78 VIRTUAL REALITY Reznek et al.

• VIRTUAL REALITY AND SIMULATION

SPECIAL CONTRIBUTIONS
Virtual Reality and Simulation: Training the Future Emergency
Physician
MARTIN REZNEK, MD, PHILLIP HARTER, MD, THOMAS KRUMMEL, MD

that show tremendous promise in overcoming most of the

deficiencies associated with live-patient training. It will be
important for academic emergency physicians to become more
Abstract. The traditional system of clinical education in involved with this technology to ensure that our educational
emergency medicine relies on practicing diagnostic, therapeutic, system benefits optimally. Key words: virtual reality;
and procedural skills on live patients. The ethical, financial, and simulation; emergency medicine; education. ACADEMIC
practical weaknesses of this system are well recognized, but the EMER-
alternatives that have been explored to date have shown even GENCY MEDICINE 2002; 9:78–87
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 evolution promises to
cornerstone for teaching. Over the years, many educators have
understood there to be significant drawbacks to this system
and have searched for other options. These other training
accelerate as computer-related advances continue to become tools, including volunteers, plastic models, animals, and
available at an exponential rate. Gordon Moore, the cofounder cadavers, have shown even greater flaws.2,3 So today,
of Intel Corporations, has observed that the power of computer believing there to be no acceptable alternatives, we continue
chips doubles every 18 to 24 months. And, Randall Tobias, a to rely on the patient as the foundation of our clinical
former vice-president of ATT, noted that ‘‘over the last 30 education. However, the continuing progress of computing
years, we have seen a 3,000-fold increase in computing power. technology is providing us with applications that will
If we had had similar progress in the automotive industry, a challenge this notion and quickly make it outdated. Advances
Lexus would cost $2, it would travel at the speed of sound and in the realms of virtual reality and computer-enhanced
go 600 miles on a thimble simulation are showing great promise in supplementing our
full of gas.’’1 traditional training system of live ‘‘models,’’ and may even
Almost every profession has learned to adapt to and eventually replace them.
subsequently exploit this ongoing progress in computing
technology. The field of medicine, however, has only just
begun to join in and is doing so at a considerably slower pace. RATIONALE
The leaders in medical education, in particular, have not taken
advantage of the technology that is becoming available, and Traditionally, we have relied on the patient as our primary
those of us in emergency medicine (EM) are no exception. vehicle for the clinical training of physicians. Unfortunately,
this teaching system is not ideal due to the simple fact that the
clinical practice of medicine has been refined over the years
specifically to improve patient care and not necessarily
education. Superior patient care and optimal physician
From the Division of Emergency Medicine, Department of Surgery, Center
for Advanced Technology in Surgery at Stanford, Stanford University training are often mutually exclusive in the clinical setting,
Medical Center (MR, PH, TK), Stanford, CA. and consequently live-patient training has several significant
Received March 7, 2001; accepted August 27, 2001. shortcomings.
Address for correspondence and reprints: Martin Reznek, MD, CATSS
Laboratory, Department of Surgery, Stanford University, School of Medicine, One can appreciate these deficiencies by considering the
300 Pasteur Drive, H3680, Stanford, CA 94305-5655. Fax: 650-724-3431; e- simple example of teaching a resident to perform a procedure
mail: mreznek@ [Link] such as central venous catheterization. Learning curves have
In EM, as in many other specialties, the traditional training been demonstrated for procedures in EM as well as other
model still exists; for diagnosis, therapeutic intervention, and specialties.4–11 Using the patient as a practice ‘‘model’’ places
performing procedures, the live patient remains the
ACADEMIC EMERGENCY MEDICINE • January 2002, Volume 9, Number 1 • [Link] 79

the patient at an increased risk of complication, but due to a keeping him or her from other clinical responsibilities. And
historical lack of satisfactory teaching alternatives, we have due to the learning curve, there theoretically will be a more
had to accept this inherent risk as a ‘‘necessary evil.’’ Even if frequent need for additional medical care due to iatrogenic
we can ethically justify allowing a resident to practice injuries sustained when an inexperienced physician performs
inserting a central line in a patient a single time, we certainly the procedure.
cannot allow the resident to repeat the exercise multiple times It is clear that the live patient ‘‘model’’ is not an ideal
until he or she has performed it correctly. Even more instrument for education, especially for the introductory
devastating to the learning process is the fact that an instructor instruction of procedures and most medical management
is ethically bound to stop the resident if he or she is making an algorithms. Technologic advances in the areas of virtual
error. For this reason, the resident will only rarely have the reality and computerenhanced simulation have introduced a
opportunity to experience complications resulting from his or new method of teaching that bypasses each of the ethical,
her actions (in other words, pneumothorax or air embolus). In financial, and practical deficiencies of live patient training that
live-patient training, the resident is often denied the luxury of have been illustrated in this section.
learning from his or her mistakes, a technique that many
educators have reported to be highly effective and some even
believe to be superior to standard methods of acquiring factual SIMULATION—BACKGROUND
knowledge.12–14 AND HISTORY
In addition to these ethical issues, live-patientdependent
education is also inefficient. In the central line example, the Simulation is the act of mimicking a real object, event, or
resident is not even guaranteed the opportunity to learn that process by assuming its appearance or outward qualities.16 In
procedure. The resident is dependent on random chance and order to be an effective teaching tool, a simulator must provide
must wait for the arrival of a patient who needs a central line both educationally sound and realistic feedback to a user’s
before he or she can practice that skill. In fact, for procedures questions, decisions, and actions.17 Sufficient realism should
with indications that are less common than those of a central be present for the user to suspend disbelief; however, it is
line, such as cricothyroidotomy, the resident may never even important to realize that a simulator does not need to be
get the chance. identical to real life to accomplish this.18 Therefore, one does
Even if the resident is fortunate enough to get the not have to include every detail of the real experience when
opportunity to perform the procedure, significant time designing an effective simulator.
constraints exist that will negatively affect his or her learning. Both the birth of modern simulation and the majority of
When learning on a patient, the resident commonly advances in this field can be credited to the aerospace industry.
