrhage Control • Fracture Management • Shock Prevention & Treatment

Cricothyrotomy Skills Trainer

Needle Decompression Skills Trainer

Bleeding Wound Skills Trainer

Visually Realistic - Comfortable - Easy to Use

Severe Amputation Skills Trainer

Severe Amputation Odor Simulation Wound Kit

Simulated Burn Wound Package

Visually Realistic - Comfortable - Easy to UseVisually Realistic - Comfortable - Easy to Use

FOR MORE INFORMATION, CONTACT:Mark D. Wiederhold, M.D., Ph.D. FACP

The Virtual Reality Medical Center858.642.0267 [email protected]

www.vrphobia.com

1

Letter from the Secretary General and Editor-in-ChiefProfessor Dr. Brenda K. Wiederhold

Dear Reader,

Stress inoculation training (SIT) is a type of trainingused to prepare individuals for stressful situations andhelps diminish the potential for a negative psycholog-ical reaction. In cognitive-behavioral therapy, SIT is ac-complished through gradual, controlled, and repeat-ed exposure to a stressor. The goal behind thisexposure is to desensitize or “inoculate” the personto the possible stimuli of a stressful situation, avoid-ing a panic or “fight or flight” response to the realthing. This repetition allows the individual to calmlyand accurately accomplish the tasks at hand in a stress-ful environment. Developed in the late 1970s by Me-ichenbaum, controlled exposure to stress-related cuescontinues to be a key feature of resiliency training.

Because SIT is a technique used to help harden indi-viduals to future potentially traumatizing stressors,it makes sense to use this method to help train thosewho must treat trauma patients. These personnelmust often perform in extremely stressful environ-ments, and optimum performance under such con-ditions requires effective management of physiolog-ical, psychological, and emotional responses tostressful stimuli. An acute stress reaction can occurduring exposure to exceptionally stressful events, re-sulting in extreme sympathetic nervous system arous-al and impaired performance. Longer-term reactionsto these situations can include acute stress disorder,Posttraumatic Stress Disorder (PTSD), and burnout.

One method to attenuate or prevent these reactionsis Virtual Reality-enhanced SIT, in which personnel“experience” highly stressful situations in a virtualenvironment. Repeated exposure enables perform-ers to gradually become desensitized to stimuli thatmay initially elicit such strong physiological arous-al that performance is impeded (e.g., freezing un-der gunfire instead of moving a wounded soldier tosafety), and therefore, psychological trauma should

be less likely. Stress inoculation training is associat-ed with a reduction in anxiety and an enhancementin work-related performance. Preliminary results ofa study by Stetz and colleagues showed that virtualenvironments do succeed in stressing medicsenough to produce an “inoculation” effect by in-creasing anxiety and dysphoria.

There is evidence that SIT can reduce PTSD. In a2000 study by Deahl and colleagues, a group of 106male British soldiers preparing for a six-month tourof duty in Bosnia received a combination of pre-de-ployment stress training and post-deployment psy-

chological debriefing. After deployment, participantsdemonstrated a drastically reduced incidence ofPTSD and other psychopathology as compared tocontrols, approximately 10 times less than figuresreported from other military samples. In fact, thelevel was so low that it precluded any possible de-briefing effect.

A recent Rand review of the evidence of effective-ness of various treatments for PTSD rated SIT as aLevel A intervention as of 2000, based on two well-controlled and two less well-controlled studies infemale sexual-assault survivors. Level A is the mostrigorous, defined as “Evidence is based on random-ized, well-controlled clinical trials for individualswith PTSD.”

“Preliminary results of a study by Stetz and colleagues showedthat virtual environments do succeed in stressing medicsenough to produce an ‘inoculation’ effect by increasing anxietyand dysphoria.”

“Because SIT is a techniqueused to help harden individu-als to future potentially trau-matizing stressors, it makessense to use this method tohelp train those who must treattrauma patients.”

Evidence of the effectiveness of SIT is certain togrow with advances in the fields of psychophysiol-

ogy and neurobiology. An example of the former isa recent study of Belgian Special Forces candidates,which showed robust increases in cortisol in a high-intensity stress (vs. a no-stress) group, with signifi-cant correlations to decreased performance on work-ing memory and visuo-spatial tests.

An example of the latter is a review article by Lyonsand colleagues that uses their longitudinal workwith squirrel monkeys to inform areas of investiga-tion for human studies of resilience. Specifically,

stress inoculation in monkeys enhances prefrontal-dependent cognitive control of behavior and in-

creases ventromedial pre-frontal cortical volumes.These and other findings“suggest that early life stressinoculation triggers devel-opmental cascades acrossmultiple domains of adap-tive functioning. Prefrontalmyelination and cortical ex-pansion induced by theprocess of coping withstress support broad andenduring trait-like transfor-mations in cognitive, moti-

vational, and emotional aspects of behavior.”

Science points the way for those leading and study-ing trauma training: Transform such training, pro-tecting the psychological well-being of first respon-ders by including resilience training exercises suchas SIT.

Letter from the Secretary General (continued from page 1)

“Repeated exposure [to VR-enhanced SIT]enables performers to gradually becomedesensitized to stimuli that may initially elicitsuch strong physiological arousal that perform-ance is impeded (e.g., freezing under gunfireinstead of moving a wounded soldier to safety),and therefore, psychological trauma should beless likely.”

Create your own reality!Brenda Wiederhold

2

3

Guest EditorialProfessor Dr. Mark D. Wiederhold

Dear Reader,

New synthetic materials for “injury” creationenable lifelike casualty trauma simulations, mak-ing obsolete the controversial use of animals suchas goats and pigs. A combination of human cadav-er use, medical simulation, and trauma centertraining yields the best results in terms of realism,human-specific injuries, and team building. Vuand Price (pg. 19) briefly describe the history oftrauma training in their article in this issue abouthigh fidelity patient simulators.

In the past, physicians and medics learned how tocare for the trauma patient through a variety ofmedical simulation tools.

The American College ofSurgeons endorses the in-tegration of simulatorsinto medical training, cit-ing the ability of “medsim” to enhance patientsafety, reduce medical er-rors, and systematically evaluate physician skills.As Bandiera (pg. 30) writes in this issue, “Traumacare is particularly suited to the use of simulation.”

Various training mannequins and part-task train-ers are available for training corpsmen and medicsto treat battlefield wounds. For example, Simulab’sTraumaMan System can teach medics the correctplacement of an emergency surgical airway(cricothyroidotomy). Corpsmen can learn needledecompression of tension pneumothorax using theHuman Patient Simulator from METI. While Sim-Man can teach management of hemorrhage, theforced-air bleeding system is expensive (as are allthe mannequins) and lacks realism.

This aspect of trauma training, wound simulation,started with moulage in 1834 when artists painted

injuries on the body. Moulage filled a role more forthe benefit of the organizers of military maneu-vers, since the level of realism at the individualmedic or corpsman level was low. Hollywood make-up and theatre techniques followed, to provide el-ements of realism, such as blood and open frac-tures, to the training simulation. Some examplesof well-made artificial wounds appear on the Syfyprogram Face Off, a competition/elimination seriesexploring the world of special-effects make-upartists.

Virtual Reality (VR) simulation has finally comeof age, as Dr. Rosen wrote in her recent articleon the history of medical simulation: “There is

currently a proliferation of commercial virtualmedical environments to provide visual and au-ditory experiences. Some laboratories add thesense of touch through haptics. The incorpora-tion of smell has been proposed as a potent stim-ulus of memory.”

Recent research performed by the Virtual RealityMedical Center (VRMC) and the University of Cen-tral Florida managed to increase the medical real-ism of wearable prosthetic devices used to simu-late injury, through improved materials andtechnologies that simulate the smell and feel of or-gans and blood. This provides an important psy-chological aspect of simulation immersion, sincemany civilian-trained medical personnel are notpsychologically prepared to face severe wartimetraumatic injuries.

“Such cutting-edge research leads us to believe that inthe near future, studies will show that the most effectivetrauma team training uses this combination of realistic,synthetic materials and virtual environments employingimproved haptics.”

“Combining the use of artificial materials withVR research, another researcher strives to createmechanical and geometric models of tissue toimprove the fidelity of force feedback (haptics)for surgeons performing robot-assisted surgery.”

In the VRMC research, lipid nanotubes filled withscent oils in the layers of the simulated skin adda realistic odor to simulated wounds. Becausethe current prosthetics can be used on humanactors, patient simulators, or stand-alone de-vices, this approach could enhance a wide vari-ety of training scenarios.

Related research into the use of nanomaterialsuses a nanogenerator technique to transfer fer-roelectric thin films to a flexible substrate, withpotential application to the creation of artificialskin. This is part of an emerging technologycalled “flexible electronics.”

Combining the use of artificial materials with VRresearch, another researcher strives to create me-chanical and geometric models of tissue to im-

prove the fidelity of force feedback (haptics) forsurgeons performing robot-assisted surgery. In onesuch experiment, the investigator made a heartmodel from silicone, silicone thinner, and pigmentwith a coffee stir straw embedded to resemble“calcification” in the phantom tissue.

Such cutting-edge research leads us to believethat in the near future, studies will show that themost effective trauma team training uses thiscombination of realistic, synthetic materials andvirtual environments employing improved hap-tics. That can’t happen too soon: Our woundedservice members in Afghanistan and other com-bat zones deserve the best trauma care, now.

Guest Editorial (continued from page 1)

Mark D. WiederholdVirtual Reality Medical Center

4

Comparison of Surgical Simulation Methods

Model Strengths Weaknesses

Animal Bleeding, individually inexpensive Ethics/animal rights, anatomyincorrect, single use, logistics

Cadaver Anatomy correct Expensive, storage issues, single

use, no bleeding

Plastic model Inexpensive, convenient,

repeat use Realism, needle tracks

Computerized mannequin Multiple applications, repeat use Realism, very expensive,

precut holes

Virtual Reality Unlimited use, practice withoutinstructor, multiple scenarios,

control degree of difficulty, reset

Realism variable, expense variable, haptic force limitation

Guest Editorial (continued from page 1)

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Professor Brenda K. WiederholdPh.D., MBA, BCIAEditor-in-ChiefC&R MagazineBelgium

Professor Rosa M. Baños, Ph.D.University of Valencia Spain

Professor Cristina Botella, Ph.D.Universitat Jaume ISpain

Professor Stéphane Bouchard, Ph.D. Universite du Quebec en Outaouais (UQO)Canada

A.L. Brooks, Ph.D.Aalborg UniversityDenmark

Professor Paul M.G. Emmelkamp, Ph.D. University of AmsterdamThe Netherlands

Professor Luciano Gamberini, Ph.D.University of PadovaItaly

Professor Sun I. Kim, Ph.D.Hanyang UniversityKorea

Professor Dragica Kozaric-Kovacic, M.D., Ph.D.University Hospital DubravaCroatia

Professor Paul Pauli, Ph.D.University of WürzburgGermany

Professor Simon Richir, Ph.D.Arts et Metiers ParisTechFrance

Professor Giuseppe Riva, Ph.D., M.S., M.A.Istituto Auxologico ItalianoItaly

Professor Paul F.M.J. Verschure, Ph.D.Universitat Pompeu FabraSpain

Professor Mark D. Wiederhold, M.D.,Ph.D., FACPVirtual Reality Medical CenterUSA

Professor XiaoXiang Zheng, Ph.D.Zhejiang UniversityP.R. China

C&R Editorial BoardGENERAL INFORMATION

CyberTherapy & Rehabilitation Magazine

ISSN: 2031-278

GTIN-13 (EAN): 9771784993017

CyberTherapy & Rehabilitation Magazine is published quar-

terly by the Virtual Reality Medical Institute (VRMI), 64 Rue

de l'Eglise, Boite 3, 1150 Woluwe-Saint-Pierre, Belgium and

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LETTER FROM THE EDITOR-IN-CHIEFB. Wiederhold p 1

GUEST EDITORIALM. Wiederhold p 3

COVER STORYCombining Stress Inoculation Training with Medical Training for Combat MedicsN. Ahmann p 12

FEATURESHemorrhage Control in the Battlefield: Role of Modeling and Simulation for Training Combat MedicsT.M. Sotomayor, D. Parsons p 14

U.S. Military Takes on High-Tech and High-Adventureto Train for Wartime LifesavingT. Talbot p 16

Large Scale Simulations in Pediatric Cardiology: Towards the Personalized Virtual Child HeartW.W. McFadden, M. Suehling p 18

New Applications for High Fidelity Patient SimulationM.P. Vu, J.W. Price p 20

Trauma Teams and Training: Making the Sum GreaterThan the PartsM. Siadat, R. Fernandez p 22

PRODUCT COMPARISON CHARTTrauma Training Devices p 24

Preoperative Patient-specific Liver Surgical SimulationL. Soler, D. Mutter, J. Marescaux p 26

Pre-Deployment Simulation Training For U.S. ArmyForward Surgical TeamsM.L. Ryan, C.M. Thorson, C.A. Otero, G.D. Garcia p 28

Simulation in Trauma Care Education–More ThanJust “How Real is That?”G. Bandiera p 30

ASK THE EXPERTR. Madelin p 33

FURTHER AFIELDL. Kong p 36

Pain Assessment for Designing a Painless MicroneedleK. Tsuchiya, K. Kajiwara, M. Kimura p 38

COUNTRY FOCUSGermanyC. Valenti, E. Butcher p 42

TABLE OF CONTENTS

9

High-Tech Wound Simulation

Effectively merging cutting-edge special ef-fects technology with material science re-search, wound simulation, or “moulage,” hasbecome an increasingly effective means oftraining combat medics. Specially-designedkits enhance the realism of training exercis-es, helping improve the odds of survival onthe battlefield.

