78 VIRTUAL REALITY
• VIRTUAL REALITY AND SIMULATION
SPECIAL CONTRIBUTIONS
Virtual Reality and Simulation: Training the Future
Emergency Physician
MARTIN REZNEK, MD, PHILLIP HARTER, MD, THOMAS KRUMMEL, MD
Abstract. The traditional system of clinical educa-
tion in emergency medicine relies on practicing di-
agnostic, therapeutic, and procedural skills on live
patients. The ethical, financial, and practical weak-
nesses of this system are well recognized, but the al-
ternatives that have been explored to date have
shown even greater flaws. However, ongoing progress
in the area of virtual reality and computer-enhanced
simulation is now providing educational applications
T HE INFORMATION age is here and, in an
unprecedented fashion, is changing nearly
every aspect of our lives. Astoundingly, this evo-
lution promises to accelerate as computer-related
advances continue to become available at an ex-
ponential rate. Gordon Moore, the cofounder of In-
tel Corporations, has observed that the power of
computer chips doubles every 18 to 24 months.
And, Randall Tobias, a former vice-president of
ATT, noted that ‘‘over the last 30 years, we have
seen a 3,000-fold increase in computing power. If
we had had similar progress in the automotive in-
dustry, a Lexus would cost $2, it would travel at
the speed of sound and go 600 miles on a thimble
full of gas.’’1
Almost every profession has learned to adapt to
and subsequently exploit this ongoing progress in
computing technology. The field of medicine, how-
ever, has only just begun to join in and is doing so
at a considerably slower pace. The leaders in med-
ical education, in particular, have not taken ad-
vantage of the technology that is becoming avail-
able, and those of us in emergency medicine (EM)
are no exception.
From the Division of Emergency Medicine, Department of
Surgery, Center for Advanced Technology in Surgery at Stan-
ford, Stanford University Medical Center (MR, PH, TK), Stan-
ford, CA.
Received March 7, 2001; accepted August 27, 2001.
Address for correspondence and reprints: Martin Reznek, MD,
CATSS Laboratory, Department of Surgery, Stanford Univer-
sity, School of Medicine, 300 Pasteur Drive, H3680, Stanford,
CA 94305-5655. Fax: 650-724-3431; e-mail: mreznek@
hotmail.com
Reznek et al.
that show tremendous promise in overcoming most of
the deficiencies associated with live-patient training.
It will be important for academic emergency physi-
cians to become more involved with this technology
to ensure that our educational system benefits opti-
mally. Key words: virtual reality; simulation; emer-
gency medicine; education. ACADEMIC EMER-
GENCY MEDICINE 2002; 9:78–87
In EM, as in many other specialties, the tradi-
tional training model still exists; for diagnosis,
therapeutic intervention, and performing proce-
dures, the live patient remains the cornerstone for
teaching. Over the years, many educators have un-
derstood there to be significant drawbacks to this
system and have searched for other options. These
other training tools, including volunteers, plastic
models, animals, and cadavers, have shown even
greater flaws.2,3 So today, believing there to be no
acceptable alternatives, we continue to rely on the
patient as the foundation of our clinical education.
However, the continuing progress of computing
technology is providing us with applications that
will challenge this notion and quickly make it out-
dated. Advances in the realms of virtual reality
and computer-enhanced simulation are showing
great promise in supplementing our traditional
training system of live ‘‘models,’’ and may even
eventually replace them.
RATIONALE
Traditionally, we have relied on the patient as our
primary vehicle for the clinical training of physi-
cians. Unfortunately, this teaching system is not
ideal due to the simple fact that the clinical prac-
tice of medicine has been refined over the years
specifically to improve patient care and not nec-
essarily education. Superior patient care and op-
timal physician training are often mutually exclu-
sive in the clinical setting, and consequently
live-patient training has several significant short-
comings.
