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Medical training simulator including contact-less sensors
A medical training simulator includes contact-less sensors and corresponding detection objects, configured to enable sensor data collected during a training exercise to be used to evaluate the performance of the training exercise. The simulator includes a simulated anatomical structure, at least one contact-less sensor, and at least one detection object. During a training exercise, a spatial relationship between the contact-less sensor and the detection object produces data for evaluating performance of the training exercise. Either the contact-less sensor or the detection object is embedded in the simulated physiological structure, while the other is included in either a support for the simulated physiological structure, or as part of a tool used during the training exercise. Many types of contact-less sensors can be employed, including capacitance sensors, impedance sensors, inductive sensors, and magnetic sensors.
This application is a continuation-in-part of a copending patent application, Ser. No. 10/718,492, filed on Nov. 20, 2003, which itself is a continuation-in-part of a copending patent application Ser. No. 09/695,380, filed on Oct. 23, 2000, the benefit of the filing dates of which is hereby claimed under 35 U.S.C. § 120.
The present invention generally pertains to medical simulators for use as medical training aids, and more specifically, to medical simulators that include contact-less sensors and corresponding detection objects, which facilitate the evaluation of a student's performance during a training exercise implemented with the medical simulator.
The use of simulated physiological structures for training medical students and for providing skill training to practicing physicians is widespread. Although cadavers have traditionally been beneficially employed for this purpose, cadavers are not always readily available and are not well suited for all types of training.
Simulated physiological structures should preferably be usable multiple times and should provide a realistic training experience corresponding to what the trainee would experience if performing a procedure on an actual patient. The need for such simulators is significant, because they can provide valuable training that will lead to more effective treatment of patients.
The use of a training model (such as a cadaver, an animal, or a simulator) is desirable to properly prepare a student or physician to perform procedures on a variety of patients. While anatomy follows general rules, variations based on sex, age, height, and weight are the norm. A surgical student should not just blindly follow directions such as "make an incision four inches long and two inches deep, starting at the navel." Normal variations, such as the amount of body fat on a specific patient, will significantly change the depth of fat tissue that must be incised to reach an internal organ. Surgeons must rely on their knowledge of general anatomy, and evident cues (e.g., visually noting whether the patient has a low or high percentage of body fat, or whether the patient is a child, an adult, a female, etc.) to determine the correct location and other variable parameters, before performing a procedure on a specific patient. The use of cadavers, animal models, and anatomically correct simulators enable surgical students and physicians to apply their knowledge of anatomy to develop experience in assessing these factors, so as to properly determine the proper parameters to be applied when executing a procedure on a live patient.
To provide the desired level of realism, a simulated physiological structure used for training medical personnel should both tactilely and visually resemble the anatomical structure being simulated. Even if a simulated physiological structure having simulated tissue faithfully portrays finer details of an actual physiological structure and provides a realistic tactile sensation during a simulated procedure, the few prior art simulators that may both tactilely and visually resemble the anatomical structure being simulated do not include means for producing objective and measurable results that can be used to evaluate how well a simulated procedure is performed. Clearly, it would be desirable to employ a simulated physiological structure that is able to provide a realistic tactile sensation during a simulated procedure, and which is also able to provide an objective indication that can be used to evaluate how well a simulated procedure was executed.
In the present invention, contact-less sensors and corresponding detection objects are used to enhance the performance of medical training systems. By using contact-less sensors and corresponding detection objects, each contact-less sensor and detection object can be incorporated into components of the medical training system in a way that hides the sensors and detection objects from view. This approach not only enhances a realistic appearance of the components of the medical training system, it also reduces a likelihood that any trainee will be able to infer a particular significance for any portion of a component of the medical training system by recognizing that a sensor or a detection object is disposed in a particular portion of the medical training system. Many different types of contact-less sensors can be employed, such as magnetic sensors, capacitance-based sensors, and inductive-based sensors.
In one embodiment, a medical model is configured to be used in connection with a simulated or actual medical instrument. At least one sensor is incorporated into either the simulated instrument or the medical model. At least one detection object is incorporated into the other of the simulated instrument or the medical model. Each sensor is logically coupled to a processor, which is preferably implemented with a personal computing device. The processor can be incorporated into the medical model or can be a stand alone unit. The detection objects are matched to the type of sensor employed. For example, if the sensor is a reed switch or a Hall effect device, then the detection object will be a magnet.
Embodiments in which the detection object is incorporated into the medical model enable less-expensive medical models to be produced, because detection objects are generally less expensive than their corresponding sensors. A single sensor integrated into a simulated instrument can detect a plurality of different detection objects distributed throughout a medical model. Furthermore, if the sensors are included in the simulated medical instrument rather than incorporated into the medical model, the medical model should not require wiring (which would complicate the manufacturing process of the medical model) to logically couple each sensor to the processor.
The location at which sensors or detection objects are incorporated into simulated instruments and medical models is largely a function of a particular exercise that will be performed using a specific simulated instrument and a specific medical model. For example, if a particular training exercise requires that a student identify a plurality of discrete different features associated with the medical model, then a detection object (or sensor) can be disposed adjacent to each feature that must be identified, such that the detection object (or sensor) is hidden from view. During the training exercise, when the student properly positions the simulated instrument adjacent to a feature to be identified, a sensor (or detection object) incorporated into the simulated instrument (for example at a distal end of the simulated instrument) is triggered, indicating that the student has correctly identified a particular feature.
In another embodiment, at least one detection object is incorporated into a disposable simulated physiological structure, such as a simulated tissue. The detection object is incorporated into a portion of the simulated tissue that must be dissected in a training exercise. Before the exercise, the simulated tissue is placed adjacent to a sensor bed, such that the sensor is triggered by the detection object in the simulated tissue structure. When the student successfully dissects the portion of the simulated tissue structure incorporating the detection object, the sensor is no longer triggered by the detection object, and the processor can provide feedback indicating that the student has successfully completed the exercise. Such a sensor bed can be beneficially incorporated into a box trainer. Further, it should be understood that the sensor bed can be used with the simulated tissue, and without a box trainer, if so desired. Additional detection objects can be incorporated into the simulated tissue, with additional sensors being incorporated into the sensor bed to facilitate proper positioning of the simulated tissue relative to the sensor bed.
The sensor data collected during a training exercise can be used to immediately provide feedback to a student during the training exercise, or can be stored for later review, or the sensor data can be manipulated to provide feedback only to a proctor monitoring the training exercise, so that the proctor knows whether the student has successfully completed the training exercise. Sensor data (or feedback generated by the processor after receiving the sensor data) can be communicated to remote locations over a network, so that the proctor and student do not need to be in the second location. Thus, the present invention is well-suited for remote learning environments.
The foregoing aspects and many of the attendant advantages of this invention will become more readily appreciated as the same becomes better understood by reference to the following detailed description, when taken in conjunction with the accompanying drawings, wherein:
Overview of the Present Invention
In the present invention, one or more sensors are incorporated into a medical training model that can be used for teaching and/or testing. Such sensors can be employed to provide feedback indicating how well a simulated procedure was performed using the medical training model. Each medical model preferably includes one or more simulated physiological structures. Preferably, much of the model, and in particular the simulated physiological structures, are formed out of elastomeric materials to enhance a realism of the medical training model.
The sensors used in the present invention do not require physical contact between the sensor and an object that is to be detected and are therefore referred to as "contact-less sensors." In the context of the present invention, the object to be detected is generally a tool used during a simulated medical procedure (although in some embodiments, a sensor is incorporated into such a tool, to detect objects incorporated into the model). Generally, the detection object or tool will be either an actual medical instrument, or a simulated medical instrument. Syringes, needles, scalpels, forceps, endoscopes, and laparoscopes are but a few of the tools that might be employed in a simulated medical procedure. Employing sensors that can detect a tool without requiring that there be actual physical contact between the tool and the sensor enables the sensors to be hidden from view. Hidden sensors are preferable for at least two reasons. First, hidden sensors enable a more realistic medical training model to be achieved (because a simulated physiological structure with clearly visible sensors would not look realistic); and second, if such sensors were visible to a student, the student might be able to identify a target location corresponding to a simulated medical procedure simply by noticing the sensors disposed adjacent to the target location.
The term "simulated medical procedure" is intended to encompass training activities corresponding to actual medical procedures (e.g., an endoscopic examination of the upper gastrointestinal tract), as well as training activities involving the use of the medical model, which do not correspond to any particular medical procedure. The term contact-less sensor is intended to encompass all sensors that are capable of detecting the proximity of a detection object (such as the tool described above) without requiring that there be physical contact between the sensor and the detection object.
Regardless of the sensor technology used, preferably, the sensor is positioned sufficiently close to a portion of the medical model involved in a specific simulated medical procedure, so that when a student correctly uses the tool to perform the simulated medical procedure, the sensor will detect the presence of the tool.
Many different types of contact-less sensors are available. The following types of contact-less sensors are intended to be exemplary, rather than limiting on the scope of this invention. Magnetic sensors (including, but not limited to, reed switches), Hall effect sensors, impedance-based sensors (including but not limited to the use of ultra-wide band impedance sensors), capacitance-based sensors, and giant magneto-resistive sensors can be employed for practicing the present invention. Combinations of infrared (IR) emitters and receivers can also be utilized. Factors relevant to the selection of a particular sensor include cost, range, sensitivity, and the preferred material of the tool or detection object to be detected.
