CIMIT Stories: Procedures

Simulation training for hospital and battlefield

Sometimes an innovative doctor will have a straightforward idea that changes the way things are done in medicine. Steven Dawson, MD, and his team have developed a technology that enables doctors to learn their skills on realistic simulators rather than on living people. As one participating doctor told Dr. Dawson, “We’ll look back in years to come and say it was remarkable that doctors ‘practiced’ on real patients at all.” And a catherization and cardiovascular medical journal published an editorial about the team’s initiatives, which said, “Their work may well represent a breakthrough of astonishing and revolutionary importance.”

Dr. Dawson heads a team which is currently developing new systems to enable doctors and medics to learn treatments by first training on a computerized facsimile of a patient. The team’s mission is to improve patient safety by developing realistic training systems that allow trainees to learn from their mistakes. Good training comes from realistic responses: If what you do would create a mistake in a patient, it should do so on a simulator. But with a simulator, no patient suffers from that mistake. TheSimGroup team, in essence, is offering a disruptive new platform to teach medical procedures.

Dr. Dawson, an interventional radiologist at Massachusetts General Hospital, believes passionately in training through simulation. He often makes the case that airline pilots must train and re-train in order to stay abreast of new techniques and procedures. His point? “Flight simulators didn’t just make flying safer for pilots, they made flying safer for passengers. Medical simulation will do the same for patients.”

Doctors don’t re-train nearly as often as pilots do. And when they do, the learning experience is generally on an actual patient. Dr. Dawson has the patient in mind as he drives to bring learning through simulation into the medical profession. Why shouldn’t doctors, nurses, first responders and military medics train on sophisticated simulators, too, so they can learn without injuring a patient?

Practice on silicon, not patients.

“The practice-on-the-patient system worked for centuries but we are at a critical tipping point in healthcare education, where revolutions in computational mathematics, engineering and education are giving us more options,” Dr. Dawson said. “We must adopt learning techniques through simulation.”

Dr. Dawson and his team began their work in simulation at the request of the Army, which wanted better training techniques for its doctors and medics. The SimGroup is dedicated to enhancing patient safety by creating the most appropriate training system for the learner’s level of experience and knowledge. These simulators require understanding of physiology, computer science, physics and math. One institution that saw its potential was CIMIT, which provided grants for the early work. In recent years the Department of Defense has funded much of Dr. Dawson’s research. Top military medical officials want the best care possible for soldiers, and they are looking to his lab to help provide it.

The team got its start working to develop a physiologically realistic mannequin for training first responders to perform chest tube insertion and prevent a leading cause of trauma deaths. It has also developed a system to teach surgeons laparoscopic skills. And today, they are integrating all the skills and knowledge of earlier simulation systems as the team develops an interactive, autonomous full-body trauma casualty system to provide realistic training for army medics and civilian first responders.

This project is called COMETS, the Combat Medic Training System. COMETS is designed to the specifications of the Army’s Joint Forces Medical Training Center, which is responsible for the majority of joint forces medical care in the field. It will be a tetherless, battery operated, durable, fully-autonomous 190-pound simulator providing training in tactical combat casualty care, including airway management, hemorrhage control, chest trauma, shock resuscitation, field management of multiple simultaneous casualties, and multi-system injury, in both conscious and unconscious configurations. Because it will be portable and self-contained, COMETS will allow medic sustainment training to proficiency during long deployments. Although this is being developed for the Joint Forces Training facilities, COMETS also has immediate dual-use potential in treatment of civilian mass casualties, who suffer similar injuries in similarly austere treatment environments. “This is the most aggressive approach to simulation that anybody has tried,” Dr. Dawson said. “There is no fully portable, fully autonomous trauma simulator.”

Ryan Bardsley, the project manager for COMETS, commented, “It’s rugged and simple. It tries to show the basic indicators of injuries with realism, no red lights or buzzers. It’s to teach medics to come on the scene, assess if someone is dead or alive, get them under cover and deliver the immediate care they’ll need to be still breathing when they reach the doctors and nurses.”

COMETS is interactive, and realistic: It responds to user actions with continuous feedback. It has been designed to be capable of reproducing common and uncommon injuries and to “physically deteriorate” without any external commands or control once the simulation scenario is under way. The prototype will “live or die” depending on how the medic or physician treats it.

CIMIT Executive Director John Parrish, MD, once a battlefield doctor in Vietnam, was among the first to appreciate the work of Dr. Dawson. He said he would have welcomed a training environment like COMETS to prepare him for situations he encountered in the field.

Other initiatives from the Dawson lab include VIRGIL, CELTS and SITU. Each has been developed to help caregivers with new cutting-edge procedures using simulation-based learning procedures.

VIRGIL is a chest-trauma training system for combat medics, using realistic anatomy in a visually advanced training curriculum.

CELTS (Computer Enhanced Laparoscopic Training System) is an advanced surgical skills training system built around integrated performance metrics derived from actual surgical practice. It produces a real-time score for every user and stratifies users according to their skills. It uses real instruments and can be adapted to a variety of surgical training drills without any modification of the base system.

SITU (Smallpox Inoculation Training System) replicates the feel and responses of traditional smallpox inoculation. Because smallpox was eradicated from earth in the 1970’s the skills involved in delivering proper inoculations has been lost. Unlike vaccination for mumps or HPV, smallpox inoculation must be created by a delicate process of scarification, and the knowledge of this technique has been lost over time. SITU represents a full training system that instructs users in proper technique and handling of the biologically active vaccine.

CIMIT has long supported the work of Dr. Dawson’s team, and its grants allowed enabled them to generate enough data to attract additional funding. In 2007, Dr. Dawson’s team received a $2 million award from the Department of Defense to continue its work. The new procedures and techniques developed will be used in both military and civilian training sessions. His work could well be used to train future generations of medical students.

The SimGroup team is working to change the way medical learning occurs. Dr. Dawson said, “We must leverage the technologies around us - computing, communications, educational science - to create new learning systems that don’t put the sickest among us at risk from the least trained among us. Simulation is a way to move the patient out of the learning curve and to let caregivers learn without putting patients at risk. This is the compassionate breakthrough we’re trying to create with our work.”