Patent Publication Number: US-2007117076-A1

Title: Cardiopulmonary patient simulator

Description:
BACKGROUND OF THE INVENTION  
      1. Field of the invention  
      The present invention relates to learning aids in general and more particularly to a simulator for simulating a health condition of a patient.  
      2. Related art  
      It is common to use various teaching tools to train healthcare students in the examination of a patient and in the diagnosis of various health conditions of the patient. The traditional practice for training healthcare students involves using patients having particular physiological conditions or disorders. However, while such training practice may be helpful to the healthcare student, it is difficult to arrange as it involves the availability of patients with various health disorders at suitable times. Moreover, a repeated examination of a patient by numerous healthcare students may not be advisable for the patient as the comfort and privacy of the patient as well as the condition of the patient should be taken into consideration.  
     SUMMARY OF THE INVENTION  
      An aspect of the present invention is to provide a method for generating a set of electrical signals representing a pulse in a simulator comprising a manikin. The method comprises creating a pulse profile, sampling the pulse profile, converting the pulse profile into a two dimensional data, performing a Fourier transform and transforming the two dimensional data to a Fourier series, introducing a phase shift to the Fourier transform of the two dimensional data, and performing an inverse Fourier transform. 
    
    
     BRIEF DESCRIPTION OF THE DRAWINGS  
       FIG. 1  is a front elevational view of a manikin of a cardiopulmonary patient simulator, according to an embodiment of the present invention;  
       FIG. 2  is an elevational view of the manikin with the manikin laying down on a table top, according to an embodiment of the present invention;  
       FIG. 3  is a rear elevational view of the manikin shown in  FIG. 1 ;  
       FIG. 4  is a cross-section of the head of the manikin showing the placement of the left and right carotid transducers, according to an embodiment of the present invention;  
       FIG. 5  is a perspective view showing a plate on which jugular transducers are mounted, according to an embodiment of the present invention;  
       FIG. 6  is an elevational view of the jugular transducers with their respective actuating arm assemblies, according to an embodiment of the present invention;  
       FIG. 7  is a perspective view of a chest plate supporting a plurality of transducers, according to an embodiment of the present invention;  
       FIG. 8  is an example of a fastening configuration used for fastening a transducer, according to an embodiment of the present invention;  
       FIG. 9  is another example of a fastening configuration for fastening a transducer, according to another embodiment of the present invention;  
       FIG. 10  is a cross-sectional view of the manikin shown in  FIG. 1  around a lower abdomen area showing the femoral transducers, according to an embodiment of the present invention;  
       FIGS. 11 and 12  are perspective views of a brachial or radial transducer, according to an embodiment of the present invention;  
       FIG. 13  is an exploded view of a transducer, according to an embodiment of the present invention;  
       FIG. 14  is an elevational view of the transducer of  FIG. 13 ;  
       FIG. 15  is a lateral cross-section of the transducer of  FIG. 13 ;  
       FIG. 16  is a rear elevational view of the manikin shown in  FIG. 1 , according to an embodiment of the present invention;  
       FIG. 17  is a perspective view of a breathing mechanism, according to an embodiment of the present invention;  
       FIG. 18  is a top view of a pulley assembly of the breathing mechanism depicted in  FIG. 17 ;  
       FIG. 19  is a top perspective view of the breathing mechanism shown in  FIG. 17 ;  
       FIG. 20  is an electronic diagram of a controlling device and other devices and systems used in the cardiopulmonary patient simulator, according to an embodiment of the present invention;  
       FIG. 21  is an electronic diagram of a chain of a components used for controlling transducers, according to an embodiment of the present invention;  
       FIG. 22  is an electronic diagram of a chain of components used to control a sound device, according to an embodiment of the present invention;  
       FIG. 23  is an electronic diagram of a chain of components used to control brachial sounds;  
       FIG. 24  is a flow chart illustrating a method for generating a set of electrical signals, according to an embodiment of the present invention;  
       FIG. 25  is a flow chart illustrating a method for generating a breathing movement, according to an embodiment of the present invention;  
       FIG. 26  is a flow chart illustrating a method for generating a pulse and a sound and coordinating and/or synchronizing between the pulse and the sound, according to an embodiment of the present invention;  
       FIG. 27  is a flow chart illustrating a method for controlling a controlling device and generating and/or timing various pulses and/or sounds, according to an embodiment of the present invention; and  
       FIG. 28  is a flow chart illustrating a subroutine in the method illustrated in  FIG. 27 , according to an embodiment of the present invention. 
