The unique control inputs of the Nintendo DS, coupled with its unexpected foray into new gaming demographics, both encouraged developers to try new kinds of games with the console. This lead to the birth of enduring franchises such as Professor Layton and Brain Age but also flashes in the pan that no longer seem viable today in main consoles such as the Nintendogs games.
In that creative environment, Atlus saw the DS touchscreen as the perfect control scheme for a medical-themed game, and as such the Trauma Center series was born. As the name implies, the games center on characters from the medical field, mostly surgeons taking advantage of the touch screen to do complex (and unrealistic) surgical procedures under emergency situations. Besides the frantic touch-based gameplay, there was also some solid drama coupled with excellent character design.
The only series where you can remove an I-Beam (WHAT??!!) from someone's liver
With five games and a jump to the Nintendo Wii, it seemed for a moment that we may have the first successful gaming franchise focusing on the unsung medical profession. However, the fifth (and in my opinion, best) game on the Wii was the final game released in the series.
What the hell happened here?
Before we try and analyze what lead to the series's decline, let us first look at each of the five games separately. While all five games take place in the same universe with occasional recurring characters, the games can be divided into their DS and Wii releases. This division may give us valuable information about the audience of the game, as well as the effects of control inputs and market conditions.
Note that regarding the install base, the DS has nearly a 1.5 advantage but its attach rate is lower. So, considering that, both consoles actually should have had a similar potential audience.
A) The DS Games:
The series started with the DS where the touchscreen control method has been pivotal to its identity and success. Two games were released on the plucky little dual-screened console.
1- Trauma Center: Under the Knife:
This game came at a time where developers were confused about how to best use the Nintendo DS's touchscreen, with many games failing to craft compelling games around the unique control inputs of the system or struggling to adapt existing properties to it. Atlus's answer to that dilemma was a game that went into a bold new direction and was rewarded with great success (but only in the North American market).
Set in a "realistic" near-future setting, the game tells the story of a surgeon with an incredible "healing touch" that suddenly finds his abilities under significant demand. A new infectious parasite thing has started to develop, threatening to start a pandemic of deadly proportions. This parasite can only be excised through quick and accurate surgery, and that's where the touch screen comes in.
All surgical procedures happen on the touch-screen, where you use the stylus to cut, suture, saw, and other surgical procedures. These operations are neither visually or medically accurate but are instead fast-paced and heavy in action, especially in harder difficulties. There is always a strict time-limit in each procedure that can reduce due to mistakes, so there is a push to be both fast and accurate. Due to the nature of the touchscreen controls, all actions are clear and intuitive.
If there was any game that can be said to be a perfect fit for a console then Trauma Center: Under the Knife would be the perfect example for such a game on the DS hardware. Not only is the core control method dependant on the DS's touchscreen, but it is also segmented into several chapters and procedures; a perfect fit for on-the-go gaming. In many ways, this was yet another example of the puzzle and visual novel genres finding success on the system. Except that the puzzles in this game are time-tracked surgical procedures with a high difficulty ceiling and digital lives at stake.
2- Trauma Center: Under the Knife 2:
This is a direct sequel to Under the Knife, featuring the same main character and some of the same supporting cast. Again, there is a fear of the original parasite disease evolving and causing a worldwide pandemic. While the game doesn't deviate much from the original's combination of visual novel story segments and arcade-style surgical puzzle operations, it does offer improvements all over the board.
For instance, there is a more grounded story with a larger variety of surgical operations. These are made easier by improved control and the inclusion of lower difficulty options for those wanting a less intense experience. Also, there were improvements made to the presentation of the story segments and a better more varied soundtrack.
Note that this game was developed on the DS after two Trauma Center games were already made for the Wii. Reportedly, there was a "demand" for a sequel to the first game on the DS, but I don't think that demand was serious given the considerably lower sales.
B) The Wii Games:
The Nintendo DS's touchscreen may have proved to be a suitable control input for the franchise's surgical procedures, but there was another Nintendo console with the ability to simulate motion through alternative means. The Nintendo Wii's motion controls were seen as a natural fit for the series, convincing Atlus to make three games for it.
Note that I played and reviewed all three games as part of my Wii REVIEWS series.
