GoogleNews.com, FierceHealthIT.com, January 19, 2010, by Neil Versel  —  As far as I can tell from news reports, what little healthcare infrastructure Haiti had before last week’s earthquake is all but gone now. Yet, some advanced health information technology soon will be on its way to the devastated, impoverished Caribbean nation.

Disaster-response specialist Randy Roberson should know later today whether a mobile medical clinic filled with state-of-the-art telemedicine gear and a satellite audio/video link will accompany him on a flight to Haiti, or whether the 20-foot shipping container known as the “Doc-in-a-Box” will have to make the journey by sea. Roberson will personally be carrying the “Bring ‘Em Back Pack,” a 25-pound, solar-powered, medical backpack with a telemedicine connection.

In either case, at least a few of the medical professionals working to help Haitians survive this unthinkable tragedy will have live, remote access to specialists stateside. The clinic also will provide doctors with digital stethoscopes, a pulse oximeter, basic ultrasound equipment, Internet access and, yes, an electronic medical record to document the cases they see. The IT is all open-source and rather rudimentary by EMR standards. “They don’t have time to learn anything,” Roberson says. “They just want to be able to point and click.”

Indeed, a humanitarian crisis of such proportions is not the ideal time to be teaching doctors how to use an EMR. Plus, Roberson won’t know exactly where the clinic will set down, which doctors will use the facility or even what types of cases it will handle until he actually arrives in Haiti. (In fact, he many not even get into that country. When we spoke over the weekend, Roberson noted that some relief has been coming in via Santo Domingo, Dominican Republic, and that the better-equipped Dominican side of the island may be where a lot of Haitians get treated.) “I don’t make any final decisions until I’ve actually been there.”

At this point, Roberson and his two Payson, Ariz.-based organizations, Disaster Logistics and Humanitarian Emergency Logistics & Preparedness (HELP) are working to line up clinicians to use the clinic and the backpack. In past disaster-response scenarios, including the 2004 Asian tsunami and earthquakes in Turkey and El Salvador, he’s worked with several Christian missionary aid organization, one of which Roberson says has indirect ties to the Clinton Foundation. Roberson says he has some funding from various churches, foundations and corporations–the latter mostly in the form of donated medical supplies, but like so many other aid groups, HELP is always looking for more resources.

One other group that’s more widely known, Médicins Sans Frontières (Doctors Without Borders) had been using an open-source EMR called OpenMRS to track surgical patients at a hospital in Port-au-Prince, but that hospital was destroyed in the quake. Dr. Hamish Fraser, director of informatics and telemedicine for Partners In Health, a Boston-based organization that supports OpenMRS and has a presence in Haiti, says his group is looking for a quick way to automate patient registration and track cases under this expected surge in demand for care. “This will include handhelds,” Fraser says in an email.

Even in such an acute disaster area, health IT will have a visible presence.

This device uses magnetic fields to separate cells by size and shape.    Credit: Hur Koser

A new device separates healthy and diseased cells

MIT Technology Review, by Katherine Bourzac  —  Researchers at Yale have demonstrated a device that uses a magnetic liquid to separate blood cells based on their size and shape in just minutes.

The device applies a magnetic field to a liquid containing magnetic nanoparticles. The nanoparticles create waves that carry cells along depending on their size, shape and mechanical properties. The researchers, led by electrical engineering professor Hur Koser, hope to develop a cheap alternative to cell-sorting techniques that are time-consuming and sometimes require expensive labeling.

Liquid suspensions of magnetic particles, called ferrofluids, are already used as industrial lubricants and in loudspeakers and computer hard disks. These liquids typically contain other chemicals to keep the particles from clumping together and from coming out of the suspension. Magnetic nanoparticles are also being explored for cancer therapies and as contrast agents for magnetic resonance imaging (MRI)–both applications that require very low concentrations.