    
    
     DETAILED DESCRIPTION OF EMBODIMENTS OF THE INVENTION  
      To enhance the teaching environment for the student, it has been proposed to employ a simulator. The simulator can be configured to simulate certain health conditions to replicate to a certain extent the physiological behavior of a body having the health condition. The simulator, for example, may include a manikin replicating the anatomy of a human body to create a more realistic environment for the student. The simulator can be tailored for a specific category or area of medicine. For example, the simulator can be configured to simulate particular biofunctions of the body such as cardiopulmonary functions of a human body. In this case, the simulator acts as a cardiopulmonary patient simulator (CPS). According to an embodiment of the invention, the CPS is configurable to simulate the bedside findings of a number of cardiac diseases. The CPS may be used for teaching in any environment in which a patient may be examined. Individual students or small groups of students may learn with or without an instructor (for example a medical doctor) by using the CPS. Larger groups of students may also be taught at the CPS bedside or in a lecture hall setting by using one or more speakers to generate heart and lung sounds.  
      Before describing in detail the CPS, it may be worthwhile to put the CPS in the context of its use as a simulator in teaching, demonstrating, or examining, various cardiac diseases. The approach to examining the CPS is the same as for a real patient. The examination approach is embodied in the “Five Fingers of Clinical Diagnosis” which are history, physical signs, electrocardiograms (ECG), xray, and laboratory diagnostics. The cardiac physical signs of each disease are presented in the CPS according to the “Five Fingers of Physical Signs” which are the physical appearance, the venous pulse, the arterial pulse, the precordial movement and the heart sounds.  
      The general physical appearance of the CPS is output via a graphical interface of the CPS which is described in more detail in the following paragraphs. The venous pulse is evaluated by inspection of the internal jugular veins which directly reflect right atrial dynamics. The jugular veins are observed (not palpated) as they undulate at the infero-lateral aspect of the sternocleidomastoid muscle. The waveform is assessed by timing its movement with the carotid pulse (which lies higher in the neck just medial to the sternocleidomastoid muscle) or with the heart sounds. A penlight may be used to shine a tangential light beam on the jugular venous pulse to better visualize the venous pulse form.  
      The carotid arterial pulse is lightly palpated high in the neck just medial of the sternocleidomastoid assessing its upstroke, peak and downstroke. The brachials and femorals can also be examined. The brachial and femoral are palpated simultaneously to detect diminution of delay in the femoral which is a sign of coarctation of the aorta.  
      Assessment of the arterial pulses includes taking the blood pressure and palpating the pulses. As with a patient, the blood pressure is taken by first palpating the right brachial artery at the medial aspect of the antecubital fossa. A stethoscope is placed over the artery and a cuff inflated. While slowly deflating the cuff and simultaneously listening through the stethoscope, the sphygmomanometer is observed to determine when the Korotkoff sounds begin and end.  
      The precordial movement is sensed by palpating specific areas of the chest wall. Multiple movements may occur both in systole and diastole. To time the palpable precordial movement, the carotid artery is palpated simultaneously with the precordial movements or the heart sounds are listened to simultaneously with the precordial movements.  