ACADEMIC EMERGENCY MEDICINE • January 2002, Volume 9, Number 1 • www.aemj.org
One can appreciate these deficiencies by consid-
ering the simple example of teaching a resident to
perform a procedure such as central venous cath-
eterization. Learning curves have been demon-
strated for procedures in EM as well as other spe-
cialties.4–11 Using the patient as a practice ‘‘model’’
places the patient at an increased risk of compli-
cation, but due to a historical lack of satisfactory
teaching alternatives, we have had to accept this
inherent risk as a ‘‘necessary evil.’’ Even if we can
ethically justify allowing a resident to practice in-
serting a central line in a patient a single time, we
certainly cannot allow the resident to repeat the
exercise multiple times until he or she has per-
formed it correctly. Even more devastating to the
learning process is the fact that an instructor is
ethically bound to stop the resident if he or she is
making an error. For this reason, the resident will
only rarely have the opportunity to experience
complications resulting from his or her actions (in
other words, pneumothorax or air embolus). In
live-patient training, the resident is often denied
the luxury of learning from his or her mistakes, a
technique that many educators have reported to be
highly effective and some even believe to be supe-
rior to standard methods of acquiring factual
knowledge.12–14
In addition to these ethical issues, live-patient-
dependent education is also inefficient. In the cen-
tral line example, the resident is not even guar-
anteed the opportunity to learn that procedure.
The resident is dependent on random chance and
must wait for the arrival of a patient who needs a
central line before he or she can practice that skill.
In fact, for procedures with indications that are
less common than those of a central line, such as
cricothyroidotomy, the resident may never even get
the chance.
Even if the resident is fortunate enough to get
the opportunity to perform the procedure, signifi-
cant time constraints exist that will negatively af-
fect his or her learning. When learning on a pa-
tient, the resident commonly experiences pressure
to ‘‘hurry’’ from the teacher as well as the patient.
The attending physician will most likely have lim-
ited time due to his or her other duties, and the
‘‘model’’ is likely only to tolerate so much.
Central venous catheterization, like any proce-
dure, is designed, of course, from a patient care
standpoint and not an educational one and as such
impedes learning. For example, sterile draping is
required during central line insertion on a live pa-
tient. These drapes obscure the important external
landmarks that the novice needs to insert the nee-
dle properly. The internal anatomy is even more
frustrating due to the fact that it cannot be visu-
alized even before draping and must be imagined.
Furthermore, with live-patient-based learning,
79
standardizing the training of central line insertion
is impossible because each educational experience
is based on an individual patient with unique anat-
omy. In addition, recording the exercise, which
would allow both the resident and the instructor
to review the procedure multiple times and to be
more objective in their assessment, is rarely per-
formed because it is difficult and expensive. As a
consequence, debriefing the resident after live-pa-
tient training is often suboptimal. Recording would
also enable the debriefing to be postponed to a time
that is more convenient and more conducive to
learning.
Finally, teaching any procedure on a live
‘‘model’’ is expensive. The instruments are not re-
usable, and it takes longer for a trainee to perform
the procedure.15 Furthermore, an attending ob-
server ideally should be present at all times, keep-
ing him or her from other clinical responsibilities.
And due to the learning curve, there theoretically
will be a more frequent need for additional medical
care due to iatrogenic injuries sustained when an
inexperienced physician performs the procedure.
It is clear that the live patient ‘‘model’’ is not an
ideal instrument for education, especially for the
introductory instruction of procedures and most
medical management algorithms. Technologic ad-
vances in the areas of virtual reality and computer-
enhanced simulation have introduced a new
method of teaching that bypasses each of the eth-
ical, financial, and practical deficiencies of live pa-
tient training that have been illustrated in this
section.
SIMULATION —BACKGROUND
AND HISTORY
Simulation is the act of mimicking a real object,
event, or process by assuming its appearance or
outward qualities.16 In order to be an effective
teaching tool, a simulator must provide both edu-
cationally sound and realistic feedback to a user’s
questions, decisions, and actions.17 Sufficient real-
ism should be present for the user to suspend dis-
belief; however, it is important to realize that a
simulator does not need to be identical to real life
to accomplish this.18 Therefore, one does not have
to include every detail of the real experience when
designing an effective simulator.