But the Yale group is the first to make a high-concentration, biocompatible ferrofluid that doesn’t contain any chemicals that are harmful to cells, yet still keeps the particles afloat. “It was very tricky to find the parameters to maintain live cells,” says Koser.

In experiments described this week in the Proceedings of the National Academy of Sciences, the Yale researchers made microfluidic channels lined with magnetic-field-generating electrodes. Cells were then added to a ferrofluid in the channel. When magnetic fields were applied along the device, the particles in the fluid pushed the cells along the channel, separating them by size and shape. Something similar can be accomplished using electrical fields, says Koser, but this can damage the cells. His group used the device to separate live blood cells from sickle cells and bacteria.

Koser believes the device could be especially helpful when trying to detect very rare types of blood cell, such as cancerous ones. Rapidly sorting cells using magnetic fields could improve the sensitivity of tests for these rare cells without adding any costly chemical labels. Tumor cells are squishier than healthy ones–possibly because they grow quickly and so don’t form a proper internal cell skeleton–and Koser hopes that magnetic fields will also be able to separate cells based on their elasticity and other mechanical properties.

“The next step is to try this in conjunction with existing sensors to improve their sensitivity and cut down on time,” says Koser.

One neuron, two innovations: A mouse neuron expressing a natural opsin for controlling it, and a natural fluorescent protein for seeing it. Credit: Brian Chow, Xue Han and Ed Boyden/MIT

The pipeline linking ecological discovery to bioengineering insight

MIT Technology Review, January 19, 2010, by Edward Boyden, Brian Y. Chow  —  “Time after time we have rushed back to nature’s cupboard for cures to illnesses,” noted the United Nations in declaring 2010 the International Year of Biodiversity. Billions of years of evolution have equipped natural organisms with an incredible diversity of genetically encoded wealth, which, given our biological nature as humans, presents great potential when it comes to understanding our physiology and advancing our medicine. Natural products such as penicillin and aspirin are used daily to treat disease, yeast and corn yield biofuels, and viruses can deliver therapeutic genes into the body. Some of the most powerful tools for understanding biology, such as the PCR reaction, which enables DNA to be amplified and analyzed starting from tiny samples, or the green fluorescent protein (GFP), which glows green and thus enables proteins and processes to be visualized in living cells, are bioengineering applications of genes that occur in specialized organisms in specific ecological niches. But how exactly do these tools make it from the wild to benchtop or bedside?

Many bioengineering applications of natural products take place long after the basic science discovery of the product itself. For example, Osamu Shimomura, who first isolated GFP from jellyfish in the 1960s, and who won a share of the 2008 Nobel Prize in Chemistry, once explained: “I don’t do my research for application, or any benefit. I just do my research to understand why jellyfish luminesce.” Around 30 years later, Douglas Prasher, Martin Chalfie, and Roger Tsien and their colleagues isolated the gene for GFP, expressed it, and began altering the gene, enabling countless new kinds of study. Bioengineering can emerge from the conscious exploration of nature, although sometimes with long latency. Every gene product is a potential tool for perturbing or observing a biological process, as long as bioengineers proactively imagine and explore the significance of each finding in order to convert natural products into tools.

Conversely, many bioengineering needs are probably satisfied, at least in part, by a process found somewhere in nature–whether it’s making magnetic nanoparticles, or sensing heat, or synthesizing structural polymers, or implementing complex computations. The question in basic science often boils down to how generally important a process is across ecological diversity, but a bioengineer only needs one example of something to begin copying, utilizing, and modifying it.

If we can build more direct connections between bioengineering and the fields of ecology and basic organismal sciences–converging at a place you might call “econeering”–we could together meet urgent bioengineering needs more quickly, and direct resources toward basic science discovery. Scientists could deploy these basic science discoveries more rapidly for human bioengineering benefit.

Recently we’ve begun to examine some of the emerging principles of econeering, as we and others pioneer a new area–the use of natural reagents to mediate control of biological processes using light, sometimes called “optogenetics.”

