CDRL A006 Training Manual User's Guide for STAT! TM EMEDS ICU Serious Medical Game Copyright 2014 Vcom3D, Inc. Release v1.0.0 - November 26, 2014 Sponsored by Air Force Research Laboratory (AFRL) Prepared For: Air Force Medical Modeling and Simulation Training (AFMMAST) Vcom3D, Inc. Point of Contact Edward M. Sims, PhD, CTO EdS@Vcom3D.com 12124 Corporate Blvd., Suite 250 Orlando, FL 32817 Tel.: 407-737-7309 SBIR DATA RIGHTS Contract No and Period of Performance FA8650-13-C-6350 26 Oct 2012-1 Dec 2014 Contractor Name and Address Vcom3D, Inc. 11474 Corporate Blvd Suite 140, Orlando, FL 32817 Expiration of Data Rights Period: 1 December 2019 The Government's rights to use, modify, reproduce, release, perform, display, or disclose technical data or computer software marked with this legend are restricted as provided in paragraph (b)(4) of DFARS 252-227-7018, Rights in Noncommercial Technical Data and Computer Software--Small Business Innovative Research (SBIR) Program. DISTRIBUTION STATEMENT B. Distribution authorized to U.S. Government agencies only, software documentation. Other requests for this document shall be referred to Air Force Research Lab, Air Force Medical Modeling and Simulation Training.
Purpose of This Guide The User's Guide provides information on how to play STAT! TM EMEDS ICU Serious Medical Game. It describes the background of the game and provides instructions for its use. Installation and start-up instructions are provided as part of the game s release notes. Background The life or death of a Warfighter wounded in combat often depends on the care he receives within the golden hour immediately following injury. Multiple casualty, multitrauma incidents require emergency medical teams, working within extreme time constraints, to make rapid and accurate decisions regarding medical assessments and procedures, and to prioritize their time and resources among the life-threatening conditions. Learning to perform effectively in such an environment requires considerable practice in making critical decisions Sooner Than Already There (STAT). However, there are few opportunities for trauma teams to practice these skills prior to deployment. Your Task You are the Critical Care Nurse working in the ICU of an EMEDS+10 facility located in Kandahar, Afghanistan. You are working with a Critical Care Physician. Although your CP Tech would ordinarily make changes to ventilator settings, in this hospital setting you will be required to make these adjustments, allowing you to become familiar with the equipment operation. The ICU has just received three trauma patients from the OR. You will be responsible for the care of these patients for the next three days. In this hospital, your physician will be available for rounds at noon every day. On day 1, you will receive the patient handoff from the OR. You will receive the physician s orders, assess each patient, verify medications and equipment settings, determine abnormal findings, report concerns to the physician, and perform interventions as appropriate within your scope. On days 2 and 3, you will assess and report changes to each patient s condition, and receive and implement new orders as appropriate. At the end of each day, you will receive feedback on your performance. A-2
User Interface Table 1 illustrates the primary features of the user interface. Table 1. Summary of Menus and Displays Radial Menus. Clicking on a patient brings up a sensitive radial menu of assessments and procedures that can be selected for the patient. Some of these buttons provide information; some are used to enter an action; and others bring up submenus to further refine your selection. You will be guided through these menus in the Orientation section of this guide. Patient Monitor. Clicking on the Propaq Patient Monitor in the 3D scene brings up a view of the front panel of the monitor. The monitor shows: Heart Rate (HR) Blood Pressure (ART): Systolic, Diastolic, and Mean Arterial Pressure (in parentheses) Central Venous Pressure (CVP) Mainstream Co2 (MCO2) Breath Rate (BR) Peripheral Oxygen Saturation (SpO2) Temperature (T2) in deg. Celsius Current Time If the monitor is alarming, you can turn this off by pressing Alarms- Suspend/Resume Bed / Patient Selector. Click this button to cycle through views of patients 1, 2, and 3. Alternatively, you can use the numbers 1, 2, and 3 on your keyboard to switch between patients. Doctor s Orders. Click here to receive orders from the Critical Care Physician. X-Ray. Click here to view X-rays for your current patient. Page-3
Labs. Click here to review labs for your current patient, including Chem8, CBC, Coagulation Factors, Blood Gases, and Lactate. Check Your Understanding. Click here to view a series of questions that check your understanding of a patient s condition, its diagnosis and treatment, and potential risks. Medication Administration Report (MAR). Click on the MAR button to see a record of medications that have been given, or are scheduled to be given to the patient. Review the MAR, along with the Physician s Orders, to determine what medications are due. As you provide medications to the patient, either as a bolus or via IV Pump, your initials ME will be added to the MAR, along with time information, showing that medications have been given. Ventilator. Click on the Impact 731 ventilator to both view and program the ventilator in accordance with protocol and/or doctor s orders. You should follow this order: BPM, Vt, PEEP, FiO2 when entering new settings. Click the button next to the value you wish to change, then click and drag on the knob at the lower center to adjust. Click the knob with the green to enter. If you enter an incorrect setting, click the button with the red X to cancel that setting. Click on the red X in the upper right of the vent to close. IV Pump. Click on the MedSystem III 3- channel IV Pump to set up and change IV infusions in accordance with doctor s orders. Labels to the left of the pump will provide information on the concentrations and volume of fluids and medications to be infused. Click on the doctor icon to review doctor s orders. F1 through F4 refer to the Soft Buttons on the IV Pump just below the display, in the order from F1 on the left to F4 on the right (annotated in the picture). The functions of these soft buttons vary, Page-4