Game-Based Approaches to Trauma Training

The Telemedicine and Advanced TechnologyResearch Center (TATRC), the Army’s high-technology medical pathfinder, among oth-ers, have been exploring the use of immer-sive, simulated environments to create agame-based approach to trauma training. Inone computer game, combat medics mustrespond to an improvised explosive deviceevent, prompting a focus on training of high-er order thinking skills, as well as helping todecrease stress through exposure tech-niques.

At the 18th Annual Medicine Meets Vir-tual Reality Conference (MMVR) held inNewport Beach, California in February2011, more than 450 participants from20 countries presented and assessedgroundbreaking developments in simu-lation, modeling, imaging, robotics andother emerging tools for patient care andmedical education.

To focus on specific military needs andbring key innovations to MMVR, the U.S.Army Medical Research and Materiel Com-mand’s (USAMRMC) Telemedicine and Ad-vanced Technology Research Center(TATRC) has strategically partnered withconference organizer Aligned ManagementAssociates, Inc., since 2001. This year,TATRC hosted two preconference sessionson medical simulation and clinical skills –“a shot in the arm for Army medical re-search and training,” according to TATRCDirector COL Karl Friedl. The two days en-joyed record-breaking attendance, withstanding room only.

On Tuesday, February 8, TATRC highlightedthe new Armed Forces Simulation Institutefor Medicine (AFSIM) in a day designed toshare military healthcare needs with devel-opers and potential users of simulation-based training systems. TATRC facilitatedthe AFSIM Industry Day on behalf of a DoDcommittee that oversees medical simula-tion research funding. Event chair HarveyMagee, the technical director of TATRC’sMedical Simulation and Training Technol-ogy Portfolio, explained, “This focused gath-ering of government, academia and indus-try attendees marks the beginning of a newera in simulation-based research to improvetraining, patient safety and clinical effec-tiveness. We are excited to inform the pub-lic about a new DoD funding source formedical simulation projects.”

TATRC helped create AFSIM to coordinatethe JPC1a efforts. At the Industry Day, AF-SIM director and chair of the JPC1a-Med-Sim Steering Committee MAJ Thomas B.Talbot, M.D., introduced the institute andits four major initiatives. Said Talbot,“Healthcare is in need of improvement,from making hospitals safer for patientsto training physicians, nurses and medicsin skills that vary greatly between deploy-ment and home duties. Advanced simula-tion technology offers a promising way toimprove the quality and quantity of med-ical training.”

On Wednesday, February 9, TATRC hosteda clinical education symposium to focuson the role of simulation in surgical train-ing, skills maintenance, competence as-sessment and certification. The event wascochaired by Kevin Kunkler, M.D., seniorclinician and subject matter expert forTATRC’s Medical Simulation and TrainingTechnology Portfolio, and Thomas Knuth,M.D., TATRC Trauma Portfolio manager.Kunkler noted, “It is vital that the militaryfind effective methods to address the de-

terioration of skills for the thousands ofsurgeons, anesthesiologists and interven-tionists who are preparing to perform dif-ferent specialized procedures during or af-ter deployment. Maintaining clinical skillsis also crucial on the civilian side.” Accord-ing to the Centers for Disease Control,medical mistakes cause 40,000 to 200,000deaths per year in the United States.

TATRC Chief Scientist Charles Peterson,M.D., said, “We organized this meeting asa forum to better understand the currentgaps and explore the directions thoughtleaders are pursuing to address needs inthis crucial area. We heard many excel-lent ideas that could help steer future pro-grams. Our hope is to inspire creative so-lutions within the healthcare community,whether through technology, standardi-zation, curriculum or other advance-ments.”

For more information on AFSIM or theTATRC Medical Simulation and TrainingTechnology Portfolio, contact Mr. HarveyMagee at [email protected].

T h e O f f i c i a l V o i c e o f t h e I n t e r n a t i o n a l A s s o c i a t i o n o f C y b e r P s y c h o l o g y , T r a i n i n g & R e h a b i l i t a t i o n

International Association of CyberPsychology, Training & Rehabilitation (iACToR)

Highlights Trauma Training Meetings of Interest

48

10

TATRC Pre-ConferenceSessions at MMVR18

Left to right – Mr. Harvey Magee, Dr. Jeffrey Stephenson, Dr. Charles Peterson, M.D., MAJThomas B. Talbot, M.D. Photo by Lori DeBernardis.

February 8-12, 2011Newport Beach, California


11

International Association of CyberPsychology, Training & Rehabilitation (iACToR)

Conference Participation Report Summer 2011

Med-e-Tel 2011International Telemedicine and eHealth ForumLuxembourg / April 6-8, 2011

This year Med-e-Tel, one of the premier events worldwide in thefield of Telemedicine and eHealth, welcomed over 450 attendeesfrom 57 countries April 6-8 in Luxembourg, including official dele-gations with Ministry of Health representatives from countries in-cluding Mali, Nigeria, Brazil, Nepal, and Kenya.

Med-e-Tel is organized by the International Society for Telemedi-cine & eHealth (ISfTeH), which is the international federation of na-tional Telemedicine/eHealth associations and is recognized as anNGO in Official Relations with the World Health Organization (WHO).Med-e-Tel is endorsed by the Luxembourg Ministry of Health, theEuropean Commission, the International Council of Nurses (ICN),the International Association for CyberPsychology, Training & Re-habilitation (iACToR), and European Health Telematics Association(EHTEL), and works together with a wide range of local and inter-national partners who are all involved in Telemedicine and eHealthresearch, development, funding and implementation.

Through its extensive conference program with 200 presentationsand an industrial exhibition and networking area, Med-e-Tel pre-sented and showcased practical experiences, ongoing projects andrecent research results of interest for its international audience ofhealthcare providers, industry representatives, consultants, re-searchers and policy makers.

Also of particular interest was a symposium presented in cooper-ation with iACToR, in which four projects funded by the EuropeanCommission teamed up to present on "Virtual Reality, MentalHealth, Stress-Related Disorders and Rehabilitation." The sympo-sium included members of INTERSTRESS (Interreality in the Man-agement and Treatment of Stress-Related Disorders), MONARCA(Monitoring, Treatment and Prediction of Bipolar Disorder Episodes),Help4Mood and ICT4Depression. The symposium gave interna-tional attendees an opportunity to learn of new technological ap-proaches being applied to help those with depression, bipolar, andstress-related disorders.

Program details and presentations are still available at www.mede-tel.eu. The next Med-e-Tel conference is scheduled for April 18-20,2012 in Luxembourg.

World of Health ITBudapest, Hungary / May 10-12, 2011

World of Health IT, a cornerstone event of eHealth Week 2011 –the largest pan-European conference and an annual gathering ofthe European eHealth communities – met May 10-12 in Bu-dapest, Hungary. The event consisted of more than 2,300 mem-bers of the healthcare community representing 60 countries,meeting to share and discuss initiatives to promote ways in whicheHealth can improve and sustain world-class healthcare.

The highest number of speakers yet, 120, spoke at the week-longevent. One conference session in particular stood out: PatientSelf-Service in Healthcare – Self Registration, Self Monitoring, mod-erated by Mr. Hyleco Nauta and Prof. Dr. A.J.P. Schrijvers from UMCUtrecht, along with the participation of Mr. Casper Marcussenfrom Denmark and Dr. Hans Kordy from University Hospital Hei-delberg in Germany. This conference session was an importantopportunity to focus attention on the increasingly active role thatpatients have in IT-enabled healthcare.

Additionally, the Leaders in Health IT Symposium, a new execu-tive level forum hosted by HIMSS Analytics Europe, was designedto provide top leaders from healthcare IT with the needed toolsand information to navigate in a changing healthcare landscape.

eHealth Week 2012 will take place in Copenhagen, Denmark onMay 7-9, 2012. For more information on the meeting, pleasevisit: http://www.worldofhealthit.org/.

Games for HealthBoston, Massachusetts / May 17-19, 2011

The seventh annual Games for Health conference met May17-19 in Boston, Massachusetts, bringing together hundredsof top researchers, health professionals and gamers fromaround the world. The largest Games for Health conferenceto date, the meeting aims to promote upon and developways in which videogames and videogame technologies canwork to improve healthcare.

The three-day event featured over 60 presentations, includ-ing an opening keynote from Dr. Martin Seligman, Directorof the Positive Psychology Center at the University of Penn-sylvania. New additions included a Ludica Medica Day, fo-cusing on medical modeling, simulation and learning, whichhelped to further discussion between medical simulationand serious games. This pre-conference event aimed to com-pliment larger medical Virtual Reality and simulation eventsand stressed their potential advantages for use in therapyincluding lowering costs, ease-of-use, and the ability to reacha new, larger audience.

Talks at Games for Health discussed topics such as activegaming, cognitive exercise, disease management, healthbehavior change, and biofeedback.

For more information on the meeting, please visit:www.gamesforhealth.org/index.php/conferences/gfh-2011/.

12

Combining Stress InoculationTraining with MedicalTraining for Combat Medics“Improvements in injury simulation technology are aimed at providingsuperior training for medics in front line care, both in terms of hands-onmedical instruction and stress management. The next generation of ICS isfocused on the development of prosthetic devices that allow medical spe-cialists to practice actual emergency medical procedures with simulatedorgans and tissue.”

By Nancy Ahmann

Stress Inoculation Training (SIT) is of-ten the umbrella term used to repre-sent a collection of coping strategiesprovided to the trainee. Often thoughtof as “mental armor,” SIT helps to “in-oculate” individuals to future potential-ly traumatizing stressors, teaching themto psychologically deal more effective-ly with the stressors. In 1988, a Nation-al Research Council study on enhanc-ing military performance found thatwhen a person is given knowledge offuture events, stress surrounding thoseevents is then reduced. In general, thisoccurs because stress is associated witha new, novel task. Stress training there-fore renders the task less novel and im-proves the trainee’s self-efficacy, whichin turn improves performance.

The goal of SIT is not to eliminatestress but to learn to respond adaptive-ly to stressful situations. The Virtual Re-ality Medical Center (VRMC) developsimmersive three-dimensional comput-erized virtual environments (VEs) forSIT for combat medics and other firstresponders.

During Virtual Reality stress inocula-tion training (VR-SIT), military person-nel “experience” highly stressful situa-tions in a VE while being physiologicallymonitored. Repeated exposure enablespersonnel to gradually become desen-sitized to stimuli that may initially elic-it such strong physiologic arousal thatperformance is impeded (i.e., “freezing

in the line of fire”) and psychologicaltrauma is more likely.

In SIT, individuals are provided with atool kit of coping strategies, which al-lows them to construct a personalizedcoping package and choose thosestrategies most efficacious for their in-dividual needs and for the particular

COVER STORY

Figure 1:Military medics practice lifesaving procedures on an actor with simulated injuries.


situation. These skill sets are developedwith the goal of helping with immediateneeds as well as future stressful situa-tions in a proactive defense against trau-ma. Some of the traditional componentsused in an SIT regimen include didacticteaching, problem solving, cognitive re-structuring, imaginal rehearsal, behav-ioral rehearsal, relaxation training, self-instruction, self-monitoring, and self-reinforcement.

In providing over 7,000 treatment ses-sions for a variety of psychological dis-orders through a combination of cogni-tive-behavioral therapy and physiologicalmonitoring over the past 15 years, in-vestigators at VRMC have noted thatsuccessful treatment of stress and anx-iety-related disorders is achievedthrough skills-based exposure trainingto increasingly stressful situations. Thistraining allows the patient or trainee toover-learn coping skills and develop asense of mastery, with the ultimate goalof improved performance and self-con-fidence in one’s ability.

VRMC’s Student State Assessment, athree-year study funded by Defense Ad-vanced Research Projects Agency(DARPA) completed in July 2005, includ-ed a combat medic training scenario inwhich medics received SIT training us-ing a computerized VE and, separately,VRMC’s Injury Creation Science (ICS)simulator prototype. The prototype em-ployed prosthetics to simulate a num-ber of battlefield injuries on human ac-tors. In these scenarios, injuries weresimulated with dynamic “bleeding”

wounds. In addition, trainees were ableto cut the “skin,” insert a chest tube, andstitch the wound closed. Participantssaid it was the most intense, realistictraining they had ever received.

Now VRMC is improving the injury sim-ulation technology to provide this ad-vanced training for medics in front linecare, both in terms of hands-on medical

instruction and stress management. Thenext generation of ICS is focused on thedevelopment of prosthetic devices thatallow medical specialists to practice ac-tual emergency medical procedures withsimulated organs and tissue. These pro-cedures include bypassing a compro-mised airway, inserting an intravenousport, preventing blood loss as a result ofarterial and venous wounds, dressingburns, and expanding a collapsed lung.Other injury simulation capabilities arecurrently under development.

The VRMC team believes that an SITcomponent may be equally importantto the acquisition of appropriate med-

ical triage and trauma training skills.Most medical training does not includea stress-hardening component, eventhough reports of high levels of stressand Posstraumatic Stress Disorder(PTSD) in medical personnel makes ev-ident the need for improved attentionto this growing problem. Although oth-er groups are developing training pro-grams for psychological resilience inmilitary personnel (e.g., Battlemind,Army Center for Enhanced perform-ance/ACEP, Warrior Reset), there remainsa division between these concepts andskills-based (hands-on) medical train-ing. VRMC’s approach is to blend SITwith skills-based medical training withthe added component of novel, highlyrealistic injury simulation technology(e.g., ICS). The intent is not to replaceother programs but to build upon andpotentially integrate these technologiesfor a more comprehensive and effectivemedical training experience.

