Beyond medicine

Adrie C.M. Dumay TNO Physics and Electronics laboratory

34

Beyond Medicine irtual Environments (VE) are simula- V tion systems in which the subject

(user) is to a large extent “immersed” in the apparent environment of a simulated, multidimensional reality [ 1,2]. VE is the term used by researchers to describe the form of computer-human interaction where the human is immersed in a world created by the machine, which is usually a computer system (see, e.g., [SI). The term is derived from the term Virtual Re- ality (VR), which was first coined by Jaron Lamer. We use the term VE to em- phasise the immersion of the subject in the virtual environment synthesised by the machine. Other terms in use for indicating this type of interface are cyberspace, telepresence, mirror world, artificial reality, augmented reality, wraparound com- puvision, and synthetic environments. This article looks at the potentials and limitations of VEs, with a focus on applications in medicine.

The VE Concept In principle, all five human senses

(sight, hearing, touch, taste and smell) are involved with the immersion in such a way that there is stimulation by the machine. The human responds to the system by actuating peripheral sensors and ab- sorbs most information by sight. Hearing comes in second, and touch third. Motor activation, speech, and headeye move- ments are exploited when it comes to re- sponding to the information presented. This response is achieved by means of advanced computer-human interface

tasks of the sensor and actuator subsystems. This concept is the basis of all VE applications, as illustrated in Fig. 2.

VE in Medicine, and Vice Versa VE technology can already be found in

training and simulation systems [5,6]. This is by no means surprising, since human beings learn hest by actively commit- ting themselves to the learning task, involving as many senses as possible. The ability to interact with the virtual environment, rather than just with the system, makes VE training and simulation systems more appreciated than multimedia systems such as interactive CD and interactive video. VE training and simulation systems can give the subject an artificial experience with intrinsic educational benefits. In order to provide simulation- based medical training facilities, innova- tive and technologically demanding concepts and techniques are needed for providing natural and high quality interaction between the subject and the machine. High performance computing and networking (HPCN) technology is an es- sential ingredient of realistic visualisa- tions.

VE applications promise a revolution in medical education [7]. Surgeons ac- quiring a proficiency level of skill may be practising in a virtual operation theatre, alleviating the burden placed on experienced surgeons who are often called out of their own schedules to supervise and train their less experienced colleagues.

techniques. At present, peripheral sensors are based on the Datasuit, DataGlove, SpaceBall and 3-D Mouse, while sight and hearing are the most prominent of the senses involved (see below). Stimulating the olfactory and gustatory senses with program controllable subsystems is still subject to experimentation [4]. In Fig. 1, we illustrate the interaction between the user and the application running on the computer system. The subject interacts with the real environment and the physically modelled environment, i.e., the subject experiences both environments. The actuator subsystem supports the subject in that experience, while the sensor subsystem enables the subject to interact with the environments. The control subsystem plays a central role in co-ordinating all

IEEE ENGINEERING IN MEDICINE AND BIOLOGY

With a simulated patient, the surgeon has, at least in principle, unlimited ability to remove, reposition and replace tissues and organs. Physiologic models and artificial intelligence control will give the surgeon the ability to feel responsible for the life of the virtual patient. The great promise of surgery simulation lies in the fact that the long and therefore expensive training trajectory, starting at text book studies. through animal studies, ending at supervised practising on humans, might be shortened.

Physicians have traditionally been very sceptical about technological inno- vations, and it is assumed that VE developments will not lack criticism. Despite the cynicism, the word cyber-radiology has already been used by radiologists, sug-

0739-51 75/96/$5.00@1996 March/April 1996

1. The user interacts with the machine through a Datasuit, DataGlove, SpaceBall or 3-D Mouse after computer stimulation of sight and hearing.

gesting that there is to some extent interest in the medical area: “What radiologist can salvage from this dark edge of the computer age are insights into the work they do and, with the help of a breakthrough or two, radical new ways of diagnosing disease” [ 81.