Contact-less sensors can be separated into two broad categories, including analog sensors and digital sensors. Analog sensors provide a signal where, for example, the amplitude of the signal varies based on a distance between the sensor and the detection object. Digital sensors, like the reed switch noted above, function like on/off or binary switches. Selection of an analog sensor or a digital sensor is based in part on how the sensor data are to be evaluated. For example, if a precise 3-dimensional positioning determination is desired, a plurality of analog sensors will be preferred (to enable positioning data to be determined using triangulation).
Certain sensor technologies require the use of a tool having a property that can be detected by the sensor. For example, some contact-less sensor technologies rely on the sensor detecting a target object using magnetic properties (such as reed switches). Reed switches are digital sensors that are triggered by the presence of a magnetic field of sufficient strength. In embodiments that employ a reed switch as a contact-less sensor, the tool used to perform the simulated medical procedure (or the detection object placed in proximity of the sensor during the procedure) must include a magnet capable of triggering the reed switch. If the simulated medical procedure requires the use of an actual or a simulated endoscope, a portion of such a tool can be formed from a magnetic material, or a magnet having a magnetic field sufficiently strong to trigger the reed switch can be incorporated into the tool. The strength of the magnetic field required to trigger the reed switch will be a function of the sensitivity of the reed switch, as well as the distance between the reed switch and the tool as it is employed in a simulated medical procedure. If, in a particular medical model, magnets cannot be used, then reed switches will be inappropriate and some other sensor technology must instead be used. Hall effect sensors detect the presence or the interruption of a magnetic field by producing either a digital signal or an analog output proportional to the magnetic field strength.
Capacitance-based sensors measure a change in capacitance, and that change is a function of a distance between a capacitor element and an object (comprising another capacitance element) affecting the baseline charge of the capacitor. Thus, capacitance-based sensors can be used as analog sensors, although they are also often available as digital (on/off) sensors. For example, as a simulated instrument is brought closer to a capacitance sensor, the baseline capacitance of the sensor increases. Capacitance sensors can therefore be used to determine the relative proximity between the sensor and an object and are thus useful in enabling a medical training model to provide feedback about the proximity (and the degree of proximity) of an object relative to the sensor. To achieve a realistic model, such sensors will preferably be encapsulated or covered with a realistic elastomeric based simulated tissue, to enhance the training experience. Capacitive sensors can respond to all types of materials, and thus, can be used with tools that are non-magnetic and non-metallic. The higher the dielectric constant of the target material, the greater the sensing range of the capacitive sensor.
Non-conductive detection objects can be used with impedance sensors. Both capacitance and impedance sensors can measure perturbations in spatially resolved, fringing electric fields. These fields are generated by applying a voltage across precisely patterned metal electrodes. As the sensor is brought near the detection object (or vice-versa), the electric field is altered. This small perturbation is measured as a change in capacitance or impedance by the sensor. In the case of a capacitance sensor, the sensor capacitance is decreased as it approaches a grounded detection object due to the effective shorting of some of its electric field lines. In the case of an impedance sensor, penetration of the detection object by the sensor's electric fields enables a precise response to the object's dielectric properties.
Inductive sensors are solid state sensors having three main components, including an oscillator, a triggering circuit, and a switching amplifier. The oscillator generates a high-frequency electromagnetic field in the sensor's target area. When a metal (preferably a ferrous metal) target enters the target area, eddy currents created in the target by the oscillator increase the load on the oscillator. When used as a digital sensor, at a specific load, the trigger circuit senses the reduction in oscillation and signals the switching amplifier to change the state of the sensor (e.g., "on" versus "off"). Inductive sensors can also be configured as analog sensors, whose signal output varies based on the distance between the metal target and the sensor. Inductive sensors detect metallic materials, and thus cannot be used with tools that are substantially non metallic.
While the use of sensors at plurality of different locations in a medical model is preferred (enabling more data points to be obtained, and facilitating more complex evaluations to be achieved), a single sensor disposed proximate to a particularly critical location might be beneficially employed. As noted above, a single sensor can be incorporated into the tool to be utilized, and detection objects can be incorporated into the medical model, which is useful where the sensors are more expensive than the detection objects. This approach enables a simpler medical model to be achieved (only the sensor incorporated into the tool needs to be logically coupled to a processor, as opposed to a plurality of sensors distributed throughout a medical model that must be coupled to a processor).
Sensors (or detection objects capable of triggering a sensor integrated into a tool) that are incorporated into medical models and simulated physiological structures can be used in a variety of different ways. Three significant uses include collection of data, which are stored for later use, collection of data to be processed to provide a contemporaneous feedback (such as a visual or an audible indication that a procedure has been performed correctly or incorrectly), which is provided to a trainee, a proctor, or both, and collection of data that are analyzed and may be used to trigger a simulated physiological response in the model or in the simulated physiological structure (e.g., a change in a simulated heartbeat, a simulated muscular response, a change in a simulated respiratory rate, etc.—all of which can be effected by controlling a servo or pump). In a relatively simple implementation, the sensor signal is used to provide a simple feedback, such as turning lights on or off, and/or the activation of aural, verbal, or textual prompts or cues. More complex sensor metrics involve determining a position of a simulated medical instrument (such as a needle, a catheter, an endoscope, or other tool) during each phase of a simulated procedure. The sensor data can be manipulated and analyzed by a logical processing device, such as a computer. Using a computer enables sensor data to be immediately processed and displayed, immediately processed but stored for later use, stored for later processing, compared to similar data, electronically distributed to other users in a network, or any combination thereof.
Instead of providing immediate feedback to a user, the feedback can be hidden from the user, and instead made available to an instructor. Based upon the feedback thus provided, the instructor may "grade" the performance of the student. Such an application will be particularly useful in skill assessments of medical personnel in training or for proficiency certification.
Such sensors may not only be disposed at a target location at which a simulated medical procedure is to be performed, but they also can be disposed at other portions of the medical model. For example, consider a simulated medical procedure in which a student is required to locate a stomach tumor within a medical model (configured as a manikin) that includes a mouth, a throat, an esophagus and a stomach. The simulated medical procedure requires the student to introduce endoscopic instruments into the stomach via the mouth. Sensors disposed proximate to the simulated stomach tumor will detect when a student has positioned a tool (such as a simulated or actual endoscope used to locate the stomach tumor) proximate the simulated stomach tumor, indicating that the student has correctly identified the stomach tumor. Other sensors can be disposed in other portions of the stomach to detect that the student has not properly positioned the tool adjacent to the stomach tumor. A sensor disposed at the entrance of the mouth will detect when the student introduces the tool into the model, as well as detecting when the tool is withdrawn from the model (providing an elapsed time for the entire simulated procedure). Sensors disposed adjacent to the beginning and end of the esophagus can be used to determine the time required by the student to advance the tool through the esophagus. Sensors disposed throughout the stomach at locations other than at the stomach tumor can be used to determine the number of other sites in the stomach that the student examined before identifying the tumor.
The following describes several preferred surgical simulators (i.e., medical models) incorporating contact-less sensors. It should be understood, however, that many other different medical models can benefit from the incorporation of contact-less sensors, and the following embodiments are intended to be exemplary, rather than limiting of the scope of the invention.
Medical model 10 includes a simulated esophagus 12 and a simulated stomach 14. Preferably, these simulated anatomical structures are formed at least in part from elastomeric materials, such that a realistic training model is achieved. Portions of the training model not being utilized in training exercises need not be anatomically correct or realistic in appearance. Esophagus 12 includes simulated abnormal tissue 16 and an esophageal stricture 18, although it should be understood that other medical conditions can also be readily simulated.
Abnormal tissue and esophageal stricture are commonly associated with gastroesophageal reflux disease (GERD), a very common disorder. GERD occurs when the sphincter muscle at the bottom of the esophagus (not shown in
A second type of tissue damage associated with GERD is an esophageal stricture. The lower esophagus can open to the size of a quarter or wider. When recurrent inflammation occurs in the esophagus, scarring develops, underlying tissues becomes fibrous, and the opening narrows. In advanced cases, this narrowing, or stricture, can be severe. The opening may be reduced to the size of a pencil or even smaller. The processing of food and liquids are delayed, and they only move slowly across the opening into the stomach. A large piece of food, such as a bite of meat, may completely block the esophagus. Thus, stricture 18 is also associated with GERD.
