Infirmary Integrated

In addition to the ACLS Practice Case #1 simulation scenario for Infirmary Integrated that was posted last week, 4 new scenarios for Infirmary Integrated simulating ACLS Practice Megacodes are available for download.

Advanced Cardiac Life Support (ACLS) Megacode Practice Case 49 by the American Heart Association (Instructor Manual, page 159). Anoxic event due to airway obstruction, scenario starts with patient being given rescue breaths via bag valve mask in symptomatic tachycardia, proceeds to cardiac arrest with multiple rhythms, results in return of spontaneous circulation.

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Advanced Cardiac Life Support (ACLS) Megacode Practice Case 50 by the American Heart Association (Instructor Manual, page 161). Severe myocardiac infarct presenting with symptomatic tachycardia, progressing into cardiac arrest with multiple rhythms, results in return of spontaneous circulation.

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Advanced Cardiac Life Support (ACLS) Megacode Practice Case 51 by the American Heart Association (Instructor Manual, page 163). Inferior myocardiac infarct presenting with symptomatic bradycardia with an ECG notable for ST changes in inferior leads, progressing into cardiac arrest with multiple rhythms, results in return of spontaneous circulation.

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Advanced Cardiac Life Support (ACLS) Megacode Practice Case 52/55 by the American Heart Association (Instructor Manual, page 165). Symptomatic bradycardia with an ECG notable for ST changes in III and aVF, progressing into cardiac arrest with multiple rhythms, results in return of spontaneous circulation.

Available for download now at the Downloads page.

This release really expands Infirmary Integrated’s functionality as a simulator with the ability to play scenarios. Scenarios are patient simulations that can progress and change as you go step by step through the scenario. For example, a scenario could have a patient progress from being mildly unstable to drastically critical, or can progress from a lethal cardiac rhythm to stable rhythm if the proper intervention is chosen.

Creating scenarios is also simple with the new Scenario Editor that is included with Infirmary Integrated. Using the Scenario Editor, you can create scenarios using the visual designer that acts like a flowchart. It is simple to create steps for the scenario, plugging in what you want the patient’s parameters to be, and then add progressions from one step to the other, including optional progressions that can change the course of the scenario.

The possibilities are limitless with Infirmary Integrated and its included Scenario Editor. For example, scenarios could be easily created and played to simulate teaching points for critical care classes, and could be used as adjunct teaching aids for the American Heart Associations’s (AHA) courses including Advanced Cardiovascular Life Support (ACLS) and Pediatric Advanced Life Support (PALS).

Additionally, freely available scenarios will be available for download at Infirmary Integrated’s website, located at https://www.infirmary-integrated.com/simulations/ and some are posted below.

Available for download now at Downloads page.

This release includes new features related to simulating pulmonary arterial (PA) catheters (also known as Swan-Ganz catheters). Now you can select where the PA catheter is, simulating insertion, placement, and wedging as the catheter travels through the superior vena cava, the right atrium, the right ventricle, through the pulmonic valve into the pulmonary artery, and lastly wedging against the pulmonary capillary bed. In Infirmary Integrated’s patient editor, if you select a PA catheter position and click “apply”, the PA catheter waveform and transduced PA pressures will update in the Monitor display.

Infirmary Integrated’s goal is to help students and clinicians advance their knowledge and practice of critical care concepts, and so this feature may be found useful for education and simulation in intensive care units and cardiac catheterization labs.

Major changes since last release (v 1.0):

• Implemented pulmonary artery placement options, to simulate insertion
  • Placement options available under “Advanced Hemodynamics”
  • Added right ventricle and pulmonary capillary wedge waveforms
• Miscellaneous bugfixes:
  • “Newer version available” message was triggering improperly
  • All Patient parameters now being saved and loaded properly

Available for download now at Downloads page.

Major changes since last release (v 0.99.03):

• Implemented the following respiratory rhythms:
  • Agonal
  • Apneustic
  • Ataxic
  • Biot
  • Cheyne-Stokes
• Implemented the following cardiac rhythms:
  • Sick Sinus Syndrome
  • Sinus Arrhythmia (non-pathologic)
  • Sinus Rhythm with Sinus Arrest
• Numerics (ECG/SpO2/RR/ETCO) measure HR/RR as average of recent beats/breaths
  • Accurately reflects HR for sick sinus, sinus arrhythmia, etc.
  • Lag time realistic (ECG: average of 8 seconds, RR: 16 seconds)
• Implemented timer for realistic delay on defibrillator charging and IABP priming
• Updated IABP user interface: dynamic text colors on display for enhanced status indication
• Source code: Improved comments for some II_Core class files
• Localization updated
• Security improvement: MD5 hashing algorithm replaced with SHA-2

Available for download now!