      Cardiac auscultation usually takes place after having assessed the venous, arterial and chest wall pulsations. However, in some circumstances, cardiac auscultation may take place before observation of venous, arterial and chest wall pulsation or other auscultation. Acoustic events of the heart are analyzed. The auscultatory examination commonly begins at the aortic area and the stethoscope inched to the pulmonary area, tricuspid area and mitral area. In addition, one may listen for posterolateral radiation of mitral murmurs, superior radiation of aortic and pulmonary valve murmurs and carotid bruits. It may also be helpful to simultaneously palpate the carotid to time the acoustic events. Finally, pulmonary auscultation can be performed. Different findings may be present on the left, right, lower (anterior and posterior) and upper fields or areas of the lungs.  
      The CPS also includes a built-in audio system, for example a wireless audio system, that enables the manikin to function as a patient so that students may practice their communication skills. The instructor is typically located in a nearby room, hears the questions through an audio system and responds through the wireless system in the CPS. Scripts may be developed from the histories provided in the CPS programs which are taken from real-life patient illness histories.  
       FIG. 1  is a front elevational view of a manikin representing an upper half of a human body from the upper thighs, according to an embodiment of the present invention. The manikin  10  comprises a wall  12  defining a hollow body or cavity  14 , a head portion  16  and arms  18 . The wall  12  is covered by a resilient layer of material. In an embodiment of the invention, an outer layer of the resilient layer has the texture of human skin. The wall  12  is made of relatively hard materials, such as hard plastics (for example, polypropylene, polyethylene or the like) to simulate a body of a human while the resilient layer is made of relatively soft materials including, for example, polyvinylchloride or polyurethanes, to simulate the human skin.  
      The manikin includes pulsation positions which include venous pulse in jugular (JUG) positions  20 R and  20 L, arterial pulse in carotid (C) positions  22 R and  22 L located in neck  17  of manikin  10 , brachial position  24  located in the arm  18  of manikin  10  and femoral artery positions  26 R and  26 L located in the lower abdomen area, in the upper thighs area, of the manikin  10 . Within each area, pulse configurations may be tailored depending on a disease. The manikin may further include sound diagnosis positions.  
      The manikin further includes precordial movement areas which include a pulmonary area (PUL)  28 , located in the upper left sternal edge of the body of the manikin, a right ventricular area (RV)  30 , located in the mid and lower left sternal edge of the body of the manikin, left ventricular area (LV)  32 , located at the apex-5 th  left intercostals space, mid-clavicular line, and the displaced left ventricular area (DLV)  34 , located at the 6 th  and 7 th  left intercostals space, anterior axillary line. Within each area, multiple movements appropriate for a given disease may be simulated.  
      The manikin includes cardiac ausculatory areas which include aortic area (AOR)  36 , located in the upper right sternal edge of the body, pulmonary area (PUL)  38  located at the upper left sternal edge of the body, tricuspid area (TA)  40 , located at the lower left sternal edge), mitral area (MA)  42 , located at the apex, mitral radiation (MR)  44 , located posterolateral to the apex, the carotids (C)  22 R and  22 L located on the upper neck  17 , the jugular (JUG)  20 R and  20 L located on the lower part of the neck  17  and the femoral area (FEM)  26 R and  26 L located at the lower part of the abdomen in the upper part of the thighs.  
      The manikin is configured to breathe and the breathing movement is simulated by a movement in the abdomen (ABD), generally indicated at  46 . With respect to the breathing, the manikin has auscultation positions at walls of a chest portion  48 . The pulmonary auscultations areas represented include the right upper quadrant lung field (RUQ)  48 A, the left upper quadrant lung field (LUQ)  48 B, the right lower posterior lung field (RLP)  48 C, right lower anterior lung field (RLA)  48 D, left lower posterior lung field (LLP)  48 E, and the left lower anterior lung field (LLA)  48 F.  
      In the positions  20 R,  20 L,  22 R,  22 L,  24 R,  24 L,  26 R,  26 L,  28 ,  30 ,  32 ,  34 ,  25 R and  25 L holes are made through the hard wall  12  of the body  14  and arms  18  of the manikin to allow pulsation generators (not shown in this FIGURE) to reach the outer flexible layer representing the skin of the manikin. The pulsation generators, which are described in detail in the following paragraphs, are disposed inside the hollow body  14  of the manikin and are attached to the hard wall  12  of the body  14 . The pulsation generators are configured to simulate movements mimicking cardiovascular pulsations and respiratory movements of the human body.  
