The operating conditions for doctors in extreme combat situations can in no way be compared to those of their hospital colleagues. Virtual Reality techniques as well as telemedical implementations seem to include promising training perspectives for general practitioners allowing them to learn how to function efficiently in a hostile environment and how to face up to stressing and precarious work circumstances. Dr. Jean-Paul Papin offered a glance at the characteristics of front-line medicine missions in France and the training means for unit doctors at the International Symposium on Telemedicine in Brussels, last October. He even illustrated his speech with a concrete example of virtual reality applied to the learning of elementary resuscitation gestures in an aggressive environment.
Dr. Jean-Paul Papin is the chief coordinator of Human Resources within the General Directorate of the Expertise and Testing Centres in France. Currently, in case of military intervention, a low-strength unit is engaged with medical support from a doctor in a front-line armoured ambulance. French army doctors are trained at CITERA (Centres d'Instruction aux Techniques ElÈmentaires de RÈanimation de l'Avant) to cope with real combat experiences in which they are supposed to blindly execute emergency resuscitation in combat gear, with a heavy helmet and a bullet-proof vest while driving in a hot, noisy and narrow vehicle, surrounded by enemy fire.
Practising on dummies with the available equipment does not suffice to give trainees a feel for survival surgery. Simulation by virtual reality can evoke the required realistic training situation. The virtual representation of the patient has to be as accurate as possible, both at the level of vision and of mobility. Papin refers to surface changes during movements; to imagery enhancement with special colours identifying specific nerves and to real-time presentation of the doctor's virtual hands, including haptic feedback. Software packages such as 'The Virtual Man' and 'The Dextrous Hand Master' provide these kind of features.
The appearance in Europe of the telemedicine network is situated in the nineties by Papin. He defines it as the generalisation of a network to an entire national or supranational health system. In the military context, operational and tactical telemedicine is based on two requirements, namely the soldier's right to a top quality medical treatment and the idea of the zero-dead war. Appropriate communication networks are installed to save human lives and to offer decision aid to front-line doctors by means of prompt transmission of medical records and data providing pertinent information about lethal or non-lethal risks.
At CITERA, a concrete training project has been set up which involves different partners such as the Human Factors Division of the Etablissement technique d'Angers, the University of Angers, the Laboratoire Robotique de Paris and a firm of architects. The initial goal consisted in developing a tool for training in a hostile environment on the practice of three elementary gestures in the region of the neck: anaesthesia of the brachial plexus; insertion of a perfusion in the jugular vein and execution of a coniotomic. All in all, an extremely delicate intervention when having to be performed blind.
After careful research, a virtual neck was designed showing the in-depth anatomy in order to act on it with virtual instruments offering a return of sensations at the level of the trainee's hands. At first, the students are able to watch the route taken by the needle while the pertinent elements are reinforced by colours. In the next stage, they only see the skin while performing the same gestures but they receive an enhanced return of the manual sensation. Then, they perform the activity by merely viewing the surface of the region and with little manual sensation. Afterwards, they can verify the result by displaying the needle's position in depth. Finally, the students have to wear combat gear while executing the task in the GEPAT (GÈnÈrateur d'Environment Physique Aggressif pour le Travail), which produces noise, heat, movement and hypoxy, just like on the battlefield.
Dr. Jean-Paul Papin states that such techniques of virtual reality constitute special tools for the practice of telemedicine in the military context. For a full account of his lecture, we refer to the Symposium web site.