experiences pressure to ‘‘hurry’’ from the teacher as well as Flight simulation was first conceived in 1929 when Edwin
the patient. The attending physician will most likely have Link designed an amusement park ride that gave the sensation
limited time due to his or her other duties, and the ‘‘model’’ of flying a plane. This machine eventually was modified into
is likely only to tolerate so much. the Link Flight Simulator.19 Training with this primitive
Central venous catheterization, like any procedure, is simulator was associated with a 90% reduction in nighttime
designed, of course, from a patient care standpoint and not an and bad-weather collisions.15 Since that first successful
educational one and as such impedes learning. For example, simulator, several major advances have been added to the
sterile draping is required during central line insertion on a concept, including motion camera displays and eventually
live patient. These drapes obscure the important external computer-generated displays. The success of this means of
landmarks that the novice needs to insert the needle properly. training as well as its cost–effectiveness in the aerospace
The internal anatomy is even more frustrating due to the fact sector has been well documented.20,21 Other industries as
that it cannot be visualized even before draping and must be diverse as the military, business management, transportation,
imagined. Furthermore, with live-patient-based learning, and nuclear power have also found success in training
standardizing the training of central line insertion is with simulation.1,16,17
impossible because each educational experience is based on The field of medicine has occasionally incorporated
an individual patient with unique anatomy. In addition, simulation into its training. However, for the majority of
recording the exercise, which would allow both the resident applications, the technology has been limited and
and the instructor to review the procedure multiple times and subsequently so has its success. The one major exception to
to be more objective in their assessment, is rarely performed this has been the use of computer-enhanced mannequins. The
because it is difficult and expensive. As a consequence, first of these simulators, Sim One, was created in 1967 at the
debriefing the resident after live-patient training is often University of Southern California. This simulator consisted of
suboptimal. Recording would also enable the debriefing to be a life-size mannequin connected to a computer, an instructor’s
postponed to a time that is more convenient and more console, an interfacing unit, and an anesthesia machine. The
conducive to learning. Sim One was able to simulate cardiac arrest, blood pressure
Finally, teaching any procedure on a live ‘‘model’’ is abnormalities, several arrhythmias, and airway compromise.22
expensive. The instruments are not reusable, and it takes Since then, significant advances in these simulators have been
longer for a trainee to perform the procedure. 15 Furthermore, made, and several different commercial models are now
an attending observer ideally should be present at all times, available.23
80 VIRTUAL REALITY Reznek et al. • VIRTUAL REALITY AND SIMULATION

The modern human patient simulators are designed to have medical responces to specific crises, and 60% is used to teach
more than 40 realistic findings in seven anatomic areas.17 general principles of teamwork and CRM.26 , 27
These mannequins have several anatomically correct clinical The ACRM course has been well received. Students of the
signs, including breath sounds associated with chest rise, heart course find the mannequin and scenarios very realistic and
sounds, palpable carotid and radial pulses, peripheral blood believe that they benefit from the crisis resource management
pressure, pupilary reflexes, and muscle twitch from nerve and teamwork discussions.23,24,28 A small number of studies
stimulation. Additionally, the mannequin is able to speak by have demonstrated construct validity of the patient simulator29
way of microphone from the operator. The simulators are as well as improvement in performance during emergencies
designed to interface with conventional monitoring devices after training with the simulator.30 Proper objective evaluation
that can record the mannequin’s electrocardiogram, respired of human performance in any setting, including ACRM, has
carbon dioxide levels, pulse oximetry signal, invasive proven thus far to be difficult. For this reason, few objective
pressures (arterial, central venous, and pulmonary artery), studies of ACRM have been undertaken. Despite the lack of
cardiac output, and temperature.24 All of the physical findings, objective data however, the subjective response has been
as well as the signals to the monitoring devices, can be positive, and more than a hundred simulator centers are
modified by the operator as needed or automatically by the running throughout the world. 31
computer during a scenario. In addition, the simulators are Other fields in medicine also have recently begun to
programmed to respond appropriately to approximately 70 recognize the potential of the patient simulators for teaching
medications24 and several physical interventions that include: in their fields. Surgeons at Penn State University and Stanford
intubation (unintentional endobronchial or esophageal University have begun pilot studies in the use of patient
intubation are possible), chest compression, ventilation, simulators for resident trauma and crisis management training.
electrocardioversion, cricothyroidotomy (the airway can be Their initial observations have led them to believe that the use
automatically altered to make intubation difficult or of these simulators in surgical education is promising;
impossible), chest tube insertion, and insertion of peripheral however, their findings are yet to be published.
venous and arterial catheters as well as central venous lines.
Two pilot studies using patient simulators for EM
Modern simulators have approximately 50 available
education have been reported in the literature. In New
preprogrammed scenarios17 and, if required, new scenarios are
Zealand, a group has developed a course to teach EM trainees
easy to design.24 Just a few examples of available scenarios
‘‘advanced airway skills.’’32 In this course, the trainees are
are: myocardial ischemia/infarction, pneumothorax,
able to practice practical airway skills as well as hone their
pericardial tamponade, hypotension, hypertension, diabetic
general management skills of an emergency. The course
ketoacidosis, brain injury, blood loss, anaphylaxis, and
creators thought that the patient simulator in conjunction with
multiple electrolyte abnormalities.
their curriculum was a very effective teaching tool for EM and
The end result of all the capabilities listed above is that the reported their intent to further develop their airway course.
modern human patient simulator is an extremely realistic and Another pilot study regarding the potential use of the patient
engaging teaching tool.23–25 These simulators have been used simulator in EM was reported from Boston.33 This group
primarily in the field of anesthesia and therefore they have developed several EM scenarios and combined ACRM
been designed mainly for this purpose. However, it has principles with the MedTeams’ Emergency Team
become clear that other specialties, including EM, can Coordination Course (ETCC) to design their pilot program.
potentially benefit from the simulators, and accordingly some The course participants, including EM attendings, residents,
initial pilot studies are being performed. and nurses, all regarded the scenarios as highly realistic, and
they believed that they benefited from the course as a whole.
SIMULATION IN The most unique aspect of this pilot study is that it appears to
be the first to explore the simultaneous use of multiple
MEDICAL EDUCATION simulators as well as patient-actors.
