Advanced Patient Simulator connected to a real IABP device. Video http://www.youtube.com/watch?v=xuWGMGtr8KU http://www.youtube.com/watch?v=mSP_yWZUi4A

1. Advanced Patient Simulator connected to an Intra-Aortic
Balloon Pump device
Ing. Juri Bendini
Laerdal Italia Srl
Via Gobetti 52/2, int.Z, 40129 Bologna, Italy
juri.bendini@laerdal.no
________________________________________________________________
ABSTRACT
Aim
Aim of this project has been letting a Laerdal SimMan to interact with a real IABP device, as
Arrow AutoCAT2 Series, creating an interaction between an advanced patient simulator and a
real intra-aortic balloon pump (IABP) device, for training purposes. People in the simulation room
must have the same feedback about their manoeuvres done on the simulated patient from both
the real IABP device monitor and SimMan simulated patient monitor.
Good results have been achieved using an Arrow software for remote assistance and clinical
support consultation, together with a custom made software, called SimIABP, developed only for
this specific project.
Results and conclusion
The results are consistent to the specification requested. Simulated Patient Monitor is the right
copy of IABP device monitor about both ECG and ABP waveforms. Catheter insertion simulation
has not been considered as part of this project.
Using a really small system made by only one custom device and only one custom made
software, it has been possible to replicate all the vital signs waveforms on the simulated patient
monitor. The entire system is managed by only one computer, but you have to use an advanced
video system (e.g. Laerdal AVS), for achieving a good quality debriefing as well.
________________________________________________________________
INTRODUCTION
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2. A growing number of people are using simulation for recreating their daily medical experiences
for training purposes, so they would like to use the same medical devices they use daily.
As a matter of fact, doing simulations today means having to interact with a number of real
medical devices as well. Unfortunately there’s still a technical gap between what you can simulate
with an advanced patient simulator, as Laerdal SimMan, and what you can’t. You’ve to define
some limits to your own simulations, because it’s not always possible to simulate everything.
With this scientific paper I want to report the ideas I had and I developed for overcoming such
limits, especially one: the possibility to use a patient simulator together with a real IABP device.
The use of a real IABP device with a patient simulator isn’t something really new. Some people
are starting to study a way for letting patient simulators to interact with real IABP devices, while
others are asking on the web for possible solutions about such issue. There’s the need to allow a
patient simulator to interact with an IABP device, but in general, it’s a really difficult process,
1
because patient simulators and IABP devices are different systems with different purposes .
There’s actually no interaction between these two genders of system, so you have to develop
something really new, starting from scratch: you have to fill out a gap.
________________________________________________________________
TABLE OF CONTENTS
Advanced Patient Simulator connected to an Intra-Aortic Balloon Pump device ...........................1
ABSTRACT ........................................................................................................................1
INTRODUCTION ................................................................................................................1
SETUP ...............................................................................................................................3
THEORY.............................................................................................................................3
MODEL...............................................................................................................................3
METHOD ............................................................................................................................6
RESULTS ...........................................................................................................................8
ACKNOWLEDGEMENTS ...................................................................................................8
REFERENCES ...................................................................................................................8
________________________________________________________________
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3. SETUP MODEL
For the development of this project I used: System description: Laerdal SimMan Advanced
• one Arrow AutoCAT2 Series IABP device Patient Simulator
(more details about it are available here: Laerdal SimMan is an advanced patient
http://www.arrowintl.com/products/IABP/); simulator. The simulator is composed by a robot
• one Arrow International Intra-Aortic Balloon directly connected to a PC. Somebody calls
Pump Interactive Patient Simulator Model SimMan manikin or dummy, but inside a SimMan
2001; there’s so much electronics I prefer to call it
• one Arrow Modem Connection Software for robot. Through the computer, Instructors can set
Your PC Software; all the patient vital signs according to the
• one Laerdal SimMan advanced patient simulation status. All the vital signs are
simulator (more details about it are available synchronized together for achieving a high quality
here: www.laerdal.com/simman/ ); of realism during the simulation.