Second Opinion is somehow a half-remake of Under the Knife on the DS. It features the same story and nearly the same procedures, but it adds in another character with their own chapter while overhauling the gameplay and upgrading the presentation. This meant that the first Trauma Center game was a launch title to both Nintendo's innovative consoles.
Naturally, being on the Wii, the gameplay was motion-centric, which fit with the medical genre very well. Using the Wiimote and Nunchuck combination, the gameplay was more about fine wrist movement rather than full arm swinging. Most surgical tools required a point and drag input, but some also required twisting the Wiimote to rotate or screw something in. It was both intuitive and mostly accurate, allowing for a good living room setup for the Wii.
Of course, the gameplay would have been rote if not for the tension created by the time limit of each procedure. The game can get bloody hard, as you try to multitask between advancing the patient's procedure while maintaining their lives. In fact, the high difficulty was a common complaint from reviews in the day.
Presentation-wise, the game's story still progresses through visual novel-like segments, but the resolution of the nice character art and the background scenery were both improved. The human body was still an unidentifiable neon-colored mess, but that's probably for the better. One thing to note is that the game is stuck at a 4:3 aspect ratio like many early Wii titles.
While the first game on the Wii was in some ways a port of a DS game, New Blood was fully developed with the Wii in mind. As such, it naturally boosts higher production values, but still adhering to the low standards of an Atlus game. The art is still gorgeous, but there is limited animation and the surgical sections didn't evolve much. One nice thing is the addition of some quality voice acting.
As for the gameplay, it controls more accurately than Second Opinion for the most part. I say for the most part because activating the special move, which is downright necessary for the latter procedures, is so frustratingly messed up. Also, I felt that the rating system for your performance was not calibrated correctly since I attribute many errors to an inherent inaccuracy to the Wiimotes themselves. Thankfully, the game's difficulty looks like it was calibrated for that inherent flaw.
Overall, New Blood marginally improved nearly everything about the very good first Wii Trauma Center game, which proved that the core gameplay and story idea of the series still worked well.
Finally, we end with what I consider to be the pinnacle of the series. While all four previous entries focused solely on surgery, Trauma Team introduces five other medical professions to the mix, each with their own different character and gameplay mechanism. While emergency medicine and orthopedics are somewhat remixes of the now-classic surgery gameplay, the other three professions are completely new to the series. Endoscopy is the game's only full-3D mode, and it is a nice-shake up to the classic formula even if it isn't good enough by itself. It is the two "investigation" modes that finally explore the visual novel possibilities of the franchise. Diagnosis and forensics sections are great to play and help show a different side of the medical field.
With the expansion of the characters also came an expansion of the story, with this being one of Atlus's largest stories at that point (in terms of lines of dialogue), and I can say that is works. The characters grow and develop well throughout the game, and the central horror of an air-borne epidemic was something inspired by the 2009 Swin flu pandemic but is closer (but MUCH DEADLIER) to the current 2020 COVID-19 pandemic.
It is clear that Atlus had high hopes for the title and they even attempted to address the franchise's main sticking point according to the critics; its high difficulty curve. Making normal mode easier worked as a double-edged sword for the game. Sure, it is now more accessible for a larger potential audience, but it removes the tension that was core to the franchise, especially when the hard mode was locked down behind completing the game. Also, it was an unnecessary alteration, as an easy mode was already available (that reviewers REFUSED to use when having trouble).
Even with that minor flaw, I honestly really loved this game, which makes its lower sales at the height of Wii ownership all the more frustrating. Note that the game was ported to the Wii U's virtual console, but that surely didn't do much to improve its fortunes.
When the franchise started on the Nintendo DS and Wii consoles, it looked like Atlus had something special that could continue for a while. True to that initial expectation, Atlus did have something special as the three games after their initial two outings all gained the same critical acclaim, with their final game on the Wii being a highpoint in terms of overall gameplay and design.
Yet, the series abruptly ended at its highwater critical moment, lasting for five years where it was the only serious game in the barren medical genre.
So, why did it die?
Downward Commercial Performance:
As is usual with all franchises, it is the question of sales that would dominate discussions about its survival. Of course, when having this discussion regarding any Atlus game, it is important to consider that neither their game budgets nor their financial aspirations should be compared to the usual AAA publisher.
