First-year military medical students practice combat casualty care in a virtual environment that includes 3-D battlefield scenes

The U.S. Military ups the ante on medical simulation with a state-of-the-art virtual environment known as WAVE.

Emergency medicine education is an evolving art. As educators and learners, emergency physicians are quick to integrate new technologies into our educational armamentarium. It’s now the norm to glean pearls from podcasters while running on the treadmill, keep up with EM conference lectures via tweets, and use a variety of handheld apps to improve bedside care. We are constantly streaming, blogging, and simulating our way to better training and patient care. Recently the Uniformed Services University of the Health Sciences (USUHS) took another big step forward – launching a Wide Area Virtual Environment (WAVE) for medical education.

Virtual reality and its use in EM education is not new. However, the WAVE is like virtual reality after blood doping. It’s a multi-million dollar, 8,000 square foot facility capable of immersing learners in a 3-D virtual environment. The WAVE is composed of two pods connected by a passageway, surrounded by 9-foot tall, 12-foot wide movie screens. One hundred and forty-four projectors are used to display 3-D interactive images.

A 5.1 channel sound system generates high fidelity positional sounds. Soon, there will be additional capabilities for smells, smoke, flying debris, and moving platforms to simulate helicopter flights, in addition to a variety of background scenes. The first group of 90 first-year medical students underwent WAVE training as a culmination of their Combat Medical Skills course. They learn basic emergency medicine skills to assess and treat combat casualties during the course. After a quick overview, the students donned 3-D glasses, and were plunged into a combat street scene – complete with gunfire, sandbags and circling helicopters. In teams of six, the students provided initial pre-hospital stabilization of two seriously injured casualties (one a standardized patient and the other a high-fidelity simulator). Initial feedback indicates the students greatly enjoyed the experience and preferred the WAVE training to conventional training modalities currently used in the course.

It’s easy to imagine this technology being used in a variety of ways in the future – residents and practicing physicians might step into virtual emergency departments to manage new or challenging patients, or refresh infrequently used skills. These virtual EDs could contain the chaos and variety we see in our daily shifts without the patient safety risk or the offending odors (unless you choose to pump in smells to “enhance” the experience). Medical students might spend time in virtual EDs during their clerkships – seeing and managing patients that would normally be cherry-picked by residents during a real shift. Interdisciplinary team communication practice could take place in a high-stress ED without real patients to inconvenience. And paramedics could use traffic carnage scenes on busy freeways to practice extricating patients from vehicles.

Every foray into a new technology always generates excitement (for both educators and learners). There’s a natural urge to jump in with both feet and make it work. But, it’s important to step-back and look at the educational process. We want to ensure we’re using a technology because it enhances education, not just because it’s exciting.

Unfortunately, even though emergency medicine educators have utilized simulation for many years, we are still not certain of the best way to do it. Dr. Ilgen et al, published a systematic review and meta-analysis of simulation in emergency medicine in the February 2013 edition of Academic Emergency Medicine. They concluded that technology-enhanced simulation is associated, “with moderate or large favorable effects in comparison with no intervention and generally small and nonsignificant benefits in comparison with other instruction.”1 At first, this seems quite discouraging for future use of the WAVE and other simulation technology. But, the authors note that the current research is limited. When comparing the effectiveness of different simulation modalities, for example, they write, “Among the few studies comparing different approaches to simulation-based education, feedback and mastery learning appear to improve learning. Higher fidelity appears to confer small to moderate benefits . . . but the studies are few and the defining features of high and low fidelity are vague and vary from study to study.”1

This leaves the door open for simulation research to show which technologies work, and how best to employ them in a cost-effective manner. Educators exploring high-technology education modalities, like the WAVE, should continue trying to answer the questions of not only how do we do it, but how do we do it effectively. In the meantime, following advice Dr. Ten Eyck published in Pediatric Emergency Care serves as an essential starting point. He suggests that we can effectively use simulation-based education by following classic educational concepts of, “defining the targeted learners, assessing their general and specific educational needs, defining learning objectives, and selecting the best educational strategy for achieving each objective.”2 Closing the loop by measuring meaningful educational outcomes will allow us to improve our delivery.

As we have fun exploring new ways to teach and learn EM, let’s look for the best evidence-based educational strategies and incorporate them as they become available. And, keep watching the educational waters; you never know when the next wave will break.

1. Ilgen, et al. Technology-enhanced Simulation in Emergency Medicine: A Systematic Review and Meta-Analysis. Academic Emergency Medicine. February 2013, Vol. 20, No. 2.
2. Ten Eyck. Simulation in Emergency Medicine Training. Pediatric Emergency Care. April 2011 - Volume 27 - Issue 4 - pp 333-341.

The views expressed in this article are those of the author and do not reflect the official policy or position of the Department of the Air Force, Department of Defense, or the US government.


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