VRMC foresees this type of fully-immer-sive, customizable training used notonly to enhance the skills of military

personnel, but also others who performin high-stress situations (doctors, emer-gency responders, etc.). Finally, it ishoped that this type of training can actas a preventative measure against PTSDand other stress-related reactions.

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“During Virtual Reality stress inoculation training (VR-SIT),military personnel ‘experience’ highly stressful situations in aVE while being physiologically monitored. Repeated exposureenables personnel to gradually become desensitized to stim-uli that may initially elicit such strong physiologic arousalthat performance is impeded (i.e., ‘freezing in the line offire’) and psychological trauma is more likely. ”

[ ]Nancy AhmannVirtual Reality Medical CenterU.S.A.

[email protected]

COVER STORY


Benefits of Stress Inoculation Training (SIT)

SIT presents a collection of coping strategies to the trainee

Trainee chooses the most efficacious for his/her individual needs/situation

Allows trainee to serve as a collaborator in constructing a personalized coping package tailored to his/her own requirements/experiences

Designed to develop coping skills for immediate problems and future stressful situations (proactive defense)

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Hemorrhage Control in theBattlefield: Role of Modelingand Simulation to SupportTraining of Combat Medics“Hemorrhage control is the most important life saving aspect in battlefield medi-cine. Approximately 85% of potentially survivable deaths are attributed to hemor-rhage. A Soldier can go into hypovolemic shock and bleed to death within min-utes after severing a large blood vessel. The Army is seeking innovative and real-istic ways to support hemorrhage control training of Combat Medics. When deal-ing with traumatic injuries, modeling and simulation play an important role increating realistic scenarios to support stress inoculation training. Realistic sce-nario-based training provides first responders with the ability to overcome initialreluctance to treat and opportunities to practice their procedural skills in a rele-vant environment.”

By Teresita Marie Sotomayor & Don Parsons

During the Vietnam War over 2,500Soldiers died due to hemorrhagefrom extremity wounds. In currentconflicts hemorrhage continues to bethe leading cause of preventabledeath in combat, therefore, it is theresponsibility of every Soldier to knowhow to control hemorrhage on thebattlef ield. For most extremitywounds the use of a temporarytourniquet has been essential in stop-ping life-threatening hemorrhage. Ifthe wound is not an extremity woundand a tourniquet is not applicable asin the case of neck, axillary, and groininjuries, the application of a hemo-static agent with pressure is neces-sary to control the bleeding. The lo-cation of the wound is the factor that

drives the tools necessary to controlthe bleeding. The more proximal theextremity wound the more difficultthe application of a tourniquet. Thesetypes of wounds currently necessitatethe use of a hemostatic agent in ad-dition to direct pressure and eventu-ally a pressure bandage to controlbleeding. Wounds of the axilla, groin,and neck can be fatal if a means ofcontrolling the hemorrhage is notreadily available.

Frequently, medics rely solely ontourniquets to stop bleeding for ex-tremity wounds. However, they needto have the experience of attemptingto use a tourniquet that may notwork on a very proximal wound.

This requires them to reevaluate theirintervention and successfully transi-tion to another hemorrhage controlmeasure if their initial attempt is un-successful. In addition, hemostaticagents are also taught as a means oftransitioning away from a tourniquetin the event of a delayed evacuationand the possibility of extremely pro-longed use of a tourniquet. Hemosta-tic agents are substances that pro-mote homeostatic coagulation whenapplied to a hemorrhaging injury. Useof such agents has drastically reducedthe number of deaths that could beprevented on the battlefield. In thelast decade, significant advances havebeen made on hemostatic agents.Each class of hemostatic agent differs

FEATURES


in application and mechanism of ac-tion; combat gauze is currently theagent recommended for use by the U.S.Army. There is currently a package ofcombat gauze in every Soldier’s Indi-vidual First Aid Kit (IFAK), and in everycombat lifesaver’s and combat medic’said bags.

Army Combat Training Schools andmedical simulation training centers relyon simulated capabilities to conduct re-alistic hands-on training and evaluationof hemorrhage control using tourni-quets and hemostatic agents.

The U.S. Army Simulation and Train-ing Technology Center (STTC) HumanDimension, Simulation and TrainingDirectorate, Army Research Laborato-ry (ARL) executed a three-year (FY07-10), joint Army Technology Objective(ATO) with the U.S. Army Medical Re-search and Materiel Command(MRMC), entitled Severe Trauma Sim-ulations. The mission of the ATO wasto research and develop innovativetechnologies to realistically simulatethe look, feel, and smell of severe trau-ma to prepare medics, combat life-savers, and Soldiers to deal with theinjuries encountered on the battle-field. The results from this effort pro-duced enhanced tools for realisticmedical training enabling the Army tomaintain better trained medics and toimprove the ability to save lives on thebattlefield.

By merging the latest special effectstechnology with material science re-search, prosthetic human tissue andwounds were developed for a realistic

live training capability. A kit containingextremely realistic simulated wounds, or“moulage” was developed based on userrequirements. Wound simulation, or“moulage,” is an integral part of scenario-based medical training, especially in live

training. This kit al-lows for the quick andeasy application ofprosthetic entry, exit,and shrapnel woundsfor live training exer-cises focused on en-hancing realism.

Another technologydeveloped under theSmall Business Inno-vative Research (SBIR)program to supportthe ATO, introduced

movement to enhance realism of thescenarios via animatronics technology.These two efforts are examples of tech-nologies that have been commercialized

and successfully transitioned to supportthe Warfighter. Research in severe trau-ma simulations continues with a focuson technologies to enhance realism andimmersion to support training. Devel-opment of these technologies has great-ly improved the realism of scenario-based training, effectively supporting thetraining of Army Combat Medics and al-lowing Soldiers to be immersed in rele-vant situations to conduct realistic, per-formance-based, hands-on training ofhemorrhage control.

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“Wound simulation, or ‘moulage,’ is anintegral part of scenario-based medicaltraining, especially in live training. Thiskit allows for the quick and easy appli-cation of prosthetic entry, exit, andshrapnel wounds for live training exer-cises focused on enhancing realism.”

Figure 1: An ICS Kitcontains prostheticappliances designedto affix to a humanactor or mannequinand consists of simu-lated skin, underlyingtissue, representationof organs or struc-tures, and a protec-tive layer next to thewearer’s skin.

Figure 2: TraumaFXTM is anend-state high fidelity simula-tor of a lower body injury usingstate-of-the-art special effectstechnology. TraumaFXTM canbe worn by human patient sim-ulators or human actors to sup-port realistic hemorrhage con-trol training. The systemprovides stress inoculationtraining to physically and emo-tionally prepare Soldiers to dealwith severe wounds.

[ ]Teresita Sotomayor, Ph.D.US ARL STTC Donald Parsons, PA-C, MPASDCMT

[email protected]://www.rdecom.army.mil/STTC/

FEATURES


The Telemedicine and Advanced Technology Research Cen-ter (TATRC), the Army’s high-technology medical pathfind-er, has been intensifying advances in wartime trauma train-ing through the use of advanced, and sometimesunexpected, approaches.

One of the most successful research and development ef-forts to date has been the COMETS manikin, designed fromthe ground up to be fully autonomous, ruggedized and pur-posed for trauma. COMETS was designed and developedby the CIMIT Simulation Group, led by Dr. Steve Dawson,and a team of researchers at Massachusetts General Hos-pital. The COMETS prototype was extremely successful andhas been commercialized by defense giant CAE, renamingit CAESAR.

When asked what makes CAESAR unique, Mark Owens, CAEHealth Care Vice President states, "CAESAR represents themost realistic and physiologically advanced trauma patientsimulator available while allowing learners to develop crit-ical thinking skills and core treatment modalities that areimportant in reducing morbidity and mortality in combatcare."

Other work sponsored by TATRC involves game-based ap-proaches to training. One example is a computer game forcombat medics who must respond to an improvised ex-

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U.S. Military Takes on High-Tech and High-Adventure toTrain for Wartime LifesavingThe Telemedicine and Advanced Technology Research Center (TATRC), theArmy’s high-technology medical pathfinder, has adopted an aggressiveapproach to revitalizing existing methods for trauma training includinggame-based approaches focusing on training higher order thinking skills, aswell as developing interactive virtual human personalities that will eventual-ly be integrated into advanced training robots.

By Thomas B. Talbot

FEATURES


Figure 1: CAESAR acts as a fully autonomous,ruggedized trauma patient simulator. 4

plosive device (IED) event. To encour-age innovation, separate awards weremade to both SimQuest and MYMIC,both leading medical game developers.The SimQuest version focuses on sim-plified patient encounters and triaginga large number of casualties, while theMYMIC game gets into more detail withfewer casualties.

Regarding the games’ approach, HarveyMagee, TATRC medsim technical direc-tor explains, “We wanted to focus ontraining higher order thinking skills.Games are a great format to do this be-cause they allow learners to try newthings and take risks. As sponsors, wesometimes maximize innovation by go-ing with parallel approaches to see whatthe different developer teams come upwith.”

Since 2009, TATRC has led a tri-serviceteam with $250 million in funding overfive years and has established theArmed Forces Simulation Institute forMedicine (AFSIM). It is hoped that muchgreater funding and an all-military ap-proach will achieve breakthrough gainsin medical training. The first fruits ofthis effort have been the Combat Casu-alty Training Consortia, two independ-ent teams that are to conduct thelargest comparisons between animalsand simulators for trauma training todate. It is hoped that the research will

identify areas where technology can re-place animals in training and identifyspecific areas where technology needsimprovement.

The AFSIM has continued the TATRCgaming tradition with three game-basedapproaches in 2010; one for anesthesiatraining, one using Microsoft Kinect™for physical therapy, and another formass casualty exercises. The mass ca-sualty game, CBRNE GAME by Break-away LTD, is designed to be an onlinemultiplayer real-time strategy simula-tion with large numbers of casualtiesflooding a hospital from both weaponsof mass destruction and explosive de-vice incidents. The training will focuson teamwork, resources and judgment.

Future plans to improve trauma train-ing are on an aggressive schedule. Thereis a significant focus on developing in-teractive virtual human personalitiesthat employ a natural language inter-face and are capable of sustained con-versations. Initial uses will include vir-tual human coaches for patients andvirtual standardized patients for train-ing. Eventually, the personality agentswill be integrated into advanced train-ing robots and intelligent talking tasktrainers. The intent is to overcome theartificial sensation of training on some-thing that the trainer may see as a hunkof plastic. Future simulators will more

convincingly emulate interactions of areal human casualty.

The fact that combat injuries are oftenbloody, disfiguring and grotesque takesa toll on people who care for the in-jured. Researchers are also asking iftrauma training can be conducted in away that improves the psychological re-silience of the medical force. Currentresearch also includes an investigationinto the sense of smell and how it con-tributes to the formation of traumaticmemories. Future efforts will tap intopromising results from Virtual Reality(VR) therapy and employ more game-based simulations and VR environ-ments.

TATRC has publicly shared the AFSIMlong-term strategy online and at theFebruary, 2011 Medicine Meets VirtualReality (MMVR) conference.

Additional details of current researchand future plans are available athttp://www.tatrc.org/ports _medSim.html.

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FEATURES


[ ]Major Thomas B. Talbot, M.D.US Army/TATRCUSA

[email protected]

Figure 2, 3: Screen shots from the SimQuest explosives event triage game.

The treatment of pediatric congenitalheart disease is hampered by the scarci-ty of relevant cases, the lack of integrat-ed data and the limited opportunities forclinical comparison among others. Yet,advances in pediatric cardiac surgery, in-terventional cardiology, intensive care andnon-invasive imaging have led to a sub-stantial increase in life expectancy formany patients with congenital heart dis-ease. However, difficult challenges stillpersist due to the evolving nature of achild’s heart and vascular system.

Since the development of the project’sproposal, Sim-e-Child (SeC), a project fund-ed by ICT for Health, European Commis-sion, has aimed to improve clinical out-comes of pediatric cardiology patients. Inorder to achieve better and more reliablerisk stratum, to improve and personalizetherapies, and to ultimately increase thepatient survival rate, SeC is focused on de-veloping comprehensive and accuratecomputer models from patient-specificdata and simulated physical constraints.

SeC aims to strengthen the impact of“Health-e-Child” (HeC), which was com-

pleted in April 2010. HeC had createdan international simulation and valida-tion environment for pediatric cardiol-ogy, supported by integrated data repos-itories. SeC is working to go beyond thestate-of-the art by providing compre-hensive and patient specific models foranatomy, function and hemodynamicsof the left heart, with a focus on thecongenital aortic arch disease and re-pair.

Sim-e-Child’s Grid Infrastructure

The first 16 months of work has seen SeCdevelop the first Trans-Atlantic platformfor large-scale simulations in cardiology.SeC’s clinical applications are being builton an evolution of HeC’s original grid in-frastructure based on the EGI Grid mid-dleware (the gLite technology and Euro-pean Grid Infrastructure - www.egi.eu)and the enabling GÉANT network, thattogether provide virtually unlimited com-puting power, data storage capacity andnetwork bandwidth.

The early stages of SeC’s work also sawthe conclusion of a significant infrastruc-

ture setup and migration, aimed at in-terconnecting HeC and SeC, with the ul-timate goal of making HeC's maturecomponents sustainable and therefore,reusable in SeC, while giving SeC a sig-nificant technical basis onto which fur-ther expansion will take place for the du-ration of the project.

Sim-e-Child’s Web Portal

The SeC Web portal is now well ad-vanced, and through public and privatesections, is providing users with accessto the grid and integrated applications.As a result of SeC’s first year’s work, thepartners have started utilizing the highbandwidth pan-European GÉANT re-search network to:

• Establish a multi-site, web-accessibledatabase of pediatric cardiology data, in-formation and knowledge for translation-al research.

