Human Patient Simulator

Research »
Teaching »
IT Services »
Emergency Plan »

Human Patient Simulator Teaching/Research Lab

Human Patient Simulator Program

Overview:

Led by Dr. Samsun Lampotang, members of the UF Human Patient Simulator (HPS) research team from the Dept. of Anesthesiology including Drs. Michael Good (Chief of Staff, Gainesville VAMC), Dietrich Gravenstein, Joachim Gravenstein, Nikolaus Gravenstein (Chair, Dept. of Anesthesiology) and Mr. James Thoman presented a detailed overview of the history, present capabilities and future prospects of this amazing technology. Special attention was given to a description of the new brain model additions to the HPS. This presentation was followed by a tour of some of their current facilities and a demonstration with the HPS. It should be noted that although the responsibility for and leadership of this program clearly resides in the Dept. of Anesthesiology, close collaborations with faculty in the College of Engineering and industry are also essential.

The initial development of the HPS began in 1986 and by 1994 the technology had been licensed to industry (this transfer was completed in 1997). In 1996, partly through fiscal support provided by the MBI-UF, the HPS team began work on developing a brain model for the HPS. To date there are 70 of these simulators found world-wide, 47 of which are using UF technology. The UF-developed HPS is now commercially available from Medical Education Technologies, Inc. (METI), Sarasota, FL. (http://www.meti.com./). Over the past 12 years numerous publications, presentations, patents, copyrights and awards have resulted from this multidisciplinary collaborative effort. Beginning next Fall, on the first floor of the new MBI-UF building there will be a major laboratory, offices for associated faculty and staff and a demonstration classroom devoted to the further development and educational uses of the HPS. In addition, the HPS is also expected to be one of the primary computer-assisted simulation technologies to utilize the MBI-UF’s new Multidisciplinary Simulation and Computer Laboratory (MSCL). (For a description of this teaching facility see the Minutes from the February 13, 1998 meeting of the IFAB at www.ufbi.ufl.edu/IFABMinutes.html.)

Description of the HPS:

The HPS is an innovative training system that has detailed models of respiratory, cardiovascular, and pharmacokinetic systems. It can quickly be configured using point and click menus to replicate any type and severity of illness in adultmale or female patients that might be found in the “field”, emergency department, operating room, or intensive care unit. The HPS consists of a lifelike patient mannequin, which breathes spontaneously, has palpable pulses, heart and lung sounds, and responds appropriately to stimuli such as electrical current from a neuromuscular blockade monitor. The mannequin can be intubated and connected to life-support systems, such as mechanical ventilators or intravenous cardiac inotrope infusion pumps. A hybrid (mechanical and mathematical) lung model allows the patient mannequin to consume oxygen and produce carbon dioxide. The HPS automatically recognizes and responds to intravenously injected medications and to inhaled anesthetic gases according to known pharmacokinetic and pharmacodynamic principles. To help simulate the consequences of intracranial mass effects and to allow realistic training in CPR, a basic intracranial pressure module and an advanced cardiac life support module have been added in the last year. Current work in progress includes: a model of intracranial pressure which incorporates autoregulation, an electro-neurophysiology module that will enable simulation of EEGs and evoked potentials, an electrical model of the heart that will generate the ECG, a pediatric patient simulator, a physiological monitor emulator, and enhanced drug and fluid quantification. In the past two years, an open architecture was implemented on the HPS to encourage third parties to develop models (e.g., a renal model) that work seamlessly with the HPS, via an application programmer's interface.

A complete array of electronic monitoring instruments (including electrocardiograph, non-invasive oscillometric blood pressure monitor, invasive arterial, pulmonary, and central venous blood pressure monitor, pulse oximeter, capnograph, spirometer, anesthetic gas analyzer, neuromuscular blockade monitor and intracranial pressure monitor) are provided with appropriate electrical and pneumatic signals as if they were connected to a real patient. Microcomputers and a custom built data acquisition and control system allow realistic clinical scenarios to be presented to the trainee (such as pneumothorax, cardiac tamponade, acute respiratory arrest, airway management difficulties, and cardiac dysfunction). The trainee is challenged to diagnose clinical and equipment problems and must correct them “hands-on” in an interactive fashion as is done in actual clinical practice. More than l00 clinical and equipment related problems are now programmed into the simulation system with more being generated by the various sites around the world, tailored to the specific regional or national practice standards.

In addition to these educational objectives, work is also in progress to utilize the HPS to expedite the pre-FDA testing, approval, and when necessary redesign of new types of medical equipment.

Applicability to MBI-UF, DoD and VA targeted educational objectives:

Surgeons, anesthesiologists, nursing personnel, pharmacists, respiratory therapists, and many other health care professionals in both hospital-based and far-forward military medical situations must work in harmony to care for patients with head, neck, and spinal cord injuries. In current education and training programs, however, each group of practitioners train individually in their own departments and colleges (e.g., Depts. of Neurological Surgery and Anesthesiology, College of Nursing, etc.). Yet, with an acutely injured soldier or civilian patient, all of these groups must work in harmony to provide optimal care. However, if one spends merely a few weeks observing clinical care, it will be apparent that the realization of this harmony has not been achieved. To rectify this situation, the MBI-UF and the HPS team have proposed that the use of simulators such as the HPS and other training devices can help in the sub-specialty training of not only the individual disciplines, but also of the entire medical care team (including those affiliated with the DoD and VA). Thus, by programming head injury, neck injury, and spinal cord injuries into the HPS, physicians, nurses and other health care providers can learn and repeatedly practice both cognitive (differential diagnosis) and psychomotor (insertion of central lines or intra-ventricular pressure monitoring systems) in an environment which is free of risk to any patient. Clearly this represents an excellent example of the MBI-UF’s “bench-to-bedside” philosophy for research, development, and training activities.

