Systems engineering is a structured approach encompassing the lifecycle of product and technology development, from analyzing how the system is to be used until the system has been developed, verified, fielded, maintained, and disposed. It is perhaps best known for the “ilities”, that is, a set of considerations that must be taken into account to ensure the best possible system. These considerations include utility, affordability, reliability, usability, and maintainability, among many others. Systems engineering is also known for its realistic approach to optimizing the most critical requirements, even at the expense of less critical requirements. The area between key requirement parameters “must haves”, called thresholds, and “nice to haves”, called objectives, is termed trade space. Optimizing requirements involves staying in that trade space for critical parameters. Further challenges arise when critical requirements for the same product and technology vary among a user community that spans military and civilian sectors with a range of levels of expertise; the trade space becomes even more complicated and narrow to truly optimize the product. Systems engineering has long been applied to modeling and simulation and more recently to medical simulation technology development. This paper presents a case for medical simulations posing unique challenges to the systems engineering process. A case study of a successful medical simulation development effort will demonstrate that these challenges can be overcome and how they can be navigated.