Medical instruments may be inserted into the esophagus to perform diagnosis or treatment related to GERD. The medical instrument can provide images to the physician, since the tissue associated with Barrett's esophagus is readily identifiable. The medical instrument may also be used to obtain a biopsy of abnormal tissue in the esophagus, to determine if any of the abnormal tissue is cancerous. Medical instruments inserted in the esophagus can be used to dilate a stricture. One dilation technique involves positioning a deflated balloon within the stricture, and then inflating the balloon to dilate the opening. Simulated tool 26 can thus be configured to simulate an endoscope, a tissue sampler, a dilator, or other medical instrument. If desired, stricture 18 can be formed using a fluid-filled bladder, so that the dilation forces fluid out of the bladder into a reservoir, enabling the stricture to be reduced in size. Fluid can then be forced from the reservoir back into the bladder, increasing the size of the stricture so that the dilation procedure can be simulated repetitively. The dilation procedure is similar to balloon angioplasty, and the same principles can be employed to simulate balloon angioplasty in an appropriately configured simulated physiological structure. Medical model 10 can be used to train students in locating and identifying strictures and abnormal tissue associated with GERD. Sensors disposed proximate stricture 18 and abnormal tissue 16 can be used to determine if a student has positioned an imaging tool immediately adjacent to such structures. Where stricture 18 is implemented as a fluid filled balloon, a contact-less sensor can be employed to determine if the structure is properly dilated, as discussed in detail below, in connection with
As noted above, medical model 10 includes a simulated stomach tumor 20. A contact-less sensor disposed proximate stomach tumor 20 can be used to determine if a student has positioned an imaging tool immediately adjacent to stomach tumor 20. Furthermore, a contact-less sensor can be used to determine if such a structure is properly removed, as discussed in detail below, in connection with
Medical model 10 further includes a plurality of contact-less sensors 22a-22h. Sensors 22a-e are disposed at regular intervals along esophagus 18. Sensor 22f is disposed adjacent to abnormal tissue 16. Sensor 22g is disposed at the junction of esophagus 12 and stomach 14. Sensor 22h is disposed adjacent a stomach tumor 20. Each contact-less sensor is coupled to a processor 24 (as indicated by connector A), which can be a separate component or integrated into medical model 10. A separate processor will reduce the cost and complexity of medical model 10. Ubiquitous personal computers can be used to implement the functions of processor 24, or a dedicated processor can instead be employed. The processor can be coupled with a display so that a trainee can receive feedback during a simulated procedure (as shown in
A distal end of simulated tool 26 includes a detection target 28, specifically selected to trigger the contact-less sensors selected. In one embodiment, detection target 28 is a magnet, and each contact-less sensor is either a Hall Effect sensor, a reed switch, or other magnetic sensor. As those of ordinary skill in the art will recognize, reed switches and many Hall Effect sensors are digital sensors. Digital sensors can be employed to evaluate a trainee's performance in the following manner.
In a hypothetical training exercise involving medical model 10, a student is required to introduce tool 26 into esophagus 12. The student is informed that medical model 10 includes an abnormality in one or more of the esophagus and stomach. The evaluation of the student's performance includes determining whether the student correctly positions the tool at a location relevant to one or more abnormalities, and the length of time it took the student to advance the tool through the esophagus and into the stomach. Detection target 28 is disposed on the distal end of tool 26. Sensor 22a is disposed at the beginning of esophagus 12. When tool 26 is introduced into the esophagus, detection target 28 will trigger sensor 22a. A signal is sent from sensor 22a to processor 24, enabling processor 24 to obtain a timing reference point corresponding to the point in time at which the student introduced tool 26 into the esophagus. As detection target 28 passes by sensors 22b, 22c, 22d, and 22e additional timing reference points are sent from the sensors to processor 24.
Sensor 22g is disposed at the juncture between esophagus 12 and stomach 14. As detection target 28 moves past sensor 22h, a signal is sent to processor 24, providing a timing reference point corresponding to the point in time at which the student has successfully advanced tool 26 through esophagus 12 into stomach 14. Thus, a potential metric with which the student's performance can be evaluated is the length of time it took the student to successfully advance tool 26 through esophagus into stomach 14 compared with the length of time required by a skilled practitioner to complete the same action.
Sensor 22f is disposed immediately adjacent to abnormal tissue 16. Preferably, sensor 22f is calibrated such that if tool 26 is not disposed immediately adjacent to abnormal tissue 16, but rather passes through esophagus 12 closer to sensor 22g than sensor 22f, sensor 22f will not be triggered. If sensor 22g is triggered and sensor 22f is not triggered, it can be concluded that the student failed to locate abnormal tissue 16. Alternatively, the student can be instructed that if any abnormal tissue or a tumor is located, the student should hold the tool immediately adjacent to the abnormal tissue or the tumor for a period of at least 30 seconds. Processor 24 can then be configured to evaluate the signal from sensor 22f (or sensor 22h) to determine if the sensor remains triggered for at least 30 seconds. If the sensor is triggered for less than 30 seconds, it will be concluded that the student passed the tool by the abnormal tissue or tumor, but failed to recognize the abnormal tissue or tumor. Failure to recognize an abnormal tissue or tumor will lower the student's score, and if desired, may indicate that the student failed the training exercise.
In the training exercise described above, sensors 22b-22e, while each providing a timing reference point providing data relating to the position of the tool within esophagus 12 at various times, are not specifically required to determine the length of time required by the student to advance the tool through the esophagus into the stomach (sensor 22a, disposed at the beginning of the esophagus, and sensors 22f and 22g, disposed at the end of the esophagus, are sufficient for that purpose) and could be eliminated if it is desired to reduce the cost and complexity of medical model 10.
As noted above, where stricture 18 is implemented as a fluid filled balloon, a contact-less sensor can be used to determine if the structure is properly dilated. A portion 30 of
Referring once again to the hypothetical training exercise discussed above in connection with
Medical model 10a of
The relative strengths of the magnets need to be selected based on the geometry of the medical model. For example, the magnetic fields produced by magnets 40a, 40b and 40c preferably should be capable of triggering their corresponding sensors when tool 26a is advanced into the esophagus sufficiently to pass by one of the magnets, even if the tool is disposed near a portion of the wall of the esophagus that is opposite the portion of the wall behind which the magnets are disposed. If desired, ring shaped magnets encircling the esophagus can be employed, or a plurality of individual magnets encircling the esophagus can be employed, to ensure the magnetic field is distributed throughout the esophagus adjacent to the magnets/detection objects, so that the tool cannot pass by a detection object without triggering the corresponding reed switch on the tool.
Processor 24 is therefore enabled to utilize the signals received from sensors 38a and 38b to determine where tool 26a is disposed within medical model 10a. For example, when processor 24 receives one signal from sensor 38a, and no sensor signal from sensor 38b, processor 24 is able to determine that tool 26a has just passed (or is disposed adjacent to) magnet 40a. When processor 24 receives two signals from sensor 38a and one signal from sensor 38b in close proximity to each other, processor 24 is able to determine that tool 26a has just passed by magnets 40b and 40c. When processor 24 receives one signal from sensor 38a and one signal from sensor 38b simultaneously, processor 24 is able to determine that tool 26a has just passed by (or is disposed adjacent to) magnet 40d.
Those of ordinary skill in the art will recognize that many different combinations of magnet strengths and magnet positions can be used to enable signals from sensors disposed on tools to be used to determine the portion of a medical model which the tool has just passed, or adjacent to which the tool is currently disposed. Thus, medical model 10a is intended to be exemplary, rather than limiting of the scope of this invention.
The detection objects used in medical model 10a require the use of a tool having more than one sensor, to be able to detect the different detection objects.
It should also be understood that medical model 10b and tool 26b can be implemented using different types of sensors and detection objects. For example, detection objects 44a through 44c can be implemented using passive (i.e. short range) radiofrequency identification (RFID) tags, and sensor 42 can be implemented using an RFID tag reader. Those of ordinary skill in the art will recognize that RFID tags can be uniquely identified, and require no power (since all of the power required by the RFID tag is obtained from the RFID tag reader, when the RFID tag reader interrogates the RFID tag).
Alternatively, detection objects 44a-44c can be implemented using bar codes (or other optically distinguishable markers), which may be visible or non-visible to a user, and sensor 42 can be implemented with a single optical sensor capable of optically distinguishing different bar codes (or other forms of optical markings). Preferably, detection objects (and sensors) incorporated into medical models in accord with the present invention will be unobtrusive, such that their presence will not be apparent to the student. Invisible bar codes (i.e., bar codes made with infrared reflective ink) have been developed, and can be used without their presence being apparent to the student.
Digital and analog sensors have been discussed above. The reed switches used for the sensors in medical model 10a (
In yet another embodiment, detection objects 44a-44c can be implemented using magnets having different magnetic field strengths, while sensor 42 is implemented as an analog Hall Effect sensor (or other analog magnetic sensor) that is capable of detecting the relative intensities of the field produced by the magnets. In still another embodiment, detection objects 44a-44c can be implemented using materials having different dielectric constants, such that the detection objects can be individually discriminated using an analog capacitance sensor (for sensor 42). For example, metal oxides have relatively high dielectric constants and can be readily discriminated from plastic and elastomeric materials that are used to construct medical model 10b. Not only will such metal oxides be readily discernible from the balance of the medical model, but the use of different metal oxides to implement each different detection object should enable sensor 42 to discriminate between different detection objects. In particular, strontium titanate and titanium dioxide have relatively high dielectric constants and should be usable in this invention.