The human patient simulator is the most impressive of the
The popularity of the human patient simulator in the field of computer-enhanced medical simulators. However, two others
anesthesia is mainly due to the work of Gaba, Fish, and exist that may be useful in EM and deserve brief mention. The
Howard that began in the late 1980s. At that time, it was first is ‘‘Harvey,’’ a cardiology mannequin simulator released
recognized that 65 –70% of all unintentional incidents in in 1976, which is able to simulate the arterial pulse, blood
anesthesia could be attributed to human error. In an attempt to pressure, jugular venous wave, precordial movements, and
gain better insight into this problem, they came across heart sounds in normal and diseased states.34 In EM,
extensive research done in the aerospace sector. The airlines ‘‘Harvey’’ has been used to determine possible areas of
and NASA had begun to address human error in their insufficient training of emergency physicians (EPs) in the
profession and developed a curriculum, called Crew Resource cardiovascular examination.35 The second simulator with
Management (CRM), to educate their pilots in avoiding potential applications in EM is a pelvic examination simulator
human error. Gaba, Fish, and Howard adapted the principles that was recently developed at Stanford University. This
of this course to anesthesia and developed a program that they pelvic mannequin is equipped with internal sensors that are
called Anesthesia Crisis Resource Management (ACRM). connected to a computer. By interpreting these signals, the
Forty percent of the course time is used to teach the proper computer is able to provide the user with visual feedback
ACADEMIC EMERGENCY MEDICINE • January 2002, Volume 9, Number 1 • [Link] 81

regarding which structures they are palpating and how much patient’s surface anatomy.39 In other words, the surgeon is
pressure they are applying.36 virtually able to see through the patient’s skin.
Functionally, there are four necessary elements
VIRTUAL REALITY—BACKGROUND comprising a VR system: software, hardware, input devices,
and output devices.19 The software essentially is a set of
AND HISTORY mathematical algorithms and equations that define the virtual
environment and its responses to the interactions with the user.
The most technologically advanced form of simulation is The hardware is needed to perform the great number of
virtual reality (VR). Jaron Lanier is credited with first coining calculations required by the software to produce the rapidly
the term ‘‘virtual reality’’ in the late 1980s; however, the changing virtual environment. The equations and algorithms
origin of this technology can be traced to work done at MIT used to generate a virtual environment can be based on real-
and Harvard University by Ivan Sutherland in the mid1960s. world data from photographs, pathology sections, plain
Sutherland envisioned a new way for computers and humans radiographs, computed tomography, magnetic resonance, or
to interact and, in 1965 , presented his groundbreaking talk ultrasound. From these data, a computer-aided design (CAD)
entitled ‘‘the Ultimate Display.’’ He proposed a model for a program is used to produce a wire-frame surface model
computer display that would simulate the physical world and consisting of polygons. These polygons are given texture and
would allow the user to interact directly with the computer coloring by a method called rendering.41 To improve the
within that world. Five years later, Sutherland’s visions were resolution of an object, the size of the polygons must be
realized when he invented the first head-mounted display,37 decreased and their number increased. However, as the
and VR was born. number of polygons increases, so does the number of
Most believe that it is sufficient to classify VR devices as calculations to produce them. Therefore, there exists a trade-
either immersive or non-immersive. For medicine, however, off between the speed of object updating and the image
it is probably more beneficial to use a classification system quality,42 both of which are important components of the
proposed by Voelter and Kraemer. They classified VR realism of the virtual environment. Ideally, image frames need
technology into four categories: immersive VR, desktop VR, to be refreshed from 24 to 30 times per second so the eye
pseudo VR, and inverse VR. Immersive VR involves a system cannot distinguish between the frames.43
that completely integrates the human user into the computer’s The virtual environment is then presented to the user
world, while desktop VR differs in that the user is not totally through various output devices. Virtual images are projected
integrated into the virtual world but is still able to observe and either on a high-resolution monitor (with or without 3-D
manage the virtual world on a computer screen. For example, capability) or on a head-mounted display. In addition to visual
modern flight simulators used by the aviation industry and the output, there also exist output devices for the other senses.
military would be considered highly immersive. The user sits Speakers can be added for audio output and devices have been
in the simulator surrounded by the visual display and realistic created to give haptic feedback, including force feedback and
sounds and the simulator can move. Similar flight simulator tactile touch. Force and tactile feedback remain the most
programs are available for personal computers; however, difficult portions of the virtual environment to simulate. The
these would be classified as desktop VR because the current methods of simulating tactile touch are not optimally
simulation occurs entirely on a computer screen in front of the realistic. Inflatable bladders covering the hand, vibrating
user. The third type of VR, pseudo VR, refers to a system in transducers, electrical stimulation, and shape memory alloys
which the user can control the computer animation and that can be altered with an electrical current have all been
observe it, but there is no further interaction. For example, a explored with limited success.41 However, other technologies,
three-dimensional (3-D) anatomic model can be rotated to including pneumatically-driven pins as well as new inflatable
improve learning, but it cannot be palpated or deformed. bladders, are being developed.
Finally, inverse VR describes the integration of a computer Force feedback simulation has had much greater success.
into the life of the user as apposed to the reverse. An example The PHANToM (produced by SensAble Technologies,
of this technology would be a program that allows Woburn, MA) is a computer-driven mechanical arm with a
quadriplegics to use a computer with eye movement-based ‘‘wand’’ extension or a thimble at its end that allows its user
controls in order to communi- to sense the position, orientation, shape, and compliance of a
cate.38 virtual object. In the virtual world, just as in the real world, a
A fifth type of VR, augmented reality, was not mentioned person relies on six degrees of freedom of movement to feel
by Voelter and Kramer, but it has been described by other an object’s position and orientation in space. The first three
groups in the literature and should be added to the degrees of freedom are the Cartesian coordinates X, Y, and Z.
