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This project uses the revolutionary iHuman platform developed by a team of EMTs and computer programmers. iHuman is a self-learning educational program that is highly interactive, building to a virtual patient with a complex, integrated physiological model that allows realistic simulation of disease states and responses to therapy. In addition, it includes a sophisticated strategy for competency assessment, making the platform extremely attractive for medical education. The iHuman team approached Dr. Daniel Davis about a collaboration to build a sophisticated critical care training/assessment model using their platform. The focus would include the core elements of our integrated model of physiology (perfusion, oxygenation and ventilation) and allow exploration of complex therapies, including the use of pressors as well as ventilator management.
California Resuscitation Collaborative (CRC)
This represents an effort to consolidate training and education among EMS providers in California. The initial focus will be in three specific disease entities: traumatic brain injury (TBI), cardiopulmonary arrest, and airway management. This program will involve ground and air EMS services, the UC Neurotrauma group (basic science and clinical researchers with interest in TBI), and the UC San Diego Center for Resuscitation Science. The effort will include summits and the generation of treatment guidelines and training materials. This effort also showcases an annual statewide California Trauma and Resuscitation Conference in San Diego.
The ROC effort represents one of the largest research endeavors in history, involving 10 sites across North America. ROC involves a series of interventional, observational and pilot studies evaluating care in cardiac arrest and trauma. The initial studies were focused on out-of-hospital interventions. However, the current proposed studies include emergency department and inpatient interventions as well. The two most relevant to UC San Diego Health System involve titrated oxygen in the emergency department and modulation of target temperature and duration of hypothermia following resuscitation from out-of-hospital cardiac arrest.
Researchers at the UC San Diego Center for Resuscitation Science have intense interest in ventilation physiology and the interactions between ventilation and both oxygenation and perfusion. We have derived several mathematical equations to describe this integrated model of the three basic physiological processes (perfusion, oxygenation and ventilation). Multiple studies and platforms will be explored to validate these concepts.
Palm-Top Ventilator studies – The recent release of the “Palm-Top Ventilators” (ReVel and EnVe) by CareFusion opens up some interesting opportunities to apply both invasive and non-invasive mechanical ventilation during acute resuscitation in the out-of-hospital, emergency department, and inpatient environments; these studies will focus on overall clinical outcomes, physiological parameters (using historical controls from the out-of-hospital environment), and ease and willingness of use.
Models – Our affiliation with the Weil Institute of Critical Care Medicine allows investigation of basic physiology in models, specifically related to the interaction between perfusion and ventilation; these include evaluation on how ventilation parameters (tidal volume, ventilation rate) affect perfusion as well as the potential ability of lung volume to “stent open” the pulmonary vasculature during CPR.
ICU – The relationship between PaCO2 and PetCO2 as a measure of perfusion will be further investigated in an ICU setting.
Tissue-to-end-tidal CO2 – The ultimate goal is to create a non-invasive measure of both perfusion and ventilation simultaneously; this includes the creation of an appropriate tissue probe and validation of the CO2 gradient in relation to changes in perfusion; potential advantages to this approach include accuracy, speed, and decreased measurement-to-measurement variability. In addition, the ability to calculate the contribution of reactive airways disease to the CO2 gradient is being modeled.
SpO2 studies – The development of the E1 ear sensor allows the potential to explore its advantages with regard to accuracy and decreased temporal latency in the out-of-hospital, emergency department, and inpatient settings; historical controls are available for the out-of-hospital setting.
UC San Diego will be implementing a comprehensive program to monitor and prevent inpatient apnea using clinical evaluation, capnography, and adaptive positive airway pressure (APAP) therapy; outcomes will focus on patient flow through the algorithm, the physiology of apnea, and clinical outcomes. In addition, the application of APAP in the inpatient setting represents a novel use of this technology and is worthy of investigation.
The local helicopter program Mercy Air provides a unique opportunity to study specific devices in a relatively controlled environment with a high frequency of critically ill and injured patients. The larger company Air Methods maintains a comprehensive database of all patient transports, allowing the opportunity for numerous registry-based analyses. Finally, the training platforms (iART, cadaver lab and airway lab) allow investigation of specific interventions and educational approaches, with the potential to link with clinical outcomes data.
The entire state of Arizona will be implementing a set of TBI “best practice” guidelines with a comprehensive education and monitoring program. We will be involved in the design of training materials and physiological data analysis.
The UC San Diego Neuroanesthesia Laboratory at the VA Medical Center has the capability for sophisticated investigations using cell culture (brain, heart) and models.
Public Health Studies
We have begun a collaborative relationship with the County Coroner and Office of Public Records. This project will investigate the patterns (age, location) of death in the county in an effort to define the opportunities for intervention. This will ultimately include consideration of futility. The goal will be to help people make educated decisions about the end of their lives, ultimately achieving “quality of death.”
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