       FIG. 2  is an elevational view of the manikin  10  with the manikin laying down on a table top  50 . The manikin  10  is supported at a suitable height on the table top  50 . The table top  50  includes a housing which houses a controlling device, e.g., a computer (not shown) of the CPS. In operable position, the manikin  10  is laid down on the table top  50  and numerous wires (not shown) connect mechanical and electrical parts (not shown) in the manikin  10  to the controlling device inside the table top  50 . The computer or controlling device of the CPS includes an input device or user interface  52  for inputting various physiologic parameters.  
       FIG. 3  is a rear elevational view of the manikin  10 . The manikin  10  has an opening  54  through which various mechanical and electrical parts of the CPS are accessed for mounting, adjustment and/or servicing. The manikin  10  comprises a plurality of pulse generators mounted on suitable platforms  56 . The platforms  56  can be made of any of a number of suitable materials. In an embodiment of the invention, the platforms are made of plastic as plastic is a dielectric and thus well suited as a base for electrical connections. The plastic can be transparent, translucent or opaque. In an embodiment of the invention, some of the platforms are made of a transparent or translucent plastic to facilitate localization of the various electrical connections.  
      There are a plurality of platforms  56  in the manikin  10 , each platform is configured to support a group of electromagnetic transducers and/or electromechanical parts. Platform or plate  58 , a portion of which is shown in  FIG. 3 , supports transducers that are used to simulate the jugular pulses at areas  20 R and  20 L (shown in  FIG. 1 ). In an embodiment of the invention, two transducers  59 R and  59 L (see  FIG. 4 ) are used to simulate the left and right carotid pulses and two transducers  60 R and  60 L are used to simulate the left and right jugular pulses. Platform  62  supports a plurality of transducers  64  configured to simulate pulmonary artery (PUL) pulse in area  28 , right ventricle (RV) pulse in area  30 , left ventricle (LV) pulse in area  32  and displaced left ventricle (DLV) pulse in area  34 . In an embodiment of the invention, four transducers  64  are used to simulate the pulses in the above regions. However, it must be appreciated that any number of transducers may be used to simulate pulses in various parts of the cardiovascular system. Platform  66  supports transducers  68 R and  68 L that are configured to simulate the femoral pulses (FEM) in areas  26 R and  26 L, respectively.  
       FIG. 4  is a cross section of the head  16  of the manikin  10  showing the placement of the left and right carotid transducers  59 R and  59 L relative to the head  16  and neck  17  of the manikin  10 , according to an embodiment of the present invention. The carotid transducers  59 R and  59 L are mounted to the wall  12  of the manikin  10  using L-shaped plates  70 R and  70 L. The L-shaped plates  70 R and  70 L penetrate through an opening  71  in the wall  12  of the head  16  of the manikin  10 . Portions of the plates  70 R and  70 L are shown in  FIG. 4  in dotted lines (phantom lines) to illustrate that the plates  70 R and  70 L penetrate through the wall  12  of the manikin  10  and cannot be directly seen in the cavity of the head  16 . The portions of the plates  70 R and  70 L shown in  FIG. 4  in phantom lines can be seen directly in solid lines in  FIG. 5  which is another view showing a back side of the head  16  and in  FIG. 3  which is a rear elevational view of the manikin  10 . As shown in  FIGS. 3 and 5 , a flat plate  72  is provided on the back of the neck  17  to link the two plates  70 R and  70 L and to attach the two plates  70 R and  70 L to the wall  12  in the back of the neck  17 . Fasteners  73 , e.g., screws, are used for that purpose.  