Education and Training

Learning Anatomy, Physiology, and Pathology

Learning (human) anatomy and physiology in VE is one educational application. Anatomical models are already available from medical text books, and the physiology of the various organs is also well-documented. Anatomical models are also available in electronic format. A geo- metrical description of the anatomy and mathematical models of the physiology of body organs are to be stored in a database, ready for visual rendering with a variable level of detail. More details can be re- vealed from viewpoints close to the body surfaces, and even details that are not vis- ible with the naked eye can be shown. In order to gain realism, photographs of real textures of the body organs may be mapped onto the virtual organs, again with variable level of detail. This educational aid can be improved by simulating pathologies as well, and giving the subject the ability to take the virtual patient apart and put back together. Optionally, the scoring of individual subjects to an educational programme can be recorded by computer-based training (CBT) equip-

ment. Figure 3 illustrates a virtual patient who’s anatomy is explored by students.

Medical Emergency-Room Training The emergency room of a hospital is a

theatre that can only function properly when medical staff are well prepared and fully informed on procedures and protocols. This requires specialist training, which may be facilitated with a VE training and simulation system. In such a system, the real emergency room can be modelled, including beds, patient tables, drawers, curtains, surgery facilities, infu- sion pumps, etc. The drawers may contain virtual medical aids such as bandages, clamps, and syringes. In principle, a virtual patient can be exposed to any injury. In an interactive VE training session, an injury can be treated following a selected protocol, giving the subject the ability to cure the patient or to inflict even worse injuries. In such a training session, the real atmosphere in an emergency-room can be approximated. Even a certain level of stress can be induced to the subject by tightening time constraints and introduc- ing computer-based models of physiology that dynamically adopt to the medical interventions.. Again, the scoring to an educational programme can be recorded automatically.

Training Ambulance Staff A relatively simple variation to a medi-

cal emergency-room training system is one suitable for the training of ambulance staff. The virtual patient does not need modification, only the virtual interior of

the emergency room is replaced by a model of the ambulance interior. A simulator of this type is especially of interest for medical services in countries where ambulance staff need more education than required for a first aid certificate.

Triage Training Triage is the assessment of physical

conditions of casualties with limited support of staff and equipment under tight time constraints [9]. The treatment of selected casualties who stand a chance to survive their inflictions aims at maintaining at least a minimal functionality of vital organs. At the sarne time, a limited number of time-consuming surgical interventions should be weighted against the maintenance of vital life functions within a larger number of casualties. In these situations, damage to the internal organs can usually not be rated by diagnostic X-ray screening. The: tools for triage and surgery vary throughout the military echelons in a combat situation. The critical problem in handling a mass casualty situation is time. Gaining experience in real- life situations is of utmost importance in medicine. There is a need to knowledge about anatomy and physiology, skills in life-saving treatment, and intervention techniques such as surgery. The assessment of the patient condition in trauma situations requires specialist medical knowledge. Mass casualty situations oc- cur at major traffic disasters, aeroplane crashes, earthquakes. etc.

Endoscopic Suirgery Training Endoscopic surgery is a technique to

operate percutaneously on a particular re- gion of interest within the body of a patient, with minimal damage to skin, muscle, surrounding tissue, and organs. The minimally invasive nature of endoscopic surgery allows operations to be performed on patients through small inci- sions, often under lcical anaesthesia. Pa- tient recovery tirnes and cosmetic detriment are thus greatly reduced, while overall quality of care is improved. These advantages have driven a growth of endoscopic surgery to a wide range of areas of the body [lo]. Today, endoscopic surgery can be applied to coronary arteries: arteriography [l 11, the chest: thoracoscopy [12], the abdomen: laparoscopy [13,14], joints: arthroscopy [15] and the gastrointestinal tract: gastroscopy [16]. Conventional surgical instruments are no longer be used. Instead, surgical devices

Morth/April1996 IEEE ENGINEERING I N MEDICINE AND BIOLOGY 35

such as graspers, scalpels, scissors, sta- plers, and forceps are customised to allow insertion through long tubes to reach the surgical site. Laser- and electrocoagula- tors are designed to fit the tube and be applied for instant moulding of scar tissue. Although the surgeon is physically close to the patient, the surgical environment is effectively remote.