• one DELL Latitude E6400 laptop, for For having a better idea about how SimMan
managing both SimMan patient simulator system works, next there’s a simple scheme of it:
and IABP device;
SimMan manikin Computer
At the end of the development phase, it has been
developed and made:
• one telephone line simulator, for directly
Simulated
connecting the Arrow AutoCAT2 Series IABP Patient Monitor
device to the laptop;
• one custom made software, called SimIABP, Figure 1 SimMan system
based on Microsoft WinCuts concept;
• one SimMan Handler, for automatically In particular, using the SimMan GUI (Graphical
replicating Arrow Simulator vital signs on User Interface), you can set a number of ECG
SimMan software during simulation waveforms which can be really detected by real
sessions. monitor/defibrillators connected on the manikin
chest through ECG cables or defibrillation pads.
The other vital signs, as ABP, CVP, SpO2 and so
on, are all synchronized together with the ECG,
THEORY
so increasing the heart rate means, for example,
The aim of this project was to let a Laerdal having a lower period between two systolic peaks
SimMan to be used for training purposes on a in the ABP waveform. Those vital signs can be
real IABP device. For that reason, it has been viewed on the SimMan Simulated Patient
used a system which involved two subsystems: a Monitor, so every time all the people involved in
Laerdal SimMan and an Arrow AutoCAT2 Series the simulation session can have a complete
IABP device. In the next paragraph you’ll get a overview of the patient status.
more detailed description of both subsystems
used in simulation.
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4. System description: Arrow AutoCAT2 Series
IABP device
Arrow AutoCAT2 Arrow Intra-Aortic
Arrow AutoCAT 2 Series IABP device is a real Series Balloon Pump
Interactive Patient
IABP device, used for treating real patients. For Simulator
training purposes, it can be connected to the
Arrow Intra-Aortic Balloon Pump Interactive
Patient Simulator for receiving simulated ECG
Arrow AutoCAT2 Series PC
and ABP waveforms as input. In that way, the modem software
IABP device works exactly as a real patient were
connected to it.
Using again a scheme for explaining the Figure 3 IABP device used with remote
connection between the IABP device and the support software
patient simulator, I can explain it using something
The need of having the same waveforms on a
like that:
PC, for increasing the simulation realism, leaded
me to study the communication between this
Arrow AutoCAT2 Arrow Intra-Aortic software and the IABP device. As it’s mentioned
Series Balloon Pump
Interactive Patient in its name, that software is connected to the
Simulator
IABP device via modem and it uses a telephone
line as a mean of communication. Another
Figure 2 IABP device used for training possibility is to connect your computer directly to
purposes
the IABP device, using a hardware modem. This
Using the Arrow Patient Simulator it’s possible to possibility has been already foreseen by Arrow
view ECG and ABP waveforms on the IABP Programmers, so it’s included in that well done
device screen and learning how to use the IABP software, but nowadays hardware modem are
device. really rare, so for establishing a direct connection
Arrow developed even an interesting software for between the IBAP device and a computer you’ve
clinical support and remote assistance. This to simulate a telephone line. That’s the reason
software is AutoCAT 2 Series PC Modem why I developed a telephone line simulator, in
Software and it allows you to remote monitoring other words, a device which simulates the
the activity on the IABP device. Including such telephone line behavior.
software inside the previous scheme, it will Using that telephone line simulator I was able to
change in that way: directly connect the PC and the IABP device, so
the previous scheme now is complete, definitive
and most of all, working:
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5. 1. SimMan software can not be changed, so it’s
not possible to show an ABP waveform
Arrow AutoCAT2 Arrow Intra-Aortic
Series Balloon Pump modified by the counterpulsator device.
Interactive Patient
Simulator SimMan SW has its own library of ABP
waveforms and they are synchronized with
the ECG, so it’s not possible to change the
Arrow AutoCAT2 shape. The first problem was to change the
Telephone Line Series PC modem
Simulator software shape of the ABP waveform due to IABP
device activity.