      The plates  70 R and  70 L are adjustable relative to the wall  12  of the manikin  10 . This allows for changing an orientation of the carotid transducers  59 R and  59 L and associated actuating studs  69 R and  69 L so that ends of the studs  69 R and  69 L are positioned in the holes  22 R and  22 L in the wall  12  of the manikin  10 . Each stud  69 R and  69 L is provided with an end-piece  74 R and  74 L to prevent damage of the outer layer of skin on which each stud  69 R and  69 L pushes against with each pulse. In order to adjust the L-shaped plates  70 R and  70 L relative to the wall  12  of the head  16 , two adjustment plates  76 R and  76 L are provided, as shown in  FIG. 5 . The adjustment plates  76 R and  76 L are mounted on the back of the neck  17  onto plate  72  using screws  77 R and  77 L. Each adjustment plate  76 R and  76 L has an elongated diagonal opening  78 R and  78 L, respectively. The screws  77 R and  77 L are inserted through the diagonal openings  78 R and  77 L, respectively. For example, by sliding adjustment plate  76 R forward or backward, with the screw  77 R guiding the movement of the plate through opening  78 R, the adjustment plate  76 R pushes against or pulls away from a side of the L-shape plate  70 R. As a result, the L-shaped plate  70 R tilts and moves relative to the plate  72 . Similarly, by sliding adjustment plate  76 L forward or backward, with the screw  77 L guiding the movement of the plate through opening  78 L, the adjustment plate  76 L pushes against or pulls away from a side of the L-shape plate  70 L. As a result, the L-shaped plate  70 L tilts and moves relative to the plate  72 . This relative movement of the L-shaped plates ( 70 R and  70 L) allows the position of the transducers to be adjusted and more specifically the position of the end of studs  69 R and  69 L so that the end pieces  74 R and  74 L are positioned inside the holes  22 R and  22 L and press on the skin layer covering the manikin.  
       FIG. 5  shows plate  58  on which transducers  60 R and  60 L simulating the jugular venous pulse (JVP) are mounted, according to an embodiment of the present invention. The plate  58  is mounted to the wall  12  of the manikin  10  using fasteners  80 , e.g. screws. The JVP transducers (right JVP transducer  60 R and left JVP transducer  60 L) are mounted to, respectively, L-shaped plates  82 R and  82 L. The L-shaped plates  82 R and  82 L are in turn mounted to the plate  58  using fasteners  83 R and  83 L for plate  82 R and fasteners  84 R and  84 L for plate  82 L. The L-shaped plate  82 R has elongated openings  85 R and  85 L through which fasteners  83 R and  83 L penetrate to attach the L-shaped plate  82 R to plate  58 , and L-shaped plate  82 L has elongated openings  86 R and  86 L through which fasteners  84 R and  84 L penetrate to attach the L-shaped plate  82 L to plate  58 . The elongated openings  85 R,  85 L,  86 R and  86 L allow the L-shaped plates  82 R and  82 L to move (translate and/or pivot) relative to the plate  58 . In this way, the position of the JVP transducers  60 R and  60 L and more specifically the position of the actuating members  87 R and  87 L connected to the transducers  60 R and  60 L, can be adjusted in various directions so as to orient and position the actuating members  87 R and  87 L so as the movement generated by the transducers reach their intended target at jugular positions  20 R and  20 L (shown in  FIG. 1 ).  
       FIG. 6  is an elevational view of the JVP transducers  60 R and  60 L with their respective actuating arm assemblies  90 R and  90 L, according to an embodiment of the invention. The actuating members  87 R and  87 L of JVP transducers  60 R and  60 L are connected to actuating arm assemblies  90 R and  90 L via connectors  91 R and  91 L. The actuating arm assemblies  90 R and  90 L each comprises three arms.  
      The actuating arm assembly  90 R comprises a first arm  92 RA fixedly attached to transducer  60 R and having an opening (not shown) through which actuating member  87 R extends. The actuating arm assembly  90 R further comprises a second arm  92 RB. Second arm  92 RB is connected to a forked end  93 R of first arm  92 RA via a hinge  94 R. The actuating member  87 R is connected through a slot in end  95 R of second arm  92 RB so that when the actuating member  87 R translates, the second arm  92 RB rotates around the hinge  94 R. The actuating arm assembly also comprises third arm  92 RC which is connected substantially perpendicularly to end  95 R of second arm  92 RB. In this way, a translation of the actuating member  87 R results in a rotation of second arm  92 RB around hinge  94 R which leads to an outward slightly arcuate movement of the third arm  92 RC (to the left of  FIG. 6 ).  
