Taking the Pulse!! of Medical Training

Students are learning from a computer simulation that borrows elements from shoot-'em-up games. But don't call it a video game

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Five years ago, Claudia Johnston had a eureka! moment. She was walking through a big-box electronics store and stopped to play a first-person shooter video game running on a floor-model TV. Johnston, who holds a PhD in nursing, had never played one before. She immediately realized that the experience of playing high-tension games like Half-Life or Doom was similar to that of navigating multiple challenges in a chaotic hospital setting.

So Johnston, the associate vice-president for special projects at Texas A&M University-Corpus Christi, decided to develop Pulse!!, a virtual, clinical-training tool for medical and nursing students that borrows design and game-play elements from first-person shooter video games.

Skills developed while gaming -- from resource and time management to quick thinking under life-and-death pressure -- could translate well to a simulated medical experience, Johnston reasoned. Plus, students who regularly enjoy playing Call of Duty on their days off might willingly work on their skills on their own time, repeatedly practicing how to respond to patients' needs.

But don't call the ambitious $7.5 million, federally funded medical-training project that Johnston is spearheading a game. It's a PC-based learning platform first and foremost, she says -- and careful labeling is crucial for wide acceptance in the medical, nursing, education, and gaming worlds.


  "The gaming industry is struggling as a whole with the concept of 'serious games,'" Johnston says, referring to the oxymoronic label of nonentertainment simulation and other video-game-like tools used by the military, educational institutions, and corporations for training purposes. "When people hear 'game,' or even 'serious game,' we lose a number of people who won't give the idea of a medical simulation a chance," she says. "So I wanted to fix that misconception and call it a platform."

Pulse!! is funded by the Office of Naval Research, and is designed by the Hunt Valley (Md.)-based developer BreakAway, which has made simulations for the U.S. Military and emergency response teams (as well as popular entertainment strategy games like Tropico). So far, the designers are working on a proof-of-concept prototype that will be completed by the end of 2006. Eventually, it will be marketed to educational institutions as a PC-based training tool.

As of early April, the BreakAway designers had finished a photorealistic model of the Bethesda Naval Hospital's Intensive Care Unit, which will serve as the virtual setting for the training tool. Some of the design details are uncannily precise. "A nurse who saw the graphics told us she was embarrassed because she recognized the old bulletin boards. She realized that the staff hadn't changed some of what's been posted for something like 10 years," says Ed Fletcher, executive producer at BreakAway.


  In the first virtual clinical case, a young soldier who has returned to the United States from Iraq is suffering from internal injuries sustained in an explosion. Fletcher says the team started with this plot purely for design reasons: The patient is a 24-year-old man in peak physical condition, meaning the designers wouldn't have to render complicated bodily details such as a paunch or flabby muscles. His body would reflect an idealized physique, similar to many popular and existing video-game characters.

And the soldier wouldn't have gaping wounds, so the designers don't have to worry about realistic blood flow or rendering anatomically correct muscle tissue, fat, or organs yet. "We don't have to model gore and blood, which are very hard to accomplish with physiological accuracy," Fletcher says.

The Pulse!! designers are tackling other renderings challenges, though. "The soldier's skin becomes shiny if he has a fever, or takes on a pallid, blue color that indicates the internal bleeding. And his breathing might change," Fletcher says. "These haven't been depicted in video games before." The basic challenge of the simulation is to diagnose correctly after observing these and other symptoms.


  The team worked closely with doctors and nurses who had first-hand experience with such symptoms and injuries, and even based the movements of the 3-D characters on the actions of a real-life medical team. Because the designers aren't allowed to videotape patients for privacy reasons, they taped re-enactments of the soldiers and doctors in the hospital, with real-life medical staff and medical students as actors. The designers then used motion-capture equipment to extract movement data from the video that they could apply to their virtual characters.

Students navigate through Pulse!! as if playing a first-person shooter, taking on the role of a health-care provider rather than looking onto a scene omnisciently. They talk and interact with a patient to discover what ails him. The scoring or grading system hasn't yet been finalized.

In future versions, players will encounter patients with detailed, biologically correct injuries that will, if all goes as planned, take blood spurts and severed limbs to new levels of realism -- beyond the gore seen in games like Grand Theft Auto.

"Next year, we'll start digging into the body and work on rendering external wounds," says Fletcher, who thinks complex medically informed 3-D renderings of the human body that the designers hope to achieve -- such as the highly textured skin that depresses when touched -- will influence the future design of entertainment games. In addition, Fletcher and his crew are working on subtle details like facial expressions that realistically show dismay and pain, two emotional elements crucial to determining a diagnosis within Pulse!! As Fletcher observes, such details are lacking in many video games today, and if, adopted, could add new depth and believability to entertainment titles.


  Design details aside, using elements of gameplay from video games in educational programs is increasingly seen as an effective training strategy, according to experts. Byron Reeves, a Stanford professor who researches the psychology of video games and other interactive media, says that "games or game-like simulations are fruitful ways to engage in learning content, because people are generally anxious to return to playing a game."

Reeves adds that "studies have shown that game play can alter hand-eye coordination -- for the better." One oft-cited example is a 2003 University of Rochester study on teenage boys' increased abilities to process visual information after playing violent shooter games.

Computer-generated graphics have increasingly been playing a role in medical-training simulations. Companies like Gaithersburg (Md.)-based Immersion Medical, a subsidiary of Immersion (IMMR), have developed virtual simulators of medical procedures ranging from endoscopy to phlebotomy. But Pulse!! is the most complex, game-influenced medical-training simulation to date.


  One of the main reasons why the design of Pulse!! relies so heavily on video-game precedents, however, is simply due to realism that can't be achieved with, say, a CPR dummy. "Pulse!! uses gaming tech because it's the most efficient way for creating believable graphics and simulation on a PC," BreakAway's Fletcher says.

And, in the arena of medical training, realism is paramount -- as is repetitive practice. Johnston adds: "In nursing and medicine, mistakes can kill. Extensive experience with real-life situations is key. So fidelity in a life-saving training tool has utmost importance."

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