• Develop a grid-based platform, support-ing the definition, execution and sharingof scientific cardiac modeling and simu-lations.

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Large Scale Simulations in Pediatric Cardiology:

Towards the PersonalizedVirtual Child HeartSim-e-Child has successfully created an “international simulation and validationenvironment for pediatric cardiology” and aims to move “beyond the state-of-theart by providing comprehensive, patient-specific models for the anatomy, functionand hemodynamics of the left heart, with a focus on the congenital aortic archdisease and repair.” This modeling helps in assessing aortic arch disease morecomprehensively and objectively and, in addition, allows to simulate the effects ofpotential interventions resulting in a more effective, personalized and predictivemanagement of pediatric cardiology patients.

FEATURES


By William W. McFadden & Michael Suehling

Some of the operational features include:

• The SeC Grid infrastructure and comput-ing resources, using a standard and inter-nationally recognized GridPMA certificate.The Portal is cross-platform and thereforeworks under MS W7/XP, major Linux distri-butions and Mac OS X.

• The SciPort database and interfaces formanipulating data and simulations' outputsis being integrated to the security infrastruc-ture so that it will be possible to enter Sci-Port directly once logged in the SeC portal.

By integrating the portal and the grid in-frastructure, SeC will provide pediatric car-diology professionals in Europe and the U.S.with a Virtual Physiological Human baseddecision-support system and virtual labo-ratory. This will enable them to constructand validate multi-scale and personalizedmodels of a growing child's heart and bloodvessels. Ultimately, this will support theirclinical decisions and allow better under-standing of their patient’s condition.

Sim-e-Child’s Heart Modeling Results of 2010

Besides technical interoperability require-ments elicitation and infrastructure bridg-ing, work focused also on the development

and validation of a comprehensive cardio-vascular anatomical model enabling firstpatient-specific hemodynamics simula-tions. The main achievements have been:

• The existing HeC heart models were val-idated by the clinical partners in the U.S.on MRI data from Tetralogy of Fallot (TOF)cases. Using linear regression and Bland

Altman plots, left and right ventricular sys-tolic (LV ESV and RV ESV), diastolic volumes(LV EDV and RV EDV) and ejection fractions(LV EF, RV EF) were compared betweenmanual and automated methods.

• The existing HeC heart modelswere extended by integrating andenhancing existing Siemens Cor-porate Research models, of the aor-tic and mitral valve. To exploit themorphological, functional andpathological dependencies and vari-ations of the different heart valves,the pulmonary valve (PV) and tri-cuspid valve (TV) have been mod-eled, in addition. The heart valvesrepresent a critical component forthe analysis, modeling, and simu-lation of the whole heart functionand this work represents the first

data-driven modeling of the completevalvular apparatus.

Patient-Specific Cardiac Blood Flow Simulations

Clinicians at SeC’s clinical centers wereprovided with the first, simulated, pa-tient-specific cardiac blood flow across

the entire cycle. Thanks to this work cli-nicians will, for instance, benefit from abetter understanding of the vorticitywhich can convey crucial informationabout the formation and dynamics ofpotentially harmful "spins." By integrat-ing these elements, SeC will provide pe-diatric cardiology professionals in Europeand the U.S. with a Virtual PhysiologicalHuman based decision support and vir-tual laboratory. This will enable them toconstruct and validate multi-scale andpersonalized models of a growing child'sheart and blood vessels. Ultimately, thiswill support their clinical decisions andallow better understanding of their pa-tient’s condition.

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“By integrating the portaland the grid infrastructure,SeC will provide pediatriccardiology professionals inEurope and the U.S. with aVirtual Physiological Humanbased decision-support sys-tem and virtual laboratory.”

FEATURES


[ ]William W. McFaddenLynkeusItalyMichael Suehling, Ph.D.Siemens AG Germany

[email protected]

Figure 2 (below): CFDblood flow simulation results basedon patient-spe-cific anatomicalmodel: Vorticitypattern in patient with bicuspid aorticvalve duringearly systole(left) and midsystole (right).

Figure 1 (above):Comprehensive

model of the heartillustrating thefour chambers

and valves.

The wail of an ambulance siren an-nounces the arrival of a trauma patientto the emergency department. Para-medics unload an injured woman fromtheir ambulance and rush her towardsthe emergency department. Inside, ateam of doctors and nurses await, readyto deal with her life threatening emer-gency. Intravenous lines are started toadminister life sustaining medication,breathing tubes and chest drains are in-serted and scans are performed on allparts of her body. “Call the operatingroom, we are coming up STAT!” is theconsensus from the doctor in charge.As paramedics and emergency depart-ment personnel fade into the back-ground, a new team of doctors andnurses in the operating room take overthe young woman’s care. After threehours of harrowing surgery, her vitalsigns stabilize, and she is transferred tothe Intensive Care Unit. In all, morethan 50 people will be involved in hercare in the first five hours after her carcrash. The efficiency and skill withwhich the team functions in this highintensity environment is the result ofyears of training and experience. Thisarticle will share some of the new meth-ods that trauma professionals are train-ing with today in order to provide assis-tance to people who suffer lifethreatening injuries requiring advancedmedical care.

History of Trauma Training

Education in trauma care has evolvedenormously over the years. Training canrange from a weekend refresher courseto yearlong training “fellowships” forsubspecialist trauma physicians. Manyof these educational experiences are es-sentially an apprenticeship where doc-tors, nurses or paramedical personnellearn their trades by a system of gradedresponsibility, initially observing seniorcolleagues, later assisting, and finally,performing the complex tasks on theirown.

In addition to the technical skills re-quired by medical personnel involvedin trauma management such as theplacement of life sustaining breathingtubes, medical educators are recogniz-ing the importance of expertise in non-technical skills in addition to experttechnical skills. Non-technical skills em-phasize the importance of human in-teraction in medical emergencies. Ad-vanced medical care is universallyprovided by a highly functioning teamof people. The model of the operatingroom is a perfect example of this: in or-der for a surgery to be successfully per-formed, a team of doctors and nursesmust work seamlessly together, commu-nicating in a language and according to

a set of rules that they all abide by. Whileeach individual must be an expert intheir specific technical field (i.e., sur-gery, anesthesia and nursing), they mustall have expert non-technical skills too(i.e., leadership, communication, dele-gation, cooperation).

High Fidelity Patient Simulation:New Tools for High Stakes Learning

Prior to this decade, non-technical skillswere not routinely taught to trauma careproviders, however, this is changing aseducators recognize the importance ofstrong teamwork and communicationin high stakes medical situations.

How do we teach and practice conceptslike “team work,” “communication” and“leadership” to trauma care profession-als? It is widely held that non-technicalskills are best taught by “doing,” but isit safe to let a novice trauma care trainee“practice” on a patient who is unstableand near death? Clearly the answer tothis question is “no.” Trauma care is highintensity and time pressured; complexdecisions must be made by individualsand by the team in seconds or minutesin order to save patients’ lives. High fi-delity patient simulators may hold thekey to teaching technical and non-tech-nical skills to junior trainees.

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Current Concepts in TraumaTraining: New Applications forHigh Fidelity Patient Simulation“Trauma is multidisciplinary by nature; patients commonly have multipleinjuries and the trauma team leader must be able to work with his team torapidly assess, simultaneously treat and diagnosis injuries, and quickly cre-ate a resuscitation plan that will involve multiple medical specialists.”

By Mark P. Vu & James W. Price

FEATURES


High fidelity simulation is a trainingmethod long employed in industriessuch as aviation and engineering. Incommercial aviation, professional pilotsparticipate in regular training on multi-million dollar flight simulators. Thesesimulators replicate emergency in-flightscenarios so that pilots can practice theirresponses to emergency situations inthe cockpit. Their training includes non-technical skills such as communicationskills and leadership in a crisis situation.Similarly, medicine is using this modelto teach these same non-technical skillsin trauma care. Air medical crews work-ing on rescue helicopters rehearse theirtreatment protocols for trauma patientsinside the modified fuselage of a heli-copter that doubles as a classroom. Theinside of the mock-helicopter cabin isidentically configured to their usual res-cue aircraft, except that there is a man-nequin in the stretcher in the place ofa real patient.

High fidelity patient simulators are be-ing used in hospitals throughout theworld to teach similar skills to physiciansand nurses. Trauma is multidisciplinary

by nature; patients commonly have mul-tiple injuries and the trauma teamleader must be able to work with histeam to rapidly assess, simultaneouslytreat and diagnosis injuries, and quick-ly create a resuscitation plan that willinvolve multiple medical specialists.High fidelity patient simulator laborato-ries are designed to replicate a traumabay or operating room almost identical-ly. These rooms will have real equip-ment, medication, anesthetic and surgi-cal equipment, as well as a highlysophisticated mannequin that providesbiofeedback to the doctors based ontheir treatment decisions during thesimulated scenario. Mannequins can“breathe” and “talk,” and trainees canperform procedures similar to real trau-ma situations. Trauma teams are able torehearse their coordinated response toa complex trauma patient in real-time.The mannequin’s vital signs (i.e., heartrate, and blood pressure) can be madeto improve or deteriorate depending onwhat the instructor is trying to teach thetrauma team. Classes are video record-ed, and after the case is completed, adebriefing occurs allowing the team to

critically analyze their performance. Thistrauma training model was used to pre-pare the multidisciplinary trauma teamsfor the Vancouver-Whistler 2010 OlympicGames with great success.

Trauma is a dynamic, high stakes spe-cialty of medicine that requires the co-ordinated, specialized technical and non-technical skills of multiple speciallytrained medical personnel. New educa-tional tools, such as High Fidelity Pa-tient Simulators, are helping trauma careeducators train the next generation ofexpert trauma specialists.

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[ ]Mark P. Vu, M.D. FRCPCJames W. Price, M.D. MEd FRCPCDepartment of Anesthesiology and Perioperative CareVancouver General HospitalCanada

[email protected]

Figures: Vancouver-Whistler 2010 Olympic Trauma Team rehearse on a high fidelity patient simulator. Photo provided

courtesy of Dr. Tom Phu and Dr. Orlando Hung.

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Trauma Teams and Training:

Making the SumGreater Than the Parts“The term ‘simulation’ spans a wide variety of formats, from the low-techactor portraying a standardized patient to high fidelity mannequin-basedhuman patient simulators and Virtual Reality-based task trainers. In fact,simulation includes any technology or process that recreates the contex-tual background of a healthcare environment ... ”

By Marjan Siadat & Rosemarie Fernandez

Trauma is the leading cause of death inthe first four decades of life, with trauma-related injuries constituting more than25% of all emergency department visitsin the U.S. In 1980 the American Collegeof Surgeons introduced the AdvancedTrauma Life Support (ATLS) system as anevidence-based approach to providingtrauma care. While ATLS does recognizethe importance of team member interac-tions and leadership performance, farmore time and attention is paid to tech-nical skill development versus teamworkand team processes, e.g., communication,coordination, and situation monitoring.Unfortunately, review of the literature sug-gests that these teamwork competenciesare critical to providing safe and effectivetrauma care.

Teams in Healthcare

Over 50 years of psychological researchdemonstrates that teams collectively pos-sessing high levels of expertise, resources,and commitment to success can still failwithout strong teamwork skills. Currentliterature goes a step further to state that,in fact, it is teamwork that guarantees ef-fectiveness. In other words, the sum isonly greater than the parts when team-work is highly developed. This is especial-

ly true for interdisciplinary action teamssuch as aircrews, military command andcontrol, and trauma teams where special-ized expertise is required under uncertainand time-pressured conditions. Klein, etal. describe trauma teams as extreme ac-tion teams, “whose members (1) cooper-ate to perform urgent, highly consequen-tial tasks while simultaneously (2) copingwith frequent changes in team composi-tion, and (3) training and developingnovice team members whose servicesmay be required at any time.” In actionteams, the quality of teamwork and teameffectiveness often means the differencebetween life and death.

In 2008 a multidisciplinary group of ex-perts in healthcare and team performancemet to propose a core taxonomy of team-work competencies for emergency med-ical teams. This taxonomy was later adopt-ed at the 2008 Academic EmergencyMedicine Consensus Conference. Whilenot specific to trauma teams, this taxon-omy addresses the functions and process-es critical for extreme action teams.Deficits in these key competencies, e.g.,back-up behavior, coordination, commu-nication, and leadership, have been shownto negatively impact clinical outcomes intrauma patients. Fortunately, the team lit-

erature demonstrates that well-designedtraining can improve team performanceand mitigate errors in interdisciplinary ac-tion teams.

Healthcare Simulation-Based Training and Assessment

Simulation has been used in healthcare,aviation, and military team training. Theterm “simulation” spans a wide variety offormats, from the low-tech actor portray-ing a standardized patient to high fideli-ty mannequin-based human patient sim-ulators and Virtual Reality (VR)-based tasktrainers. In fact, simulation includes anytechnology or process that recreates thecontextual background of a healthcare en-vironment, allowing providers the oppor-tunity to experience an authentic clinicalinteraction with patients and other health-care team members. Simulation-basedtraining does not rely on chance encoun-ters but rather creates a need for team in-teraction. Events begin with a “trigger” toactivate the team and create the require-ment for some type of team interaction.Well-designed event sequences are alsocareful to minimize the interdependenceof performance quality. This allows edu-cators and researchers to identify not onlywhat happened (outcome measures), but

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also why it happened (process measures).As such, simulation can provide a plat-form for training and assessment that isdiagnostic of individual, team, and, poten-tially, systems-based threats to ensure suc-cessful performance.

