In early 2006, a dozen staff members from the California Department of Health Services received extensive training on how to administer antibiotics from the Strategic National Stockpile in the event of an anthrax attack.

Unlike previous exercises the state had run, however, this simulation didn't involve recruiting mock patients or setting up a staging area. The setting - and patients - were all virtual. Researchers from the University of California-Davis Health System re-created a 3-D model of the California Exposition and State Fair in Second Life, an Internet-based world in which people are represented by virtual body doubles called avatars.

"The aim of the exercise was to see if the state could constantly train people in setting up emergency clinics," explained principal investigator Dr. Peter Yellowlees, a professor of psychiatry at UC-Davis, whose research interests include the use of virtual reality for health education on the Internet. "One big advantage is that they could do this training 24/7 from wherever they are, and you don't have to recruit patient volunteers."

Yellowlees isn't alone in seeing the potential of using virtual reality simulation to train first responders, medical personnel and emergency management officials. Across the country, researchers are exploring how simulations can augment training efforts. Much of the impetus is coming from the growing use of simulation in medical training. Most medical schools are incorporating simulation in their curricula and measuring its  effectiveness.

Another driving force is the U.S. Department of Defense, which for years has been funding research about computer simulation for war fighting and medical purposes. Research to support military operations done by organizations such as the Telemedicine and Advanced Technology Research Center is being customized for homeland security exercises.

Robert Furberg, a research analyst for the Center for Simulator Technology at research institute RTI International in Research Triangle Park, N.C., noted that virtual reality simulations are appealing for emergency response training.

"A full-scale exercise takes a lot of advanced preparation and requires daylong drills - it is expensive and time-consuming," he said. "With simulation, we can run through a mass casualty event and change the parameters. Each case is a little different, and it is available 24/7."


Virtual Patients
With an $80,000 grant from the California Department of Health Services, Yellowlees and his staff sought to determine if they could make the training in Second Life realistic and worthwhile for emergency medical personnel.

Two years ago, they went to a real-life simulation held at the Sacramento Exposition Center, with 250 state employees and 1,000 members of the public volunteering as trial patients. Yellowlees and his crew taped the exercise as patients were registered, signed consent forms, were examined and given simulated antibiotics.

They then worked to re-create the environment in Second Life. Virtual patients flowed through the clinic, while staff members role played. The program can be adjusted to simulate different numbers of patients. For instance, it could be ramped up from 100 to 150 patients per hour. Yellowlees said his team also built quiz tools to assess how well people have grasped what they've learned.

He said he believes the project was a success because they made the virtual environment look reasonably like the real thing. Also, feedback from state employees indicated the program worked quite well. Nevertheless, California has yet to expand its use. "That was 18 months ago and they haven't taken us up on it yet," he added. "They are trying to see how it fits into their long-term goals."

Virtual Reality Triage

With funding from the Telemedicine and Advanced Technology Research Center, RTI has been working for several years on a simulation platform for primary care doctors, nurses and paramedics. A virtual reality simulation that runs on a basic laptop computer allows medical workers to study and

practice their triage skills in a role-playing game.

The entire system is situated within a learning management system that includes didactic content, such as Flash animations and audio narratives that medical workers review before entering the simulation environment.

The program includes 30 examples of casualties that trainees can encounter, with a total of nine in any one scene. "The bulk of the cases are trauma victims, but we are adding in medical cases," said Furberg, who is a practicing paramedic. "Realistically people are going to be injured by more than kinetic forces. Someone will be so freaked out, they have a heart attack. Or a diabetic person will forget to eat. These have to be triaged as appropriately as everyone else in the mix of injuries."

The triage simulator has been used at pre-deployment training of Army medical staff on their way to Iraq. RTI also developed a program to train civilian Iraqi primary care physicians to use the Simple Triage and Rapid Treatment method.

Furberg's efforts to localize the content of that simulation led him to a startling realization. "I was looking to make it appropriate for local learners and asked a few contacts in Baghdad to send a picture of a triage tag doctors use in Iraq that I could insert in the simulation," he recalled.

When he got no response within a week, he contacted them again. His Green Zone contacts said they had asked several Iraqis and no one knew what Furberg meant by color-coded triage tags. "They said in Baghdad they don't do triage. They just load all the wounded into a van and sort them out at the hospital," he said. "Apparently for these emergency physicians, this simulation was the first time they were getting any formal triage training."

The triage simulator also was tested at the Duke University School of Medicine in 2006. In a program designed to prepare medical students for disaster management, some students were trained using verbal presentations while others used virtual reality-based training. Furberg said that when asked to perform triage, the trainees who used the simulator performed as well, or better than, the group trained traditionally.

Furberg is convinced that virtual reality simulation is a valid educational method for triage training, and that it should be carried over to widespread civilian use.

"It is a high-yield way of upgrading skills with minimal investment upfront," he said, adding that triage in an emergency situation challenges the standards of normative care. It asks emergency physicians and other care providers to make decisions they don't normally need to make.

Also, he argued that these are perishable cognitive skills. To apply them effectively, you have to use them. "If there is one skill that could maximize or improve the outcome in a mass casualty incident, it's triage," he added. "It drives the remainder of the response."

Running Simulations for EOCs
While some simulations are designed to help first responders practice, others use modeling to train people in emergency operation centers (EOCs). The Emergency Management Training, Analysis and Simulation Center (EMTASC) in Suffolk, Va., works to create realistic simulations to help train managers to communicate in an emergency.

"You've got a guy driving in to the EOC who hasn't sat in that chair in more than six months," explained Randy Sickmier, EMTASC's exercise plans manager. "During the day, he's the public works officer for Staunton, Va., and all of a sudden he's in charge of some aspect of this emergency response. It's not something he does every day. This is where the simulation can be valuable."

With grant funding from Virginia, the nonprofit EMTASC was formed in 2005 as a partnership between Old Dominion University and 17 companies involved in modeling and simulation efforts. For agencies that want to

include simulations in their EOC exercises, EMTASC can model an incident such as a hurricane and feed emergency response managers data in the same format they would receive it during an emergency.

Officials in Virginia, who run an annual training effort called the Virginia Emergency Response Team Exercise, have taken advantage of the modeling capability, said Sickmier, who is an employee of Northrop Grumman Corp., on loan to EMTASC.

In one training scenario, the agency modeled plans to reverse traffic on Interstate 64 so that all traffic would be outbound during a hurricane evacuation. "We modeled the capacity of the roadways with maps and data from the Virginia Department of Transportation and the state emergency management plan," Sickmier said. "It allowed the team to assess how long it would take to evacuate a certain region."

Although users' response has been enthusiastic, Sickmier admits that finding customers among state and local emergency response organizations has been difficult so far.

"Localities are always going to have difficult funding decisions to make," he said. "It's tough for them to make the choice between spending on hardware such as radios versus more information or training.

But as the models are developed through federal grant funding, Sickmier said, other regions will be able to adopt it at lower cost, and then modify them for their particular environment. 

"Every time you do it," he said, "it gets cheaper."