classification to make it complete.39,40 Augmented reality is Freedom of movement in these three axes is necessary for a
achieved by presenting virtual images on a see-through person to define an object’s position. The remaining three
headmounted display, thereby superimposing the virtual degrees of freedom refer to the directions of rotation around a
world on the real one. For example, a program has been point or an object, sometimes referred to as ‘‘pitch,’’ ‘‘yaw,’’
created to aid in maxillofacial surgery by enabling the surgeon and ‘‘roll.’’19 Rotation in these three degrees is important for
to view the internal anatomical structures of a patient’s face establishing an object’s orientation. In combination with a
(based on prior radiographic studies) superimposed on the visual display, the PHANToM is able to realistically convey a
82 VIRTUAL REALITY Reznek et al. • VIRTUAL REALITY AND SIMULATION

virtual object’s position and orientation using six degrees of Another virtual anatomy program, called the ‘‘3D Human
freedom. For force feedback simulation, the PHANToM is Atlas,’’ has been developed in Japan. This program facilitates
able to convey only three degrees of freedom to its user. This students’ understanding of anatomic cross-sections and how
limitation is due to the fact that the force feedback at any given they relate to the anatomy of the entire body. Cross-sections,
instant can be simulated from only a single point on the virtual based on magnetic resonance imaging (MRI) scans of a live
object’s surface. This is similar to feeling the compliance of model, are shown simultaneously alongside a 3-D computer
an object such as a grapefruit through a pencil; some rendering of the entire body of that model. An opaque plane
compliance information can be conveyed but the information through the 3-D model indicates the orientation of the MRI
is somewhat limited. Despite this hindrance, the force crosssection, thereby enabling the student to better understand
feedback simulation is very realistic when supported by how the cross-section relates to the entire body. Additionally,
simultaneous visual simulation. The PHANToM has been the external and internal structures of the 3-D whole-body
programmed to simulate the shape and compliance of many rendering have varying opacities, allowing the user to develop
objects, including anatomic structures, and programs also a better understanding of the anatomic relationships of these
exist that simulate the sensation of puncturing one or more organs.46
layers of varying compliance. A VR program has also been designed for teaching brain
The computer’s output or feedback to the user is important anatomy to medical students. This program includes 2-D
for the realism of the virtual experience; however, the input modules of gross brain sections, histology, and
from the user to the computer is also essential in that it makes neuroradiology, in addition to a 3-D anatomic model of the
the experience truly interactive. Conventional input devices, brain. The user can adjust the views of the brain, and variable
including the keyboard, mouse, and voice recognition opacities exist to allow better understanding of deeper
technology, can all be useful in VR, but several more structures and their relative positions.45,47
advanced innovations have been developed specifically for
VR. Tracking devices are used to detect the position and Clinical Scenarios. The number of programs that have been
movement of the user’s head, body, and limbs. For most created for basic science education is limited; however, more
purposes, tracking the hand(s) and head are sufficient for applications have been developed for advanced levels of
realism; however, full body suits have been developed. medical training. The military, likely due to its success with
Electromagnetic, mechanical, and gyroscopic sensors have VR in aviation and combat training, has been interested in
been used for positional and movement detection, and using VR for training its medical personnel in battlefield
biosensors are currently being developed to track muscle and trauma management. Accordingly, a military group in
neuronal activity.41 Germany has produced a desktop VR program that facilitates
Despite VR technology’s only being in its early stages, it the training of medics in casualty triage, resuscitation, and
is already impressive and certainly advanced enough to be evacuation.48 In this system, 30 different injuries can be
used in many medical applications. It must be noted that the simulated, multiple interventions can be performed, and the
existing simulation capabilities are somewhat limited in their condition and vital signs of the patients are dynamic and
realism and can be disappointing if one expects too much. respond appropriately to the specific injuries and
However, it is also essential to realize that improvements in interventions. This program incorporates an educational
all four of the functional portions of VR (software, hardware, module, as well as practice modules and a testing module for
input sensors, and output devices) are continually becoming each injury. There are text and graphic feedback as well as
available and the realism will continue to improve. audio and visual feedback in the form of a realistic virtual
VIRTUAL REALITY IN MEDICAL patient; however, there is no haptic feedback. Similar VR
medic trainers have also been developed by other groups. 49,50
EDUCATION One trainer developed at the University of Pennsylvania
differs slightly from the others in that a virtual medic has been
Basic Science. Several VR projects are currently under way added to the animation. In this program, users are able to
for basic science education. One system, called the Anatomic watch the virtual medic perform the examinations or
VisualizeR, is being developed at the University of California, procedures that they have selected. 49
San Diego. This program contains several 3-D anatomic In addition to out-of-hospital patient care, a virtual
models that are based on data from the Visible Human Project. emergency department (ED) program has also been created. 51
A student is able to virtually dissect these 3-D models while This system is in an early stage of development and is limited
simultaneously accessing other supporting 2-D resources, in the current number of procedures and interventions that are
such as diagrams, text, and videos. The program also allows programmed; however, the graphics are very realistic and
the user to adjust the size, opacity, and orientation of the multiple patient types are possible ( including newborns,
various organs in order to better reveal the adjacent and deeper males and females). In addition to increasing the number of
structures. This function of the program provides the user with available disease/injury scenarios and medical interventions,
an extremely effective method for learning the anatomic the designers intend to enhance the program in other ways to
relations of or- make it more realistic. One anticipated upgrade is to enable
gans.44,45 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
ACADEMIC EMERGENCY MEDICINE • January 2002, Volume 9, Number 1 • [Link] 83

their intention to use their program to facilitate the continued evaluation tool; however, it remained inferior to porcine
medical education of EPs in remote locations. animal models. Another study documented that it ‘‘showed
The outlook for the multiple user virtual EDs is promising promise’’ as a teaching tool; however, no concrete
because a similar project in neonatology has shown initial conclusions were drawn. When interpreting these results, it is
success.53 A virtual delivery room has been programmed with important to understand that this thoracotomy program is an
a newborn that has variable breathing, movement, crying, innovative but early simulator. It is not as interactive as many
heart rate, and skin color. These five parameters are controlled newer simulators and does not use haptic feedback. It is the
from a command computer that can be networked to other only one of the simulators listed above that would be classified
computers by local cables or an internet connection. This as pseudo VR. Therefore, generalizing the results from these
allows multiple users, even if separated by a great distance, to two studies to other VR simulators is not appropriate because
simultaneously observe the changing condition of the virtual the thoracotomy program differs in its level of interaction and
neonate. The individual users are able to communicate with potential realism.
each other in real time through headphones and a microphone A number of VR programs have also been developed to
at each console. Currently, users can only observe the virtual simulate minimally invasive or noninvasive procedures and
baby; however, further development of the software is examinations. These include: occular examination,
currently under way that will allow the users to perform virtual ultrasound, hysteroscopy, sigmiodoscopy, ureteroscopy,
medical interventions on the baby. Eventually, this interesting brochoscopy, and upper GI endoscopy.75–82 The ultrasound and
VR setup will allow several users to care for the virtual endoscopic simulators have been found to be very realistic. In
neonate simultaneously much as nurses, residents, and both cases, the simulated medical instruments and visual
attendings do in the real world. output appear very real. Both use tracking devices that allow
the computer to sense the actions of the user, and the
Medical Procedures. The greatest amount of work to date endoscopic simulators use a robotic interface to provide the
in VR for medical education has come in the arena of medical appropriate force feedback on the scope. These tracking and
procedures. Virtual reality trainers have been developed for feedback devices are hidden from the user so they do not take
several different examinations, invasive procedures, and away from the realism of the simulators.
