Mirroring Functionality Restored: Bugfix

As part of developing and maintaining Infirmary Integrated, I often come across bugs in the software that need patching. I am announcing a unique bugfix that repaired Infirmary’s “cloud” functionality today.

Infirmary Integrated’s server has been migrated to a new host. As part of the migration, access to the website and the server may be spotty for a day while DNS records update. Regardless, aggressive testing during the migration exposed a problem that Infirmary’s “mirroring” functionality had broken in the past several months when PHP upgraded recently. Since PHP is the language the server’s functions are written in, the issue cropped up and impacted Infirmary.

I tracked down and fixed the problem, restoring the “mirroring” functionality. Specifically, Infirmary Integrated can be used to mirror simulations. When you launch Infirmary Integrated’s simulator and set up a patient simulation, you can choose to “broadcast”, which sends the simulation to Infirmary’s server in the cloud. The bug that was fixed specifically broke this functionality!

Once a simulation is broadcast via the server, somebody running Infirmary Integrated’s simulator can “mirror” or receive the simulation, retrieving it from the cloud. Additionally, mirroring updates every few seconds so that any changes made by the broadcaster propagate to all mirrors almost immediately!

I am glad to announce this insidious problem was discovered through testing and resolved. Any bugs that are found by the community can also be reported via the Github repository in an issue or discussion for resolving.

Advancing Social Justice in Healthcare Education through Accessibility: Celebrating Infirmary Integrated’s Use in 50+ Countries

10 years ago, as a new nurse, I had dreams of improving healthcare around the world. While my positive impact in nursing was generally limited to the patients I cared for in the hospitals I worked at, I searched for a way to improve healthcare beyond my physical presence. When I stumbled onto the idea that eventually became Infirmary Integrated, I always aimed to make it accessible for healthcare educators around the world, regardless of borders, language barriers, or technology barriers.

When I first started developing Infirmary Integrated, I ensured that I published it with accessibility in mind. To that end, I licensed it as free and open source software, free to be used for healthcare education with no restrictions in the classroom: free to download, and free to use. While healthcare has accessibility barriers around the world, educational software can easily be democratized and can be used to improve healthcare delivery around the world. That was my underlying goal.

To track progress on that goal and Infirmary’s use around the world, the program does collect anonymized usage data that I also use to guide feature implementation such as language localization. Every time I see Infirmary used in a new area of the world, I am excited to know that a healthcare educator may have found the software that will satisfy a niche in their classroom to further their students’ education, just how I use Infirmary regularly in a variety of courses that I teach.

To celebrate 4 years since the full release of version 1.0 (and 5 years since its first published pre-release version), I am ecstatic to announce that Infirmary has been used in 54 countries around the world! While I can’t identify how Infirmary is being used, for what, or by who, I am satisfied knowing that healthcare educators around the world have free access to tools that can enrich their classrooms and further their students’ knowledge, ultimately improving patient care and patient outcomes!

With that in mind, I look forward to expanding Infirmary’s usage, functionality, and strength as an educational tool. Together, we can advance healthcare education!


Ibi Keller, MSN, RN, CCRN, CEN

Map: Countries where Infirmary Integrated has been used are marked in green.
Countries where Infirmary Integrated has been used are marked in green.

ARM Hardware Support

To accommodate recently released hardware based on the ARM64 architecture, Infirmary Integrated is now packaged and published with installers and binaries to run on this architecture. Packages for newly supported hardware include support for:

  • Apple desktops and laptops with M1 or newer “Apple silicon” processors, including MacBook and Mac desktops built in 2020 or later
  • Microsoft Surface tablets or laptops with Qualcomm processors, including tablets with the SQ1 or newer chips built in 2020 or later
  • Linux devices running on ARM64 architecture (e.g. Raspberry Pi 4, although it may not meet the minimum necessary specifications to run Infirmary Integrated otherwise)

Installers and binaries can be found on the “Download & Install” page and on the GitHub repository’s list of Releases.

V 2.5: Defibrillator Enhancements, Stability

Available for download on the Downloads page.