Both the birth of modern simulation and the
majority of advances in this field can be credited
to the aerospace industry. Flight simulation was
first conceived in 1929 when Edwin Link designed
an amusement park ride that gave the sensation
of flying a plane. This machine eventually was
modified into the Link Flight Simulator.19 Training
with this primitive simulator was associated with
a 90% reduction in nighttime and bad-weather col-
80 VIRTUAL REALITY
lisions.15 Since that first successful simulator, sev-
eral major advances have been added to the con-
cept, including motion camera displays and even-
tually computer-generated displays. The success of
this means of training as well as its cost–effective-
ness in the aerospace sector has been well docu-
mented.20,21 Other industries as diverse as the mil-
itary, business management, transportation, and
nuclear power have also found success in training
with simulation.1,16,17
The field of medicine has occasionally incorpo-
rated simulation into its training. However, for the
majority of applications, the technology has been
limited and subsequently so has its success. The
one major exception to this has been the use of
computer-enhanced mannequins. The first of these
simulators, Sim One, was created in 1967 at the
University of Southern California. This simulator
consisted of a life-size mannequin connected to a
computer, an instructor’s console, an interfacing
unit, and an anesthesia machine. The Sim One
was able to simulate cardiac arrest, blood pressure
abnormalities, several arrhythmias, and airway
compromise.22 Since then, significant advances in
these simulators have been made, and several dif-
ferent commercial models are now available.23
The modern human patient simulators are de-
signed to have more than 40 realistic findings in
seven anatomic areas.17 These mannequins have
several anatomically correct clinical signs, includ-
ing breath sounds associated with chest rise, heart
sounds, palpable carotid and radial pulses, periph-
eral blood pressure, pupilary reflexes, and muscle
twitch from nerve stimulation. Additionally, the
mannequin is able to speak by way of microphone
from the operator. The simulators are designed to
interface with conventional monitoring devices
that can record the mannequin’s electrocardio-
gram, respired carbon dioxide levels, pulse oxime-
try signal, invasive pressures (arterial, central ve-
nous, and pulmonary artery), cardiac output, and
temperature.24 All of the physical findings, as well
as the signals to the monitoring devices, can be
modified by the operator as needed or automati-
cally by the computer during a scenario. In addi-
tion, the simulators are programmed to respond
appropriately to approximately 70 medications24
and several physical interventions that include: in-
tubation (unintentional endobronchial or esopha-
geal intubation are possible), chest compression,
ventilation, electrocardioversion, cricothyroidotomy
(the airway can be automatically altered to make
intubation difficult or impossible), chest tube in-
sertion, and insertion of peripheral venous and ar-
terial catheters as well as central venous lines.
Modern simulators have approximately 50 avail-
able preprogrammed scenarios17 and, if required,
new scenarios are easy to design.24 Just a few
Reznek et al. • VIRTUAL REALITY AND SIMULATION
examples of available scenarios are: myocardial is-
chemia/infarction, pneumothorax, pericardial tam-
ponade, hypotension, hypertension, diabetic ke-
toacidosis, brain injury, blood loss, anaphylaxis,
and multiple electrolyte abnormalities.
The end result of all the capabilities listed
above is that the modern human patient simulator
is an extremely realistic and engaging teaching
tool.23–25 These simulators have been used primar-
ily in the field of anesthesia and therefore they
have been designed mainly for this purpose. How-
ever, it has become clear that other specialties, in-
cluding EM, can potentially benefit from the sim-
ulators, and accordingly some initial pilot studies
are being performed.
SIMULATION IN
MEDICAL EDUCATION
The popularity of the human patient simulator in
the field of anesthesia is mainly due to the work of
Gaba, Fish, and Howard that began in the late
1980s. At that time, it was recognized that 65–70%
of all unintentional incidents in anesthesia could
be attributed to human error. In an attempt to gain
better insight into this problem, they came across
extensive research done in the aerospace sector.
The airlines and NASA had begun to address hu-
man error in their profession and developed a cur-
riculum, called Crew Resource Management
(CRM), to educate their pilots in avoiding human
error. Gaba, Fish, and Howard adapted the prin-
ciples of this course to anesthesia and developed a
program that they called Anesthesia Crisis Re-
source Management (ACRM). Forty percent of the
course time is used to teach the proper medical
responces to specific crises, and 60% is used to
teach general principles of teamwork and CRM.26,27
The ACRM course has been well received. Stu-
dents of the course find the mannequin and sce-
narios very realistic and believe that they benefit
from the crisis resource management and team-
work discussions.23,24,28 A small number of studies
have demonstrated construct validity of the pa-
tient simulator29 as well as improvement in perfor-
mance during emergencies after training with the
simulator.30 Proper objective evaluation of human
performance in any setting, including ACRM, has
proven thus far to be difficult. For this reason, few
objective studies of ACRM have been undertaken.