surgeries. These trainers use haptic as well as visual feedback, Only a few of these simulators have been formally studied
and most of them have been well received. to date. The ultrasound simulator has been examined for its
Virtual reality simulators have been developed for potential in training surgical residents. Investigators
abdominal trauma surgery, laparoscopic cholecystectomy, concluded that it was equally as effective as live patient
neurosurgery, endoscopic sinus surgery, temporal bone training but superior in its convenience.77 The sigmoidoscopy
dissection, arthroscopic surgery of the knee and shoulder, and simulator has been shown to improve performance, but it has
vascular anastamosis.54–61 In general, the minimally invasive not been compared with the current standard of training, the
surgeries are easier to simulate due to the limited visual and live patient.79 Clearly all of these simulators, including the few
haptic feedback. The surgical field is viewed on a screen, that have been subjected to initial review, require further
away from the patient, and the haptic feedback is transmitted investigation.
through the surgical instruments. Several of these simulators
have multiple interactive modules, including educational,
practice, and testing. All of these simulators have been well
COMBINED VIRTUAL REALITY AND
received and are considered to have great potential; however, SIMULATION IN MEDICAL EDUCATION
most of them have not yet been adequately tested for validity
or their effectiveness as teaching tools. Members of the department of EM at the University of
In addition to the surgeries listed in the previous Michigan have created an immersive training environment,
paragraph, several non–operating room invasive procedures called the Medical Readiness Trainer (MRT), that
also have been simulated using VR technology. Again, most simultaneously uses both VR and computer-enhanced
of these use haptic as well as visual feedback, and the more mannequin simulation.83 The MRT uses a mannequin
advanced programs have multiple modules for education, simulator for haptic feedback and a CAVE system for the
practice, and testing. Similarly to the surgical VR programs, visual and auditory feedback. The CAVE system is essentially
these have also been well received, but most presently lack a room with computer-generated stereoscopic (3-D) images
significant testing. Simulators have been developed or are projected onto its walls. The participants wear stereoscopic
currently under development for: intravenous catheter glasses that enable them to see the wall images in three
insertion, skin suturing, lumbar puncture, epidural anesthesia, dimensions but do not otherwise distort their vision of the real
bone marrow biopsy, leg trauma assessment and treatment, world. The MRT allows participants to care for the mannequin
cardiac catheterization, inferior vena cava filter placement, simulator in a variety of virtual environments, including an
pericardiocentesis, cricothyroidotomy, diagnostic peritoneal injury scene in the field, an ED, a sick bay on a rocking naval
lavage, and emergency thoracotomy. 62–73 vessel, a rescue helicopter, an ambulance, and even a
The emergency thoracotomy program is unique in that it battlefield. There are currently no reports of formal testing of
previously has been studied in the EM literature. 73,74 the MRT, but its creators are hopeful that this combination of
Investigators found that the program was a reliable and valid
84 VIRTUAL REALITY Reznek et al. • VIRTUAL REALITY AND SIMULATION

mannequin simulation and VR will prove to be an excellent in EM in the medical, computer, and engineering literature
training tool. 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
DISCUSSION Because the involvement of EPs has been limited, most of
the VR programs as well as the mannequin simulators have
Virtual reality and computer-enhanced simulation represent not been designed with EM in mind. It is fortunate for us that
the future of medical education. Despite this technology’s many of these simulators are still useful for EM education;
only being in its infancy, several applications have already however, in many cases their designs could be improved for
shown themselves to be effective teaching tools. Given this our specific needs. By EPs assuming an active leadership role
early success and the certainty that computer and engineering in this area, we will be able to ensure that future VR and
technology will continue to advance at an exponential rate, it simulation technology will be steered in a direction that will
is clear that the potential of VR and simulators for medical most benefit education in our field.
education is astounding.
We predict that once they have reached a sufficient level
of sophistication and cost-efficiency, VR applications and References
simulators will be broadly accepted into medical education.
One can easily envision an educational system in which 1. Krummel TM. Surgical simulation and VR: the coming
revolution. Ann Surg. 1998; 228:635–7.
medical students and residents will first learn procedures and 2. Nelson MS. Models for teaching emergency medicine skills. Ann
other elements of patient care on simulators or in the virtual Emerg Med. 1990; 9:333–5.
world. Once these trainees have safely mastered certain basic 3. Totten VY. Ethics and teaching the art of emergency medicine.
skills, they then can begin to hone these skills with patients in Ethical Issues Clin Emerg Med. 1999; 17:429–39. 4. Shackford SR, Rogers
FB, Osler TM, Trabulsy ME, Clauss DW, Vane DW. Focused abdominal
the real world. sonogram for trauma: the learning curve of nonradiologist clinicians in
Despite the tremendous potential of simulators and VR, it detecting hemoperitoneum. J Trauma. 1999; 46:553–62.
5. Delaney KA, Hessler R. Emergency flexible fiberoptic
is important that we do not prematurely accept them solely due nasotracheal intubation: a report of 60 cases. Ann Emerg Med. 1988; 17:919–
to the positive subjective responses that they receive 26.
(sometimes referred to as the ‘‘wow’’ factor). Evaluation of 6. Smith JE, Jackson AP, Hurdley J, Clifton PJ. Learning curves for
these new teaching tools, based on sound scientific and fiberoptic nasotracheal intubation when using the endoscopic video camera.
Anaesthesia. 1997; 52:101–6.
educational principles, should be performed before they are 7. Watson DI, Baigrie RJ, Jamieson GG. A learning curve for
incorporated into medical curricula. It will benefit the medical laparoscopic fundoplication. Ann Surg. 1996; 224:198–203.
community greatly to develop a standardized methodology of 8. Martin KR, Burton RL. The phacoemulsification learning curve:
evaluating these new teaching instruments. However, we per-operative complications in the first 3000 cases of an experienced surgeon.
Eye. 2000; 14:190–5.
remain confident that these studies will, in fact, prove the 9. Carmody BJ, Otchy DP. Learning curve of transrectal ultrasound.
future simulators and VR programs to be more efficient, more Dis Colon Rectum. 2000; 43:193–7.
economical, and more ethical than our current teaching 10. Vrancic JM, Piccinini F, Vaccarino G, Iparraguirre E, Albertal J,
methods. Navia D. Endoscopic saphenous vein harvesting: initial experience and
learning curve. Ann Thorac Surg. 2000; 70: 1086–9.