Each of the embodiments discussed above in conjunction with
Turning now to
By monitoring the magnitude of the electrical currents flowing in the evaluation circuits, the evaluation circuits can be used to determine the position of the distal end of tool 26d. As a result, medical model 10d can be used to provide feedback about several different simulated esophageal procedures. In a simulated diagnostic procedure, feedback can be provided when, or if, the trainee properly positions an endoscope adjacent to simulated abnormal tissue 16. In a simulated biopsy, feedback can be provided when, or if, the trainee properly positions a tissue sampler to obtain a sample of simulated abnormal tissue 16, as opposed to normal esophageal tissue. In a simulated dilation procedure, feedback can be provided to determine if the trainee has properly positioned the dilator to expand stricture 18a. As noted above, other sensors can be used to determine if a fluid filled stricture has been properly dilated.
While all of the medical models illustrated in the preceding Figures and discussed in detail above have generally corresponded to a torso and related internal body cavities of a human, it should be understood that the present invention is not limited to application only in such medical models, but can also be implemented in many other different types of medical models, simulating many different type of anatomical structures.
Sensor 56a is disposed adjacent to a skin layer of simulated knee 52, to determine if a person doing the procedure has selected the proper position for insertion of tool 54. As illustrated, sensor 56a is a ring shaped sensor, which is triggered when tool 54 is inserted generally into the center of the annulus defined by ring sensor 56a. While not specifically shown, it should be understood that each sensor in
As shown in
Simulated tissue structure 66 includes features 68, 70, and 72; and detection objects 74, 76, and 78. As discussed in detail above, the detection objects are selected based on the type of sensor included in sensor bed 64. In one embodiment, sensors 80, 82 and 84 in sensor bed 64 are implemented using magnetic sensors; such as reed switches or Hall Effect sensors. Detection objects 74, 76 and 78 can then be implemented using magnets of appropriate magnetic field strengths, such that when simulated tissue structure 66 is positioned properly relative to sensor bed 64, sensors 80, 82, and 84 are triggered. It should be understood that the magnetic sensors and magnets noted above are not the only types of detection objects and sensors that can be implemented in exercise objects and sensor pads. Other types of detection objects and sensors generally consistent with those discussed above can also be employed.
For sensor bed 64 and simulated tissue structure 66 to function properly, simulated tissue structure 66 needs to be accurately positioned relative to sensor bed 64. Several techniques can be used to enable such accurate positioning. In one embodiment, sensor bed 64 is visually distinguishable from the rest of base 62. For example, if simulated tissue structure is 3 inches square, an appropriate sensor bed would also be about 3 inches square. Sensor bed 64 can be formed from a different color plastic than the rest of base 62, so that a trainee can readily identify on what portion of base 62 the simulated tissue structure needs to be positioned. Furthermore, one or more of the sensors in sensor bed 64 can be configured to detect a corresponding detection object in simulated tissue structure 66, such that when the simulated tissue structure is properly positioned relative to sensor bed 64, an audible or visual feedback is provided to the trainee to indicate that the simulated tissue structure is properly positioned. For example, detection objects 74 and 76 are disposed at opposed edges of simulated tissue structure 66. Sensor bed 64 includes a sensor 80 and a sensor 84. When simulated tissue structure 66 is properly positioned, sensor 80 is triggered by detection object 74, and sensor 84 is triggered by detection object 76. If digital sensors are employed, some degree of misalignment may still result in the feedback being provided to the trainee that the simulated tissue structure is properly positioned. If analog sensors are implemented, more quantitative feedback can be provided to the trainee, until the simulated tissue structure is more precisely positioned (e.g., the more accurately positioned the simulated tissue structure is, the greater will be the magnitude of the signals provided by sensors 80 and 84).
Simulated tissue structure 66 is useful in the following exercise. The trainee is provided box trainer 60 and simulated tissue structure 66, as shown in
Note that the box trainer and exercise object described above together define a medical model that includes both detection objects and contact-less sensors. The other medical models described above include an esophagus and stomach (i.e., medical models 10, 10a, 10b, 10c, 10d, and 10e) and each required the use of a specific tool, where either a sensor or detection object was incorporated into the tool (or the tool itself was the detection object). The endoscopic tools discussed above in connection with the box trainer of
In a block 88, a medical training system including contact-less sensors and corresponding detection objects is provided. In an optional block 90, an instructor (or qualified practitioner, such as a surgeon or other medical doctor) performs a baseline procedure using the medical training system. In an optional block 92, sensor data obtained when such a skilled practitioner or instructor successfully completes a simulated medical procedure/training exercise are stored. Such sensor data can be used as a baseline for comparison to sensor data collected from an identical simulated procedure/training exercise performed by a student and used to evaluate student sensor data. For example, referring to medical model 10b of
In a block 94, a student performs a simulated medical procedure (or a training exercise). If baseline sensor data have been collected, the student should perform an identical simulated medical procedure. In a block 96, sensor data are collected during the student's performance of the procedure. In a block 98, feedback is provided, based on the collected sensor data in comparison to the baseline sensor data.
The feedback provided is a function of how the processor is configured to manipulate the sensor data received from the contact-less sensors. In the training exercise noted above with respect to a baseline procedure being performed by a skilled practitioner, the processor is configured to provide feedback based on the following three factors: (1) the time required to negotiate the esophagus with the tool; (2) the time required to locate the tumor once the tool was advanced into the stomach; and, (3) whether the tumor was successfully located. Such feedback can be provided to the student during the exercise, or kept hidden from the student until the exercise is complete, or can be sent to a proctor for grading the student's performance. Based on the above-noted three factors, a proctor may determine that the student's performance with respect to all three factors must be acceptable in order to achieve a passing grade for the exercise, or the proctor may determine that a passing grade will be achieved as long as the tumor is located, and that the timing data will simply be provided to the student as feedback, rather than be used to determine if the student passed or failed the exercise. Those of ordinary skill in the art will recognize that sensor data can be used in many different ways to evaluate a student's performance.
In a simple form, contact-less sensors in accord with the present invention can be configured to provide feedback to a student during a simulated procedure. The data from the contact-less sensors can be utilized in a variety of different ways. For example, the data can be used to provide relatively simple feedback, such as turning lights on or off, and/or activating aural or verbal prompts or cues. The data from the contact-less sensors can also be manipulated and analyzed by a more complex processing system, such as a computer. The use of a computer enables data collected during a training exercise to be immediately processed and displayed, immediately processed but stored for later use, stored for later processing, compared to similar data, electronically distributed to other users in a network, or any combination thereof. Where a student has previously performed the simulated procedure, the evaluation can include a comparison of the student's past performance in carrying out the procedure with the student's current performance. Thus, even if the student fails to achieve a passing score, the student may receive positive reinforcement of any improvement, based on a comparison with earlier attempts.
The concept of saving an old score and comparing the old score with a current score can be extended to include a comparison of a current score with the scores of other trainees. For example, a medical school may collect data for students in each year of medical school who perform the same simulated procedure. Those scores can be averaged to determine a standardized score for first year students, a standardized score for second year students, and so on. Trainees can then compare their scores with such standardized scores, to evaluate their progress. The scores of other students can be further separated by class rank, so that trainees can evaluate their performance based on class rankings to see if their score is consistent with a higher class ranking or a lower class ranking. Scores can also be collected nationally, so that trainees can evaluate their progress compared to a national average learning curve or other national statistics.
One score based metric that is likely to be very useful is a measurement of a rate at which skills are learned. Learning institutions that wish to increase the efficiency of their programs need to collect data relating to different teaching strategies, in order to compare the different strategies and identify those strategies that consistently result in higher evaluation scores. Simulators including contact-less sensors can be used to evaluate the performance of students undergoing different training curriculums, and the results obtained can be compared to identify the curriculum that leads to students receiving higher scores.
As shown in
Preferably, simulated ultrasound imaging probe 134 will have a size, shape, and weight corresponding to an actual commercially available ultrasound imaging probe. If simulated ultrasound imaging probe 134 includes a sensor (and trainer 124 includes a plurality of detection objects), then the sensor in simulated ultrasound imaging probe 134 will be logically coupled to processor 148. If simulated ultrasound imaging probe 134 includes a detection object (and trainer 124 includes a plurality of sensors), then the plurality of sensors implemented in trainer 124 will be logically coupled to processor 148. To enhance a resolution (i.e., to enhance the ability of trainer 124/processor 148 to accurately determine the physical position of simulated ultrasound imaging probe 134 relative to trainer 124), it may be useful to include an additional detection object/sensor in simulated ultrasound imaging probe 134, at a position spaced apart from the first detection object/sensor in simulated ultrasound imaging probe 134.
Regardless of whether detection objects or sensors are implemented in trainer 124 (the other of the detection objects and sensors being implemented in simulated ultrasound imaging probe 134), the detection objects, the contact-less sensors, and the processor are configured to be able to determine a position of simulated ultrasound imaging probe 134 relative to simulated tissue 130 (and simulated kidneys 132). Thus, processor 148 can use an appropriate ultrasound image to display to the student. As the student moves simulated ultrasound imaging probe 134 relative to simulated kidneys 132, a different ultrasound image will be displayed to the student.