Simulation in Trauma Training

The use of simulation in trauma teamtraining mirrors its use in aviation andother areas of healthcare, where the fo-cus is interdisciplinary communicationand interaction. Scenarios, whether cre-ated using a life-sized human mannequinor VR-based avatars, force participants tointeract under time-pressured and com-plex conditions. Teams must then utilizetheir individual knowledge and teamworkskills to treat a patient(s) in an appropri-ate manner. Additional complications,such as power outages, mass casualties,and difficult coworkers can be broughtinto the scenario to meet training objec-tives. Simulations can target specific com-ponents of teamwork to help teams un-derstand the various roles andresponsibilities inherent in a trauma team.Such shared understanding (shared men-tal models) positively impacts team per-formance, especially under stress.

Mannequin-based simulation training hasthe advantage of allowing healthcare teammembers the opportunity for hands-ontraining. Events happen in real-time, of-ten in an environment created to mimica true emergency room or operating roomsetting. In fact, technology now allows forportable mannequins that can be broughtdirectly into actual patient care areas, fur-ther enhancing the richness of the train-ing experience by allowing trainees expe-rience within their own system and withtheir usual equipment. In a small pilotstudy, Knudson, et al. demonstrated im-proved teamwork skills in individualstrained using mannequin-based simula-tion combined with didactic training ver-sus didactic training alone. These resultsare supported by a study conducted byFalcone, et al., demonstrating improvedtrauma management of pediatric patientsfollowing multidisciplinary simulation-based trauma team training.

While mannequin-based team trainingholds significant promise for improvingteam performance, there are also limita-

tions that are important to mention. Firstand foremost, high fidelity mannequin-based simulations can be quite costly,both from equipment and personnel (fac-ulty trainer) standpoints. Simulation ses-sions are complex to develop, and assuch, significant faculty time is requiredto develop each case. Additional costs areincurred when trainees are pulled fromtheir work duties to participate in train-ing, and often release time is difficult toobtain. Furthermore, mannequin-basedtraining is, by design, hands-on. Trainingmust therefore be done in small groupsto allow team members the opportunityto interact as they normally would. Thisplaces an additional burden on facultytrainers, as many more faculty hours arerequired to conduct mannequin-basedsimulations versus a large lecture-baseddidactic session.

To address some of these limitations, re-searchers have turned to technology inthe form of computer-based virtualworlds. Medical virtual worlds are housedon the Internet and use many of the fea-tures common in the gaming industry,including avatars. Trainees can thereforetake on the role of an avatar and interactin a virtual patient care scenario as aphysician, nurse, etc. Patient avatars (orrobotars, if prescripted computer charac-

ters) provide opportunities for traineesto interact via their avatars. In this virtu-al world, teams can practice teamworkand trauma skills through their avatarsfrom remote sites spanning the globe.Multiple patient triage, challenging envi-ronments, and tactical missions can allbe programmed in to meet the objectivesof the trauma training. Metrics, such astime to critical action (e.g., IV start, bloodtransfusion, etc.) or teamwork (e.g., com-munication, coordination of functions,etc.) can be assessed to provide measuresof individual and team performance. Vir-tual world-based training is not hands-onand can be challenging for gamingnovices, however, it does offer an alter-native approach to team training that canovercome some of the logistical chal-lenges inherent to large-scale mannequin-based training programs.

[ ]Marjan Siadat, M.D., M.P.H.Rosemarie Fernandez, M.D.Wayne State University Schoolof MedicineU.S.A.

[email protected]@comcast.net

Figure 1: Trainees work together in arealistic resuscitation setting to care fora critically ill "patient" simulator.

24

PRODUCT

Trauma FX

METI LIVE

Injury Creation Science

(ICS) Kits

ActFast Anti Choking

Trainer

Bioterrorism Simulated

Medical Emergency

Response (BioSimMER)

Ultimate Hurt

Trauma Team

VIRGIL

iStan

Emergency Room:

Code Red

DESCRIPTION OF PRODUCT

a line of durable, wireless, trauma training mannequins combined with

special effects technology and made with artificially formulated tissue,

the simulated battlefield injuries prepare professionals for real-life

medical emergencies and stressful conditions

an educational tool set in a virtual world, delivers medical simulation

training by recreating virtual hospitals with existing patient simulators;

patients are virtually controlled by an operator

developed from a physiologically-based research program, consists of

the cricothyrotomy, needle compression, and wound management skills

trainers; each trainer is built with prosthetic tissue and simulated wounds

to provide medical trainees with practice and life saving skills for

emergencies with real injured patients

learning tool for CPR students, Anti Choker Trainer vest prepares indi-

viduals for emergencies related to choking and breathing; during prac-

tice, a foam plug will shoot into the air, indicating both accuracy and

survival in a realistic scenario

VR-based tool prepares individuals to respond in fast-paced, stressful

situations like terrorist attacks; in this virtual scenario users are expect-

ed to act quickly to address casualties and injuries

mannequin contains realistic aspects that enforce practice on itself rather

than patients; various injuries can be simulated, allowing students to

perform learned procedures on the human-like subject

a 3-D Nintendo Wii game used as a surgery simulator, patients have

visible injuries while characters (controlled by the players) perform

treatments based on their specializations

system consists of an anatomically correct mannequin with a PC-based

graphical interface that tracks the internal position of chest darts and

chest tubes during training – because any mistakes made on this sim-

ulator could potentially occur in real-life instances, the system encour-

ages practice and learning in a simulated trauma scenario

high-performance, realistic, wireless patient simulator with reactive

eyes, among other interactive features, and ruggedized body for med-

ical education and critical care in the classroom or in the field

PC game designed to place players in different emergency room sce-

narios that contain real-life medical injuries, tools, and instruments;

users play the role of an ER doctor and are expected to stabilize pa-

tients, determine the cause of various conditions, and administer ef-

fective treatments

MANUFACTURER

Kforce Government

Solutions

Meti

Virtual Reality

Medical Center

ActFast Medical LLC

Sandia National

Laboratories

The Israel Center for

Medical Simulation

Atlus

The Simulation

Group at CIMIT

Meti

Legacy Interactive

Product Comparison Chart:Trauma Training Devices

PRODUCT COMPARISON

RESEARCHER:

Kimberly Huynh, Editorial DepartmentC&R Magazine

www.vrphobia.eu, [email protected]

Wounds of War III: Coping withBlast-related Traumatic BrainInjury in Returning TroopsEDITED BY:Professor Dr. Brenda K. Wiederhold, Ph.D., MBA, BCIA

The post-conference book reflects the key topics

discussed in the four sections at the workshop:

First Session - Characterization of TBI

Second Session - Diagnostic and Assessment

Issues Surrounding TBI

Third Session - Treatment of TBI

Fourth Session - Quality of Life

WOUNDS OF WAR III: COPING WITH

BLAST-RELATED TRAUMATIC BRAIN

INJURY IN RETURNING TROOPS

On February 20-22, 2011 the NATOAdvanced Research “Wounds of War III:Coping with Blast-related Traumatic BrainInjury in Returning Troops” drew over 30eminent experts from 11 countries to dis-cuss the topic of increased TraumaticBrain Injury (TBI) in our service men andwomen.

Held in Vienna, Austria at the HotelRegina, discussion topics includedincreased TBI as a result of missions, aswell as how TBI may be prevented.Research has shown that those who haveserved in both combat missions andpeacekeeping operations are at anincreased risk for TBI. The ultimate aim ofthe workshop was critical assessment ofexisting knowledge and identification ofdirections for future actions. The co-organizers of the workshop alongsideProfessor Brenda K. Wiederhold includedProfessor Kresimir Cosic, Professor MarkD. Wiederhold and Colonel Carl Castro.

Full papers were published with IOS PressTO ORDER: [email protected]

The Interactive Media Institute9565 Waples Street, Suite 200 – San Diego, CA 92121

phone: (858) 642-0267 – fax: (858) 642-0285 – www.interactivemediainstitute.com

“The liver is the most frequently injured intra-abdominal organ in situationsinvolving abdominal trauma. However, hepatic surgery remains an essentiallydifficult procedure due to the high vascular variation of the liver’s anatomy ...our work aims at overcoming these limitations by offering preoperativesurgical simulation based on patient-specific modeling.”

26


FEATURES

Preoperative Patient-Specific Liver SurgicalSimulation

By Luc Soler, Didier Mutter & Jacques Marescaux

Violent behavior and road accidentsaccount for the majority of liver in-juries. Liver injuries, secondary to blunttrauma, are typical in Europe, whilepenetrating injuries are the most fre-quent in North America. If liver trau-ma represents between 15-20% ofblunt trauma, its mortality rate growsto 50% of all blunt trauma deaths. Sur-gical procedures remain the optionthat offers the foremost success rate.Regretfully, surgery remains complexdue to huge vascular variations in theliver vascular anatomy from one pa-tient to another. Our work, developedwithin the scope of the European PASS-PORT Project of the 7th FrameworkProgramme, aims at overcoming theselimitations by offering preoperativesurgical simulation based on patient-specific modeling.

Geometrical and Anatomical Modeling

There is a large set of medical imageprocessing methods providing liver seg-mentation. These systems are usuallylimited to the liver and its internal

structures, which is of course not suf-ficient to develop patient-specific he-patic surgical simulation. Indeed, suchsurgery requires the modeling of sur-rounding organs in order to be realis-tic enough. To overcome such limits,we have developed and validated a newmethod based on hierarchical segmen-tation of visible organs, from the sim-plest to the most complex. Thismethod allows us to visually extract

the main organs of the thoraco-ab-dominal area. The second step then de-lineates veins, the liver and its inter-nal lesions.

Anatomical Patient Modeling

For many years, the anatomical seg-mentation of the liver has been thetopic of many discussions. The Couin-aud segmentation is currently the ref-erence used by most surgeons but iscriticized by authors who point out thelimitations or even the errors of thatsegmentation. Couinaud himself de-scribed such topographic anomalies in

2002. In order to solve this problem, wehave defined a new correct functionalanatomy. This new definition is basedon a simple rule applied specifically to

“Combined with the SOFA open-source framework,resulting patient-specific models will lead to a preop-erative surgical simulator that could be used for plan-ning and education. Moreover, the multicentric clini-cal validation will be pursued in order to prove clini-cal benefits of the new anatomical modeling in link

with patient-specific surgical planning.”

each patient: two portal venous sub-networks can only be in a same seg-ment if and only if they come from thesame crossing of a same portal branch.For the sake of rigor and in order touse that definition in clinical routine,we proposed to implement a labelingsystem based on numbers and lettersclose to Couinaud’s classification. Ourvalidation shows that the new labelingis always topologically correct, due tothe definition.

Software Integration: From Modeling to Surgical Planning

We have first developed an Image View-er Software working on Windows, Lin-ux and MacOS. VR-Render WeBSurgLimited Edition©IRCAD2010, availablefreely on WeBSurg, (www.websurg.com/softwares), has been downloaded andis used by more than 8,000 users. Wehave then developed a virtual surgicalliver resection planning software. VR-Planning©IRCAD2010 offers the oppor-tunity to resect the liver into severaltopological components. Thus, it allowsfor multi-segmentectomy. It also auto-

matically computes the future liver re-main rate and volume after resection.

Clinical Validation

In order to collect anonymous patient-specific data and to validate 3-D mod-eling and surgical planning software,we have opened a free online servicefor the European PASSPORT projectpartners. More than 300 clinical cas-es have been modeled since 2008.Each 3-D modeling was realized andvalidated by experts using VR-Renderand VR-Planning software. The result-ing algorithm shows 93% sensitivityand 94% specificity, 1.46mm of aver-age precision in three-minute process-ing. First clinical applications showthe great benefits of using such soft-ware for preoperative hepatic liversurgery.

Future Applications

Our work, developed in the scope ofthe European project PASSPORT, hasallowed the development of patient-specific geometrical and anatomical

modeling. Combined with surgicalplanning software dedicated to liversurgery, it offers new possibilities al-lowing the improvement of hepaticsurgery. The last year of the projectwill aim at finishing software integra-tion by adding mechanical and bio-logical modeling. Combined with theSOFA open-source framework, result-ing patient-specific models will leadto a preoperative surgical simulatorthat could be used for planning andeducation. Moreover, the multicentricclinical validation will be pursued inorder to prove clinical benefits of thenew anatomical modeling in link withpatient-specific surgical planning.

27


FEATURES

[ ]Luc Soler, Ph. D.Didier Mutter, M.D., Ph. D.Jacques Marescaux, M.D.,F.R.C.S., F.A.C.S.IRCAD/EITS InstituteFrance

[email protected]

Figure 1: Patient-specific geometrical modeling: image segmentation followed by 3-D mesh generation.

Figure 2: Preoperative surgical simulation of three different liver resections.

Since September 2001, the Army TraumaTraining Center (ATTC) at the Universityof Miami has provided instruction andtraining in the management of combatcasualties for every Forward Surgical Team(FST) deployed to Iraq or Afghanistan.Each FST is composed of medics, nurs-es, and physicians with varying degreesof combat experience. It is therefore es-sential that teams receive intensive, fo-cused training in clinical management,teamwork, and resource utilization in acontrolled environment rather than onthe battlefield. Participants are subject-ed to a two-week educational rotationcomposed of didactic instruction, cadav-eric surgical exposure training, and aporcine-model mass-casualty exercise.An essential component of FST traininginvolves simulation of acute injury usingan advanced clinical simulator, the Sim-Man 3G.

The SimMan 3G (Laerdal Medical, Wap-pingers Falls, NY) is a patient simulationmodel with advanced clinical functional-ity combined with vital signs monitoringand an interactive software suite. It al-lows for testing and training in standard

ACLS resuscitation protocols, as well asuser-customized treatment scenarios.Mannequins are capable of manifestingclinical symptoms, such as pupillary di-lation, eye secretions, blinking, breath andcardiac sounds, palpable pulses, convul-sions, hemorrhage, and other signs ofshock. Models also demonstrate physio-logical responses to treatment with med-

ications as well as procedural interven-tions (chest decompression, intubation,ventilation, thoracentesis, defibrillation/cardioversion, foley catheterization). Thedevice has been deployed as an instruc-tional tool in several U.S. Army MedicalSimulation Training Centers around the

world for the simulation of battlefieldinjuries.