Following the incorporation of VR and computer- 11. Gates EA. New surgical procedures: can our patients benefit while
enhanced simulation into medical education, we also predict we learn? Am J Obstet Gynecol. 1997; 176:1293–8.
that a less tangible but equally important benefit of this 12. Wu AW, Folkman S, McPhee SJ, Lo B. Do house officers learn
from their mistakes? JAMA. 1991; 265:2089–94.
technology will come to light. We believe that their use in 13. Short D. Learning from our mistakes. Br J Hosp Med. 1994;
medical education will actually improve the patient–physician 51:250–2.
relationship. Under our current system of education, the 14. McIntyre N, Popper K. The critical attitude in medicine: the need
doctor in training often removes himself or herself from a for a new ethics. Br Med J. 1983; 287:1919–24.
15. Haluck RS, Krummel TM. Simulation and virtual reality for
patient when using that patient to learn medical skills. This surgical education. Surg Technol Int VIII. 1999; 8:59–63. 16. Gorman PJ,
naturally occurs because the trainee must focus on the learning Meier AH, Krummel TM. Simulation and virtual reality in surgical education:
task at hand and also because, for many of us, it is difficult to real or unreal? Arch Surg. 1999; 134;1203–8.
17. Issenberg SB, McGaghie WC, Hart IR, et al. Simulation technology for
accept that we may be causing additional pain or harm to a health care professional skills training and assessment. JAMA. 1999;
person for our own gain. If the skills to be performed by a 282:861–6.
trainee were practiced on a simulator prior to his or her 18. Jones K. Simulators: A Handbook for Teachers. New York: Nichols
introduction to the patient, the advantage would be twofold. Publishing Co., 1980.
19. Ahmed M, Meech JF, Timoney A. Virtual reality in medicine. Br J Urol.
The doctor in training could focus more of his or her attention 1997; 80(suppl 3):46–52.
on developing a relationship with the patient, and the patient 20. Lessons learned. Army devises systems to decide what does, and does
would be much more trusting and receptive. not, work: the real value of experience. Wall Street J. May 23, 1997, p
A1.
The potential of VR and computer-enhanced simulation in 21. Goldiez BF. History of networked simulators. In: Clarke TL (ed).
medical education has been well recognized by Distributed Interactive Simulation Systems for Simulation and Training
anesthesiologists and surgeons. Up to this point, they have in the Aerospace Environment. Bellingham, WA: SPIE Optical
been the pioneers in the field and emergency physicians rarely Engineering Press, 1995, pp 39–58.
22. Abrahamson S. Sim One—a patient simulator ahead of its time.
have been involved. A search for virtual reality and simulation Caduceus. 1997; 13(2):29–41.
ACADEMIC EMERGENCY MEDICINE • January 2002, Volume 9, Number 1 • [Link] 85

23. Forrest F, Taylor M. High level simulators in medical education. Hosp Reality: Global Healthcare Grid. Amsterdam: IOS Press and Ohmsha, 1997,
Med. 1998; 59:653–5. pp 529 –
24. Doyle DJ, Arellano R. The Virtual Anesthesiologye training simulation 38.
system. Can J Anaesth. 1995; 42:267–73. 48. Willy C, Sterk J, Schwarz W, Gerngross H. Computer-assisted
25. Gaba DM, DeAnda A. A comprehensive anesthesia simulation training program for simulation of triage, resuscitation, and evacuation of
environment. Anesthesiology. 1988; 69:387–94. casualties. Milit Med. 1998; 163:234–8. 49. Chi DM, Kokkevis E, Ogunyemi
26. Gaba DM, Fish KJ, Howard SK. Crisis Management in O, et al. Simulated casualties and medics for emergency training. In: Morgan
Anesthesiology. New York: Churchill Livingstone, 1994. KS, Hoffman HM, Stredney D, Weghorst SJ (eds). Medicine Meets Virtual
27. Howard SK, Gaba DM, Fish KJ, Yang G, Sarnquist FH. Anesthesia Reality: Global Healthcare Grid. Amsterdam: IOS Press and Ohmsha, 1997,
crisis resource management training: teaching anesthesiologists to pp 486–94.
handle critical incidents. Aviat Space Environ Med. 1992; 63:763–9. 50. Kizakevich PN, McCartney ML, Nissman DB, Starko K. Virtual
28. Gaba DM, DeAnda A. A comprehensive anesthesia simulation medical trainer: patient assessment and trauma care simulator. In: Westwood
environment. Anesthesiology. 1988; 69:387–94. JD, Hoffman HM, Stredney D, Weghorst SJ (eds). Medicine Meets Virtual
29. Devitt JH, Kurrek MM, Cohen MM, et al. Testing internal consistency Reality: Art, Science, Technology: Healthcare (R)evolution.e Amsterdam:
and construct validity during evaluation of performance in a patient IOS Press and Ohmsha, 1998, pp 309–15.
simulator. Econ Health Sys Res. 1998; 86: 1160–4. 51. Stytz MR, Garcia BW, Godsell-Stytz GM, Banks SB. A
30. Chorpra V, Gesnik BJ, de Jong J, Bovill JG, Spierdjik J, Brand R. Does distributed virtual environment prototype for emergency medical procedures
training on an anesthesia simulator lead to improvement in training. In: Morgan KS, Hoffman HM, Stredney D, Weghorst SJ (eds).
performance? Br J Anaesth. 1994; 73:293–7. 31. Gaba DM. Human Medicine Meets Virtual Reality: Global Healthcare Grid. Amsterdam: IOS
work environment and simulators. In: Miller RD (ed). Anesthesia. Press and Ohmsha, 1997 , pp 473–85.
Philadelphia: Churchill Livingstone, 2000. 52. Halvorsrud R. The MATADOR project—a novel simulator in
32. Ellis C, Hughes G. Use of human patient simulator to teach emergency medicine. Proceedings of the Medicine Meets Virtual Reality
emergency medicine trainees advanced airway skills. J Accid Emerg Med. 2001 conference, Newport Beach, CA, Jan 24 –27, 2000.
1999; 16:395–9. 53. Divjak M, Holobar A, Prelog I, Zazula D. VIDERO—virtual
33. Small SD, Wuerz RC, Simon R, Shapiro N, Conn A, Setnik G. delivery room. Proceedings of the Slovenian Electro-technical and Computer
Demonstration of high fidelity simulation team training for emergency Science Conference, Portoroz, Slovenia, Sept 2000.
medicine. Acad Emerg Med. 1999; 6:312–23. 54. Bro-Nielsen M, Helfrick D, Glass B, Zeng X, Connacher H. VR
34. Gordon MS, Ewy GA, DeLeon AC, et al. ‘‘Harvey,’’ the simulation of abdominal trauma surgery. In: Westwood JD, Hoffman HM,
cardiology patient simulator: pilot studies on teaching effectiveness. Am J Stredney D, Weghorst SJ (eds). Medicine Meets Virtual Reality: Art, Science,
Cardiol. 1980; 45:791–6. Technology: Healthcare (R)evolution.e Amsterdam: IOS Press and Ohmsha,
1998, pp 117–23.