Initially, the Trauma Center games were high-sellers for Atlus, with the first two games selling in the same ballparks as hallmark franchises such as SMT and Etrian Odyssey. However, there was a clear drop with the sales of the last two games, both selling less than 200K units with Under the Knife 2 selling around 30% of the first game. Most damningly, it showed that even when Atlus improved the production and addressed the series's main complaints with the excellent Trauma Team, that did not arrest the downward trend.
What is most curious about the sales data for the series is the extremely lukewarm commercial reception in Japan, where the games have collectively barely reached 50K units sold. The lack of sales in its home country meant that Atlus depended on Western sales, which was probably a hindrance to their customer research efforts.
So, with a downward sales trend despite the warm critical reception, coupled with a weak sales performance in its home country, Atlus is probably excused for concluding that the franchise is not a safe financial bet.
A Departure from Atlus's Usual Games:
A quick lock at Atlus's published and developed game would reveal a ton of RPGs (and genres derived from RPGs) and the occasional Beat 'em Up developed by Vanillaware. A third category would be some visual novels published for the DS and PSP. This is an important point to consider because Atlus is not a well-known publisher, but they are extremely loved by their fans; a cult-publisher if you will.
As such, it is to be expected that these fans "expect" some kind of gaming experience from Atlus's games. A gaming experience that is very different from the one Trauma Center provides. This leaves Atlus with the difficult task of convincing their existing fanbase of trying a different genre while also trying to rope in new gamers.
Maybe some people were seriously frustrated trying to pull off the super move in New Blood (I know I was)
I think that's one reason for the downward sales trend. At the beginning of the DS and Wii lifecycles, a new demographic came into both systems that were more ready to purchase unestablished games and genres, and a medical surgery game just fit in with that demographics. However, as we can see from the latter sales in both consoles, that demographic didn't stick around for more than two or three years, leaving Atlus to depend on its core fanbase which never fully accepted the franchise.
It is important to note that Atlus is no longer a niche developer today, as the massive success of the Persona series coupled with their acquisition by Sega means that they are recognized by a wider audience. Which brings us to our final point:
Sega's Acquisition of Atlus:
In 2013, Sega Sammy Holdings bought the then bankrupt Index Corporation, which at that point was effectively the owner of the Atlus brand and business. Prior to Sega's acquisition, Atlus was probably the only subsidiary under Index Corporation making a consistent profit, which explains why Index let them simply do their thing. Also, that is why when Index went under, Sega Sammy simply came in to pluck its best brand.
Initially, Sega Sammy reassured Atlus fans that they will not interfere with how Atlus runs. Yet, a look at the company's output before the trouble at Index started and now shows a stark contrast. Previously, Atlus was more likely to bet on new IPs and had many more game releases a year. Now, there is a significant lack of anything that isn't Persona related as Atlus focuses mostly on their major cash cow.
Note that this may be due to the now higher production demands expected from Atlus in comparison to the 2000s when it was expected from them that they will cut corners. This is why a game that doesn't expect high sales even if they increase the production values like Traum Center may not be in Sega Sammy's plans.
If we can't envision a franchise continuing, then we wouldn't be super sad about seeing it end and go away. In the case of Trauma Center, it is very obvious that there is a place for it in the current gaming landscape, and here are three simple reasons why I think a new game from the series would still be welcome today:
Unique Medical Setting:
There was always a sporadic release of medical-themed games, but those releases didn't start a franchise nor did they have the consistent quality of the Trauma Center series. Consequently, we really only have this franchise representing the medical field in a genre of its own. In contrast, there are scores of movies, TV shows, and covering a medical setting.
As such, not only does Trauma Center have a unique selling point regarding its subject matter, but also a responsibility to expand the medium of videogames into more varied genres and themes. Here is a game about saving lives rather than taking them.
With all the intensity that entails
It is entirely coincidental that I am writing his blog now ((I chose it from a list of possible franchises by a random number generator) about a medical series at the same time the world is reeling from the COVID-19 epidemic, and this shows not only the importance and heroism of those working in the medical fields but also the vast storytelling potential and drams inherent in the genre. A genre that Trauma Center has entirely for itself.