At the ATTC, the SimMan 3G is utilizedas an adjunct to the clinical instructionprovided at Ryder Trauma Center, a lev-el 1 trauma center located in Miami-Dade country with approximately 4,500admissions per year and a high frequen-

cy of penetrating injury. Participants re-ceive simulation training before start-ing the rotation and once more uponits completion. Prior to beginning theexercise, trainees are given the oppor-tunity to survey the room and familiar-ize themselves with the equipment.

Forward Surgical Teams deployed to Iraq and Afghanistan “receive intensive,focused training in clinical management, teamwork, and resource utilizationin a controlled environment rather than on the battlefield.” The use of realis-tic patient simulation models, such as the SimMan 3G, serve as a valuableadjunct to more traditional methods of training and clinical instruction.

“The SimMan 3G (Laerdal Medical, Wappingers Falls,

NY) is a patient simulation model with advanced clin-

ical functionality combined with vital signs monitoring

and an interactive software suite. It allows for testing

and training in standard ACLS resuscitation protocols,

as well as user-customized treatment scenarios.”

28


FEATURES

Pre-Deployment SimulationTraining for U.S. ArmyForward Surgical Teams

By Mark L. Ryan et al.

They are then brought into an adjacentroom, where they are informed of thepatient’s mechanism of injury and pro-vided a brief overview of their clinical

status. The model is made to simulatea patient who has suffered either a blastinjury or a gunshot wound. Participantsare expected to rapidly address the pa-tient’s injury while adhering to Ad-vanced Trauma Life Support Protocols.Over the course of the exercise, progressis monitored by the instructor via a wire-less tablet PC. The instructor is also ableto input changes in clinical status to fur-ther challenge the team as necessary.The team then participates in an AfterAction Review (AAR) to evaluate theirclinical performance. This simulationexercise serves as a valuable tool to as-sess team readiness prior to the initia-tion of their clinical duties, as well asfor evaluating improvements in per-formance upon completion of their ro-tation.

Although the device has proven ex-tremely useful for clinical simulationand team readiness, there are multiple

scenarios for which the use of a simu-lator is not yet feasible. The limitedportability of these devices has restrict-ed their utility in our mass-casualty ex-ercises, where rapid triage, treatment,and evacuation from the patient treat-ment areas are required to adequatelysimulate combat conditions. Also, thereis currently no adequate simulation toolfor the advanced operative managementof battlefield injuries. A model capableof providing instruction in methods ofhemorrhage control, organ exposure,and patient stabilization prior to evac-uation would be extremely valuable inproviding a consequence-free environ-ment in which to hone these skills. An-imal and cadaveric training are extreme-ly expensive and labor-intensive. With

current funding limitations and in-creased scrutiny of animal exercises, itis essential that novel, cost-effective sim-ulation models are developed in orderto alleviate our current dependence onthese methods.

29


FEATURES

[ ]Mark L. Ryan, M.D.Chad M. Thorson, M.D.Christian A. Otero, M.D.LT COL George D. Garcia, M.D.University of Miami Miller Schoolof Medicine, Ryder Trauma CenterU.S.A.

[email protected]

Figure 1 (left): Simulation exercisesare conducted in a recreation of asurgical tent similar to that used inthe field.

Figure 2 (below): Initial assessmentof a simulated patient by members ofa Forward Surgical Team.

“[SimMan 3G] has beendeployed as an instructionaltool in several U.S. ArmyMedical Simulation TrainingCenters around the world forthe simulation of battlefieldinjuries.”

Medicine has a long tradition of learn-ing within a clinical environment underthe watchful eyes of experienced super-visors. While this model still forms thebackbone of most post-licensure med-ical education, the old adage of experi-ential learning, “See one, do one, teachone,” has fallen by the wayside in favorof more controlled, deliberate, and evi-dence-based curriculum delivery. Medi-cine has been slow to take up simulationas a means to formalize learning, butconcerns about patient safety resultingfrom physicians learning in practice, re-duced resident work hours limiting op-portunities for patient contact (and thuslearning), and increasing evidence in sup-port of competency-based educationmodels have stimulated acceleratedadoption of new methods. Thankfullytechnology, and more importantly, thefields of cognitive psychology and learn-ing theory, have also risen to the chal-lenge. Trauma care is particularly suitedto the use of simulation. The dynamic,fast-paced and diverse practice of re-sponding to acute severe injury com-bines elements of protocol-driven prac-

tice with quick information processing,complex decision-making and effectiveteam management. Simulation showspromise to help with all of these dimen-sions of care, but the most effective useof simulation may not necessarily be thehigh-tech Virtual Reality wonders thatmight come to mind. Sometimes, sim-ple solutions matched to specific educa-tional needs are all that is required.

Effective trauma care is contingent uponskillful performance of procedures. Highfidelity (life-like) part-task trainers (phys-

ical models simulating various body or-gans and cavities) have been developedand deployed to teach the mechanics ofindividual procedures with great effect.

Even low fidelity models have beenshown to improve subsequent perform-ance of procedures on real patients (Fig-ure 1). Such simulations can be deliv-ered in a laboratory environment outsideof a formal trauma resuscitation roomand can be delivered to large numbersof learners at once, increasing the ap-peal. A common scenario involves agroup of learners rotating from stationto station with a different procedure ateach station supervised by a senior fac-ulty member. In addition to traditionalmeasures such as time on task, error

rates and global assessment of end re-sults, technology has allowed the use ofhaptic responses, time-motion analysis,pressure sensing, and paucity of move-

“Simulation has allowed researchers to further their understanding of how cer-tain factors in a learner’s environment can affect learning and performance ...One particularly interesting line of research is into the effects of stress on learnerperformance ... These findings have huge implications for the role of repeatedexposures, desensitization protocols and explicit stress mitigation teaching thathas thus far not been part of most medical education curricula.”

30


FEATURES

Simulation in TraumaEducation – More ThanJust “How Real is That?”

By Glen Bandiera

“Beyond the procedures themselves, decision-making iscritical to successful trauma care. To effectively teachand assess this, it is desirable to replicate the clinicalenvironment as closely as possible, and computerizedhigh f idelity simulation clearly is the preferred choice.”

ment scales to gauge learner progress.The ability to create “variations on thenormal” (e.g., anatomical variations orunanticipated swelling of the upper air-way during an attempt to pass a tubeinto it) has been introduced to test alearner’s response to complications. Inaddition, portable technology has al-lowed computerized mannequins to beembedded into a real environment (forexample, placed in a real emergency de-partment treatment room to carry outa pre-planned specific simulated caseduring a regular shift) or into non-tradi-tional educational environments suchas a simulated mass casualty incident ina local gymnasium.

Beyond the procedures themselves, de-cision-making is critical to successfultrauma care. To effectively teach and as-sess this, it is desirable to replicate theclinical environment as closely as possi-ble, and computerized high fidelity sim-ulation clearly is the preferred choice.Learners must be able to recognize thecontext, there should be minimal needfor them to suspend disbelief, and mostimportantly, they must be able to trans-late what they learn back and forth fromthe simulation lab to real life. Mock trau-ma resuscitation rooms and trauma op-erating theaters are easily created and asingle simulation lab can be convertedfrom one to the other in about 30 min-utes. When outfitted with all necessarymedical equipment and equipped with

re levant rea l - t imemonitoring and on-line operator control(to allow a tailored re-sponse to learner ac-tions), almost any clin-ical contingency canbe replicated to test alearner’s ability tothink on the fly. As im-portant as the technol-ogy are the cases usedfor teaching, includingdetailed goals and ob-jectives for the case,precise scripts androles for all partici-pants, and clear expec-

tations for performance including, if inan evaluative setting, what constitutessatisfactory versus unacceptable perform-ance. The development of such cases re-quires considerable time and expertiseand has been a major limiting factor tothe effective deployment of simulationas a teaching and evaluation method.Advances in these areas, informed by cur-riculum development theory and sup-ported by on-line repositories and li-braries, have helped the field moveforward in recent years.

More than anything, trauma care is aboutteamwork and simulation has been suc-cessfully adopted to test teams, ratherthan individuals. Despite the fact that in-dividuals from multiple healthcare pro-fessions are expected to work togetherin practice, true interprofessional educa-tion, wherein practitioners from thesedisciplines learn with and from each oth-er, is new. Simulation has provided an op-portunity to embrace this form of edu-cation and focus on skills that have untilrecently not been explicitly taught. Cri-sis resource management techniques,adopted from the airline industry by thespecialties of anesthesia, critical care andemergency medicine/trauma, haveformed an appealing basis for establish-ing performance and evaluation stan-dards for teams. Designing scenarios andevaluating the participants not on indi-vidual decision-making and technicalskills but rather on communication, in-

terpersonal dynamics and role aware-ness, is seen as a ripe frontier and is thefocus of ongoing research in medical ed-ucation.

Finally, simulation has allowed re-searchers to further their understandingof how certain factors in a learner’s en-vironment can affect learning and per-formance. Until the advent of realisticsimulation, it has been difficult to suffi-ciently create and control an environ-ment for experimentation of this type totake place. One particularly interestingline of research is into the effects ofstress on learner performance. By meas-uring perceived stress using validatedquestionnaires and physiologic stress us-ing salivary cortisol levels, it has beenshown that careful variations in a sce-nario can significantly vary the stress ex-perienced by a participant without nec-essarily changing the complexity of thedecisions, procedures or medical care re-quired. Researchers have shown that in-creased stress can have a negative im-pact on performance of complexcognitive tasks and that this effect canbe minimized with repeated exposure.These findings have huge implicationsfor the role of repeated exposures, de-sensitization protocols and explicit stressmitigation teaching that has thus far notbeen part of most medical education cur-ricula.

For complex, high stakes fields like trau-ma care, where the real environment isunpredictable and hard to control, sim-ulation has proven to be an invaluableaid to educating the future generationof practitioners. With ongoing focus andjudicious deployment, we can expectsafer, more evidence-based educationand care in the future.

31


FEATURES

[ ]Glen Bandiera, BASc, M.D., MEd,FRCPCSt. Michael’s HospitalCanada

[email protected]

Figure 1: More basic simulation to test motor skills.

Ask the Expert:Robert Madelin

Brenda K Wiederhold: I am here today atthe European Commission in Brussels, Bel-gium with Mr. Robert Madelin. Thank youfor this opportunity Mr. Madelin. In 2010you were appointed to a new position inthe Commission. Can you tell me whatposition that is please?

Robert Madelin: Yes, I was appointed inApril 2010 as the Director General for theInformation Society, which means that Icoordinate that part of the Commission’swork that deals basically with research inICT and policymaking and regulatory in-terventions across the range of electroniccommunications and audiovisual media.

BKW: Excellent. I want to ask you somemore about your current position, but firstI want to take a step back and read yousomething I found about your previous po-sition and let you comment on that. It wassaid of you, “Madelin had transformed theway the Health and Consumers Directoratewas run. He took risks and established whathe called cooperative voluntarism as thenew way of doing things, getting stakehold-ers to sit around a table and sign up to vol-untary commitments as an alternative tolegislation.” Can you speak to that please?

RM: Well I think that it’s a bit too flatter-ing in the sense that the conception ofhaving cooperative voluntarism is some-thing that has been around both in Eu-rope and I think in many parts of the world,as an efficient alternative to some previ-ous state interventions. So I wouldn’t sayI invented anything. But this past decadein Europe has been a good time to runsuch experiments and in particular in2004, ‘05, ’06 where we were looking at is-sues like controlling the advertising of high-fat-salt-sugar food to children, promotingphysical activity, encouraging a reductionof harmful use of alcohol. All these issuesturned out to be very good candidates formulti-stakeholder interventions and at thesame time, the different stakeholders bothin civil society, health professions and thecorporate sector were ready to try.

BKW: So right time, right place?

RM: Yes.

BKW: And in your current position? Whatdo you see as some of the things that youwant to accomplish?

RM: Well in a sense I am lucky because I

come to this job at the time that the newCommission has adopted a "Digital Agen-da for Europe," which really covers thewhole set of issues where this part of theCommission should be active. Getting theresearch protocols right for the next ten,fifteen years is a big piece of the discus-sion in the current oncoming years andsimilarly implementing better regulatoryframeworks so that the Internet can real-ly take off in Europe like everywhere elseas a good basis for helping citizens to havemore of what they want to have – betterlives.

BKW: And had you always been in the fieldof healthcare legislation policy?

RM: No, not at all. I started as a public ser-vant at the end of the 1970s in London,and I began spending about twenty, twen-ty-five years doing international econom-ic relations. So, with the World Trade Or-ganization negotiations, for example. Icame to health in 2003, 2004 but at thattime I found I had actually already donequite a lot of work around health regula-tory issues, both with health services in thecontext of the trade negotiations and onfood-chain regulation, also from the trade

33

Director General for Information Societyand Media, European Commission

&

“... using ICT to make behavioral helpavailable in a private, non-stigmatizing,autonomous way for individuals would

be a huge bridge between almost infinite additional need and very

constrained resources.”

INTERVIEW

perspective. So it was a bit like moving upthe value chain instead of dealing with theconsequences of regulation being respon-sible for it.

BKW: What would you consider to be theICT for health’s main achievements in 2010and what are the priorities looking beyond?