This update is the culmination of many small enhancements and bugfixes implemented since version 2.4. While there is nothing newly groundbreaking, lots of fixes, implementations, and enhancements make version 2.5 a more realistic, stable, and effective simulator. Changes include:

Defibrillator Enhancements

  • Options to select maximum defibrillation energy and energy increments
    • Simulates Zoll (200 J) or LifePak (360 J)
    • Can increment at 10 J or 20 J such as to simulate institution preference/settings
  • Audio tones for “charging” and “charged” electricity states
    • Audio playback controlled by main window’s audio settings (on/off)
    • Audio options for defibrillator now include:
      • “Off”: device is muted
      • “Defibrillator”: only charging/charged tones will play
      • “Heart Rate/QRS” and “SpO2”: both charging/charged tones and QRS/SpO2 tones play
  • Color coded indicators for defibrillator state in Dark (colorful) color scheme
    • The “Defibrillator Settings” numeric entirely changes color based on defibrillator state
      • Charging: yellow; Charged: red
      • Analyzing rhythm: yellow-green
      • Pacing enabled: orange
      • All other discharged states return to light blue

General Enhancements

  • Numerous Avalonia UI (window manager) package updates merged into this build version
    • Includes numerous bugfixes for compatibility and functionality across supported operating systems
    • Should help with program speed and stability on all platforms

Minor releases since version 2.4.0 include:

  • Minor update 2.4.1: bugfixes
    • This update fixes several minor bugs
    • The biggest fix in this update is the ability to open an .ii simulation file by double-clicking on it from the desktop, launching the program directly into the simulation file.
  • Minor update 2.4.4: Signing Doses w/ MAR & Bugfixes
    • This update includes the ability to sign off doses of medications on the MAR and add comments
    • This update also includes the ability to edit comments and sign off via the Scenario Editor
    • This update fixes several additional bugs, including a functionality-breaking bug
      • On opening Infirmary with an update available, the program sometimes hangs or crashes- this fixes that problem
  • Minor update 2.4.5: QOL Improvements
    • This update fixes several quality-of-life issues improving Tracing responsiveness during vital sign changes
      • Including more responsive Tracings when loading files
    • ECG lead labels are now properly aligned to top-left for realism

V 2.4.5: Minor Update with Quality-of-Life Improvements

Available for download on the Downloads page.

This minor update fixes several “quality of life” issues that improve the performance and responsiveness of Infirmary Integrated in certain edge cases, especially when making on-the-fly simulations and presentations. Specifically, waveform tracings now respond more robustly to rate changes made to vital signs, including:

  • Vital sign rate changes now properly trigger responses in patient physiology and waveforms according to the “apply buffer” timer. This is most notable when simulating a heart rate < 20 bpm or a respiratory rate < 10. For example:
    • Before this fix: when simulating a profoundly bradycardic or bradypneic patient, changes to vital signs would take 1 cardiac or respiratory cycle (up to 60 seconds!) before reflected in waveform tracings.
    • After this fix: changes to vital signs will be reflected in waveform tracings in 5 seconds or less.
    • This does not include waveforms on the External Fetal Monitor (EFM) or Tocograph.
  • Loading a simulation file (.ii file) now starts waveform tracings immediately.
    • Before this fix: when loading a simulation file, it would take 1 cardiac or respiratory cycle to begin waveform tracings- this could be up to 60 seconds in a profoundly bradycardic or bradypneic patient!
  • 12-lead ECG tracings are now labeled in the top-left corner of their leads, simulating real-life 12-leads.

V 2.4.4: Functionality-Breaking Bug Fixed

This past week, a functionality-breaking bug was found and fixed in Infirmary Integrated. This bug does not pose any security risk. The bug occurred when a new update was made available for Infirmary and the program attempted to notify the user of the update- instead, the program experienced a “soft” crash and just stopped working. The bug only occurred if Infirmary detected a new update was available. Since the “update available” startup routine is rarely tested by the developers, this bug went unnoticed for some time and likely has been an annoyance.

The bug was partially fixed in v 2.4.3 by allowing Infirmary to finish loading and skipping the update notification.

The bug has been completely fixed in v 2.4.4 and the update notification has been fixed as well.

Updating to the latest version 2.4.4 will resolve this issue- along with giving you access to new features in the latest version of Infirmary!

V 2.4 Medication Administration Record (MAR)

Available for download on the Downloads page.

This is the first release bringing Infirmary Integrated into simulating the electronic health record (EMR). This release includes a moderately-featured electronic Medication Administration Record (MAR) that can display drugs ordered and doses to be given in a layout familiar to anybody that has used an electronic MAR. Doses are plotted on a time-grid and you can navigate forward and backwards in time to see future or past doses. This release also includes the ability to add patient demographic information, so patient identifiers are displayed on the MAR to allow students to complete all the rights of drug administration.