Despite the lack of objective data however, the sub-
jective response has been positive, and more than
a hundred simulator centers are running through-
out the world.31
Other fields in medicine also have recently be-
gun to recognize the potential of the patient sim-
ulators for teaching in their fields. Surgeons at
Penn State University and Stanford University
ACADEMIC EMERGENCY MEDICINE • January 2002, Volume 9, Number 1 • www.aemj.org
have begun pilot studies in the use of patient sim-
ulators for resident trauma and crisis management
training. Their initial observations have led them
to believe that the use of these simulators in sur-
gical education is promising; however, their find-
ings are yet to be published.
Two pilot studies using patient simulators for
EM education have been reported in the literature.
In New Zealand, a group has developed a course
to teach EM trainees ‘‘advanced airway skills.’’32 In
this course, the trainees are able to practice prac-
tical airway skills as well as hone their general
management skills of an emergency. The course
creators thought that the patient simulator in con-
junction with their curriculum was a very effective
teaching tool for EM and reported their intent to
further develop their airway course. Another pilot
study regarding the potential use of the patient
simulator in EM was reported from Boston.33 This
group developed several EM scenarios and com-
bined ACRM principles with the MedTeams’ Emer-
gency Team Coordination Course (ETCC) to design
their pilot program. The course participants, in-
cluding EM attendings, residents, and nurses, all
regarded the scenarios as highly realistic, and they
believed that they benefited from the course as a
whole. The most unique aspect of this pilot study
is that it appears to be the first to explore the si-
multaneous use of multiple simulators as well as
patient-actors.
The human patient simulator is the most im-
pressive of the computer-enhanced medical simu-
lators. However, two others exist that may be use-
ful in EM and deserve brief mention. The first is
‘‘Harvey,’’ a cardiology mannequin simulator re-
leased in 1976, which is able to simulate the ar-
terial pulse, blood pressure, jugular venous wave,
precordial movements, and heart sounds in normal
and diseased states.34 In EM, ‘‘Harvey’’ has been
used to determine possible areas of insufficient
training of emergency physicians (EPs) in the car-
diovascular examination.35 The second simulator
with potential applications in EM is a pelvic ex-
amination simulator that was recently developed
at Stanford University. This pelvic mannequin is
equipped with internal sensors that are connected
to a computer. By interpreting these signals, the
computer is able to provide the user with visual
feedback regarding which structures they are pal-
pating and how much pressure they are applying.36
VIRTUAL REALITY —BACKGROUND
AND HISTORY
The most technologically advanced form of simu-
lation is virtual reality (VR). Jaron Lanier is cred-
ited with first coining the term ‘‘virtual reality’’ in
the late 1980s; however, the origin of this technol-
81
ogy can be traced to work done at MIT and Har-
vard University by Ivan Sutherland in the mid-
1960s. Sutherland envisioned a new way for com-
puters and humans to interact and, in 1965,
presented his groundbreaking talk entitled ‘‘the
Ultimate Display.’’ He proposed a model for a com-
puter display that would simulate the physical
world and would allow the user to interact directly
with the computer within that world. Five years
later, Sutherland’s visions were realized when he
invented the first head-mounted display,37 and VR
was born.
Most believe that it is sufficient to classify VR
devices as either immersive or non-immersive. For
medicine, however, it is probably more beneficial
to use a classification system proposed by Voelter
and Kraemer. They classified VR technology into
four categories: immersive VR, desktop VR, pseudo
VR, and inverse VR. Immersive VR involves a sys-
tem that completely integrates the human user
into the computer’s world, while desktop VR differs
in that the user is not totally integrated into the
virtual world but is still able to observe and man-
age the virtual world on a computer screen. For
example, modern flight simulators used by the avi-
ation industry and the military would be consid-
ered highly immersive. The user sits in the simu-
lator surrounded by the visual display and realistic
sounds and the simulator can move. Similar flight
simulator programs are available for personal com-
puters; however, these would be classified as desk-
top VR because the simulation occurs entirely on
a computer screen in front of the user. The third
type of VR, pseudo VR, refers to a system in which
the user can control the computer animation and
observe it, but there is no further interaction.