As an example: Opsins are light-sensitive proteins that can, among other things, naturally alter the voltage of cells when they’re illuminated with light. They’re almost like tiny, genetically encoded solar cells. Many opsins are found in organisms that live in extreme environments, like salty ponds. The opsins help these organisms sense light and convert it into biologically useful forms of energy, an evolutionarily early sort of photosynthesis.

Plant biologists, bacteriologists, protein biochemists, and other scientists have widely studied opsins at the basic science level since the 1970s. Their goal has been to find out how these compact light-powered machines work. It was clear to one of us (Boyden) around a decade ago that opsins could, if genetically expressed in cells that signal via electricity (such as neurons or heart cells), be used to alter the electrical activity of those cells in response to pulses of light.

Such tools could thus be a huge benefit to neuroscience. They could enable scientists to assess the causal role of a specific cell type or neural activity pattern in a behavior or pathology, and make it easier to study how other excitable cells, such as heart, immune, and muscle cells, play roles in organ and organism function. Furthermore, given the emerging importance of neuromodulation therapy tools, such as deep brain stimulation (DBS), opsins could enable novel therapies for correcting aberrant activity in the nervous system.

What might be called the “example phase” of this econeering field began about 10 years ago, when several papers suggested that these molecules might be used safely and efficaciously in mammalian cells. For example, foundational papers in 1999 (by Okuno and colleagues) and 2003 (by Nagel and colleagues) revealed and characterized opsins from archaebacteria and algae with properties appropriate for expression and operation in electrically excitable mammalian cells. Even within these papers, basic science examples began to lead directly to bioengineering insights, demonstrating in the case of the Nagel paper that an opsin could be expressed and successfully operate in a mammalian cell line. In 2005 and 2007, we and our colleagues, in a collaboration between basic scientists and bioengineers, showed that these molecules, when genetically expressed in neurons, could be used to mediate light-driven activation of neurons and light-driven quieting of neurons. In the few years since, these tools have found use in activities ranging from accelerating drug screening, to investigating how neural circuits implement sensation, movement, cognition, and emotion, to analyzing the pathological circuitry of, and development of novel therapies for, neural disorders.

Now this econeering quest is entering what could be called the “classification phase,” as we acquire enough data to predict the ecological resources that will yield tools optimal for specific bioengineering goals. For example, in a paper from our research group published in Nature on January 7, 2010, we screened natural opsins from species from every kingdom of living organism except for animals. With enough examples in hand, distinct classes of opsins emerged, with different functional properties.

We found that opsins from species of fungi were more easily driven by blue light than opsins from species of archaebacteria, which were more easily driven by yellow or red light. The two classes, together, enable perturbation of two sets of neurons by two different colors of light. This finding not only enables very powerful perturbation of two intermeshed neural populations separately– important for determining how they work together–but also opens up the possibility of altering activity in two different cell types, opening up new clinical possibilities for correcting aberrant brain activity. Building off of data from and conversations with many basic scientists, we then began mutating these genes to explore the classes more thoroughly, creating artificial opsins to help us identify the boundary between the classes. Understanding these boundaries not only gave us clarity about the space of bioengineering possibility, but told us where to look further in nature if we wanted to augment a specific bioengineering property.

In the current model of econeering, the “example phase” and the “classification phase” both provide opportunities for productive interactions between bioengineers and ecologists or organismal scientists. During the example phase described above, both basic scientists and bioengineers tested out candidate reagents to see what was useful, and later many groups initiated hunts for new examples. During the classification phase, more systematic synthetic biology and genomic strategies enabled more thorough assessment of the properties of classes of reagents.

Interestingly, something similar has been happening recently with GFP, as classes of fluorescent protein emerge with distinct properties: for a while, it’s been known that mutating the original jellyfish GFP can yield blue and yellow fluorescent proteins, but not red ones. A decade ago, an example of a red fluorescent protein from coral was revealed– now this example has yielded, through bioengineering, a new class of fluorescent molecules with colors such as tomato and plum. So it is possible that the cycle described here –find an example, define a class, repeat–might represent a generally useful econeering process, one of luck optimization intermeshed with scientific and engineering skill.