2. The connection between the counterpulsator
Figure 4 Previous scheme with telephone line device and a computer. The idea was to be
simulator able to gather the waveforms showed by the
counterpulsator while it’s connected to a
The problem signals simulator, and forward them to a
Laerdal SimMan Patient Simulator and Arrow laptop for letting those devices to
AutoCAT 2 Series IABP device are two communicate each other. Then, the same
independent systems. It means they’ve been waveforms must be shown on the simulated
designed and developed with different purposes, patient monitor as well, for increasing the
so nobody felt the need to develop before a way simulation realism and having the same
for letting them to interact each other. I’ve already waveforms both on the IABP device screen
written how each of the two systems work, so and on the simulated patient monitor.
now you’ve an idea of them and in particular you 3. The request of simulating the catheter with
know they’re each a complete system. In other balloon insertion. Fortunately the procedure
words, they’re fully independent: no need of for inserting it can be learned in a different
interactions or connections with other devices. manner and it’s usually done by Surgeons,
SimMan has been developed only for training so during simulation there was no need of
and education purposes. It can be used with real simulating such procedure as well. In other
airways management devices, real ECG monitors words, I didn’t receive any strict specification
and real defibrillators: in other words, those about the simulation of such insertion
typical devices you use during emergency cases. procedure. The only specification was to
AutoCAT 2 Series is an IABP device and unlike have a real feedback from the interaction
SimMan, it’s a real medical device and it can be between the emergency team, working with
used with its own simulator for training Doctors in IABP device, and the patient simulator. In
particular, everything done using the IABP
the use of such device.
device had to have the same feedback both
This project was born because there was the
on the IABP device monitor and on the
need to allow those systems to interact each
simulated patient monitor (especially
other, for training a team of Doctors and Nurses
counterpulsated ABP waveform).
in the use of an IABP device.
During the development of such project, I’ve
encountered the next three main issues:
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6. METHOD works, I was able to replicate a real telephone
line making a “telephone line simulator”. Thanks
Because it’s not possible to change the SimMan to this simulator, laptop internal modem and IABP
software, I needed to find a different way for device internal modem started to communicate
overcoming such obstacle. each other. In particular I was able to use the
Studying more in details the technical information direct connection feature available in the Arrow
about the counterpulsator device, I noticed it’s software, which allowed me to view all the IABP
possible to connect your computer to the device monitor waveforms on my laptop screen
counterpulsator using a modem. Arrow as well.
developed a software by which you can connect Using the telephone line simulator I augmented
your computer to the IABP device for giving the number of devices needed for a simulation
remote support and clinical consultation. The with an IABP device, but such device is
most important thing is you can also connect to it absolutely necessary for creating a bridge
directly, without the need of a telephone line in between two systems which otherwise will never
between. communicate each other: I mean the SimMan
This information is really interesting, because in and IABP device.
such way it’s possible to view the same Once you have all on your laptop, then you can
waveforms on a Client PC and then forward them do whatever you want, because everything can
to the SimMan Patient Monitor. This is what I be managed in a easier way than when it’s
decided to do. available only on separate devices.
I started to study how the connection between an
external modem and the IABP device internal Software
modem works. The connection has been thought As I mentioned previously, Laerdal SimMan GUI
as it worked along a telephone line. So even if doesn’t include a counterpulsated ABP waveform
you connect your laptop to the IABP device among its available vital signs. For letting the
directly, you always need a mean for let those people in the simulation room to view a
two modems to behave as there was a telephone counterpulsated ABP on the simulated patient
line in between. These aim can been achieved monitor I’ve developed a custom software only
using an external hardware modem, but for this purpose. Once you’ve established a
unfortunately nowadays such modems are hard connection between your laptop and the IABP
to find and rarely available. For example, in all device, through the telephone simulator, all the
the laptops available on the market only software waveforms and parameters available on the IABP
modems are available (they’re also called device screen are available on the Arrow Modem
“WinModem”, because the OS uses the laptop Connection Software as well, which is running on
hardware as a real modem for communications). your laptop. So after having a copy of IABP
A software modem is not able to interact with the device monitor on my laptop screen, I put in
IABP internal modem because in that way both action an approach already thought by Microsoft:
2
modems don’t realize there’s something like a I used WinCuts . WinCuts is a way for allowing
telephone line in between. computer users to replicate arbitrary regions of
For solving such problem I needed to develop a existing windows into independent windows
solution which simulates a telephone line. called WinCuts. Each WinCut is a live view of a
Reading documents about how a telephone line region of the source window.
