| insert credit | feature | virginia |


by Mathew Kumar


Of course, all this was to change with the release of the Nintendo DS. Featuring (as you well know) a touch screen interface, and a hardware manufacturer desperate to see innovation, companies have been falling over themselves to use the hardware in interesting ways. Of these, surgery simulator Trauma Center: Under the Knife is one of the most successful.[10]

Note that when I say that, Iím not saying itís one of the best games on the system, just that itís certainly one of the first to use the touch screen in a sensible way to add to the game experience. Unlike many earlier releases which still seemed to shoehorn in the touch screen as the form of control, here the stylus acts as whichever surgical tool you currently have equipped, and you use it almost exactly as you would use the tool if it was actually in your hands.

The stylus truly is the tool.

This is an interesting development, because as I have explored, up until this point, medical gaming and surgical simulations were largely devoid of the training of surgical technique due to the limitations of the hardware, or disinterest of the developers, as itís somewhat hard to explore technique using the keyboard and a mouse. Itís true Ė a copy of Life or Death isnít anymore going to turn you into an expert surgeon than an FPS is going to turn you into an expert crazed gunman.

With the DS, the possibility to learn by doing is quite possible with a system that costs $130. But how likely is it? And how well does it compare to commercial simulators?

- -- -

Test 1: Trauma Center: Under the Knife "Standard Procedure" (DS) vs. Old Dominion Universityís Surgical Wound Debridement Simulation Based Training System (Virginia)

At the Old Dominion University in Norfolk, after being given yet another boring talk in a lecture hall, we were taken through to a room and shown this system Ė the Surgical Wound Debridement Simulation-Based Training System (there doesnít appear to be an acronym).

Wound debridement is the technical name for removing contaminated tissue and/or foreign material from a wound, a minor surgical procedure that anyone in the medical world would be expected to be able to perform, and usually trained, as many skills are, using actual patients.

The Old Dominion Universityís system consists of a haptic[11] interface and a screen projected as a mirror image on to a surface, with a Ďvirtual agentí providing feedback as you work. This provides at least a slight feeling of realism, as you work looking downwards as if towards the patient, and your hand works within the area of the screen, as if part of it. The interface is gripped as a pen and used as such.

The quite large haptic debridement system, and the avatar that trains you.

The procedures and techniques explored are to remove large debris (in the example I tried, large pieces of glass) with forceps, scrub clean with a brush, and rinse with a saline solution.

Altusís system is a Nintendo DS (and soon, a Wii, but we'll discuss this one, as it's out). As Iíve described, this has a touch screen, which doesnít provide force feedback, and if you so wish, you can place the system on a surface and look down upon it as if you were looking down upon a patient Ė indeed, if you have anyone willing, they could lie down and you can place the DS on the (in-game) affected body part. The interface is a stylus, an in game avatar provides feedback while you work.

The procedures and techniques explored by Trauma Centerís first level, are to remove large pieces of glass with forceps, clean wounds with healing gel, and stitch the larger wounds shut.

Trauma Center versus ODU's trainer.

These systems seem remarkably similar, and in practice, itís utterly amazing how close these simulations are. While the Universityís debridement simulation has the benefit of haptic feedback and wounds based on the National Library of Medicineís Visible Human Project, the feedback from the visual agent is surprisingly poor. Much like in a game of Life and Death I was allowed to perform surgery in a grossly unprofessional way, crudely grinding pieces of glass out of a gaping wound, with the haptics giving feedback that feels exactly what I imagine unskillfully stabbing someone in the arm does, scrubbing with a gay abandon, and squirting saline everywhere.

Indeed, in comparison to the simulation shown in Trauma Center, it feels almost amateur, ignoring the expensive force feedback system. Trauma Centerís Nurse Mary chastises you for not pulling the glass out in the opposite direction of entry, and while a concept such as Ďhealing gelí is grossly unrealistic, in the majority of missions it serves the same purpose that wound cleaning does. The loss of the haptics actually means far less than you would think Ė with the Universityís system also using a form of pen input, itís clear that simply using your hands in a movement analogous to the techniques used in surgery are enough to make the lessons stick.