      Similarly, the actuating arm assembly  90 L comprises a first arm  92 LA fixedly attached to transducer  60 L and having an opening (not shown) through which actuating member  87 L extends. The actuating arm assembly  90 L further comprises a second arm  92 LB. Second arm  92 LB is connected to a forked end  93 L of first arm  92 LA via a hinge  94 L. The actuating member  87 L is connected through a slot in end  95 L of second arm  92 LB so that when the actuating member  87 L translates, the second arm  92 LB rotates around the hinge  94 L. The actuating arm assembly also comprises third arm  92 LC which is connected substantially perpendicularly to end  95 L of second arm  92 LB. In this way, a translation of the actuating member  87 L results in a rotation of second arm  92 LB around hinge  94 L which leads to an outward slightly arcuate movement of the third arm  92 LC (to the right of  FIG. 6 ). The third arms  92 RC and  92 LC are in contact with the outer flexible skin layer of manikin  10  at jugular pulse areas  20 R and  20 L (shown in  FIG. 1 ). Hence, respective movements of the JVP actuators  60 R and  60 L is transferred to the third arms  92 RC and  92 LC of actuating arm assemblies  90 R and  90 L which allow to simulate pulses of the jugular veins at area  20 R and  20 L.  
       FIG. 7  is a perspective view of chest plate or platform  62  which supports a plurality of transducers  64  including transducer  98 , transducer  99 , transducer  100  and transducer  102 , according to an embodiment of the present invention. The chest plate  62  is fastened to wall  12  of manikin  10  by using appropriate fixtures. Transducer  98  is configured to simulate pulmonary artery (PUL) pulse in area  28 . Transducer  99  is configured to simulate right ventricle (RV) pulse in area  30 . Transducer  100  is configured to simulate left ventricle (LV) pulse in area  32 . Transducer  101  is configured to simulate displaced left ventricle (DLV) pulse in area  34 . Each of the transducers  64  is provided with an actuator at an end of which is placed an end-piece. The end-piece is adapted to come into contact with the flexible outer layer or skin of the manikin. Each end-piece is shaped to fit into respective holes in areas  28 ,  30 ,  32  and  34  of the wall  12  of manikin  10 . In addition, each of the transducers  64  is adequately oriented so that its associated actuating member reaches its intended area. For example, DLV transducer  101  is oriented such that its associated actuating member reaches area  34  in the wall  12  of manikin  10 . Each of the transducers  64  including transducers  98 ,  99 ,  100  and  101  is attached to plate  62  by using brackets and/or fasteners disposed in a certain fastening configuration.  
       FIG. 8  shows an example of a fastening configuration, according to an embodiment of the invention. In this embodiment, transducer  64  is attached to plate  62  by a combination of fasteners  102  and  103 . A number of fasteners  102  (e.g., a combination of nuts and bolts), in this case three, hold the transducer  64  against the plate  62  while a number of fasteners  103  (e.g., screws), in this case two, push against a surface  104  of the transducer  64 . For example, the screws  103  are passed through threaded holes in plate  62  and push against the surface  104 . By providing this combination of fasteners, the transducers  64  can be adjusted, for example tilted, relative to the plate  62 . This can be done, for example, by unscrewing nuts of fasteners  102  and screwing fasteners  103  to a certain degree so that a desired orientation of the transducers  64  is achieved and finally tightening nuts of fasteners  102  to hold the transducer  64  in place. This fastening configuration may be suited in adjusting, for example, transducer  101  which is configured to simulate displaced left ventricle (DLV) pulse in area  34 .  