For example, a three-dimensional (3-D) anatomic
model can be rotated to improve learning, but it
cannot be palpated or deformed. Finally, inverse
VR describes the integration of a computer into the
life of the user as apposed to the reverse. An ex-
ample of this technology would be a program that
allows quadriplegics to use a computer with eye
movement-based controls in order to communi-
cate.38
A fifth type of VR, augmented reality, was not
mentioned by Voelter and Kramer, but it has been
described by other groups in the literature and
should be added to the classification to make it
complete.39,40 Augmented reality is achieved by pre-
senting virtual images on a see-through head-
mounted display, thereby superimposing the vir-
tual world on the real one. For example, a program
has been created to aid in maxillofacial surgery by
enabling the surgeon to view the internal anatom-
ical structures of a patient’s face (based on prior
radiographic studies) superimposed on the pa-
tient’s surface anatomy.39 In other words, the sur-
82 VIRTUAL REALITY
geon is virtually able to see through the patient’s
skin.
Functionally, there are four necessary elements
comprising a VR system: software, hardware, in-
put devices, and output devices.19 The software es-
sentially is a set of mathematical algorithms and
equations that define the virtual environment and
its responses to the interactions with the user. The
hardware is needed to perform the great number
of calculations required by the software to produce
the rapidly changing virtual environment. The
equations and algorithms used to generate a vir-
tual environment can be based on real-world data
from photographs, pathology sections, plain radio-
graphs, computed tomography, magnetic reso-
nance, or ultrasound. From these data, a com-
puter-aided design (CAD) program is used to
produce a wire-frame surface model consisting of
polygons. These polygons are given texture and
coloring by a method called rendering.41 To im-
prove the resolution of an object, the size of the
polygons must be decreased and their number in-
creased. However, as the number of polygons in-
creases, so does the number of calculations to pro-
duce them. Therefore, there exists a trade-off
between the speed of object updating and the im-
age quality,42 both of which are important compo-
nents of the realism of the virtual environment.
Ideally, image frames need to be refreshed from 24
to 30 times per second so the eye cannot distin-
guish between the frames.43
The virtual environment is then presented to
the user through various output devices. Virtual
images are projected either on a high-resolution
monitor (with or without 3-D capability) or on a
head-mounted display. In addition to visual out-
put, there also exist output devices for the other
senses. Speakers can be added for audio output
and devices have been created to give haptic feed-
back, including force feedback and tactile touch.
Force and tactile feedback remain the most diffi-
cult portions of the virtual environment to simu-
late. The current methods of simulating tactile
touch are not optimally realistic. Inflatable blad-
ders covering the hand, vibrating transducers,
electrical stimulation, and shape memory alloys
that can be altered with an electrical current have
all been explored with limited success.41 However,
other technologies, including pneumatically-driven
pins as well as new inflatable bladders, are being
developed.
Force feedback simulation has had much
greater success. The PHANToM (produced by
SensAble Technologies, Woburn, MA) is a com-
puter-driven mechanical arm with a ‘‘wand’’ exten-
sion or a thimble at its end that allows its user to
sense the position, orientation, shape, and compli-
ance of a virtual object. In the virtual world, just
Reznek et al. • VIRTUAL REALITY AND SIMULATION
as in the real world, a person relies on six degrees
of freedom of movement to feel an object’s position
and orientation in space. The first three degrees of
freedom are the Cartesian coordinates X, Y, and Z.
Freedom of movement in these three axes is nec-
essary for a person to define an object’s position.
The remaining three degrees of freedom refer to
the directions of rotation around a point or an ob-
ject, sometimes referred to as ‘‘pitch,’’ ‘‘yaw,’’ and
‘‘roll.’’19 Rotation in these three degrees is impor-
tant for establishing an object’s orientation. In
combination with a visual display, the PHANToM
is able to realistically convey a virtual object’s po-
sition and orientation using six degrees of freedom.
For force feedback simulation, the PHANToM is
able to convey only three degrees of freedom to its
user. This limitation is due to the fact that the
force feedback at any given instant can be simu-
lated from only a single point on the virtual object’s
surface. This is similar to feeling the compliance of
an object such as a grapefruit through a pencil;
some compliance information can be conveyed but
the information is somewhat limited. Despite this
hindrance, the force feedback simulation is very re-
alistic when supported by simultaneous visual
simulation. The PHANToM has been programmed
to simulate the shape and compliance of many ob-
jects, including anatomic structures, and programs
also exist that simulate the sensation of punctur-
ing one or more layers of varying compliance.