Studies on times required to gain a proficiency level of skill required for operations on patients showed that these vary from three months [17] to two years [ 1 SI. An acceptable level of proficiency is reached when about 25 supervised procedures have been performed [15]. Pres- ently, surgeons are trained to perform endosurgical procedures in a number of ways: practising with surgical training devices, using animal models, and assisting experienced surgeons. Training surgeons under supervision of experienced surgeons is time consuming and hence expensive. In addition, many animals must be sacrificed during the course of surgical skills acquisition and the surgical equipment industry is playing a leading role in creating and maintaining large scale training centres where surgeons can train with the latest devices and new techniques. Since no standardised methods exist for teaching skills, each subspecialty has developed different methods of assessing a physician’s competency. However, there is no single measure for quality exists D91.

High levels of proficiency are needed in vision, vision control, and manipulation before a surgeon may operate on a patient. These skills, on the other hand, cannot be acquired without training and practise. Training facilities are needed to prepare surgeons for their tasks. Figure 4 illustrates the concept of an endoscopic training system.

Today, endoscopic surgery simulators are already available (e.g., [20-23]), and an angioplasty simulator has been demonstrated at the American College of Cardi- ologists 1994 Annual Conference [68].

Radiotherapy Planning Diagnostics and interventional therapy

are two steps in the treatment of malignant tumour cells which rely heavily on deci- sions made by the physician on the basis of visual impressions. One of the most important treatment methods is conforma- tion radiotherapy of tumours, i.e., expos- ing tumours to radiation.

The close vicinity to the target area of

control subsystem ItJ 2. The general structure of a virtual environment system.

radiosensitive organs, such as the optic nerves, the spinal cord, and the brain stem, often means that with conventional radiotherapy it is not possible to administer a sufficiently high dose to the tumour without inducing serious damage to the surrounding healthy tissue. With conformal precision radiotherapy planning, the target area is delineated in scanned patient data and visually presented to the opera- tor. Optimal directions of irradiation are computed from a desired dose distribution 1241. Such therapy planning can be carried out in VE, in which the patient can be modelled and the planning results can be shown. Faulkner [25] applies VE technologies to hyperthermia treatment planning. In Fig. 5, we illustrate the localisation of a brain tumour.

Surgery Computer-Assisted Surgery

Computer-assisted surgery can be applied in, e.g., (stereotactic) neurosurgery after careful planning of the intervention following similar 3-D image processing methods. Here, VE technology can be applied as an interface to robot-controlled surgery, where an (extremely) high precision is required for micromanipulation. The surgical intervention can be carried

out in VE before instructions are sent to the robot for actual intervention in the patient. The feasibility of computer-assisted surgery has already been demonstrated [26, 271.

Surgery Planning and Simulation Microsurgery includes the creation of

(small) blood vessels in humans. In order to study the effects of a surgical intervention, animal studies are often performed prior to the actual intervention in man. To lessen the need of animal studies and to improve surgical protocols, VE simulation systems can be applied to plan a surgical intervention. The need of planning and careful consideration is also present in cosmetic surgery. A graphical model can be derived from scanned patient data, and the effect of surgical interventions can be visualised. Progress and problem areas for craniofacial surgery planning are reported in [28].

Surgery planning on scanned patient data in a virtual environment can be facilitated with tools to create corridors through safe areas, without putting the patient at nsk. Virtual land marks can be placed at microvessels, nerves, or critical locations. Indeed, a whole trajectory can be planned and landmarks can be recognised even before the patient is in the surgery theatre.

36 IEEE ENGINEERING IN MEDICINE AND BIOLOGY March/April 1996

3. In a training session the anatomy of the virtual body is explored by trainees who observe through binocular display devices. The trainees interact with virtual surgical instrumentation while manipulating real instruments connected to feedback sensors.