Major features with this release:

  • Add simulated patient demographics and drug orders in the Infirmary Integrated Scenario Editor
  • View and navigate the MAR in the Infirmary Integrated Simulator by loading a simulation file with the relevant data
  • In the Scenario Editor, each Step can have a different date/time set, so simulations can progress over time
  • Drug and dose data includes: drug, dose, units, route, frequency (prn, once, repeat), priority (routine, now, stat)
  • Administration and Indication fields can receive free-text: can enter hold parameters (“hold for SBP < 100”) or infusion instructions (“infuse over 60 minutes”)
  • Color coding: past-due doses (> 1 hour in the past per simulated time) are marked in red, scheduled doses marked in blue, prn doses marked in green
  • Automatic sorting of drug orders: scheduled doses present first, prn orders underneath, and all drugs are sorted alphabetically by name

Features that are not implemented, but are planned for future releases include:

  • Signing off drug doses after administering them
  • Marking past doses as being given or not given in the Scenario Editor

Minor update 2.4.1

  • This update fixes several minor bugs
  • The biggest fix in this update is the ability to open an .ii simulation file by double-clicking on it from the desktop, launching the program directly into the simulation file.

Minor update 2.4.4

  • This update includes the ability to sign off doses of medications on the MAR and add comments
    • This update also includes the ability to edit comments and sign off via the Scenario Editor
  • This update fixes several additional bugs, including a functionality-breaking bug
    • On opening Infirmary with an update available, the program sometimes hangs or crashes- this fixes that problem

A simulated MAR with sample (fake) patient identifiers for students to complete the rights of drug administration:

V 2.3 External Fetal Monitoring (Cardiotocography), Device Audio

Available for download on the Downloads page.

This release has been years in the making, with work beginning on the External Fetal Monitoring (EFM, cardiotocography) simulator in 2020, but then being placed on the backburner due to the pandemic and to make way for cross-platform porting… it’s finally complete and stable!

External Fetal Monitoring (EFM, Cardiotocography)

New features with the External Fetal Monitor include simulation of:

  • Fetal heart rate (FHR)
  • Fetal heart rate variability (baseline variability)
  • Uterine contractions via “toco”: set the frequency and the duration
  • Fetal heart rhythms (interval variability) including:
    • Baseline (minimal variability)
    • Accelerations
    • Early Decelerations
    • Late Decelerations
    • Variable Decelerations

All on the background of the standard cardiotocography strip! Just set the variables and let Infirmary’s patient modeling do the rest to create your simulation or educational materials (e.g. rhythm strips).

Additional features include:

  • Multiple “strip speeds” available on the EFM’s menu to fast-forward the simulation: 1:1, 1:10, 1:25 speeds are available.
  • Temporal smoothing implemented for obstetric rhythms: when you make changes to the “patient”, Infirmary smoothly transitions the changes into the future waveform drawings.

Device Audio (and Alarm improvements)

Improvements have also been made to the Cardiac Monitor, the Defibrillator, and the Intra-Aortic Balloon Pump simulators as well, mainly including audio enhancements!

  • Monitoring “beep” implemented for the Cardiac Monitor and the Defibrillator (sometimes called “anesthesia monitoring”)
    • Beeps a traditional tone on each heart beat, used to audibly keep track of heart rate and/or pulse oximetry in a busy environment
    • Can set to ECG mode: beeps on each QRS complex
    • Or can set to SpO2 mode: beeps on each SpO2 waveform and the tone changes depending on the SpO2 reading
    • Device alarms still sound in addition to the monitoring beep
  • Audio alarm for Intra-Aortic Balloon Pump’s augmentation alarm
    • A unique tone unmistakable among the cacophony of potential critical care alarms
  • Visual alarm improvement for Intra-Aortic Balloon Pump’s augmentation alarm


External Fetal Monitor (EFM) baseline tracing with moderate variability.
External Fetal Monitor (EFM) modeling early decelerations.
External Fetal Monitor (EFM) modeling accelerations.
Cardiac Monitor with options for audio monitoring via heart rate or pulse oximetry.

V 2.2.3 QRS/QT Morphology, Temporal Smoothing, Bugfixes

Available for download on the Downloads page.

In this minor release, a few subtle but important changes and fixes were implemented:

QRS/QT Morphology

  • QRS interval and QTc interval is now adjustable under “Cardiac Profile”
  • As you would expect, on all ECG tracings on all simulation devices, the QRS and ST segments are now drawn to those set intervals
  • Allows for advanced simulation of narrow or wide complex morphologies, or abnormally elongated or shortened QTc pathology

Temporal Smoothing

  • Changes made to vital signs, etc. (to the underlying digital patient model) are now applied synchronously with the cardiac and respiratory cycles
  • Changing cardiac vital signs or rhythms no longer creates artifact or “ectopic”-appearing beats on ECG waveforms
  • Changing respiratory vital signs or rhythms no longer creates artifact as well


Some minor bugfixes were made to the Simulator interface for improved user experience. A bugfix was made to the Scenario Editor that fixed a feature-breaking bug. Specific details are in commit notes and issues logs.