Great Core Gameplay:
If all the series has was its unique medical setting, then a continuation of it would depend on the possibility of making a good game based on that setting. Thankfully, this is not the case with Trauma Center, as it already has five very good games under its name with a core gameplay hook that is both thematically appropriate and engagingly challenging. Surgery in the series may not be at all accurate, but its unique gameplay method with a lot of gaming potential.
What other game lets you mess around inside a patient's body
One concern going forward is that the franchise always needed alternate control methods to enable its unique gameplay, whether it was touch-control on the DS or motion-control on the Wii. However, with the Nintendo Switch supporting both options while being highly successful, there is no concern about the franchise not finding a home.
Other than surgery, there is also a potential in advancing the visual novel portions of the game, adding in more character choices and relationships into the mix. Also, like in Trauma Team, there could be more medical fields presented, leading to different gameplay modes, which brings us to our next point:
Endless Potential Going Forward:
Like we have seen with the last game in the series, there is huge potential in adding in more unconventional gameplay systems as they add in more medical professions. There is no reason for the series to settle on its current formula or feel trapped by its current gameplay loop. With its unique setting, the next games can feature any mix of gameplay styles that fit the general theme and work.
Similar to how Trauma Team did it
Of course, the series would be better served to always have a core gameplay hook (like surgery), but the vast potential of putting in more modes or focusing on the adventure aspects can help the series evolve and avoid stagnation.
Basically, no matter what direction the franchise decides to take, there is potential in creating excellent gameplay sequences and story scenarios.
Since the release of Trauma Team in 2010, the only activity in the series was a port of that game on the Wii U's virtual console. Other than that, despite Atlus's proficiency on the 3DS, there hasn't been even the whisper of a new game.
At the same token, there hasn't been any outright dismissal of the series. Knowing Atlus, there are really only two stark futures for the series, either it continues or it ends. There won't be any mobile ports or mobile only-games, as that hasn't been Atlus's style so far. As such we will either have a new game sometime in the next three to five years or the franchise will unceremoniously end.
A New Game in the Mold of Catherine:
If the Nintendo Switch was not released to such an enthusiastic reception, I would not think that there is any possibility of the franchise having any kind of future. After all, the alternate control schemes of the DS and Wii were instrumental to the gameplay. As it turned out, the Nintendo Switch still allows for that kind of gameplay, giving me some hope for the continuation of the series.
I think that Sega is no longer interested in Atlus making games that make a profit by simply selling around 300K Units and as such any new Trauma Center game will need to increase its production values in an attempt to attract a larger audience. This is why I think any new game in the series will aim to look and play like the adventure-puzzle game, Catherine, except with the franchise's medical-themes gameplay instead of block puzzles.
Maria would look great with Catherine's graphics
Another point that could be similar to Catherine, and indeed much of Atlus's output, is introducing a relationship-building element to the story or even a decision-making element that could change how the story progresses. I think that would be a great and fitting addition to the games, making them even more like medical dramas.
Honestly, I think such a game, if marketed correctly and made with engaging gameplay modes, can be a great success for Atlus. Even though the Trauma Center were never big sellers, they still managed to sell well at a time where Atlus was not at all a household name. I don't think the franchise ever reached its true sales potential, and it would be interesting to see how it performs if Atlus fully commits to the game as it does fro the Persona series.
An Unceremonious End:
Unless we are told otherwise, we must assume that the Trauma Center franchise is not even on life support; it al in all probabilities dead and buried. No amount of CPR and no defibrillator can help resuscitate it. It is deceased, demised, passed on, no more, ceased to be, expired, bereft of life, it is by all account an ex-parrot, err... I mean ex-series.
Originally, the release of two unique consoles inspired the creation of the series. Later, the swine-flu epidemic invigorated the writing for the its final game. If the Switch couldn't inspire a new game in the franchise, and if the COVID-19 epidemic didn't give any interesting ideas to the writers of Atlus, then I don't think the series will have any future.
I think that if we don't get a new game in three or five years then we will know that the series is surely dead. We will also know that the old Atlus is also dead, forever changed by Sega Sammy's acquisition.
The "Where the Hell is" is going to be a series where I discuss the decline and disappearance of game franchises that interested me greatly, and now are gone. For a series to be covered, it needs to have three or more games, an unresolved conclusion or different storylines and is a series I somewhat played. Please feel free to give me any feedback or recommendation, as I always try to write better blogs.