The computer’s output or feedback to the user
is important for the realism of the virtual experi-
ence; however, the input from the user to the
computer is also essential in that it makes the ex-
perience truly interactive. Conventional input de-
vices, including the keyboard, mouse, and voice
recognition technology, can all be useful in VR, but
several more advanced innovations have been de-
veloped specifically for VR. Tracking devices are
used to detect the position and movement of the
user’s head, body, and limbs. For most purposes,
tracking the hand(s) and head are sufficient for re-
alism; however, full body suits have been devel-
oped. Electromagnetic, mechanical, and gyroscopic
sensors have been used for positional and move-
ment detection, and biosensors are currently being
developed to track muscle and neuronal activity.41
Despite VR technology’s only being in its early
stages, it is already impressive and certainly ad-
vanced enough to be used in many medical appli-
cations. It must be noted that the existing simu-
lation capabilities are somewhat limited in their
realism and can be disappointing if one expects too
much. However, it is also essential to realize that
improvements in all four of the functional portions
of VR (software, hardware, input sensors, and out-
put devices) are continually becoming available
and the realism will continue to improve.
ACADEMIC EMERGENCY MEDICINE • January 2002, Volume 9, Number 1 • www.aemj.org
VIRTUAL REALITY IN MEDICAL
EDUCATION
Basic Science. Several VR projects are currently
under way for basic science education. One system,
called the Anatomic VisualizeR, is being developed
at the University of California, San Diego. This
program contains several 3-D anatomic models
that are based on data from the Visible Human
Project. A student is able to virtually dissect these
3-D models while simultaneously accessing other
supporting 2-D resources, such as diagrams, text,
and videos. The program also allows the user to
adjust the size, opacity, and orientation of the var-
ious organs in order to better reveal the adjacent
and deeper structures. This function of the pro-
gram provides the user with an extremely effective
method for learning the anatomic relations of or-
gans.44,45
Another virtual anatomy program, called the
‘‘3D Human Atlas,’’ has been developed in Japan.
This program facilitates students’ understanding
of anatomic cross-sections and how they relate to
the anatomy of the entire body. Cross-sections,
based on magnetic resonance imaging (MRI) scans
of a live model, are shown simultaneously along-
side a 3-D computer rendering of the entire body
of that model. An opaque plane through the 3-D
model indicates the orientation of the MRI cross-
section, thereby enabling the student to better un-
derstand how the cross-section relates to the entire
body. Additionally, the external and internal struc-
tures of the 3-D whole-body rendering have vary-
ing opacities, allowing the user to develop a better
understanding of the anatomic relationships of
these organs.46
A VR program has also been designed for teach-
ing brain anatomy to medical students. This pro-
gram includes 2-D modules of gross brain sections,
histology, and neuroradiology, in addition to a 3-D
anatomic model of the brain. The user can adjust
the views of the brain, and variable opacities exist
to allow better understanding of deeper structures
and their relative positions.45,47
Clinical Scenarios. The number of programs that
have been created for basic science education is
limited; however, more applications have been de-
veloped for advanced levels of medical training.
The military, likely due to its success with VR in
aviation and combat training, has been interested
in using VR for training its medical personnel in
battlefield trauma management. Accordingly, a
military group in Germany has produced a desktop
VR program that facilitates the training of medics
in casualty triage, resuscitation, and evacuation.48
In this system, 30 different injuries can be simu-
lated, multiple interventions can be performed,
83
and the condition and vital signs of the patients
are dynamic and respond appropriately to the spe-
cific injuries and interventions. This program in-
corporates an educational module, as well as prac-
tice modules and a testing module for each injury.
There are text and graphic feedback as well as au-
dio and visual feedback in the form of a realistic
virtual patient; however, there is no haptic feed-
back. Similar VR medic trainers have also been de-
veloped by other groups.49,50 One trainer developed
at the University of Pennsylvania differs slightly
from the others in that a virtual medic has been
added to the animation. In this program, users are
able to watch the virtual medic perform the ex-
aminations or procedures that they have selected.49
In addition to out-of-hospital patient care, a vir-
tual emergency department (ED) program has also
been created.51 This system is in an early stage of
development and is limited in the current number
of procedures and interventions that are pro-
grammed; however, the graphics are very realistic
and multiple patient types are possible (including
newborns, males and females). In addition to in-
creasing the number of available disease/injury
scenarios and medical interventions, the designers
intend to enhance the program in other ways to
make it more realistic. One anticipated upgrade is
to enable multiple users to interact in the virtual
ED at the same time. A group in Norway also has
begun to address this issue.52 It is their intention
to use their program to facilitate the continued
medical education of EPs in remote locations.
