The “Cave:”
a place where virtual life and virtual death offer swift and unforgettable lessons to the physician in training

There’s no Alice, but immersive virtual reality is nevertheless enough of a wonderland to have its creators grinning like the Cheshire Cat. It’s a world where things are not as they seem but where the “reality” created by technology is more useful than the real thing — where a human being that bleeds fake blood and goes into fake shock can provide invaluable insights to a medical student or a practicing physician in a way never before possible. For Dag von Lubitz, Ph.D., a scientist who is director of the Emergency Medicine Research Laboratories and participant in an unusual enterprise known as a virtual reality “cave,” it’s at least as mind-bending as Alice’s experiences after she tumbled down the rabbit hole. (The word ”cave” is actually an acronym for “cave automated virtual environment.” The basic product is licensed by Pyramid Systems and uses Silicon Graphics computer technology.)

“The possibilities are limitless,” says von Lubitz, of a six-month-old research effort in the Department of Emergency Medicine. “We ourselves, within this little group of enthusiasts, are discovering new frontiers almost daily.”

“Immersive virtual reality” results from the fusion of two technologies: one that makes a robot-like plastic and wire invention act very much like a living, breathing human being and another that, via a complex set of goggles, infuses a make-believe operating room with enough high-tech computer data that it begins to look and feel very much like the real thing. The result is a whole that’s greater than the sum of its parts, what von Lubitz calls “a hyper-rich environment.”

The team that’s doing all this, which includes engineers, computer specialists, emergency physicians and von Lubitz himself, is as impressive as the results it’s producing. Von Lubitz, who holds degrees in neuropathology and marine biology, believes it could exist only at a place like Michigan because of the presence of academic stars in so many disciplines and an underlying philosophy that nourishes collaboration. “It wouldn’t happen, to my mind, anywhere else,” he says. “We could serve as a model of how an interdisciplinary team should work.”

Members of the team include Timothy Pletcher, an information technology “genius,” as von Lubitz describes him; Klaus Peter Beier, Ph.D., a naval architect and world recognized authority on virtual reality; William H. Wilkerson, M.D., clinical assistant professor of emergency medicine, James A. Freer, M.D., clinical assistant professor of emergency medicine, and David J. Treloar, M.D., clinical assistant professor of pediatrics and communicable diseases and clinical assistant professor of emergency medicine — all senior emergency medicine physicians. “The beauty of this team is that it needs no leader because we communicate so well,” von Lubitz says. “But the critical and absolutely unique achievement of our team is the fact that we merged these two technologies into a seamless entity,” he adds. “We created what we now call a hyper-rich environment, where we can expand the tactile, visual combination of learning that the patient simulator gives you with any type of medical information available to you by any electronic means.”

“There are about 60 universities worldwide that are using human patient simulation in anesthesiology training,” says von Lubitz. “We are the first to make emergency medicine and trauma medicine a primary target, exposing students to elements that are destructive, elements that are stressful, elements that increase the adrenaline rush and decrease the amount of, shall we say, readily available knowledge. All that comes with experience, but experience can be rather costly in terms of poor performance. This system allows you, for the first time, to combine a number of elements that you have in real life, and drop your trainee into hot water and say, ‘Deal with it, that’s real life!’”

Having once served as a junior medical officer on a military ship, von Lubitz is familiar with operating under adverse conditions. “Many years ago, I was on a minesweeper in the North Sea and one of the seamen tripped on the threshold of a hatch, flew headlong along the passageway and broke his forearm,” he says. “It was the simplest fracture, but we were in a very nasty gale with mountainous seas. The ship behaved like a totally unpredictable express elevator and it took me one and a half hours to deal with the problem. That experience has stayed with me forever because I was not prepared for it. You don’t have any type of training that prepares you for unpredictable, sudden motions of the floor, smells that are excruciatingly unpleasant.” If von Lubitz has his way, virtual reality will soon allow students to experience every kind of real-life horror in the virtual reality “cave,” facing useful challenges never possible to experience in this way before.

“It’s completely unconventional,” Tim Pletcher says, “but it’s also very persuasive. When you put a student into this environment, where the learning takes place by feeling, by seeing, you quickly see that we learn best by using our senses. You can see that a student learns more about pharmacology by seeing the physiological response of the human patient simulator than by reading five chapters in a book of pharmacology.”

Because virtual reality is so real it has dramatic implications for research as well as for teaching. “We’ve done a couple of experiments where we’ve simply repeated animal experiments on the simulators to see what happens, and our results were within 10 to 15 percent of the lab results,” von Lubitz says. “If it turns out we can use them as predictors of bench research, that could mean massive savings in expenses on research animals, and also saving a number of research animals.”

The virtual patient in von Lubitz’s “cave” may also offer whole new ways of testing the competence of medical students. Instead of a paper exam, he or she might be presented with a “virtual” elderly, slightly obese woman with elevated blood pressure who has just fallen in the street. “Based on information from the triage nurse or EMT, the doctor has to start managing the case,” says von Lubitz. “That simulator is very, very physiological. You either do it right or you do it wrong and if you do it wrong, you may well kill the patient, which obviously terminates the examination.”

Von Lubitz, who gives great credit to William Barsan, chair of the Department of Emergency Medicine, for his courage in supporting such an unlikely venture and to Jocelyn DeWitt, Ph.D., director of the Hospital’s information technology, delights at the thought of all the possiblities that lie ahead in immersive virtual reality. “The intellectual atmosphere of this department is absolutely unprecedented,” he says. “Great discoveries lie ahead. Alice? She would have loved it.”

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