The main flaw inherent in Trauma Centerís system at this point is the willfully faked, unrealistic patient data, however, as a basis of training on very basic procedures, the first level seems to match the Universityís system in the ability to teach me (a layman) procedures that I imagine I would now perform better in a real life situation.

Had I any reason to.

- -- -

Test 2: Trauma Center "Standard Procedure 2" (DS) vs. The Virtual Operating Room Concept Demonstration: Emergency Ectopic Pregnancy (Virginia)

Shortly before playing Standard Procedure 2 of Trauma Center, in one of the many (often slightly forced) vignettes, the main character, one Derek Stiles, is chastised for not sleeping at least six hours. I suspect that this kind of education is quite easy to hide, subtly, in games, so another mark off for boring old simulators as education devices, eh?

However, the Virtual Operating Room is more than simply a mere device, itís an entirely immersive simulation of the full doctorís experience. After the trainee has visited with, and diagnosed a patient that will require an Emergency Ectopic Pregnancy (played by an actress, so this segment of the training canít really be included in this evaluation) the surgery itself is performed.

In a room measuring about ten by ten feet. the environment of an operating room is projected on the walls. In the centre of the room is a ĎNoelleí mannequin (a maternal/neonatal birthing simulation mannequin) attached to a LapSim simulator (a laparoscopic simulator, consisting of a interface and view screen similar to a laparoscope). Team members can be either real or virtual (projected on to the wall) and the procedure is performed, following all the rules that would be expected in actual surgery.

Standard Procedure 2 of Trauma Center is a tumor removal, a procedure that uses several of the same techniques used in an emergency ectopic pregnancy, involving using an ultrasound to find the tumor, draining and cutting, and cleaning and sealing these cuts.

Itís here the gap between Trauma Centre and a fully featured medical simulation becomes apparent Ė paying attention to only the LapSim simulator, the device uses an interface directly correlating to a real laparascope machine, and the simulation itself holds and edge over Trauma centre by the depth of simulation offered by voxels.

You remember voxels, right?

Voxels, a rendering option almost completely ignored by the games industry (in particular since the beautiful, if boring, disaster of Outcast and the popularization of graphics cards designed to push polys) has been far more deeply explored by the medical modeling industry, as it allows objects to be easily Ďfilledí Ė unlike a model of a human in a commercial game, which is nothing more than a collection of edges, even the arm I manipulated in the debridement simulation was utterly full of voxels, all simulating the inside of an arm. While not particularly noticeable (nor needed) in that simulation, here they added a great deal Ė while in Trauma Centre the tumor for removal is little more than a bitmap, in the simulation the ectopic pregnancy is a full object, that palpates and warps on probing or cutting.

Despite that, however, Trauma Centre does hold its own in many ways. The procedures are still replicated perfectly on the small screen, including such things as draining away blood and using the laser to cauterize cuts, and the NPC guiding you through the procedure does just as good a job as the scary, eight-foot-tall projected virtual team members from the virtual operating room.

Both the game and the simulation do a good job at chastising you for errors and ranking you at the end of the procedure, though naturally though due to the environment, the virtual operating room offers more areas for you to be ranked on. Being chastised for not briefing new members of the team that appear during the operation seems like it would be a cruel thing to demand of Nintendo DS users, even if it does have a microphone.

The few comparisons I was able to perform showed that a $130 system with a touch screen is easily capable of holding itís own against incredibly expensive, large scale systems for surgical training. Not that Iím saying that a prospective surgeon should any more use this game to learn his trade than he should life or death. Indeed, heíll likely gain a somewhat skewed idea of surgery, as unfortunately Trauma Centre takes a turn into fantasy after about level seven Ė first with a time slowing Ďhealing touchí special move (Iíd rather not have a surgeon perform a pentagram in the air directly before operating on me) and later by including a whole bunch of completely insane medical problems, such as moving, color shifting tumors, and parasites that literally tear a personís insides out.

[Next: Chapter Eight]


[Chapter Two/One]


[Chapter Three/Four]

[Chapter Six]

[Chapter Seven]

[Chapter Eight]