The outlook for the multiple user virtual EDs
is promising because a similar project in neonatol-
ogy has shown initial success.53 A virtual delivery
room has been programmed with a newborn that
has variable breathing, movement, crying, heart
rate, and skin color. These five parameters are con-
trolled from a command computer that can be net-
worked to other computers by local cables or an
internet connection. This allows multiple users,
even if separated by a great distance, to simulta-
neously observe the changing condition of the vir-
tual neonate. The individual users are able to com-
municate with each other in real time through
headphones and a microphone at each console.
Currently, users can only observe the virtual baby;
however, further development of the software is
currently under way that will allow the users to
perform virtual medical interventions on the baby.
Eventually, this interesting VR setup will allow
several users to care for the virtual neonate si-
multaneously much as nurses, residents, and at-
tendings do in the real world.
Medical Procedures. The greatest amount of work
to date in VR for medical education has come in
the arena of medical procedures. Virtual reality
84 VIRTUAL REALITY
trainers have been developed for several different
examinations, invasive procedures, and surgeries.
These trainers use haptic as well as visual feed-
back, and most of them have been well received.
Virtual reality simulators have been developed
for abdominal trauma surgery, laparoscopic chole-
cystectomy, neurosurgery, endoscopic sinus sur-
gery, temporal bone dissection, arthroscopic sur-
gery of the knee and shoulder, and vascular
anastamosis.54–61 In general, the minimally inva-
sive surgeries are easier to simulate due to the lim-
ited visual and haptic feedback. The surgical field
is viewed on a screen, away from the patient, and
the haptic feedback is transmitted through the
surgical instruments. Several of these simulators
have multiple interactive modules, including edu-
cational, practice, and testing. All of these simu-
lators have been well received and are considered
to have great potential; however, most of them
have not yet been adequately tested for validity or
their effectiveness as teaching tools.
In addition to the surgeries listed in the previ-
ous paragraph, several non–operating room inva-
sive procedures also have been simulated using VR
technology. Again, most of these use haptic as well
as visual feedback, and the more advanced pro-
grams have multiple modules for education, prac-
tice, and testing. Similarly to the surgical VR pro-
grams, these have also been well received, but
most presently lack significant testing. Simulators
have been developed or are currently under devel-
opment for: intravenous catheter insertion, skin
suturing, lumbar puncture, epidural anesthesia,
bone marrow biopsy, leg trauma assessment and
treatment, cardiac catheterization, inferior vena
cava filter placement, pericardiocentesis, cricothy-
roidotomy, diagnostic peritoneal lavage, and emer-
gency thoracotomy.62–73
The emergency thoracotomy program is unique
in that it previously has been studied in the EM
literature.73,74 Investigators found that the pro-
gram was a reliable and valid evaluation tool; how-
ever, it remained inferior to porcine animal mod-
els. Another study documented that it ‘‘showed
promise’’ as a teaching tool; however, no concrete
conclusions were drawn. When interpreting these
results, it is important to understand that this tho-
racotomy program is an innovative but early sim-
ulator. It is not as interactive as many newer sim-
ulators and does not use haptic feedback. It is the
only one of the simulators listed above that would
be classified as pseudo VR. Therefore, generalizing
the results from these two studies to other VR sim-
ulators is not appropriate because the thoracotomy
program differs in its level of interaction and po-
tential realism.
A number of VR programs have also been de-
veloped to simulate minimally invasive or noninva-
Reznek et al. • VIRTUAL REALITY AND SIMULATION
sive procedures and examinations. These include:
occular examination, ultrasound, hysteroscopy, sig-
miodoscopy, ureteroscopy, brochoscopy, and upper
GI endoscopy.75–82 The ultrasound and endoscopic
simulators have been found to be very realistic. In
both cases, the simulated medical instruments and
visual output appear very real. Both use tracking
devices that allow the computer to sense the ac-
tions of the user, and the endoscopic simulators
use a robotic interface to provide the appropriate
force feedback on the scope. These tracking and
feedback devices are hidden from the user so they
do not take away from the realism of the simula-
tors.