RM: I think in 2010, one of the main achieve-ments that we had was a policy achievement,rather than a research breakthrough, whichis to get agreement across the college of Com-missioners, the Parliament and all memberstates to a new form of partnership. Whatwe are going to develop is a European Inno-vation Partnership where you take the peo-ple who are working around health as an is-sue, the ICT and research actors, but alsomember state governments, regional author-ities, health insurers, civil society, and we tryto bring ICT benefits for health more quick-ly to the individual citizen. I see that as quitean interesting breakthrough with parallels tomy past life.

BKW: Quite a big endeavor. What do yousee as some of the biggest obstacles facingthe implementation of ICT in Europe?

RM: Specifically in the health field, it’s clearthat developing a trustable solution to pri-vacy problems is essential, both for the in-dividual patient and for the individual healthprofessional. The second challenge I thinkmore on the side of the professionals is tomake it clear that ICT makes life easier. Ifit just looks like another set of tools to learnand yet more folders to fill in, then healthprofessionals may very rapidly reject inno-vation. So I think overcoming both obsta-cles to adoption by health professionals andobstacles to trust on the part of the patientsare the twin obstacles to more rapid rollout.

BKW: C&R is focused on behavioral health-care. We were talking earlier about this. Canyou speak to me about some of the Com-mission’s priorities in behavioral healthcare?

RM: I think that behavioral healthcare isthe area in Europe where there is the mosthealth gain to be made. In most developedcountries infectious diseases and pandemicscontinue to be a threat: let’s not forget TB,for example. But what's really killing us Eu-ropeans is the way we live. Therefore, thehuge gain to be made comes from help withbehavioral issues, whether it's more respon-sible use of nutrition or alcohol, smokingcessation, mental health management.

These are issues where people need day-to-day help so that they can take charge andyet health-professional help is constrained.There aren't enough experts to go around.So using ICT to make behavioral help avail-able in a private, non-stigmatizing, au-tonomous way for individuals would be ahuge bridge between almost infinite addi-tional need and very constrained resources.It’s a very exciting area because some of theICT solutions can be relatively low-tech.

BKW: If you had to choose one thing thatyou were most proud of in your career whatwould that be?

RM: So far?

BKW: Yes so far.

RM: Can I choose two? I mean I think therewas a day or two in 1993 when I think Imade some contribution to finishing the"Uruguay Round" of global trade negotia-tions. It was very important at the time tocreate a more open platform for growtheverywhere, including in developing coun-tries. And then from my time in the healthfield, I would pick the creation in 2005 ofthe first multi-stakeholder platform to pro-mote better nutrition and reformulation ofprocessed food and physical activity, whichafter five years has got a positive healthcheck this year from the evaluators. In mycurrent job I haven't been here long enoughto achieve something.

BKW: And what do you want to accomplishthen?

RM: In a job such as this I have a five, six-year mandate. I think in that time deliver-ing really on the goals we have now set forourselves in the digital agenda would behuge. The challenge that I think is very im-portant is, in a way our slogan, is "enablingevery European to be digital." Not forcingthem, but enabling them. Thirty percent ofEuropean citizens have not yet ever goneonline, and in some countries it’s more likehalf or more than half, and in some poorercommunities in some member states ofthe union it may be seventy-five percent.So we are looking at a huge disparity acrossEurope and if we can level up so that everyEuropean citizen has that opportunity anddoesn’t just go online to sort of do super-ficial things but finds the tools for betterhealth, for better government service, forbetter community life, then I think we canbegin to have made a difference.

BKW: And how long do you think that willtake?

RM: Well if you look at a country like theUnited Kingdom they are aiming by 2012to have everybody online. So it doesn’t takeso long if you can stretch out and find allthe people in the communities and in allpeoples’ homes, in workplace settings, in ap-prenticeship colleges and work with that;you can't do it from the top down. But manydifferent member states in Europe are try-ing to pursue this in the ways that work intheir communities. In Poland they are us-ing the rural public libraries and in Maltathey are using the prison service and ap-prentice colleges. So I think that helping thedifferent member states to do more of thatis really the way forward.

BKW: What gets you up every morning?What is your passion, your true passion?

RM: I believe that the job I do, the profes-sional pursuit of the public good is a verybig challenge. It’s an even bigger challengeat a time of budget austerity and societaltransformation and that gets me out of bed.

BKW: And can you say a bit about EU-U.S.cooperation?

RM: Yes, so on the international front, onresearch, for example, we want the best ideasand the best research from across the world.So we have taken a very open stance to part-nering on the research end of our work withinstitutions and individuals from wherever.Equally I think the EU-U.S. relationshiparound policy and regulation is also a verystrong one and in the area of healthcare,health promotion and so-called eHealth,there is a long tradition of dialogue. We aresigning with the U.S. Administration a newprotocol to work together on eHealth, par-ticularly ICT in healthcare settings. But mypersonal belief is that our partnerships cango much more broadly than that and to is-sues of behavioral health promotion and as-sistance to citizens. There is already sometradition of working together around sub-jects such as nutrition and physical activity,but we haven't yet built in the ICT compo-nents of this work to do that as well.

BKW: Anything else you would like to add?

RM: No, I think that’s about it.

BKW: Okay, thank you very much for yourtime.

34

ASK THE EXPERT Robert Madelin

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36

India’s health-care industry hasbeen experienc-ing tremendousgrowth and is ex-pected to be a ma-jor component ofthe country’s econ-omy. Due to factorssuch as the in-

creasing accessibility to health insurance,the growing senior population, and the in-flux of people from overseas seeking world-class quality of medical treatments at af-fordable rates, India’s healthcare, currentlyestimated at $37.5 billion in 2008 accord-ing to a Technopak Advisors' report, is ex-pected to grow by a factor of two over thenext year, and a factor of 10 by 2022. How-ever, the rapid economic growth in thehealthcare industry has left little time forthe industry to upgrade its system to theproper standards, especially in emergencyand accident-related trauma care. Nearly20% of all emergency hospital cases in In-dia are associated with trauma, making itthe ninth leading cause of death. By 2020,it is estimated that trauma will move tothe third leading cause of death.

There is a great need for a well-developedemergency care system in India. Naturaldisasters such as earthquakes, cyclones,landslides, and floods, as well as man-made mishaps such as road accidentsand industrial injuries, put great pressureon the hospitals. India has not yet devel-oped a uniform hospital emergencyphone line due to the various levels ofgovernment, corporate, and personallyowned clinics across the country. Thosein rural environments are usually unableto obtain the basic care available in theurban facilities, and those in urban facil-ities are unable to access specialized carewhich is only available in major cities.

In addition to the lack of formal regula-tions for trauma care procedures, mosthospital personnel are not equipped withthe education and training to properlycare for trauma victims. In 2005, only 4%of paramedics had formal training, manyof whom worked for private hospitals.One-third of the country’s ambulancesare used solely for inter-hospital trans-portation purposes and only half havethe ability and equipment for providingairway support and splintage. Thirty-per-cent of emergency patients in India diebefore even reaching a hospital. Theneed to improve the training infrastruc-ture and educational exposure of India’shealthcare personnel is urgent.

Fortunately, the investment opportuni-ties in India’s healthcare industry arestrengthening trauma care to raise it tothe proper standards. Many education-al programs have been established toimprove the skills of India’s healthcarepersonnel. One prime model is theSRM/STRATUS Centre for Medical Sim-ulation of SRM University, a medical cen-ter that collaborates with the Neil andElise Wallace STRATUS Center for Med-ical Simulation of Harvard MedicalSchool to bring cutting-edge simulationprograms to train India’s medical per-sonnel. Equipped with state-of-the-arttechnology, the SRM Centre is a highlyadvanced educational facility that pro-vides training for medical professionalsthrough reality-based patient care sim-ulations. One program offered at thecenter, Laerdal’s SimMan, is a high-fi-delity simulator that can be physiolog-ically monitored, defibrillated, and ad-ministered medications, among otherdiagnostic and therapeutic procedures.The center has an Operation Theatrethat mimics an operation room for sur-geons-in-training. For practicing non-in-vasive surgery techniques, clinicians canattend to the Arcade Room. The Partial-Task Room allows students to learn es-

sential skills such as IV cannulation, air-way management, and central lines.

Among the programs offered at the SRMCentre, such as Basic Life Support andAdvanced Cardiac Life Support, the Ba-sic and Advanced Trauma Life Supportprograms will have a large impact on In-dia’s healthcare quality. These programsfamiliarize medical professionals withthe equipment used in trauma care,both in-hospital and in the field. In thebasic training program, essential skillssuch as intubation, chest tube insertion,cricothyroidotomy, and Focused Assess-ment through Sonography in Trauma ex-aminations are taught. In the advancedprogram, the students learn triage andtrauma safety, shock management, air-way and ventilator management, sys-tem-specific trauma care, and resusci-tation and initial stabilization of traumavictims.

As shown through the SRM/STRATUSCentre, trauma care in India is alreadyundergoing improvement efforts. To sus-tain this improvement, two key changesmust occur. The first is the acknowledge-ment of and commitment to the needfor policy reform of the healthcare sys-tem and the establishment of unifiedtrauma systems. The second is a contin-uous stream of funding for the advance-ment of the quality of trauma care. Withthese needs met, the people of India, aswell as visitors and those traveling to un-dergo medical procedures, will greatlybenefit in the future.

FURTHER AFIELD:Awakening the Realm of Trauma Care in India

By Lingjun Kong

[ Lingjun Kong, PMPVirtual Reality Medical CenterU.S.A.

[email protected]

167INFORMATICSANDTECHNOLOGY

Annual Review of Cybertherapy and Telemedicine 2011Advanced Technologies in Behavioral,Social and Neurosciences

Editors: Brenda K. Wiederhold Stéphane Bouchard Giuseppe Riva

HEALTH

167 B

.K. W

iederhold, S. Bouchard

and G. R

iva (Eds.)

STUDIES IN

ISBN 978-1-60750-765-9

Annual R

eview of C

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edicine 2011

Cybertherapy – the provision of healthcare services using advanced tech-nologies – can help improve the lives of many of us, both patients andhealth professionals, while tackling the challenges to healthcare systems.

Despite the potential of cybertherapy, its benefits and the technical ma-turity of the applications, the use of cybertherapy services is still limit-ed, and the market remains highly fragmented. Although many coun-tries – including USA, Europe, Korea and Japan – have expressed theircommitment to wider deployment of cybertherapy, most cybertherapyinitiatives are no more than one-off, small-scale projects that are notintegrated into healthcare systems.

It is recognized that integrating these new types of services in health-care systems is a challenging task. The aim of this book is to supportand encourage all the interested countries in this endeavor, by identify-ing and helping to address the main barriers hindering the wider use ofcybertherapy and by providing evidence to build trust and acceptance.

Healthcare systems focus on meeting the needs of patients. Achievingcybertherapy’s potential, therefore, depends on patients being convincedof its ability to satisfy their healthcare needs. Acceptance by patients de-pends crucially on acceptance by the health professionals treating them,given the high degree of trust the former place in the latter. An impor-tant factor for ensuring the confidence and acceptance of health profes-sionals is enhanced dissemination of the evidence base regarding theeffectiveness of cybertherapy services, their safety features and user-friendliness.

Contents:• Critical Reviews summarize and evaluate emerging cybertherapy top-ics, including Interreality, CyberAddiction and Telemedicine;

• Evaluation Studies are generally undertaken to solve some specificpractical problems and yield decisions about the value of cybertherapyinterventions;

• Original Research presents research studies addressing new cyberther-apy methods or approaches;

• Clinical Observations include case studies or research protocols witha long-term potential.

Annual Review of Cybertherapy and Telemedicine 2011

Advanced Technologies in the Behavioral, Social and Neurosciences

Visit our Web site for more information or order online at www.iospress.nl or www.booksonline.iospress.nl

New IOS Press Publication!

Volume 167 Studies in HealthTechnology and InformaticsEditors: B.K. Wiederhold, S. Bouchard,and G. RivaJune 2011, 224 pp., hardcoverISBN: 978-1-60750-765-9Price: US $167 / Euro 115 / £104

38


Figure 1: SEM images of a painless microneedle.

FEATURES

Pain Assessment for Designing aPainless Microneedle

By Kazuyoshi Tsuchiya, Kagemasa Kajiwara & Minoru Kimura

“ ... we propose a pain evaluation test to design a painlessmicroneedle to determine the maximum diameter to miti-gate pain.”

Using a microneedle mimicking the size ofa female mosquito’s labium, which collectsblood almost painlessly, is an effective wayto mitigate injection pain for patients. Here,we have a microneedle production tech-nique which uses a type of sputtering dep-osition method. In the production proce-dure, firstly, a microneedle material on arotating wire substrate at the speed of 3-5rpm by the sputtering deposition methodis deposited. Secondly, the wire substrate isetched by a chemical solution after a heattreatment. Finally, the titanium micronee-dle is produced (outer and inner diameter:60 μm and 25 μm) in the size mimickingthat of female mosquito’s labium (seeFig.1).

Here, the inner diameter of the injectionneedle is decreased when the outer diam-eter is decreased in order to mitigate pain,

hence, the rigidity of the needle is decreasedand the pressure drop by pipe friction is in-creased. Therefore, a little larger size thanthe female mosquito’s labium is needed tosatisfy the mechanical properties for thepainless microneedle. However, we do nothave any evaluation techniques to judgethe pain quantitatively.

In this study, we propose a pain evaluationtest to design a painless microneedle to de-termine the maximum diameter to miti-gate pain.