Mathematical Tools

Dynamical Behaviour

Soft Tissues

,Training system

J/ Application Generation

system \ Interactive Tools Interactive Tools --__.__---

Model Extraction Texture Mapping "'

_/'

El "'=--- Scanned Patient Data

(CT, MR) Photographs on soft tissues

4. The concept of an endoscopic training system with anatomical computer model, dynamic model of the deformation of soft tissues and computer peripherals.

Diagnostic Radiology Visualisation and interpretation are the

main topics in diagnostic radiology. Tra- ditionally, the radiologist interprets 2-D X-ray images of (parts of) the patient in order to support medical decision making. Since the introduction of computer tomography to the field of diagnostic imaging, radiologists have gained experience in interpreting 3-D X-ray, nuclear, and magnetic resonance images. These 3-D images, however, are often visualised on a slice-by-slice basis rather than in 3-D, although true 3-D applications have already been demonstrated.

VE technology may provide a whole new repertoire of applications to diagnostic radiology. All applications should start from scanned patient data from which computer models are to be extracted and represented in VE. The main advantage to the physician of moderating patient data through graphical models lies in the fact that this type of representation is closer to looking at real body organs than to looking at grey level images. At the same time, however, this is also a main disadvantage. Physicians have become familiar to screening grey tone images for faint flaws in structures, symmetry, grey level, etc.,

taking into account thi: nature of the physical phenomenon underlying the imaging. A functional design of this type of environment has been described [29]. The radiologist can be supported with metaphors and 3-D widgets in the virtual environment. These tools allow interactive place- ment of markers at locations of interest without wasting original patient data.

Telepresence Medicine Telemedicine is the area where tele-

communication meets medicine. Obvi- ously, where telecommunication is applied, some type of human-system interface is needed, of which VE should be considered. Telemedicine can be applied in remote consultation (physician-physician and patient-phys cian). Remote diag- nosis and surgery cart be carried out by a specialist through giving assistance to a (non-) specialist in, e.g., a hazardous or inaccessible environment, during actual procedures.

Teletriage Teletriage is a special type of telecon-

sultation, aimed at supporting the military physician in a war or crisis situation with on-line help from a remote medical expert. While the milit,ary physician is examining a casualty, he can report his findings to the remote medical expert by voice. The medical expert herself, or a team of experts, can respond by projecting instructions through VE technology onto the eye of the military physician. This gives the military physician the opportu- nity of having his hands free while being instructed by specialists, without the need of being a specialist himself.

Linking the VE triage support system to an electronic triage systems (ETS) based on PACS (Picture Archiving and Communication Systems) [30] is yet an- other future possibility. The need of advanced imaging tools in combat situations has already been reported [31]. Eventu- ally, remote surgery in a combat situation can be controlled by a surgeon in one of the higher echelons, through teletriage support systems.

Telediagnostics imd Telesurgery Instructions from the specialist can be

transmitted to the consulting physician through VE. The local and remote physicians can share the same virtual space in which the patient is present. In this way, the normal and pathollogic anatomy can be projected onto the e:ye of the consulting

March/April1996 IEEE ENGINEERING I N MEDICINE AND BIOLOGY 37

physician while examining the patient. The same can be done for surgical instructions. Hazardous environments can be found in war situations, while submarines and other naval vessels in full operation are considered to be inaccessible environments. Telemedicine can be particularly useful to support peace keeping efforts of nations in politically and military unstable areas with a poor (medical) infrastructure. The Olympic Games, scheduled in At- lanta in 1996, will serve as a testbed to provide instant access to an individual’s home country to a cross language barriers [321.

Discussion and Conclusions In this article, we elaborated on appli-

cations of VE technology in medicine, which we consider feasible. We identified the following application areas: i) education and training, including education on anatomy, physiology and pathology, medical emergency-room training, training of ambulance staff, triage training, and minimal access surgery training; ii) conformal radiotherapy planning; iii) rehabilitation, including communication and therapeutic rehabilitation; iv) surgery, including computer-assisted stereotactic neurosurgery and planning of microsurgery and cosmetic surgery; v) diagnostic radiology; vi) telemedicine for consultation purposes and vii) biomechanics for interactive posture recognition and cor- rection and the design of equipment. Lit- erature provides further VE applications for the delivery room of the future [33], human development anatomy [34], design purposes which are especially interesting for domains outside medicine [35] , eye surgery [36], and the successful treatment of Parkinson’s disease akinesa [37].