The kidney displayed in ultrasound image 126 includes abnormal tissue 128. Preferably, ultrasound image 126 will be an actual ultrasound image of the kidney that includes actual abnormal tissue. However, ultrasound image 126 can also be implemented by taking an actual ultrasound image of a healthy kidney and modifying the image to include a simulated portion of abnormal tissue. Depending on the training scenario being implemented using trainer 124, each ultrasound image displayed to the student can be an ultrasound image of a healthy kidney, an ultrasound image of a diseased kidney, or combinations of ultrasound images of healthy kidneys and diseased kidneys (for example, the right simulated kidney could simulate a healthy kidney, and the left simulated kidney could simulate a diseased kidney). It should be understood that trainer 124 can include additional organs, or different organs, so that ultrasound images of other organs are displayed to the student based on the position of simulated ultrasound imaging probe 134 relative to trainer 124. Thus, an ultrasound trainer in accord with the present invention including a simulated kidney is intended to be exemplary, rather than limiting on the scope of the present invention.
In at least one embodiment, trainer 124 includes a sensor field of Hall effect or similar sensors incorporated into (or disposed beneath) simulated tissue 130, such that the sensor field is hidden from the user's view. Each sensor in the sensor field is logically coupled to processor 148, so that each sensor sends a signal to the processor when sensing the detection object (a magnet when the sensor field comprises magnetic sensors) incorporated into simulated ultrasound imaging probe 134. The processor is configured to process signals received from the sensor field, to determine the position of simulated ultrasound imaging probe 134 relative to the sensor field incorporated into trainer 124. Based on the position of simulated ultrasound imaging probe 134, the processor is further configured to select an appropriate ultrasound image from memory 150. As the position of simulated ultrasound imaging probe 134 changes relative to trainer 124 (i.e., as the student manipulates simulated ultrasound imaging probe 134), the processor will receive updated sensor data from the sensor field, and a new ultrasound image may be selected, as appropriate.
Simulated tissue 130 will include a plurality of individually identifiable detection objects or contact-less sensors (generally consistent with the principles discussed above in detail) such that the position of simulated ultrasound imaging probe 134 relative to simulated tissue 130 can be determined with a relatively high resolution. This high resolution of the position will enable processor 148 to determine an appropriate ultrasound image to display to the student, based on the position of the simulated ultrasound imaging probe relative to the trainer. The greater the resolution provided, the more sensitive the training system will be to movements of the ultrasound imaging probe, and the more realistic the training simulation will be.
Simulated tissue 130 is preferably implemented as a plurality of different layers. In some embodiments of the invention, simulated tissue 130 is incisable, such that a student can use a scalpel or other surgical instrument to penetrate to the simulated tissue, to gain access to simulated kidneys 132. Alternates to the preferred embodiment may have more or fewer layers, to simulate the different anatomical features for a given area of the human body.
Where an incisable simulated tissue is employed, trainer 124 can be used for both ultrasound training and surgical training. It should be understood that the use of an incisable tissue to facilitate surgical training is optional and not required. In embodiments including incisable tissue, the trainer has swatches of simulated human tissue structure draped over practice surgery areas and over areas of body cover 123, and these swatches are preferably fastened to trainer 124 with hook and loop fasteners or snap fasteners (not shown). The incisable simulated tissue is intended to be replaced after its useful life is expended. Only the practice surgical swatches need be replaced instead of the entirety of body cover 123. Because body cover 123 is not intended to be incised, body cover 123 can be coupled to a rigid plastic base. Preferably, the practice surgery areas include the abdomen, the chest, and the neck areas. Each of the practice areas may include further simulated anatomical features and more tissue structure, as described below.
If trainer 124 is not intended for surgical training as well as ultrasound training, a simpler simulated human tissue (including only a skin layer and a detection object/sensor layer) can be employed, as discussed below. Simulated human tissue 130 preferably includes a number of layers of elastomeric compositions selected and configured to replicate the actual layered membranes and sub-membranes of a human body. The layers may be of similar formulation or they may be of different formulations, depending on the human tissue being simulated. For instance, simulated fat is of a different consistency than simulated muscle. As used herein, a stratum, or layer is used to denote a substantially uniform area extending generally parallel to the outer surface. Layers in the human tissue structure may be bonded to one another, or they may be individual layers that are placed atop one another without being bonded. Layers may even be separated by members that are not a part of the human tissue structure. Further, for any given surgical area, the layers of simulated tissue 130 can vary in thickness.
Beginning with the uppermost and outermost layer, a composite skin layer 136 simulates human skin. For the purposes of this description, skin is considered a membranous layer. Composite skin layer 136 includes an elastomeric layer 136a and a fibrous layer 136b. Elastomeric layer 136a is preferably implemented using a silicone blend, which can be pigmented to generally achieve a flesh tone. As is known in the elastomeric arts, any of a number of suitable pigments for coloring silicone blends can be used to visually represent different layers. The silicone used in the invention is preferably obtained from Silicones, Inc. of High Point, N.C., and is sold under the trademark XP-153A™. Preferably, the silicone is mixed with a thinning agent, also obtained from Silicones, Inc., and sold under the trademark GI THINNER™. The volume ratio of silicone to thinner may be adjusted to achieve a suitable hardness and texture, but preferably, the volume ratio is between about 2:1 and about 10:1 of silicone to thinner. Techniques for molding and curing items of silicone and thinner are known by those of ordinary skill in the art and need not be set forth herein to enable the present invention. Although silicone has been found to perform best, other elastomeric materials, such as latex, may alternatively be used.
It should be noted that attaching a fibrous layer to a silicone-based simulated skin layer requires care. In general, it is difficult to get a non-silicone material to bond to a silicone material. One method of coupling a fibrous layer to a silicone-based simulated skin layer involves coating the fibrous substrate with a silicone material. Such a silicone-coated fibrous layer substrate can be coupled to a silicone-based skin layer using a silicone compatible (preferably a silicone-based) adhesive. The fibrous layer is used because composite layer 136 represents a membranous layer. Thus, a reinforcing layer is combined with the elastomeric layer to enhance the realism of the skin layer.
For the purposes of this description, human tissue, not including bone or cartilage, may be divided into two classes. The first class is tissue whose presence in a human body fills or lends significant bulk. The second class is tissue whose function is to line, support, or surround the first class of tissue. As used herein, the second class of tissue is thus referred to as a "membrane" or "membranes," or as "membranous tissue." By implication, the first class is referred to as "sub-membranous tissue." Membranes are generally thinner, but are characterized in that they are comparatively more dense and tougher (to dissect) than sub-membranous tissue, due in part to their composite construction, since they typically include a fibrous layer. The types of membranes found in a human body include skin, serous membranes (such as the peritoneum, pericardium, or parietal pleura), and any of a number of fasciae or connective tissues, such as the deep fascia, which binds muscles (including the anterior and posterior rectus sheath or aponeuroses, ligaments, and tendons). By comparison, sub-membranous tissue, such as fat, muscle, or extraperitoneal tissue, occupies more space and is generally easier to dissect than membranes. However, even in the different tissues that are sub-membranous, there can be a great disparity in tissue consistency. For instance, fat is much easier to dissect and has a very different tactile characteristic than muscle. In some instances, the blunt end of a scalpel can be employed to readily dissect fat. Given the need to provide realistic simulation and training models, it is therefore appropriate to impart a level of realism to surgical trainers that enables a user to experience the subtle differences between membranous and sub-membranous tissues, as well as to experience the tactile and visual characteristics of various types of each.
The substrate used in fibrous layer 136b imparts a realistic resistance to cutting, similar to the resistance of real human skin. The substrate is preferably made of a nylon mesh material. However, other fabrics that perform equally well can alternatively be used. Any number of synthetic and natural fabrics are effective for use in this layer. While composite skin layer 136 is intended to be a very close approximation to actual human skin, it is to be recognized that real human skin includes numerous strata of virtually imperceptible differences. However, composite skin layer 136 of the present invention closely represents the epidermis and dermis of actual human skin. Preferably, a pigment is added in the silicone blend to color the skin similar to human skin so that as the skin layer is dissected, the color of the elastomeric material is suggestive of human tissue. Composite skin layer 136 is preferably about 2 millimeters to about 4 millimeters thick. While a preferred embodiment of composite skin layer 136 includes a single reinforcing fibrous layer 136b, other embodiments can utilize additional reinforcing layers.
Sensor layer 140 of simulated tissue 130 is the layer including the network of detection objects/sensors (i.e., the sensor field discussed above). As noted above, the more detection objects/sensors included in sensor layer 140, the more responsive to the training system will be to movements of the simulated ultrasound imaging probe. Relatively few detection objects/sensors would mean that a student would need to move the simulated ultrasound imaging probe a greater distance in order for processor 148 to display an additional ultrasound image to the student, compared to a sensor layer 140 that includes a greater number of detection objects/sensors. Suitable technology for implementing detection objects/sensors has been discussed in detail above.