Continuing in beta testing and bug fixing while implementing new features.

Major implementations since last release (v0.97):

• All personal data (usage statistics and statistics for patient mirroring) uploaded to server are anonymous, hashed with MD5
• Cardiac axis deviation implemented: modeled normal, left physiologic, left pathologic, right, extreme, and indeterminate.
• Pulsus paradoxus modeled and displays on waveforms and arterial blood pressure reading
• Pulsus alternans modeled and displays on waveforms
• Realism adjustments and dampening to waveforms based on intrathoracic pressure (respiratory rhythm, ventilation status)
• Vital sign clamping for respiratory rhythms separate from cardiac rhythm vital sign clamping
• Waveform variation implemented (for realism)
• Localization strings all updated (for all 15 languages)

Beta testing bug fixes:

• Fixed multiple Strip drawing bugs/issues including
  • Flatline delay on rhythm change
  • Forward (future) Strip buffer length to fix brady waveforms disappearing/failing to complete polygon
  • Remedied delayed changes of future Strip drawing (by dynamically changing forward Strip buffer according to updates on HR/RR)
• Fixed multiple issues with pacemaker including
  • Pacemaker spikes spamming Strip when rate turned to 0 (“divide by 0” bug)
  • Pacemaker no longer turns on when switching modes (timer was reset/restarted bug)
• Miscellaneous bug fixes and improvements:
  • Resetting switches/counters for cardiac aberrancy that were remaining on during rhythm changes
  • Numerics update at dynamic times based on every 2nd beat and breath
  • Drawing of pacer spikes fixed as actual spikes (not ramps)
  • Code styling for solution saved/tracked; CodeMaid cleaning up code.
  • Mirror accession key TextBox filtered for alphanumeric input (making it safe for SQL queries)
  • Mirror password TextBoxes changed to PasswordBox for password masking

Available for download!

Version 0.97 includes the ability to mirror (broadcast) the simulated patient’s parameters utilizing a “server and client” method. For example, an instructor (the host), can create a simulated patient on one computer, and set up multiple computers (or students logging in remotely) to mirror the broadcast data in real-time!

Continuing on the security features added in previous releases, portions of data transmitted over the Internet are encrypted and, specifically, passwords are not transmitted or stored in raw form; Infirmary uses industry standard the MD5 hashing algorithm for passwords.

And to use Infirmary without broadcasting, simply select “Inactive” (which is the default mode anyway!).

Available for download now!

File formatting for save files (.ii) are now utilizing encryption (previously just utilized obfuscation). This allows for safe transmission across the Internet (for future planned features) and cannot easily be read into by text editors.

Note: save files created with previous versions of Infirmary cannot be opened by version 0.96 onward. Contact me if you need any files converted to this new file format!

Available for download!

Major changes since last release (v0.93):

• Defibrillator functionality: defibrillation, cardioversion, and transcutaneous pacemaker implemented
  • Can defibrillate and cardiovert with regular sequence (select function, change energy, charge, shock)
  • Transcutaneous pacemaker functional: select energy and rate, will pace if it meets patient’s capture threshold
    • Patient’s capture threshold adjustable in Patient Editor
• Realism updates
  • Waveform modeling (e.g. CVP) with both atrial and ventricular components now draw both portions dependent on rhythm
• Localization strings updated.
• Server functionality implemented:
  • Automatically checks for updates to Infirmary, notifies if update available
  • Basic data collection for usage statistics (Infirmary version, date/time, username, IP address, MAC address)
  • Exceptions (handled program crashes) updated to server for debugging purposes
• Debugged implementation of:
  • Save()/Load() functionality, all pertinent data passed through and processed
  • Error handling and exception handling strengthened

Next steps before release: beta testing and minor interface updates/debugging.

Major features introduced in v0.93:

• Intracranial pressure waveform and reading added
  • Increased ICP (range 15 – 25) progressively decreases compliance on waveform.
  • Cerebral perfusion pressure (calculated from arterial MAP) displayed on numeric reading
• Intra-abdominal pressure waveform and reading added
  • Adjusts for intrathoracic pressure on waveform amplitude

Realism and interface updates and debugging:

• Issues in waveform propagation and timing fixed (issues #20, #16, #15, #14)
• Waveform amplitude adjustable on DeviceMonitor via context menu
• Miscellaneous debugging and logic fixes (issues #17, #18)

Infirmary Integrated has the functionality to save and load simulation files. If you create a patient profile that you want to save for future simulations, simply save the file from the main menu. The .ii simulation file can be easily loaded and recreate the entire simulation.

Simulations can now be found on the Simulations page!