Did the opsin community do “better” than the fluorescent protein community, in speeding up the conversion of basic science insight into bioengineering application? Well, one of the opsins that we screened in this month’s paper was first characterized in the early 1970s, and it was better at changing the voltage of a mammalian cell than perhaps half of the other opsins we screened. So one could argue that a decent candidate reagent had hidden in plain sight for almost 40 years!

Although these two specific fields have benefited from basic scientists and bioengineers working together, a more general way to speed up the process of econeering would be to have working summits to bring together ecology minded and organismal scientists and bioengineers at a much larger scale, to explore what natural resources could be more deeply investigated, or what bioengineering needs could be probed further. Then interfaces, both monetary and intellectual, could facilitate the active flow of insights and reagents between these fields. The next step could involve teaching people in each field the skills of their counterparts: how many bioengineers would relish the ability to hunt down and characterize species in the ocean or desert? How many organismal biologists and ecologists would benefit from trying out applications in specific areas of medical need?

To fulfill the vision of econeering, we should devise technologies for assessing the functions of biological subsystems fully and quickly, perhaps even enabling rapid basic science and bioengineering assessments to be done in one fell swoop. Devices for point-of-discovery phenotyping that allow for gene or gene pathway cloning, heterologous expression, and functional screening–and maybe even downstream methodologies such as in-the-field directed evolution–would allow the rapid assessment of the physiology of the products of genes or interacting sets of gene products. (Note well: the gene sequence is important, but only the beginning; gene sequences are not sufficient by themselves to fully understand the function of a gene product in a complex natural or bioengineering context.)

Bioinformatic visualization tools could be useful: can we scan ecology with a bioengineering lens, revealing areas of evolutionary space that haven’t been investigated (at either the example or class level)? What are the areas of bioengineering need where examples from nature might be useful in inspiring solutions?

Ideally, an econeering toolbox will emerge that will let us confront some of our greatest unmet needs–not just brain disorders, but needs in complex spaces such as energy, antibiotic resistance, desalination, and climate. If we can better understand, invent from, and improve the preservation of our natural resources, we’ll be poised to equip ourselves with a billion years of natural bioengineering. This will give us a great advantage in tackling the big problems of our time–and help future generations tackle theirs. 

GenomicsLawReport.com, January 19, 2010, by Dan Vorhaus  —    The latest stop on the road to the $1,000 genome? San Francisco, CA, where J.P. Morgan’s 28th Annual Healthcare Conference is in full swing. There is an abundance of real-time Twitter coverage from the conference, but certain announcements warrant a more detailed discussion.

The announcement generating the biggest buzz today came from Illumina, Inc., whose CEO Jay Flatley unveiled a new genome sequencing machine, the HiSeq 2000. According to Matthew Herper of Forbes.com, Illumina’s new machine “will decode a person’s DNA in one week using $10,000 worth of materials – five times cheaper than any other competing gadget on the market.” Herper adds that the machines will begin shipping in February with a cost of $690,000 (compared to $500,000 for Illumina’s current model). Illumina’s own product page for the HiSeq 2000 provides more technical details, including coverage (~30x) and read length (2×100 bp). There have also been unconfirmed rumors that the machine will come equipped with an iPhone user interface, a concept that Flatley first pitched at last summer’s Consumer Genetics Show.

If it performs as advertised, the HiSeq 2000 is likely to be a huge hit with large genome sequencing centers, as evidenced by the announcement that the BGI (formerly the Beijing Genomics Institute) has agreed to purchase a whopping 128 of the new sequencing systems. But what, if anything, does the Illumina announcement mean for individuals consumers interested in receiving a complete genomic sequence?