depending on the current state of the IV Pump program. After starting the pump with the desired new settings, click Standard Display to see all three channels running. Note: If you do not click Standard Display after Start Stop, the information will not be saved and you will have to start over. Click on the red X in the upper right of the pump to close. Time, Date, and Level. A clock in the upper left corner of the screen indicates the current game time, as well as level of the game. You will interact with your patient starting at noon on each of three consecutive days. Your tasks on each day will require an average of 15 minutes to perform. A Pause button to the right of the clock will turn from green to yellow if you fail to meet any objectives in an appropriate and timely manner. Click on this button to view your status at any time in the game. As you complete your tasks for each day, you will click the Advance to next level button in the lower right corner of the screen. This will transport you forward in time to noon on the following day. Starting the Game The game file includes an executable file (.exe) and a data directory in the same directory on your computer. To start the program, double click on the executable. You should see a Configuration window (Figure 1) that allows you to select screen resolution and graphics quality. The screen resolution should always remain at 1024x768 windowed and graphics quality should be set at Beautiful. Then click Play!. Figure 1. Selecting Screen Resolution and Graphics Quality. Page-5
There is also a web-based version of the game available on the AFMMAST portal at the following link: https://usaf.deps.mil/usaf/afmmast/smg. This game version requires the Unity Plug-in to operate via the web. Once you have accessed the hyperlink, click on the Unity Player and Plugin link on the left side of the page to download and run the files on your local computer (detailed instructions on installation steps are included on the AFMMAST portal). Then, click on the SMG EMEDS ICU link on the left side of the page to load and begin playing the game. The web-based version of the game screen resolution is automatically configured and proceeds straight to Figure 2 after loading in the web browser. The next window, Figure 2, requires the student to enter their EDIPI CAC Number (numeric entry only). This will allow detailed tracking of each student's actions and performance for later capture if needed. Once the EDIPI CAC Number is entered press "Start Simulation" to begin the orientation phase of the game. Figure 2. Student Identification Window Orientation We recommend that you first take a trial run through the scenario to orient yourself to the environment and the features of the game. After opening the game: 1) You will see a brief introduction to the EMEDS ICU Serious Medical Game. After reading, click Done. 2) You will see the first patient in bed 1 of the ICU. To see other patients, you can either: a. Click the Bed 1 button at the center left of the screen to cycle between the three beds, or b. Press 1, 2, or 3 on the keyboard to see the corresponding patient. 3) Click on a patient to see the radial top-level patient menu. You will use this menu frequently to: a. Receive patient handoff from OR b. Assess the patient for sedation, wound care, NG tube status, urine output, chest and abdomen, and chest tube status c. Review Medication Administration Record (MAR) and administer medications d. Give bolus medications and fluids e. Transfuse blood Note that at any time you can close any radial menu or any equipment interface menu by clicking the Red X in the upper right of the screen. Page-6
4) Click on Receive Handoff to get a history of your patient in Situation Background Assessment Recommendation (SBAR) format. 5) Click Done to close the Handoff screen. 6) Click on the Doctor s Orders icon to see the orders for the patient you are viewing. You may need to review these orders as you assess each patient in order to determine how to adapt the orders based on the patients evolving conditions. As you perform the assessments and interventions below, click on the Pause button at any time to review objectives that you have completed. 7) Click on the Propaq Monitor to review the patient s vital statistics and compare these to the Doctor s Orders. 8) Click on the Lab button and review to determine any changes in treatment required per orders or protocol. 9) Click on the X-Ray button and review to determine any changes in treatment required per orders or protocol. 10) Click on the Patient, then Check Wounds and select from the options for wound care. Click X to close. 11) Click on Review MAR (Medication Administration Record) to review the log of medications that have been administered previously. 12) Click on Give Medications and select medications that are due. 13) Click on IV Pump and make programming changes as required per orders or protocol. 14) Click on Review MAR (Medication Administration Record) to confirm the new medications that have been given. 15) Click on NG Tube to assess. 16) Click on Urine Output to assess. 17) Click on Chest and Abdomen Assessment to assess. 18) Click on Check Chest Tube to assess, if applicable. 19) Click on Check ET Tube to assess. 20) Click on Give Fluid Bolus and select the fluid volume and type (if any) that has been ordered. 21) Click on Transfuse Blood Products and select the units and type (if any) that has been ordered. 22) Click on Ventilator and make any changes in settings required per orders or protocol. When you have completed your tasks as outlined above, you will have an opportunity to assess your understanding of the patient s condition and the interventions that were made. Click on the Check Your Understanding icon and answer the questions provided. Upon selecting the In-Game Pause Button, the After Action Review will present current key performance objectives for the game, as shown in Figure 3. If an objective has been met, a green check mark will appear to the left. If it has not been met, a red X will be displayed. By clicking on the Information button ( ), you will receive feedback on how to improve your perfomance. Page-7
Figure 3. After Action Review When you click on the Information Button, a pop-up screen, such as shown in Figure 4 will appear. Page-8
Figure 4. Missed Objective on AAR After you have studied the AAR, click on Continue to advance to the next level. Once you have completed your assessments and interventions for all three patients for all three days, the game will be completed. Close the application window to exit. SCORM Compliance The STAT! TM EMEDS ICU Serious Medical Game captures all actions students take as they progress through the game. In the Web-based version of the game, the ability exists to automatically capture the results in an AFMMAST designated Learning Management System through the SCORM Adapter. In the executable version, the results for each student are saved in the same file location as the game with the following naming convention: ICU_1_0_0_Data[CAC_NUMBER]@[DATE]@[TIME].txt Page-9