Generally, the techniques for measuringphysiological stress changes of blood pres-sure, heartbeat, diaphoresis, etc., are enu-merated as an objective evaluation tech-nique for pain. It is observed that stressgenerally arises due to a physical stimulus.However, it is difficult for the physiological

stress change to be easily influenced by themeasurement environment and to evalu-ate only the pain. When the sympatheticnerve system becomes active due to a phys-ical stimulus such as the injection of a nee-dle, the digestive system is inhibited andonly the salivary gland is active. The amountof α-amylase in saliva is changed by an ac-tivity change in the sympathetic nervoussystem, so that the value rises due to un-pleasant conditions or the value decreasesin comfortable conditions. Therefore, thepain is defined as a psychological stresscaused by the injection of a microneedle inthis research, and we focus on the changein the amount of α-amylase in saliva as apain evaluation test. Here, the advantage ofusing the amount of α-amylase in saliva asa measurement technique to evaluate stressis firstly, it ensures a quick response after aphysical stimulus, and secondly, it is easy to

measure the value quantitatively, and last-ly, it is a non-invasive test.

In this study, we adopted the amount of α-amylase in saliva for mice, and the relationbetween stress and the pain resulting fromthe injection of a needle was evaluated.The needle injection in a mouse is consis-tent to measure the amount of α-amylasein saliva, compared with that of a human,and there are few individual differences be-tween mice. Here, the experimental condi-tions to investigate the relation betweenstress and pain for injection of a needle,are described. (1) Nanopass 33 (TERUMOCorporation, 100 μm and 200 μm in innerand outer diameter) (2) substitution nee-dles (the leading end was polished at 12degrees; outer diameters: 35, 70, 95, 100,150, and 200 μm) were used. Institute ofCancer Research (ICR) mice were used inthe study. The needle was injected in thefemoral region where the nerves are con-centrated. Also, for the extraction of themouse’s saliva, a micro pipette was insert-ed into the mouth. The extraction volumeof saliva for mice was 1 μl. The extractedsaliva is diluted by phosphate bufferedsaline because the clinical biochemistryautomated analyzer for α-amylase needsthe solution amount of 100 μl. The salivasample was extracted 10 times on eachcondition and an average was taken. The

schemes of the effectiveness for the painassessment are the following.

(1) The amount of α-amylase in saliva forinjection of Nanopass 33 compared withits control as a stable condition. Two groups(the data for injection needle and the datafor control) were statistically compared us-ing the Mann-Whitney-U assay. As a result,the p (probability) value of two groups wassignificant at the level of 0.01. Therefore,the effectiveness for the proposed painevaluation test to measure the amount ofα-amylase in saliva was confirmed (see Fig.2). The proposed pain assessment to meas-ure the amount of α-amylase in saliva iseffective.

(2) There are no commercial-based nee-dles with a diameter smaller thanNANOPASS 33, therefore, the amount ofα-amylase in saliva for injection of substi-tution needles compared with itsNANOPASS 33 and the effectiveness forthe substitution needle was confirmed.Here, we have confirmed that there is nodifference for the amount of α-amylasebetween Nanopass 33 and a substitutionneedle (outer diameters: 200 μm). We havealso confirmed that the stress attributedto pain was not dependent on the differ-ence between the shape of leading endsand the surface condition.

(3) The amount of α-amylase in saliva forvarious outer diameters in substitutionneedles compared with its control. In or-der to evaluate pain for injection needleswith various outer diameters, two groups(each data for injection needle and thedata for control) were statistically com-pared using the Mann-Whitney-U assay.Fig. 3 shows the comparison of amount ofα-amylase in saliva between injection ofsubstitution needles and the control. As aresult, the significant difference has beenconfirmed in all the needles except small-er needle groups (less than 100 μm outerdiameter against the control group). Here,it was confirmed that a significant differ-ence was 0.05 between the control groupand the injection of 100 μm outer diam-eter needle as a substitution needle. There-fore, it is clear that the maximum outer di-ameter to mitigate the pain for amicroneedle is 100 μm or less.


FEATURES

39

[ ]Kazuyoshi Tsuchiya, Ph.D.Kagemasa Kajiwara, MSDMinoru Kimura, Sc.D.Tokai UniversityJapan

[email protected]

Figure 2: Comparison of amount of α-amy-lase in saliva between injection of Nanopass33 and the control.

Figure 3: Salivary α-amylase activity when eachneedle with various outside diameters is injectedinto the skin.

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Credited with establishing psychology as an academicdiscipline after the first experimental psychology lab wasopened in 1879, Germany has a history of proactiveresearch in the field. The country and its people haveovercome appalling historical setbacks. Now, healthcareresearchers and officials are working towards a brighterfuture in the field.

[ ]C&R in Germany

n Germany, psychology was formu-lated as a field of study in the 19thcentury as the trends in science

began to be applied to the mind. Many ear-ly psychologists were in fact physicists, doc-tors, and experimental physiologists. Theconnection between science, technology andpsychology was established early on, and theintegration of the fields persists today.

Psychology as an Academic Discipline is Born

One such scientist, Wilhelm Wundt, whosestudents included Emil Kraepelin, James Mc-Keen Cattell, and G. Stanley Hall, opened thefirst experimental psychology lab in Ger-many at the University of Leipzig in 1879.Germany is credited with establishing psy-chology as an academic discipline, and thetrend quickly spread to universities. Journals,such as PSYCHE, began circulating, discussinginnovations and new theories that devel-oped as Germany became more prominent

in the field. German was an important andoften-used language for psychological pub-lications and Germany continued to be aleader in the field of scientific psychologythrough the first third of the 20th century.

Revolutionary work in the field included re-search done by Hans Berger, a student at theUniversity of Jena who invented and record-ed the first electroencephalogram (EEG) af-ter becoming obsessed with the idea of “psy-chic energy,” by Hermann von Helmholtzwho studied attentional processes, and Her-mann Ebbinghaus’ experimental studies intomemory. The results of their successful re-search continue to have an impact on psy-chological practices today.

Theories of psychoanalysis developed by Sig-mund Freud, from the neighboring countryof Austria, along with Carl Jung, caught onquickly in Germany and institutions were es-tablished to utilize and build on these newpractices. The Berlin Psycholanalytic Insti-

tute, founded by Karl Abraham and MaxEitingon, was opened in 1920 to developupon these new approaches and foster thedevelopment of the field. Institutions, inturn, transformed psychology into a profes-sion as well.

The Impact of National Upheaval

The devastation that followed World War Iled to an immense economic depression, aswell as a loss in morale that inevitably gaverise to Nazi Germany. Under Adolf Hitler’sThird Reich, Freud’s practices were bannedand many of his books were burned through-out Germany. Instead, Hitler carried out hisown philosophy of ridding Germany of allthat he deemed unfit for his country. Thementally ill and the disabled were the firsttargets of persecution.

In 1933, the Sterilization Law was passed inGermany that allowed the obligatory steril-ization of anyone suffering from hereditary

I

> COUNTRY FOCUS


42

AUTHORS:

Christina Valenti & Emily ButcherEditorial DepartmentC&R Magazine

[email protected]

43

> COUNTRY FOCUS

diseases such as schizophrenia, manic-de-pressive insanity, hereditary epilepsy, and anysevere hereditary deformity. The steriliza-tion and legalized murder of mental unde-sirables caught the attention and admirationof many eugenicists of the time and helpedfuel the eugenics movement worldwide. InNazi Germany, mental patients were sent toextermination camps alongside Jews. Thou-sands were killed in the gas chambers, andcamps, and many were subjects in lethal ex-periments.

Although many psychologists still had re-spect for Freud’s theories, non-Jewish in-stitutions were established in order to con-tinue practicing under Hitler. The GermanInstitute for Psychological Research andPsychotherapy in Berlin was opened in1936 under the leadership of MatthiasHeinrich Goring. Eminent Jewish psychol-ogists were harassed, fired from their jobs,or murdered, leading others to immigrateor resort to suicide.

Academic psychology was dealt a devastat-ing blow and Germany’s scientific output dra-matically decreased as experts in the fieldfled the country or were murdered. Increas-ingly, psychology professors at German uni-versities held positions based less on theirhistory of scientific excellence, and more ontheir political loyalty to the Nazis. More thanhalf the professors in West Germany were for-mer members of the Nazi party in 1947. Af-ter the war, the field’s deficits were not ad-dressed and only a few of the emigratedscientists returned home; only one psychol-ogy professor was invited to return to his pre-viously held chair.

Following the defeat of Nazi Germany at theend of World War II, survivors of the war, par-ticularly those who survived concentrationcamps, suffered from severe psychologicaldistress. The need to rehabilitate survivorswas a major concern for medical profession-als and researchers in postwar Germany, andsparked the reemergence of mental health-

care. In 1961, psychoanalyst William G.Niederland created the term “Survivor Syn-drome” to describe the effects experiencedby Holocaust survivors. The syndrome en-compassed a wide range of symptoms includ-ing anxiety related to death that often result-ed in physical deterioration such as ulcersand colitis, withdrawal, emotional numbing,distrust in relationships, reoccurring dreams,depression, images and thoughts about deathtriggered by smells and other senses, and guiltabout surviving while so many others per-ished. Niederland’s outline provided a basisfor treatment to try to alleviate some of thepain and anguish that plagued survivors.

The Reform of Healthcare

In the mid 1970s, during a time of drastic so-cial and political reform, Germany adopteda community-based mental healthcare sys-tem. The deinstitutionalization of the systemcontinued, and in 1990, when East and WestGermany were reunited, dramatic changes in

C&R in Germany


82.6

80.2

1.3

44.9

74%

7.8%

9.1

0.5

45

50%

17.1%

3.9%

18.6%

Population (Million)

Life Expectancy (Years)

Fertility Rate

Population Median Age (Years)

Percentage of Urban Population

Unemployment Rate (Native Born)

Suicide Rate (Per 100,000)

Psychiatric Hospital Beds

(Per 100,000)

Number of Universities Offering

Psychology Programs

Percentage of the Population Satisfied with

Current Healthcare System

Lifetime Prevalence of Unipolar Depression

(Percentage of General Population)

Lifetime Prevalence of Panic Disorder


Lifetime Prevalence of Mood Disorders


the overall structure and quality of careresulted. Organized as a subsidiary sys-tem controlled by the 16 federal states,German healthcare is spread amongmany sectors and characterized by re-gional differences.

Although the general population issatisfied with the current healthcaresystem, services and care remaincostly. The main concern then, is ifand how the system can be ade-quately maintained without increas-ing costs.

Current ICT Research for MentalHealthcare in Germany

A recent report by a German health in-surance company pointed to the dra-matic increase in sick leaves due to psy-chopathological distress in recent years.With an increasing workload and result-ing stress negatively effecting the pop-ulation, this trend calls for new, im-proved treatment approaches.

While most labs implementing Virtu-al Reality (VR) in a research context areprimarily involved in the fields of en-gineering science or neuroscience, asmall number are dedicated to workinvolving psychology and clinical psy-chology.

In these labs, VR is used as a tool for ba-sic research into emotions and anxietyand, in particular, to examine treatmentof phobias including flight phobia, heightphobia, spider phobia, claustrophobia, andsocial phobia. For analyzing treatmentmechanisms, cue and especially contex-tual fear conditioning, paradigms are re-alized with the help of VR.

Professor Paul Pauli and Professor AndreasMühlberger are involved with the psychol-ogy department at the University ofWürzburg, a public university of Bavaria,and said, “[We conducted] basic researchon fear, anxiety and anxiety disorders, andrecently established a VR paradigm forcontextual conditioning; we found thathigh trait anxiety is related to enhancedcontext conditioning.”

Other examples of work include Dr. Oliv-er Stefani’s use of VR in the field of engi-neering with the Visual Technologies Teamat Fraunhofer addressing effects of light-ing and displays on humans. This workstudied how light emitting diodes (LED)-backlit computer screens affect circadianphysiology and cognitive performance insubjects.

Labs in Germany benefit from mutual col-laboration and research with many inter-national groups, including other European

countries and the U.S. Germany also drawsmany international students to developand diversify their studies; it is the mostcommon destination for foreign studiesamong Eastern European students.

Zukünftige Anwendungen

Professor Pauli believes that ICT researchhas a strong future in Germany and willhelp to aid the “exact analysis of behav-ior in ecologically valid virtual environ-ments; unravel the laws of human behav-ior and to be able to develop moreeffective therapeutic tools for treatment.”

These tools will undoubtedly be strength-ened by further research and support asICT methods gain national support andfunding in Germany. With a rich historyand unwavering ability to overcome pastobstacles, Germany is establishing a sta-ble, efficient mental healthcare system forits people.

44

> COUNTRY FOCUS

Sources:

Personal communication with PaulPauli, Ph.D., Andreas Mühlberger, Ph.D.,Oliver Stefani, Ph.D., and the Organi-zation for Economic Cooperation andDevelopment.

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The Official Conference of the International Association of CyberPsychology, Training & Rehabilitation (iACToR)

This year's conference focus is two fold:

First, Technologies as Enabling ToolsCT17 will explore the uses of advanced technologies such as Virtual Reality simulations, videogames, tele-health, video-conferencing, the internet, robotics, brain computer interfaces, wearable computing, and non-invasive physiological monitoring devices, in the diagnosis,assessment, and prevention of mental and physical disorders. Inaddition, we will look at interactive media in training, education,rehabilitation, and therapeutic interventions.

Second, The Impact of New TechnologiesCT17 will investigate how new technologies are influencingbehavior and society, for example, through healthy aging initia-tives, positive and negative effects of social networking tools,and online gaming.

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2012 CALL FOR PAPERSSUBMISSION/REGISTRATION

DEADLINES:

Abstract Deadline Submission: March 1, 2012

Notification of Acceptance/Rejection ofAbstract: April 1, 2012

Full Paper/Presenter RequirementsDeadline: June 1, 2012

Early Registration Deadline:July 1, 2012

cybertherapy & rehabilitation, issue 4 (2), summer 2011

Documents