Example possible curriculum:

One of the main goals of the HPS team is to work with various UF departments and colleges to develop customized curricula tailored to address specific management concerns of any given user. For the DoD the Navy might wish to teach decompression while the Army might prefer a chemical injury course. To provide a more graphic description of how this might work, one envisions a curriculum which would include clinical problems similar to the following:

A motor vehicle accident victim presents with clinical signs of increased intracranial pressure, associated cardiovascular abnormalities, such as a slow pulse rate, hypertension and ST changes on the electrocardiogram, inadequate spontaneous respiration, and facial trauma with associated airway bleeding. Anesthesia, emergency, and critical care physicians would learn the different approaches and techniques for securing the airway (awake vs. asleep endotracheal intubation, use of the fiber optic bronchoscope, cricothyrotomy, etc.), establishing adequate intravenous access as well as intra-vascular catheters (arterial, pulmonary artery, central venous) for blood pressure monitoring, and the use of vasoactive medications to counteract the cardiovascular changes. An advanced patient simulator could be developed to provide appropriate clinical signs enabling neurosurgeons to practice neurologic assessment (pupillary and other eye signs, reflexes, response to painful stimuli, etc.). Respiratory therapists would need to initiate and monitor appropriate levels of ventilation in a patient with increased intracranial pressure.

Similar clinical training scenarios could be developed for nearly any clinical problem typically encountered in the care of neurotrauma patients. Again, the approach begins by establishing the educational objectives. Skills which are usually taught in the clinical environment on real patients are ideal candidates for programming in the HPS.

Current methods of clinical education and training programs suffer because they rely on the clinical environment, which is uncontrollable and unpredictable. Safety of the patient always takes precedence over learning. Lectures, though highly structured, are passive forms of learning, and research in education clearly shows that active, hands-on, problem based education results in greater learning and greater retention of learning. The education and training program proposed for the MBI-UF makes use of advanced educational technologies, specifically, the HPS and associated training devices to help health care professionals understand and learn to operate complex medical instruments confidently and safely and to perform complex medical procedures. The resulting curriculum would be problem based, yet completely free of any risk to patients.

Selected References:

Beneken JEW, van Oostrom JH: Tutorial: Modeling in Anesthesia. J Clin Monit, 1998, 14:57-67.

Euliano TY, Caton D, van Meurs WL, Good ML: Modeling Obstetric Cardiovascular Physiology on a Full-Scale Patient Simulator. J Clin Monit, 1997, 13:293-297.

Euliano TY, Mahla ME, Banner MJ: Clinically Relevant Discovery Recognized During Simulator Training Session: Free-Standing Peep Valve Solves Problem of Incompetent Exhalation Unidirectional Valve in an Anesthesia Circle Breathing System. J Clin Monit Comp, 1998. In Press.

Lampotang S, Good ML, Heijnen PMAM, Pane B, Safa A, Carovano R, Gravenstein JS: TWITCHER: A Device to Simulate Thumb Twitch Response to Ulnar Nerve Stimulation. J Clin Monit Comp, 1998, 14:135-140.

Lampotang S, Good ML, Westhorpe R, Carovano RG: Logistics of Conducting a Large Number of Individual Sessions with a Full-Scale Patient Simulator at a Scientific Meeting. J Clin Monit, 1997, 13:399-407.

Lampotang S, Gravenstein JS, Euliano TY, van Meurs WL, Good ML, Westhorpe R: Influence of Pulse Oximetry and Capnography on Time to Detection of Critical Incidents in Anesthesia: A Pilot Study Using a Full-Scale Patient Simulator. J Clin Monit Comp. In press

Lampotang S, Ohrn MAK, van Meurs WL: A Simulator-Based Respiratory Physiology Workshop. Academic Medicine, May 1996, 71 (5).

OEhrn MAK, van Oostrom JH, van Meurs WL: A Comparison of Traditional Textbook and Interactive Computer-Based Learning of Neuromuscular Block. Anesth Analg, 1997, 84:657-61.

Thoman WJ, Lampotang S, Gravenstein D, van der Aa J: A Computer Model of Intracranial Dynamics Integrated to a Full-Scale Patient Simulator. Computers and Biomedical Research, 1998, 31:32-46.

van Meurs WL, Euliano TY: Model Driven Simulators from the Clinical Instructor's Perspective: Current Status and Evolving Concepts. Simulators in Anesthesiology Education, editors: Henson L, Lee A, Basford A. New York: Plenum, 1997. In Press.

van Meurs WL, Good ML, Lampotang S: Functional Anatomy of Full-Scale Patient Simulators. J Clin Monit, 1997, 13:317-324.

van Meurs WL, Nikkelen E, Good, ML: Pharmacokinetic-Pharmacodynamic Model for Educational Simulations. IEEE Trans Bio Med Eng 1998, 45:582-590