Underlying composite skin layer 136 and sensor layer 140 is a layer 142 that simulates the subcutaneous fat found in actual human tissue. For purposes of this description, subcutaneous fat is considered a sub-membranous layer. Subcutaneous fat layer 142 is preferably formed of a silicone blend and includes a pigment. However, to simulate the less dense texture of fat, the formulation is adjusted to be different than that used for the layer simulating skin. The volume ratios used for the fat layer are preferably in the range from about 1:1 to about 2:1, silicone to thinner. Subcutaneous fat layer 142 is similar in texture and hardness (tactile sensation) to a layer of subcutaneous fat found in humans. In humans, the subcutaneous fat occurs as a thin layer of loose fatty tissue underlying the skin and binding it to underlying layers. It is optional to provide a fibrous material or fibrous layer in the subcutaneous fat and to add pigments. Preferably, subcutaneous fat layer 142 is from about 10 to about 60 mm thick. It will be appreciated, therefore, that the relative thicknesses of layers in simulated human tissue 130 are not drawn to scale.
Underlying subcutaneous fat layer 142 is a composite layer representing an anterior rectus sheath layer 144. For purposes of this description, the anterior rectus sheath is considered a membranous layer. The anterior rectus sheath layer includes an elastomeric layer 144a (preferably a silicone blend) and a reinforcing silicone-coated fibrous layer 144b. Preferably, the fibrous material is a nylon mesh; however, SPANDEX™ material has also been found to perform well for this layer. Fibrous layer 144b is pre-formed and bonded to elastomeric layer 144a using the method described above. Elastomeric layer 144a can instead be provided as a non-bonded layer. The formulation of silicone and thinner used to form anterior rectus sheath layer 144 is preferably in the range from about 1:0 to about 2:1, silicone to thinner. Silicone alone (with no thinner) may be used for this layer because the rectus sheath is a dense, tough serous layer, and these characteristics can be achieved by using little or none of the thinner.
Preferably, the silicone used for elastomeric layer 144a is of a different consistency than that used for composite skin layer 136 or subcutaneous fat layer 142. The silicone preferably used for producing anterior rectus sheath layer 144 is obtained from Silicones, Inc. under the trademark GI-1000A™. This formulation of silicone is of a higher specific gravity, and therefore, upon curing, will be denser than composite skin layer 136 or subcutaneous fat layer 142. For the sake of comparison, the lighter silicone, XP-153A™, has a specific gravity of about 0.98, while the more dense silicone, GI-1000A™, has a specific gravity of about 0.99. Preferably, anterior rectus sheath layer 144 is from about 0.5 to about 1.5 mm thick, and more preferably, about 1.0 mm thick. While a preferred embodiment of anterior rectus sheath layer 144 includes a single reinforcing silicone-coated fibrous layer 144b, additional reinforcing layers can be used. If desired, simulated tissue 130 can include additional underlying layers, such as a muscle layer and additional membranous layers (neither shown).
Note that the relatively complicated simulated tissue 130 is intended to provide a realistic training experience when a student physically manipulates the simulated tissue, such as in a simulated procedure where the student is required to perform an incision and remove a simulated kidney. In embodiments where simulated tissue 130 will be incised, the simulated tissue is a consumable item that is intended to be readily replaced.
In other aspects of the present invention, simulated tissue 130 simply prevents the contact-less sensors/detection objects associated with the skin layer from being visible to the student. In such an embodiment, simulated tissue 130 can be implemented using a single elastomeric layer and a sensor/detection object layer. While
Such an ultrasound trainer will enable students to gain familiarity with obtaining and reading ultrasound images, and to learn how the manipulation of ultrasound imaging probe relative to a patient will result in the collection of different types of ultrasound images. In early training stages, a student may simply be instructed to obtain an ultrasound image of the kidney. Trainer 124 will enable a student to practice positioning an ultrasound imaging probe relative to a patient (i.e., relative to the torso portion of trainer 124) until the simulated ultrasound imaging probe is properly disposed to obtain an ultrasound image of the kidney. The student can perform this training exercise without requiring an actual patient to be present, and if the ultrasound images have been previously generated by ultrasound imaging of real patients, the student will be able to gain familiarity with actual ultrasound images. In this basic training scenario, it is likely that the ultrasound images (stored in memory 150) of the kidney selected by the processor for display will correspond to healthy kidneys. In more advanced training scenarios, ultrasound images from a patient having a disease condition relating to the kidneys can be obtained, and stored in memory 150. A training exercise can be constructed using such images in which a student's ability to recognize the disease condition is tested. Significantly, the basic training exercise and the more advanced training exercise are performed on the same trainer. The only change that needs to be made is to instruct processor 148 to display ultrasound images of normal kidneys, or ultrasound images from diseased kidneys. All of those images can be stored in memory 150. At the beginning of the training exercise, a menu may be displayed to the student such that the student can select an advanced or basic training exercise, and so that the images selected by the processor in response to the student's manipulation of the simulated ultrasound probe will correspond to either the advanced training scenario (the presence of a disease condition in the kidneys) or the basic training scenario. Significantly, in ultrasound training exercises involving live patients, a patient having a kidney disease condition must be available in order for a student to obtain familiarity with visualizing disease conditions in ultrasound image during a training exercise. Using the present invention, a student can practice visualizing both healthy kidneys and diseased kidneys using the same trainer, without the need for any live patient to be available.
With respect to potential disease conditions of the kidney, cancer of the kidney is one of the more common kidney disease conditions. Renal cell carcinoma is the most common type of kidney cancer, accounting for more than 90% of malignant kidney tumors. Although renal cell carcinoma usually grows as a single mass within the kidney, a kidney may contain more than one tumor. Memory 150 can store ultrasound images from several different patients having diseased kidneys, thereby enabling trainer 124 to display a wide variety of different tumor sizes and locations. In actual patients, a disease condition can affect both kidneys at the same time. In a training exercise implemented using trainer 124, processor 148 can be configured to simulate a patient having a disease condition present in only one kidney, or in both kidneys.
The present invention can be implemented as a system that collects data using contact-less sensors that are incorporated into a simulated physiological structure (or a simulated tool used to manipulate the simulated physiological structure, or a sensor bed, as discussed in detail above), stores the collected data in a digital format, processes and evaluates the data, and compares the data to related data. The benefits of the present invention will thus be readily apparent from the discussion presented above.
Although the present invention has been described in connection with the preferred form of practicing it and modifications thereto, those of ordinary skill in the art will understand that many other modifications can be made to the present invention within the scope of the claims that follow. Accordingly, it is not intended that the scope of the invention in any way be limited by the above description, but instead be determined entirely by reference to the claims that follow.
1. A physiological training and evaluation simulator suitable for training and testing personnel, comprising:
- (a) a simulated physiological structure into which a detection target is incorporated; and
- (b) a sensor bed configured to support the simulated physiological structure, the sensor bed including at least one contact-less sensor configured to respond to a proximity of the detection target during a training simulation, wherein the detection target is embedded within a portion of the simulated physiological structure that is to be removed during the training simulation, so that when the portion is successfully removed, the at least one contact-less sensor is no longer triggered by the detection target, indicating that the training simulation has been successfully performed with the removal of said portion.
2. The physiological training and evaluation simulator of claim 1, wherein the detection target is embedded in a way so that the detection target is hidden from view during a simulated procedure, such that a user cannot see the detection object while the simulated physiological structure is manipulated during a simulated procedure, the detection target being hidden from view by a portion of the simulated physiological structure disposed proximate the detection object.
3. The physiological training and evaluation simulator of claim 1, wherein the sensor bed is incorporated in a box trainer, and the simulated physiological structure is disposed within a working volume in the box trainer.
4. The physiological training and evaluation simulator of claim 1, wherein the at least one contact-less sensor comprises at least one sensor selected from the group consisting of an inductive sensor, an eddy-current sensor, a capacitance sensor, and an impedance sensor.
5. The physiological training and evaluation simulator of claim 1, wherein the at least one contact-less sensor comprises a plurality of analog contact-less sensors distributed throughout the physiological training and evaluation simulator, so that by monitoring the plurality of analog contact-less sensors, a processor determines a three-dimensional location of the detection target during the training simulation.
6. The physiological training and evaluation simulator of claim 1, wherein the detection target comprises a radiofrequency identification (RFID) tag, and the at least one contact-less sensor comprises an RFID tag reader.
7. A medical training simulator suitable for training and testing personnel, comprising:
- (a) a contact-less sensor;
- (b) a detection object adapted to trigger the contact-less sensor;
- (c) a simulated physiological structure configured to visually and tactilely resemble an anatomical structure; and
- (d) a sensor bed configured to support the simulated physiological structure, the detection object being incorporated into one of either the sensor bed or the simulated physiological structure, and the contact-less sensor being incorporated into the other of the sensor bed and the simulated physiological structure, such that the one of the detection object and the contact-less sensor incorporated into the simulated physiological structure is embedded within a portion of the simulated physiological structure that is to be removed during the training simulation, so that when the portion is successfully removed, the contact-less sensor is no longer triggered by the detection target, indicating that the training simulation has been successfully performed with the removal of said portion.
8. The medical training simulator of claim 7, wherein the detection object comprises a radiofrequency identification (RFID) tag, and the contact-less sensor comprises an RFID tag reader.