The most promising of these areas is education and training, since VE technology primarily allows the user to actively committ to a learning task with as many senses as possible. The great promise of VE lies in the fact that the long, and therefore expensive training trajectory, starting at text book studies through animal studies, and ending at supervised practising on humans, might be shortened.

At present, there are a number of simulators commercially available. There is a great variety in the level of realism reached within this first generation of surgery simulators. There are several issues at stake, influencing the realism. First, most simulators were developed by computer graphics engineers, who focused on

5. Optimal directions of irradiation can be computed on the basis of the location of the target area, here illustrated for the brain. The target area and the planning results can be presented in VE.

rendering human anatomy. Physiologic and pathological modelling are often neglected in these simulators. However, the level of detail of the anatomical, physi- ological, and pathological models together is a key criterion for realism. A limited frame update rate, imposed by the performance of the chosen computer hard- ware, and limited resolution of display devices force developers to opt for models with minimal functionality, instead of models reflecting reality. A second key criterion for evaluating realism is the syn- chronisation of processes. Within inter- f rame t ime intervals , anatomic, physiologic, and pathologic models must be updated according to actual status information extracted from all sensors. At present, developments are limited to syn- chronising deformation computation as a result of a user manipulation of (one of the) objects and visualisation. Synchroni- sation with physiology is often neglected due to limited computational power. A third criterion for evaluating realism can be found in spatial calibration of manipulation devices. Each device is featured with its own spatial resolution, mechani- cal constraints, and read-out complexity. Linking these devices into a single simulation imposes the use of a single spatial reference frame in order to avoid mis-

match of information about position and orientation. Multiprocessor architectures may provide a solution to the computational demand following from the realism requirements. Last, but certainly not least, human factors must be taken into account before any surgical simulator is designed.

These considerations conduct us to the key question “Can medicine and health care benefit from Virtual Environments?” VE technology is available. However, tactile and force feedback may yet face about ten years of development before reaching a mature level required for surgery simulation. Display technology also needs im- provement before high resolution devices are made available without the inconven- ience of wearing them head-mounted or being linked to a computer system by cable. Present display devices have a resolution in terms of image size that is critical to medical applications. Solutions to these limitations are expected to be operable within three to five years. Advances by the U S . military towards that direction are reported by Satava [38]. First, developments towards surgical simulators have clearly demonstrated the great potential of virtual environment technology for training purposes. Besides, this potential is not limited to medical applications, but ex- tends to virtually any domain. Surgery

38 IEEE ENGINEERING IN MEDICINE AND BIOLDGY March/April 1996

(also endoscopic) simulation needs advanced tactile and force feedback technology, high resolution display devices, and affordable super computing power. All three technologies are currently driven by both national and transnational research programmes throughout the world. Break- throughs towards innovation are expected within 5 to 10 years.

Future developments should be di- rected towards virtual environments for clinical practice. However, clinical applications are subject to a conglomerate of standards, and their acceptance depend strongly on safety, reliability, precision, and financial issues. Fornage et al. [39], e.g., demonstrated the positioning of a needle for biopsy of a suspected breast tumour by combining virtual environment technology and ultrasound techniques. Applications like this one clearly demon- strate that VE technology can assist physicians, provided that they allow themselves a new way of using existing techniques. Augmented reality, metaphors and 3-D widgets, and functional augmented reality create new ways of treating patients. The virtual environment becomes then a dialogue tool between patient and physician on the one hand, and physician and nurses on the other. Virtual corridors can be projected onto the body of the patient to support the surgeon to remain within a safe area, not risking the patient’s life. The potential of situational awareness to remote sites make virtual environment technology suitable for remote consultation. A local physician and a remote consultant may share the same virtual space and may come interactively to a single conclusion about their subject.