35. Jones JS, Hunt SJ, Carlson SA, Seamon JP. Assessing bedside
examination skills using ‘‘Harvey,’’ a cardiology patient simulator. Acad 55. Tseng CS, Lee YY, Chan YP, Wu SS, Chiu AW. A PC-based
Emerg Med. 1997; 4:980–5. surgical simulator for laparoscopic surgery. In: Westwood JD, Hoffman HM,
Stredney D, Weghorst SJ (eds). Proceedings of Medicine Meets Virtual
36. Pugh CM, Srivastava S, Shavelson R, et al. The effect of simulator
use on learning and self-assessment: the case of Stanford University’s E- Reality: Art, Science, Technology: Healthcare (R)evolution.e Amsterdam:
pelvis simulator. In: Medicine Meets Virtual Reality 2001: Outer Space, Inner IOS Press and Ohmsha, 1998, pp 155–60.
Space, Virtual Space. Amsterdam: IOS Press and Ohmsha, 2001, pp 396– 56. Tanaka H, Nakamura H, Tamaki E, Nariai T, Hirakawa K. Brain
400. surgery simulation system using VR technique and improvement of presence.
37. Schroeder R. Virtual reality in the real world. Futures. 1993; In: Westwood JD, Hoffman HM, Stredney D, Weghorst SJ (eds). Medicine
Nov:963–72. Meets Virtual Reality: Art, Science, Technology: Healthcare (R)evolution.e
Amsterdam: IOS Press and Ohmsha, 1998, pp 150–4.
38. Voelter S, Kraemer KL. Virtual reality in medicine: a functional
classification. In: Lemke HV, Inamura K, Jaffe CC, Vannier MW (eds). 57. Weghorst S, Airola C, Oppenheimer P, et al. Validation of the
Computer Assisted Radiology. New York: Springer, 1995, pp 1297–8. Madigan ESS simulator. In: Westwood JD, Hoffman HM, Stredney D,
Weghorst SJ (eds). Medicine Meets Virtual Reality: Art, Science,
39. Wagner A, Rasse M, Millesi W, Ewers R. Virtual reality for
orthognathic surgery: the augmented reality environment concept. J Oral Technology: Healthcare (R)evolution.e Amsterdam: IOS Press and Ohmsha,
Maxillofac Surg. 1997; 55:456–62. 1998, pp 399–405.
40. Raposio E, DiSomma C, Fato M, et al. An ‘‘augmentedreality’’ 58. Wiet GJ, Bryan J, Dodson E, et al. Virtual temporal bone
aid for plastic and reconstructive surgeons. In: Morgan KS, Hoffman HM, dissection simulation. In: Westwood JD, Hoffman HM, Mogel GT, Robb RA,
Stredney D, Weghorst SJ (eds). Medicine Meets Virtual Reality: Global Stredney D (eds). Medicine Meets Virtual Reality 2000: Envisioning
Healthcare Grid. Amsterdam: IOS Press and Ohmsha, 1997, pp 232–5. Healing: Interactive Technology and the Patient–Practitioner Dialogue.
Amsterdam: IOS Press and Ohmsha, 2000, pp 378–84.
41. Burt DER. Virtual reality in anesthesia. Br J Anaesth. 1995;
75:472–80. 59. Muller W, Bockholt U. The virtual reality arthroscopy training
simulator. In: Westwood JD, Hoffman HM, Stredney D, Weghorst SJ (eds).
42. Rawn CL, Gorman PJ, Graham WP, Krummel TM, Mackay DR.
Medicine Meets Virtual Reality: Art, Science, Technology: Healthcare
Virtual reality becomes reality in plastic surgery. Perspect Plast Surg. 2000;
(R)evolution.e Amsterdam: IOS Press and Ohmsha, 1998, pp 13 – 9.
14:105–18.
43. Edmond CV Jr., Wiet GJ, Bolger B. Virtual environments. 60. Smith S, Wan A, Taffinder N, Read S, Emery R, Darzi A. Early
Surgical simulation in otolaryngology. Otolaryngol Clin North Am. 1998; experience and validation work with Procedicus VA—the Prosolvia virtual
31:369–81. reality shoulder arthroscopy trainer. In:
Westwood JD, Hoffman HM, Robb RA, Stredney D (eds). Medicine Meets
44. Hoffman H, Murray M, Danks M, Prayaga R, Irwin A, Vu D. A
Virtual Reality: The Convergence of Physical & Informational Technologies:
flexible and extensible object-oriented 3D architecture: application in the
Options for a New Era in Healthcare. Amsterdam: IOS Press and Ohmsha,
development of virtual anatomy lessons. In: Morgan KS, Hoffman HM,
1999, pp 337–43.
Stredney D, Weghorst SJ (eds). Medicine Meets Virtual Reality: Global
Healthcare Grid. Amsterdam: IOS Press and Ohmsha, 1997, pp 461–6. 61. O’Toole RV, Playter RR, Krummel TM, et al. Measuring and
developing suturing technique with a virtual reality surgical simulator. J Am
45. Hoffman H, Vu D. Virtual reality: teaching tool of the twenty-first
Coll Surg. 1999; 189(1):114–28.
century? Acad Med. 1997; 72:1076–81.
62. Ursino M, Tasto JL, Nguyen BH, Cunningham R, Merril GL.
46. Suzuki N, Takatsu A, Hattori A, Ezumi T, Yanai T, Tominaga H.
CathSim: an intravascular catheterization simulator on a PC. Stud Health
3D and 4D atlas system of living human body structure. In: Westwood JD,
Technol Inform. 1999; 62:360–6.
Hoffman HM, Stredney D, Weghorst SJ (eds). Medicine Meets Virtual
Reality: Art, Science, Technology: Healthcare (R)evolution.e Amsterdam: 63. Webster RW, Zimmerman DI, Mohler BJ, Melkonian MG, Haluck
IOS Press and Ohmsha, 1998, pp 131–6. RS. A prototype haptic suturing simulator. In: Westwood JD, Hoffman HM,
Mogel GT, Stredney D, Robb RA (eds). Medicine Meets Virtual Reality
47. Kling-Petersen T, Rydmark M. The brain project: an interactive
2001: Outer Space, Inner Space, Virtual Space. Amsterdam: IOS Press and
learning tool using desktop virtual reality on personal computers. In: Morgan Ohmsha, 2001, pp 567–9.