9. The medical training simulator of claim 8, wherein the RFID tag is embedded in the simulated physiological structure.
10. A method for evaluating a performance of a simulated medical procedure, comprising the steps of:
- (a) performing the simulated medical procedure, wherein proper performance of the simulated medical procedure requires removing a portion of a simulated physiological structure from a balance of the simulated physiological structure, such that one of either a contact-less sensor or a detection object is moved relative to the other of the contact-less sensor and the detection object, the contact-less sensor producing sensor data during the simulated medical procedure in response to the detection object and the portion being removed is configured to resemble an anatomical structure;
- (b) collecting the sensor data during the performance of the simulated medical procedure, wherein the sensor data are collected without requiring physical contact between the contact-less sensor and the detection object; and
- (c) using the sensor data to evaluate the performance of the simulated medical procedure, including the step of determining if the portion of the simulated physiological structure removed contained one of the contact-less sensor and the detection object, and if so, concluding that the simulated medical procedure was performed correctly.
11. The method of claim 10, wherein the step of using the sensor data to evaluate the performance of the simulated medical procedure comprises the step of comparing the sensor data obtained during the simulated medical procedure with sensor data obtained from a baseline procedure, in order to evaluate the performance of the simulated medical procedure.
12. The method of claim 10, wherein the step of collecting sensor data during the performance of the simulated medical procedure comprises the step of collecting the sensor data based on at least one of: a capacitance, an impedance, a magnetic field, and an inductance.
13. The method of claim 10, wherein the detection object comprises a radiofrequency identification (RFID) tag, and the contact-less sensor comprises an RFID tag reader.
14. A physiological training and evaluation simulator suitable for training and testing personnel, comprising a simulated physiological structure including a simulated esophagus, the simulated esophagus including a simulated stricture, the simulated stricture comprising a sensor, the sensor being configured to determine if the simulated structure is properly dilated during a simulated medical procedure.
15. The physiological training and evaluation simulator of claim 14, wherein the simulated stricture further comprises a first fluid chamber, a second fluid chamber, and a valve disposed between the first fluid chamber and the second fluid chamber, such that when the simulated stricture is properly dilated during the simulated medical procedure, a fluid moves from the first fluid chamber into the second fluid chamber.
16. The physiological training and evaluation simulator of claim 14, wherein the simulated stricture further comprises a detection object, and the sensor comprises a contact-less sensor.
17. A medical trainer for teaching and testing personnel, comprising:
- (a) a simulated physiological structure, a portion of the simulated physiological structure being configured to be removed during the performance of a simulated procedure, the simulated physiological structure comprising an elastomer and being configured to simulate an anatomical structure, the simulated physiological structure being disposed within a working volume defined by the physiological training and evaluation simulator;
- (b) a detection object; and
- (c) a contact-less sensor configured to respond to a proximity of the detection object, one of either the detection object or the contact-less sensor being disposed in the portion of the simulated physiological structure, and the other of the detection object and the contact-less sensor being disposed adjacent to the portion of the simulated physiological structure, such that removal of the portion of the simulated physiological structure during the simulated procedure is detected, because the detection object is no longer detected by the contact-less sensor after the portion of the simulated physiological structure is removed, wherein the contact-less sensor does not require physical contact between the contact-less sensor and the detection object to detect the detection object.
18. The medical trainer of claim 17, wherein the detection object comprises a radiofrequency identification (RFID) tag, and the contact-less sensor comprises an RFID tag reader.
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- Patient Simulator Program, http://www.cscc.edu/docs/nurs/patientsim.htm.
Patent History
Type: Grant
Filed: Apr 7, 2005
Date of Patent: Feb 23, 2010
Patent Publication Number: 20050181342
Inventor: Christopher C. Toly (Seattle, WA)
Primary Examiner: Xuan M Thai
Assistant Examiner: Timothy Musselman
Attorney: Ronald M. Anderson
Application Number: 11/101,776
International Classification: G09B 23/28 (20060101);


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VAT support service
Our VAT support service is a collaborative approach to supporting you with your day to day VAT queries, whilst allowing us to develop a strong working relationship with you. This support service often results in us identifying potential issues before they hit and enables us to put remedial measures in place to avoid high VAT charges or penalties.
General VAT planning points: February 2017
There are some very simple ways to ease your VAT cashflow or make the VAT rules work for you.
VATflash: HMRC lose in relation to input VAT for Single Farm Payment Entitlement
HMRC have recently lost an important case which has resulted in farming businesses that have purchased units of Single Farm Payment Entitlement, where HMRC have disallowed the input VAT claims, to now make a back claim to HMRC for the VAT plus interest.
VATflash: Place of establishment
If your business trades internationally you should be aware of the implications of the concept of 'establishment' for VAT purposes and how the agenda is being driven by the Courts.
VATflash: An update on the Mini One Stop Shop
Information and guidance on the MOSS VAT regime is being released on a regular basis by the EU Commission and HMRC and it is clear that several aspects will have a significant impact on UK businesses which will need to be addressed.

subset: commoncrawl


text:
A Palmerstonian diplomat in Central America: Frederick Chatfield, Esq
University of Arizona Press, 1964 - History - 385 pages
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Abbreviations Used in the Text xii
The Upstart Spy
Consul and Minister
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Common terms and phrases
action affairs alliance allies Altos April August Belgian Belize Belizean Bidwell blockade Britain British agent British consul Captain Carrera Central America Chat claims coast Cockburn Colonel consul-general Costa Rica December December 15 December 20 decree dispatch documentation encl encl.s England English Englishmen fact favored February February 15 federal congress federal government force Foreign Office Frederick Chatfield Galindo Granville Greytown Guate Guatemala City Honduras Ibid interests island January January 24 John Jose Juan Lindo July June letter liberal loan London Lord Palmerston Macdonald Mahelin Majesty's March MDCIA Memel ment Miguel Alvarez Minister mission Morazan Morazanistas moreover Mosquitia Mosquito Shore nation naval negotiations Nicaragua November November 12 October perhaps political port Prussia question Quezaltenango Quijano Rafael Carrera refused Republic request righters Ruatan Russian Salvadorean San Juan San Salvador September serviles settlement Shee ships Squier suggested territorial Tigre tion trade treaty union unionist United Warsaw Wyke Zebadua


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All sign ups are due at least 2 hours before each run. Failing to do so will slow the run down and maybe cost you your lot for the day.
List your name and absence reason here if you will be missing this run.
Name - Reason
List your name and jobs available here if you will be attending this run. List jobs in order of preference We will try and keep you within your preferences.
Name - Jobs


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Real estate transactions represent transfer of real property recorded with the Gaston County Register of Deeds. The following information is provided: seller, buyer, location of property and estimated selling price.
Real estate transactions represent transfer of real property recorded with the Gaston County Register of Deeds. The following information is provided: seller, buyer, location of property and estimated selling price.