Although Herper declares that Illumina’s machine is “five times cheaper than any other competing gadget on the market,” I’m not entirely sure that is true. According to Illumina, the $10,000 price tag is for “reagent costs at list price” and does not include other significant costs, including purchasing the machine itself or analyzing the raw genomic data. In fact, it’s not even clear to me that the announcement represents a five-fold drop from the commercial whole-genome sequencing Illumina announced last June. That service offered consumers the opportunity to purchase a whole-genome sequence at the same 30x coverage for $48,000 and, although interpretation was similarly not included, consumers weren’t required to purchase their own sequencing machine and did receive a free iMac as part of the bargain.

Also in the middle of the whole-genome sequencing competition is sequencing-as-a-service provider Complete Genomics, which is presenting at the J.P. Morgan conference tomorrow morning and may well have at least a partial answer for Illumina’s announcement. Even if there’s no big news forthcoming from Complete, the company’s November announcement that it had sequenced three whole-genomes for an average materials cost of $4,400 and reports that it is selling whole-genome sequences at $20,000 apiece in minimum orders of five, with the price dropping as the order size increases positions Complete as a clear competitor to Illumina, at least from a pure price standpoint.

All told, Illumina’s announcement strikes me less as a sequencing milestone and more as a tightening of an already extremely fierce race toward the $1,000 genome. Nonetheless, if there are consumers out there who are awaiting a whole-genome sequence and look at $10,000 (and not $1,000) as the magic number, Illumina’s announcement could bode well. It seems likely that Illumina will drop the price of its own commercial whole-genome sequencing service from its current $48,000 and direct-to-consumer (DTC) whole-genome sequencer Knome, which uses the BGI to perform its sequencing, is also a likely candidate to announce a price reduction in the coming weeks (the current cost is believed to be $68,000).

Finally, the substantial buzz surrounding Illumina’s announcement and the continued tightening of the race to the $1,000 genome encourages me to reiterate what I wrote just last week in Five Questions for Personal Genomics in 2010:

The success of personal genomics, which is what really matters to consumers, patients and healthcare providers, requires more than inexpensive genomic data. The real breakthrough in personal genomics will come when we can offer individuals affordable access to their whole-genome sequence as well as to the genomic tools and knowledgebase necessary for those individuals to put that data to use.

 

Update 1/12: Ed Winnick of GenomeWeb has additional details on Illumina’s launch of the HiSeq 2000 and its partnership with BGI, including Jay Flatley’s statement that BGI’s order will ultimately allow it to sequence 11,000 human genomes per year.

Update 1/13: Daniel MacArthur of Genetic Future, Luke Jostins of Genetic Interference and David Dooling of PolITiGenomics all offer their analysis of what Illumina’s announcement means for the present and future of genomic sequencing. Also, in breaking news, Linda Avey is covering Complete Genomics’ presentation this afternoon and reports that the company has delivered 50 genomes to date and expects to deliver another 5,000 in 2010.

Update 1/14: GenomeWeb Daily News has more coverage of Complete Genomics’ announcements, including that the company plans to sequence up to one million human genomes worldwide over the next five years and is interested in exploring the IPO market. Also worth noting is the fact that the Complete Genomics sequencing-as-a-service model includes analysis and reporting, not just raw data, which makes comparing the current price tags for Complete ($20K) and Illumina ($10K for reagents only, no analysis) a bit like comparing apples to oranges.

MIT Technology Review, January 20, 2010, by Emily Singer  —  A newly unveiled sequencing machine can sequence two genomes in about a week.

Genomics giant Illumina, based in San Diego, pushed forward the race for the fastest sequencing technology with the announcement of its latest machine, called the HiSeq 2000. According to the company, the device can sequence two human genomes at once, completing the process in about a week.

The Wall Street Journal reports:                                             

Running two genomes at once, said [Jay Flatley, Illumina’s chief executive], will enable researchers to run a person’s genome at the same time it runs, for instance, the genome of a cancer tumor taken from the same person. The results could lead to more knowledge about tumors and, scientists believe, match patients with treatments likely to be effective against their tumors.