The introduction of distributed interactive simulation (DIS), a well-known communication protocol to link (military and space) simulators, opens pathways to whole new applications, supporting physicians in decision making and intervention, and increasing quality at reduced costs. New concepts of medicine can be created and linked through the electronic highway. Physicians and patients can share one singe VE, supported with simulations, without the need of meeting at one time in one place.

In conclusion, the great promise of simulation in a virtual environment lies in the fact that the long and therefore expensive training trajectory, of at text books to supervised practise, might be shortened. Further research is required with respect to display technology, tactile and force

feedback, and affordable super computing power. Breakthroughs are expected in 5 to 10 years from now. Developments towards surgical simulators have clearly demonstrated the great potential of virtual environment technology for surgical training purposes. With these limitations and problem areas in mind, we believe that we are in the cradle of a whole new generation of applications beyond medicine.

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34 Doyle,MD,Noe, A, Carlbom,I, Ang, C, and Martin, D: (1994) The virtual ambryo VR applications in human developmental anatomy Pro- ceedings Medicine meets Virtual Reality San Diego Aligned Management Associates, pp 38- 41

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Electrical Engineering (Information The- ory) from the Delft University of Technol- oev in 1984 and 1986. rewectivelv. the

dry E: (1990) SonograPhlc Appearance andU1- trasound Guided Fine-Needle Aspiration Biopsy of Brest Carcinomas Smaller Than 1 cm J U1 trasound Med 9, pp 559-568

PKD. in 1992, the CertifiLate of &ofi- clency 1n English from Cambridge versity (UK) in 1990, and is presently an MBA candidate at the University of Tees-

3

side/Haagse Hoge school. He is-author of over 35 papers and abstracts in conference proceedings and international scientific journals for medical, space, military and industrial communities. Adrie C.M. Du- may was a member of scientific commit- tees and symposiums in robotics and medicine and is on several editorial com- mittees. He is a member of the European Society for Engineering and Medicine.

Dr. Dumay can be reached at TNo Physics and Electronics Laboratory, Oude WaalsdorPerweg 6 3 , 2597 AK, The Hague, The Netherlands. E-mail: dumay@ fel. tno-nl.

Adrie Dumay is a Senior Scientist and Manager for New Busi-

at the Physics and Laboratory Of the Neth- erlands Organisation of Applied Scientific Re- search. He applies vir-

tual environments and distributed interactive simulation to the field of training/education, tele-operations, and advanced decision support for the military, space and medical communities. He re- ceived the B.Sc.- and M.Sc.-degree in

The VRT Revolution (continued from page 33) ing control, noninvasive detection of coronary artery disease, and the under- standing of the autonomic nervous system. He organized several workshops on “Fuzzy Logic, Wavelets, Advances in Signal and Image Processing” at the Inter- national Conferences. He also organized the special sessions on the “New Ad- vances in Biomedical Modeling and Sig- nal Processing” at the International

Meetings. In addition, he established a new track on “Emerging Technologies in Medicine and Biology” for the Artificial Neural Networks in Engineering (AN- NIE’94). He was a co-chair of the Interna- tional Conference on the Artificial Neural Networks in Engineering ( A ” I E ’ 9 5 ) .

He is coauthor of the new edition of the book entitled Theory and Design of Biomedical Instruments (Academic Press, 1991 and is author of Biomedical Signal Processing (Academic Press, 1994). He is

also author of Detection and Estimation of Biomedical Signals, (Academic Press, 1996).

Dr. Akay is a senior member of IEEE, a member of Eta Kappa, Sigma Xi, Tau Beta Pi, BMES. The American Heart As- sociation, and The New York Academy of Science. Address for correspondence: Biomedical Engineering Dept., Rutgers University, Piscataway, NJ 08855.

40 IEEE ENGINEERING IN MEDICINE AND BIOLOGY Morch/April 1996

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