Only a few of these simulators have been for-
mally studied to date. The ultrasound simulator
has been examined for its potential in training sur-
gical residents. Investigators concluded that it was
equally as effective as live patient training but su-
perior in its convenience.77 The sigmoidoscopy sim-
ulator has been shown to improve performance,
but it has not been compared with the current
standard of training, the live patient.79 Clearly all
of these simulators, including the few that have
been subjected to initial review, require further in-
vestigation.
COMBINED VIRTUAL REALITY AND
SIMULATION IN MEDICAL EDUCATION
Members of the department of EM at the Univer-
sity of Michigan have created an immersive train-
ing environment, called the Medical Readiness
Trainer (MRT), that simultaneously uses both VR
and computer-enhanced mannequin simulation.83
The MRT uses a mannequin simulator for haptic
feedback and a CAVE system for the visual and
auditory feedback. The CAVE system is essentially
a room with computer-generated stereoscopic (3-D)
images projected onto its walls. The participants
wear stereoscopic glasses that enable them to see
the wall images in three dimensions but do not
otherwise distort their vision of the real world. The
MRT allows participants to care for the mannequin
simulator in a variety of virtual environments, in-
cluding an injury scene in the field, an ED, a sick
bay on a rocking naval vessel, a rescue helicopter,
an ambulance, and even a battlefield. There are
currently no reports of formal testing of the MRT,
but its creators are hopeful that this combination
of mannequin simulation and VR will prove to be
an excellent training tool.
DISCUSSION
Virtual reality and computer-enhanced simulation
represent the future of medical education. Despite
ACADEMIC EMERGENCY MEDICINE • January 2002, Volume 9, Number 1 • www.aemj.org
this technology’s only being in its infancy, several
applications have already shown themselves to be
effective teaching tools. Given this early success
and the certainty that computer and engineering
technology will continue to advance at an exponen-
tial rate, it is clear that the potential of VR and
simulators for medical education is astounding.
We predict that once they have reached a suf-
ficient level of sophistication and cost-efficiency,
VR applications and simulators will be broadly ac-
cepted into medical education. One can easily en-
vision an educational system in which medical stu-
dents and residents will first learn procedures and
other elements of patient care on simulators or in
the virtual world. Once these trainees have safely
mastered certain basic skills, they then can begin
to hone these skills with patients in the real world.
Despite the tremendous potential of simulators
and VR, it is important that we do not prematurely
accept them solely due to the positive subjective
responses that they receive (sometimes referred to
as the ‘‘wow’’ factor). Evaluation of these new
teaching tools, based on sound scientific and edu-
cational principles, should be performed before
they are incorporated into medical curricula. It
will benefit the medical community greatly to de-
velop a standardized methodology of evaluating
these new teaching instruments. However, we re-
main confident that these studies will, in fact,
prove the future simulators and VR programs to
be more efficient, more economical, and more eth-
ical than our current teaching methods.
Following the incorporation of VR and com-
puter-enhanced simulation into medical education,
we also predict that a less tangible but equally im-
portant benefit of this technology will come to
light. We believe that their use in medical educa-
tion will actually improve the patient–physician
relationship. Under our current system of educa-
tion, the doctor in training often removes himself
or herself from a patient when using that patient
to learn medical skills. This naturally occurs be-
cause the trainee must focus on the learning task
at hand and also because, for many of us, it is dif-
ficult to accept that we may be causing additional
pain or harm to a person for our own gain. If the
skills to be performed by a trainee were practiced
on a simulator prior to his or her introduction to
the patient, the advantage would be twofold. The
doctor in training could focus more of his or her
attention on developing a relationship with the pa-
tient, and the patient would be much more trust-
ing and receptive.
The potential of VR and computer-enhanced
simulation in medical education has been well rec-
ognized by anesthesiologists and surgeons. Up to
this point, they have been the pioneers in the field
and emergency physicians rarely have been in-
85
volved. A search for virtual reality and simulation
in EM in the medical, computer, and engineering
literature revealed only 13 publications. Of the 13,
just six were published in the EM literature, and
of those, two dealt with only pseudo VR and one
was an editorial.84
Because the involvement of EPs has been lim-
ited, most of the VR programs as well as the man-
nequin simulators have not been designed with
EM in mind. It is fortunate for us that many of
these simulators are still useful for EM education;
however, in many cases their designs could be im-
proved for our specific needs. By EPs assuming an
active leadership role in this area, we will be able
to ensure that future VR and simulation technol-
ogy will be steered in a direction that will most
benefit education in our field.
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