Complete Genomics, a Mountain View, CA-based company that offers a sequencing service rather than selling instruments, reported last November sequencing three human genomes for an average cost of $4,400 in reagents. However, that company does not yet offer that price commercially. Sequencing costs can be calculated in different ways, and often do not include the cost of analyzing the information, making it difficult to directly compare them.

It’s not yet clear whether Illumina will drop the price of its personal genome sequencing service, which is available with a physician’s prescription for $48,000.

The Beijing Genomics Institute (BGI) is the first major buyer of the machines–Illumina says it has purchased 128 HiSeq 2000 sequencing systems, which will be installed in BGI’s new genome center in Hong Kong.

Inflatable life-saver: A balloon-based device can be inserted into a deep, penetrating wound and inflated in less than 90 seconds to stanch life-threatening bleeding. The balloon is made of polyurethane-coated nylon, and expands to a maximum length of eight inches and diameter of two inches. It conforms to the shape and size of the wound.  Credit: Brittany Sauser 

A fast, efficient balloon-based system could save lives on the street and battlefield

MIT Technology Review, January 19, 2010, by Brittany Sauser  —  Uncontrolled bleeding is a major cause of death on the battlefield, and according to military medical experts, it accounts for 80 percent of otherwise preventable deaths. One problem is that there are no effective treatments for deep, penetrating wounds, which are too severe for gauze packing and are in areas where a tourniquet cannot be applied. To stop life-threatening bleeding in such instances, Maynard Ramsey, the chief executive officer and chief technology officer at CardioCommand, a Tampa, FL-based medical device company, has developed a balloon-based system that can be inserted into a wound and inflated in less than 90 seconds.

The device looks like a long, thin, flexible wand, around which is a tightly wrapped compression balloon covered by a removable sheath. Once a medic inserts the device into the wound, he can inflate it with a hand pump or syringe to a maximum of eight inches long and two inches wide. The balloon conforms to the shape and size of the wound, putting pressure on its walls to stanch bleeding until the patient can be transported to an operating room.

Thousands of people die on the streets and battlefield every day because of stab wounds and gunshot wounds that result in uncontrolled bleeding, says Joseph Garfield, an associate professor of anesthesiology at Harvard Medical School and Brigham and Women’s Hospital in Boston. “Ramsey has developed an ingenious device to combat this problem.”

Ramsey has successfully tested the device in 200-pound pigs, and is currently trying to work with the military to conduct more extensive tests.

“The device is ready to be in the field tomorrow,” says Rutledge Ellis-Behnke, a researcher at MIT, who is also building materials to stop bleeding. He says the new device does have some issues. For example, anyone using the device would need to avoid further damaging tissue while navigating the wound track. Also, a medic using the device could drive shrapnel across a healthy artery and accidentally sever it, he says. But, Ellis-Behnke adds, the device addresses a problem that right now has no solution. “The deployment of it will save lives,” he says.

The balloon is made of two walls of material: the outer wall is nylon coated on the inside with polyurethane; the inner wall is a layer of soft polyurethane. The design makes the balloon resistant to punctures from sharp objects, like shrapnel, that might be inside the wound. The balloon will also conform to the shape of the wound and compress it. Similar balloon devices, used mostly in operating rooms, “stretch when inflated, but they want to take their ‘natural’ shape, and do not therefore contour to fit the wound track,” says Ramsey.

The CardioCommand device was developed for areas where conventional tourniquets cannot be applied, such as the groin or shoulder. But even tourniquets have drawbacks because they can’t be left on for more than 30 minutes and can cause secondary tissue damage. The new device was also made for puncture wounds too deep and severe for traditional methods of treatment.