V 2.2 Alarms, Scenario Editor Cross-Platform Port

Available for download on the Downloads page.

Multiple major improvements in this release, starting off with both visual and audio alarms in the Cardiac Monitor simulator. Many healthcare personnel are already overly familiar with alarms, so this probably does not need explaining… but I will:

Alarms (Visual and Audio!)

  • Alarm limits able to be enabled, high/low values set, and alarm priority (low, moderate, high) are all adjustable in the Scenario Editor, as well as a default set of alarms (appropriate for adult patients) being enabled by default. Future plans exist for adjusting alarm limits in the simulator, as well as including default limits for other age groups, but this is not currently implemented.
  • Alarms are present for all hemodynamic parameters (vital signs and advanced hemodynamics)

When alarms are active and set, if a physiologic parameter falls outside of an enabled alarm limit:

  • The number visually flashes in the cardiac monitor. The numbers flash at different speeds based on priority- low priority is slow flashing, high priority is fast flashing.
  • An audio alarm is sounded, and the audio alarm is selected based on alarm priority. Low priority alarms have a slow low-frequency beep and longer intermediary pause, high priority alarms have more rapid high-frequency beeping with slower pause.

Note: Audio is played cross-platform using libraries provided by the LibVLC project, a subset of the VLC Media Player. These libraries are bundled into the Windows and MacOS versions of Infirmary Integrated, but require installation of VLC and its libraries on Linux platforms. If the LibVLC libraries are missing, Infirmary Integrated will simply run without audio.


  • Alarms (includes both visual and audio) can be enabled and disabled in the Cardiac Monitor simulator via a newly-created menu option.
  • Audio can be enabled or disabled in the main Infirmary Integrated simulator window via a newly-created menu option. This option will be used to silence all audio from all simulated devices, as audio is integrated into other devices in future versions.
  • All changes localized into supported languages

Scenario Editor

This release brings back the Infirmary Integrated Scenario Editor as a cross-platform standalone tool used for creating simulation files that can be saved, shared, and then loaded into Infirmary Integrated and run in a stepwise manner. Simulation files created with the Scenario Editor can have multiple “steps” each with their own simulated patient’s parameters and vital signs. Steps can “progress” in different ways, depending on which progression is selected in the scenario player (which is part of Infirmary Integrated’s simulator). An example case for using simulation files created with the Scenario Editor would be for an educator to simulate a patient in a stable state, progressing to a deteriorating state, then depending on a student’s actions or response, could progress to an improved state or a declined state of hemodynamic parameters- all simulated with Infirmary Integrated.

While the Scenario Editor existed before in older releases of Infirmary Integrated, the following new features are part of this major release:

  • Cross-platform functionality (runs on Windows, Linux, and MacOS) for both the Simulator and the Scenario Editor.
  • Installer packages for Windows, Linux, and MacOS now include the Scenario Editor
  • Improved major re-design of the Scenario Editor for ease of use and improved workflow
  • Miscellaneous minor quality-of-life improvements and small features added

Additionally, some of the new features in the Scenario Editor blend into the Simulator when loading simulation files, including:

  • The ability to choose which devices automatically open when loading a simulation file (e.g. cardiac monitor, 12 lead ECG, etc.)

Stability and Testing

There were also tons of behind-the-scenes improvements made to the entire program suite, including a large effort of modernizing the code that powers Infirmary Integrated. Many advancements in the C# programming language and the frameworks that Infirmary Integrated are built on are now utilized thoroughly. The language and frameworks have had significant changes over the last 5 years, improving overall performance and stability of Infirmary Integrated!

Lastly, immense amounts of testing went into this release, ensuring that all features work as intended! Although all computer programs have “bugs” in them, large amounts of testing went into this release to ensure that all major bugs are fixed and that Infirmary Integration is “production-ready”. This is the main reason why the project went from version 2.0 to 2.2: by the time version 2.1’s updates were tested as being stable, half of the updates for version 2.2 were already being added!


Some major bugfixes and issues resolved in this release are:

  • #139: Fixed atrial flutter drawing problems (out of phase synchronicity between A/V; A:V ratio)
  • Fixed pacemaker spikes from blocking atrial flutter and fibrillation on isoelectric line drawing
  • #143: Fixed “Reset Parameters” from unlinking patient model from device simulators (also disabled this button if auto-apply changes are enabled)
  • #140#137