Dayle Guffey Properties to Christopher and Jennifer Andrews, property at 3844 Yellow Jasmine Drive, Gastonia, $177,000
Regent Homes to Kevin Pearsall III, property at 313 Lewellyn St., Belmont, $149,000
Marjorie Weaver to Dana Blackmon, property at 710 Woodhaven Lane, Gastonia, $136,000
State Employees� Credit Union to John and Erika Robinson, property at 2257 Swain Court, Gastonia, $90,000
Kenneth and Karen Dooley to William and Heather McCollough, property at 125 Church St., McAdenville, $220,000
JP Morgan Chase Bank to THR North Carolina, property at 217 Black Rock School Road, Cherryville, $72,000
Clyde and Chong Millman to CCGB, property at 106 Mariposa Road, Stanley, $350,000
Meredith and Priscilla Scruggs to Balatsias Invesments LLC, property at 25 South Main St., Belmont, $75,000
Caral Associates to Jeremy Burns, property at 2006 Dallas-Cherryville Highway, Dallas, $740,000
Belmont Federal Savings and Loan to Susan Hundley, property at 161 Woodbridge Circle, Mount Holly, $106,000
Providence Management to Jessica Burgess, property at 2108 Pine Needle Court, Gastonia, $166,000
Brian and Amanda McWhirter to Benjamin and Laura Moretz, property at 1345 Indigo Run Lane, Gastonia, $189,000
Martha Gardner to Phyllis Stroupe, property at 4042 Broadview Lane, Gastonia, $123,000
Cartus Corporation to Timothy and Heather Foreman, property at 9025 Petunia Court, Gastonia, $252,000
Odell and Zena Armstrong to Cartus Corporation, property at 9025 Petunia Court, Gastonia, $243,000
Phyllis Stroupe to Jessica Sanford, property at 212 Treeline Drive, Belmont, $154,500
Margaret Winfred to Christopher and Jamie Evans, property at 1475 Quailwoods Road, Gastonia, $146,000
William and Rebecca Aglinsky to Michael McKeever, property at 8326 Catawba Cove Drive, Belmont, $527,000
Paul and Gail Marr to Harold Arrendale, property at 1489 Pine Ridge Drive, Gastonia, $65,000
M&W Industries to James Carver, property at 4315 Freeport Drive, Gastonia, $99,000
Neal and Kelly Mitchell to Nancy Bedard, property at 1222 N. New Hope Road, Gastonia, $118,000
Blain and Wendy Harvey to Timothy and Stephanie Fox, property at 1006 McLaren Drive, Belmont, $225,000
Brandon and Giannina Phillips to Thomas and Robin Adkins, property at 1129 Vistalite Lane, Dallas, $90,000
Builders of Hope to Tah Reit, property at 101 Kings Mountain Lane, Gastonia, $95,000
Builders of Hope to Tah Reit, property at 1036 Kings Mountain Lane, Gastonia, $88,000
Keith and Paige Meares to Manuel and Debora Lozana, property at 301 Augustus Lane, Mount Holly, $168,000
Richard Redding to Michelle Redding, property at 1454 Lower Dallas Highway, Dallas, $67,000
Weekley Homes to Gregory and Burneta Barley, property at 404 Brookridge Drive, Mount Holly, $518,000
Klean Outs Inc. to John and Eileen Geiger, property at 508 W. 8th Ave., Gastonia, $65,000
Y. David Keever to Crissy Maynard, property at 2428 Pamela St., Gastonia, $95,000
Helen Davis to Jessica and David Peterson, property at 303 Lanier Ave., Mount Holly, $102,00
Robert Heavner to Yujia Huo, property at 1942 Oak Hollow Road, Gastonia, $85,000


text:
Customized TV Listings are available here: www.latimes.com/tvtimes
Click here to download TV listings for the week of May 19 - 25, 2013 in PDF format
Doctor Who The Doctor's (Matt Smith) greatest secret is discovered in the season finale. With Alex Kingston and Jenna-Louise Coleman. 5 and 8 p.m. BBC America
Diners, Drive-Ins and Dives In this new episode Guy Fieri takes viewers behind the scenes. 10 p.m. Food
Saturday Night Live Ben Affleck hosts the season finale with musical guest Kanye West. 11:29 p.m. NBC
2013 Rock and Roll Hall of Fame Induction Ceremony Heart, Randy Newman, Public Enemy, Rush, Donna Summer, Albert King, Quincy Jones and Lou Adler. 9 p.m. HBO
For a Good Time, Call... Lauren Miller and Ari Graynor star in this 2012 comedy as former college mates who start a phone-sex business. 6:30 p.m. Cinemax
Moonrise Kingdom Director and co-writer Wes Anderson's acclaimed 2012's independent film stars Jared Gilman and Kara Hayward) as love-struck 12-year-olds who run away together just before the approach of a violent storm. 7:15 p.m. HBO
Brave A princess (voiced by Kelly Macdonald), who is proficient with a crossbow, seems destined for a marriage she doesn't want in this 2012 Disney animation. 8 p.m. Starz
Good Morning America (N) 7 a.m. KABC
McLaughlin Group 6:30 p.m. KCET
The Chris Matthews Show Washington controversies; 2014 midterm elections: David Ignatius, the Washington Post; Howard Fineman, Huffington Post; Gloria Borger; Kasie Hunt, NBC. (N) 5:30 a.m. KNBC
Today A marine and his daughter; painting with dolphins. (N) 6 a.m. KNBC
Good Morning America (N) 6 a.m. KABC
State of the Union With Candy Crowley Washington controversies: White House advisor Dan Pfeiffer. IRS controversy; AP leak investigation; Benghazi: Sen. Rand Paul (R-Ky.). Panel: Donna Brazile; Ana Navarro; Susan Page, USA Today; Jessica Yellin. (N) 6 and 9 a.m. CNN
CBS News Sunday Morning (N) 7 a.m. KCBS
Fareed Zakaria GPS Managing controversies: Former Reagan chief of staff Ken Duberstein. The deficit; Europe's economic troubles; IRS controversy: Zanny Minton Beddoes, The Economist; R. Glenn Hubbard. Technology: Eric Schmidt, Google; Jared Cohen, Google Ideas. Afghanistan: Author William Dalrymple. (N) 7 and 10 a.m. CNN
Meet the Press IRS controversy; Benghazi; AP leak investigation: Sen. Mitch McConnell (R-Ky.). White House's response to controversies: White House advisor Dan Pfeiffer. IRS controversy: Rep. Dave Camp (R-Mich.). Obama foreign policy; sexual assault in the military: Former Defense Secretary Donald Rumsfeld ("Rumsfeld's Rules"). Panel: Rep. Xavier Becerra (D-Los Angeles); Bob Woodward; Peggy Noonan. (N) 8 a.m. KNBC
This Week With George Stephanopoulos Controversies facing the White House: Dan Pfeiffer, assistant to the president. IRS; Bengazi; AP leak investigation: Sen. Robert Menendez (D-N.J.); Sen. Rob Portman (R–Ohio); Rep. Tom Price (R-Ga.); Rep. Charles B. Rangel (D-N.Y.). Panel: George Will; Ron Fournier, National Journal; April Ryan; Katrina vanden Heuvel, the Nation; Jeff Zeleny. (N) 8 a.m. KABC
Fox News Sunday With Chris Wallace Controversies in Washington: White House advisor Dan Pfeiffer; Rep. Paul D. Ryan (R-Wis.). Attorneys Victoria Toensing and Joseph diGenova. Panel: Brit Hume; Kirsten Powers; Karl Rove; Dennis Kucinich. (N) 8 a.m. KTTV
Reliable Sources Coverage of Washington controversies: Jennifer Loven; Jane Hall, Joe Concha. IRS controversy: David Shuster, Current TV; Jennifer Rubin, CNBC. Preventable double mastectomy: Michelle Cottle, Newsweek. (N) 8 a.m. CNN
Face the Nation White House advisor Dan Pfeiffer; Sen. John Cornyn (R-Texas); Rep. Jason Chaffetz (R-Utah); Gary Pruitt, Associated Press. Panel: Dan Balz, the Washington Post; Lois Romano, Politico; David Sanger, the New York Times; John Dickerson. (N) 8:30 a.m. KCBS
60 Minutes Computer facial recognition technology; Shin Dong Hyuk's escape from a North Korean prison camp. (N) 7 p.m. KCBS; Children flee Afghanistan hope of a better life in Europe; Dereck and Beverly Joubert; Taylor Swift. (N) 8 p.m. KCBS


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The use of taser guns in Maysville may be allowed if a request from the police chief is approved by the city council.
Police Chief Clarence Sullens spoke at the Maysville City Council work session Thursday on the use of taser guns for the police department.
Currently, the Maysville Police Department does not own any taser guns, but hopes to purchase two, each costing about $1,000.
Sullens, also a taser instructor, explained that having taser guns would be good for the liability of the police department. Bringing along a thick packet of research, Sullens explained that when tasers are implemented, injuries for both officers and offenders are lowered. In 2007, 12,649 incidents of tasing were reported and only four (0.031 percent) resulted in death.
Maysville police chief wants tasers
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There have been approximately one billion tribute, cover, and parody versions of Gotye's 'Somebody That I Used To Know.' One of my favorites was this amazing Star Wars parody, but this shredding solo acoustic guitar version by Mike Dawes is another contender.
There are so many different versions, actually, that Gotye himself has mashed up all, or at least pretty much all, of them into one amazing video. And really - it's amazing. Both of the versions above are in there, as well as a ton more.
I know, I know—nothing to do with video games. Still though, this is sweet.
And here, for posterity, is that amazing Mike Dawes version, in case you haven't seen it. Check it out:


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[Update: Time to go let us know which of these 56 themes you'd love to see included in Alfred v1.2. Pop over to the Facebook album and dish out the thumbs up.]
Since we launched Alfred two years ago, users of the free version have been able to choose between a light and dark colour theme. When Lion was released, we added a matching theme to celebrate its arrival. Today, we are looking for new and exciting custom themes for Alfred and are turning to you!
If we choose your theme to add to the Alfred core, you'll get recognition in front of a million users as well as some unique Alfred goodies. Read on to find out how to participate or vote.
Contributing your own theme
To participate, create the most gorgeous custom colour theme for Alfred and post a link to the screenshot and theme file in the comments below. You have until Thursday 12th April to submit your theme.
In your comment on this blog post, include:
- A link to a screenshot of your theme
- A link to the theme file
- A valid email address (in the address field) so that we can contact you
To participate, you need to have your own Powerpack license and the theme needs to work well for common uses (e.g. over other windows).
Don't know how to export your theme? Have a look at this knowledge base item.
If your theme has a fun name or a story, we'd love to hear it 🙂
Voting for your favourite theme
By Friday 13th April, we'll put all of the themes on our Facebook page where you can look through the album we've created to vote for your favourites.
We'll post a link to the album here on Friday but you can join us on Facebook now to get a headstart!
Pop by our Facebook photo album to like your favourite themes so that they're in with a chance to be included in version 1.2!
To vote, click the Like button on Facebook for the themes you love the most. At the end of the week, we'll pick 2 of the 5 themes you've liked the most to include in Alfred's core set of themes.
This means that if your custom theme wins, over a million Alfred users will be able to pick it as their everyday theme. Instant celebrity status! 😉
The two winners will get the following:
- An upgrade from single user license to mega supporter (for a lifetime of Alfred updates) or a single license for a friend
- Their theme and name published as part of Alfred's core themes for all users to see
- Some Alfred goodies (stickers and keyboard brushes) in the mail
What are you waiting for? Set your inner artist free and create a beautiful Alfred custom theme and submit it before Thursday for your chance at these prizes.