The device is part of a recent effort to develop more effective methods to control bleeding from severe trauma. For example, the U.S. military uses a bandage made by HemCon that has chitosan, a blood-clotting agent, to seal a wound and stop the hemorrhaging. The military also uses QuickClot, a pourable product that uses zeolite-based agents to soak up the blood and adhere to the tissue at and around the wound site. Newer methods still in development include a pouch, built by Aurora Flight Sciences, that swells when put inside an injury, and nanoparticles designed to mimic the clotting capability of blood platelets. The nanoparticle research is led by Erin Lavik, a bioengineer at Case Western University in Cleveland.

But, says Ellis-Behnke, “All of these have drawbacks.” They can swell bigger than the wound, putting pressure on and damaging vital organs, or cause clots that can travel to other areas of the body, he says. Also, most are not biodegradable, he says.

No device is as well directed toward the problem of hemorrhage control as CardioCommand’s device, says Steven Glorsky, a trauma surgeon at Brooke Army Medical Center in San Antonio, TX. “This could have huge benefits on the battlefield.”

Medicine Meets Simulation
 

MIT Technology Review, January 19, 2010,  —  A distracted driver accelerates through a stop sign, knocking a rider off his bike. Soon an ambulance blares onto the scene. Medics rush out, check the man’s vital signs, and intubate him to allow him to breathe. They load him onto a stretcher and transport him to a nearby medical facility, where the doctors immediately get to work.

The patient may survive. Or not. Even if he doesn’t the medical team can review what they did wrong and try again, this time perhaps saving his life. Because this patient is not alive. He’s a simulation.

Until recently, doctors mostly trained by first watching procedures, then practicing them directly on patients. Researchers estimate that deaths from medical errors range between 44,000 and 98,000 every year. Nearly one million additional injuries are also attributed to medical error. “So you don’t want to be the first one that the doctor or nurse works on,” says John Anton, founder of the Florida-based simulation company Information Visualization and Innovative Research (IVIR). “Give them the opportunity to repeat situations they’re going to have to face—that’s what simulation is all about.”

Once, doctors might have used a hard plastic figure to stand in for a patient. Today’s mannequins simulate breathing, exhibit a pulse and mimic other vital signs, and can even “respond” to treatments. They offer a safe way for medical students, nurses, and emergency medical technicians (EMTs) to get their hands on patients and practice procedures over and over, literally gaining a realistic feel for applying lifesaving methods before they ever come in contact with a suffering human being.

Mannequins Come to Life

A major breakthrough in medical simulation took place more than 40 years ago, when Michael Gordon of the University of Miami invented a mannequin that he named Harvey, after an honored professor. Harvey could embody a number of the different cardiac diseases a doctor might confront; and depending on the disease, a stethoscope to the chest encountered any one of a number of different heart sounds. Transformative changes in technology have resulted in the latest versions of Harvey, who can now mimic dozens of cardiac and lung diseases with all their appropriate rushes and gurgles.

In 1996, Medical Education Technologies, Inc. (METI), based in Florida, began selling the first whole-body human simulators. Instead of lifeless, immobile mannequins, these models intricately mimic human physiology, with palpable pulses, discernable breathing, and the ability to talk and to respond to treatments. The “patient” can be programmed for any type of physiology and disease. According to Lou Oberndorf, CEO of METI, “It opened up an enormous number of possibilities in the ways to teach.”

Today’s simulators take advantage of the latest technology to go beyond simulating the vital signs and responses of diseases. The latest versions are plumbed to excrete from every orifice: they spurt blood at the site of a severed artery, and clear liquid streams from their eyes and noses to mimic the effects of a biological attack.

Beth Pettitt, division chief of the Soldier Simulation Environments at the Army’s Simulation and Training Technology Center, explains that her office has challenged in-house and contract researchers to “come up with better representations of skin, bone, blood— so these wounds look right, smell right, feel right, and behave with physiological accuracy. Soldiers have to control bleeding, put a tourniquet on, and use a clotting agent if appropriate.”