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7. Unfortunately Microsoft didn’t allow other people IABP device, and such feedback is immediately
to use such approach for their own activities, so I forwarded on the patient monitor.
needed to develop a software from scratch. For reducing the work done by Instructor, most of
It took a while for me for replicating such the vital signs available on the Arrow Simulator
approach, but at the end I developed the has been replicated in a SimMan Handler.
software I needed. I called that software SimMan Handlers are a sort of software
SimIABP, and you can see it in action in the next procedures you can call every time a special
picture. event occurs. A SimMan Handler is perfect for
reducing the workload for Instructors, because it
allows them to simply press a button on the
screen every time you’ve selected a different
rhythm on the Arrow Simmulator, instead of
opening the entire list of available waveforms and
selecting the right one according to the same
choice done on the other simulator.
Figure 5 SimMan GUI, Arrow Modem
Connection software and SimIABP
As you can see from the picture above, there are
the SimMan GUI, on the left side of the latop
screen, and the Arrow Modem Connection
Software on the top right of the screen.
Underneath the Arrow Modem Connection
software the SimIABP is running: it has already
selected the region of the Modem Connection
Software and it is replicating it on the SimMan
Figure 6 A picture of the control room: on the
GUI. Such reproduction, as you can see from the left side, a copy of the modified simulated
buttons available in the software, can be moved patient monitor with the counterpulsated ABP
waveform; on the upper right side the
on the Patient Monitor allowing the people in the telephone line simulator
simulation room to see exactly the same ECG
and ABP waveforms available on the IABP Another issue encountered during this
device screen. development was about the debriefing session.
The SimIABP GUI allow the Instructor to decide Using the previously described solution means
exactly when modifying the Patient Monitor for recording two different ABP waveforms, one from
letting the people in the simulation room to see the IABP device and another one from the
the right waveforms. So Instructor, using only one SimMan software. For that reason I used the
laptop, can manage the SimMan according to Laerdal Advanced Video System (AVS) with one
what is happening on the IABP device. Arrow camera input out of four directly connected to a
Modem Connection Software is used at the same VGA-to-RCA converter. In that way I was able to
time as a feedback about what is going on the forward the modified Patient Monitor in all the
other rooms where people was watching the
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8. simulation session in real time, and recording great support given during the development
videos from the other three cameras according to and his constant helpfulness.
the modified Patient Monitor. Next a simple • Ing. Alessandro Moriggi, Clinical Support
scheme which describes such easy solution: Specialist Cardiac Care, Teleflex Medical
Milan, for his helpfulness.
SimMan manikin Computer
• Prof. Riccardo Pini and Dr. Paolo Valoti,
Firenze University Florence, for having
tested the entire system and used it during a
Simulated Video splitter
Patient Monitor simulation session at Florence Heart 2009
Congress, September 2009, Florence.
AVS VGA-to-RCA
converter
REFERENCES
Figure 7 SimMan system with the AVS
included [1] High Fidelity Scenario’s: A Technical
Report to the Use of an Aortic Balloon
RESULTS Pump, Dylan Campher and Daniel Host,
Queensland Health Skills Development
This project has been tested during a simulation
Centre. SimTecT 2008 Health.
session at Florence Heart 2009 Congress in
[2] WinCuts: manipulating arbitrary window
Florence, on September 2009. During such
regions for more effective use of screen
congress it was possible to understand there was
space Desney S. Tan, Brian Meyers and
really no need to continue in the use of Arrow
Mary Czerwinski, Microsoft Research,
IABP Interactive Patient Simulator, because all
Redmond, WA
the needed vital signs have been previously
recorded in a library of files, available on Arrow
Modem Connection software, and used during a
simulation session. In that way you can reduce
the number of the necessary devices for creating
an IABP scenario for SimMan. Only in case of
special scenarios you can use such simulator as
well.
Another important achieved result is the entire
system can be managed by only one person,
from the Instructor PC, because everything is
available there.
ACKNOWLEDGEMENTS
• Mr. Luigi Grisoni, Clinical Support Specialist
Cardiac Care, Teleflex Medical Milan, for the
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