KS, Hoffman HM, Stredney D, Weghorst SJ (eds). Medicine Meets Virtual
64. Gorman P, Krummel T, Webster R, Smith M, Hutchens D. A
prototype haptic lumbar puncture simulator. In: Westwood JD, Hoffman HM,
86 VIRTUAL REALITY Reznek et al. • VIRTUAL REALITY AND SIMULATION

Mogel GT, Robb RA, Stredney D (eds). Medicine Meets Virtual Reality Healing: Interactive Technology and the Patient–Practitioner Dialogue.
2000: Envisioning Healing: Interactive Technology and the Patient– Amsterdam: IOS Press and Ohmsha, 2000, pp 207–13.
Practitioner Dialogue. Amsterdam: IOS Press and Ohmsha, 2000, pp 106–9. 84. Cavanaugh S. Computerized simulation technology for clinical
65. Hiemenz L, Stredney D, Schmalbrock P. Development of the teaching and testing. Acad Emerg Med. 1997; 4:939–43.
force-feedback model for an epidural needle insertion simulator. In:
Westwood JD, Hoffman HM, Stredney D, Weghorst SJ (eds). Medicine
Meets Virtual Reality: Art, Science, Technology: Healthcare (R)evolution.e
Amsterdam: IOS Press and Ohmsha, 1998, pp 272–7.
66. Machado LdS, de Mello AN, Lopes RdD, Filho VO, Zuffo MK.
A virtual reality simulator for bone marrow harvest for pediatric transplant.
In: Westwood JD, Hoffman HM, Mogel GT, Stredney D, Robb RA (eds).
Medicine Meets Virtual Reality 2001: Outer Space, Inner Space, Virtual
Space. Amsterdam: IOS Press and Ohmsha, 2001, pp 293–7.
67. Delp SL, Loan P, Basdogan C, Rosen JM. Surgical simulation: an
emerging technology for training in emergency medicine. Presence. 1997;
6(2):147–59.
68. Medical Devices on Parade. St. Paul: Pioneer Press, May 20, 2000.
69. Hahn JK, Kaufman R, Winick AB, et al. Training environment for
inferior vena caval filter placement. In: Westwood JD, Hoffman HM,
Stredney D, Weghorst SJ (eds). Medicine Meets Virtual Reality: Art, Science,
Technology: Healthcare (R)evolution.e Amsterdam: IOS Press and Ohmsha,
1998, pp 291–7.
70. Kaufmann C, Liu A. Trauma training: virtual reality applications.
In: Westwood JD, Hoffman HM, Mogel GT, Stredney D, Robb RA (eds).
Medicine Meets Virtual Reality 2001: Outer Space, Inner Space, Virtual
Space. Amsterdam: IOS Press and Ohmsha, 2001, pp 236–41.
71. Thurfjell L, Lundin A, McLaughlin J. A medical platform for
simulation of surgical procedures. In: Westwood JD, Hoffman HM, Mogel
GT, Stredney D, Robb RA (eds). Medicine Meets Virtual Reality 2001: Outer
Space, Inner Space, Virtual Space. Amsterdam: IOS Press and Ohmsha, 2001,
pp 509–14.
72. Liu A, Kaufmann C, Ritchie T. A computer-based simulator for
diagnostic peritoneal lavage. In: Westwood JD, Hoffman HM, Mogel GT,
Stredney D, Robb RA (eds). Medicine Meets Virtual Reality 2001: Outer
Space, Inner Space, Virtual Space. Amsterdam: IOS Press and Ohmsha, 2001,
pp 279–85.
73. Chapman DM, Marx JA, Honigman B, Rosen P, Cavanaugh SH.
Emergency thoracotomy: comparison of medical student, resident and faculty
performances on written, computer and animal-model assessments. Acad
Emerg Med. 1994; 1: 373–81.
74. Chapman DM, Rhee KR, Marx JA, et al. Open thoracotomy
procedural competency: validity study of teaching and assessment modalities.
Ann Emerg Med. 1996; 28:641–7.
75. Kaufman DM, Bell W. Teaching and assessing clinical skills using
virtual reality. In: Morgan KS, Hoffman HM, Stredney D, Weghorst SJ (eds).
Medicine Meets Virtual Reality: Global Healthcare Grid. Amsterdam: IOS
Press and Ohmsha, 1997, pp 467–72.
76. Stallkamp J, Walper M. UltraTrainer—a training system for
medical ultrasound examination. In: Westwood JD, Hoffman HM, Stredney
D, Weghorst SJ (eds). Medicine Meets Virtual Reality: Art, Science,
Technology: Healthcare (R)evolution.e Amsterdam: IOS Press and Ohmsha,
1998, pp 298–301.
77. Knudson MM, Sisley AC. Training residents using simulation
technology: experience with ultrasound for trauma. J Trauma. 2000; 48:659–
65.
78. Vanchieri C. Virtual reality: will practice make perfect? J Natl
Cancer Inst. 1999; 91:207–9.
79. Tuggy ML. Virtual reality flexible sigmoidoscopy simulator
training: impact on resident performance. J Am Board Fam Pract. 1998;
11:426–33.
80. Merril J, Millman A, Walderman T, Merril G. Kidney stones and
virtual reality. Virtual Reality Special Rep. 1995 ; Nov/Dec:44–6.
81. Bro-Nielsen M, Tasto JL, Cunningham R, Merril GL. PreOpe
endoscopic simulator: a PC-based immersive training system for
bronchoscopy. In: Westwood JD, Hoffman HM, Robb RA, Stredney D (eds).
Medicine Meets Virtual Reality: The Convergence of Physical &
Informational Technologies: Options for a New Era in Healthcare.
Amsterdam: IOS Press an Ohmsha, 1999, pp 76–82.
82. 5DT releases world’s first virtual reality esophago-gastroduodeno
(EGD) scope training simulator. Pract Gastroenterol. 2000; 14(7):54, 57.
83. Medical Readiness Trainer Team, University of Michigan Health
System. Immersive virtual reality platform for medical training: a ‘‘killer-
application.’’ In: Westwood JD, Hoffman HM, Mogel GT, Robb RA,
Stredney D (eds). Medicine Meets Virtual Reality 2000: Envisioning