       FIG. 9  shows another example of a fastening configuration according to another embodiment of the invention. Similar to the configuration shown in  FIG. 8 , the transducer  64  is attached to plate  62  by a combination of fasteners  102  and  103 . A number of fasteners  102  (e.g., a combination of nuts and bolts), in this case four, hold the transducer  64  against the plate  62  while a number of fasteners  103  (e.g., screws), in this case four, push against a surface  104  of the transducer  64 . The transducers  64  can be adjusted, for example tilted, relative to the plate  62  by adjusting the different fasteners  102  and  103  in the manner described above. The fastening configuration shown in  FIG. 9  may in certain circumstances provide an enhanced control for adjustment compared to the fastening configuration shown in  FIG. 8 . This fastening configuration (shown in  FIG. 9 ) may be suited for adjusting, for example, transducer  98  which is configured to simulate pulmonary artery (PUL) pulse in area  28 , transducer  99  which is configured to simulate right ventricle (RV) pulse in area  30  and/or transducer  100  which is configured to simulate left ventricle (LV) pulse in area  32 .  
       FIG. 10  is a cross-sectional view of the manikin  10  around the lower abdomen area showing the position of the femoral transducers  68 R and  68 L, according to an embodiment of the invention. The femoral transducers  68 R and  68 L which are configured to simulate femoral pulses in areas  26 R and  26 L of the wall  12  of manikin  10  are supported by platform or plate  66 . The transducers  68 R and  68 L include actuating members  106 R and  106 L, respectively. Actuating members  106 R and  106 L include studs that are provided with end-pieces  107 R and  107 L. The actuating members  106 R and  106 L extend to reach the flexible outer layer  108  of the manikin  10  through holes in the wall  12  of the manikin  10  at areas  26 R and  26 L, respectively.  
       FIGS. 11 and 12  are perspective views of a transducer assembly used to generate brachial and radial pulses, according to an embodiment of the present invention. Transducer  110  is mounted on a plate  112 . The plate  112  is mounted on a wall  12  in arm  18  of manikin  12 . Transducer  110  comprises an actuating member  114  at an end of which is mounted a connector  116 . An actuating arm assembly  118  is connected to the transducer  110 . The actuating arm assembly  118  comprises a first arm  119  and a second arm  120 . The first arm  119  is an elongated bar that is fixedly attached at one end  121  to the body of transducer  110  using fasteners  122 . The first arm  119  has a forked end  124 . The second arm  120  has an L-like shape as shown more clearly in  FIG. 12 . The second arm  120  is connected to the forked end  124  of first arm  119  via a hinge  126 . The second arm  120  is driven by actuating member  114  via connector  116 . The second arm  120  has a slotted end. A pin through connector  116  rides in the slot to drive second arm  120 . When the actuating member  114  translates, the second arm  120  rotates around the hinge  126 . As a result an end  128  of second arm  120  pivots around hinge  126  as indicated by the double arrow in  FIGS. 11 and 12 . The end  128  of second arm  120  is in contact with the outer flexible skin layer of manikin  10  at brachial pulse area  24  (shown in  FIG. 1 ). Hence, the movement of transducer  110  is transferred to the second arm  120  of actuating arm assembly  118  to simulate the brachial and radial pulses.  
       FIG. 13  is an exploded view of a transducer used to generate pulses according to an embodiment of the present invention.  FIG. 14  is an elevational view of the transducer of  FIG. 13 . Transducer  130  depicted in  FIGS. 13 and 14  is an example of a transducer that can be used as carotid transducers  59 R,  59 L, jugular transducers  60 R,  60 L, femoral transducers  68 R,  68 t, pulmonary transducer  98 , right ventricle transducer  99 , left ventricle transducer  100 , displaced left ventricle transducer  101  and brachial and radial transducers  110  discussed above.  
      The transducer  130  comprises a first plate  132  and a second plate  134  spaced apart from the first plate  132 . The transducer  130  further comprises two elongated elements  136  configured to hold the first plate  132  and the second plate  134 . An armature  138  is slidably mounted on the two elongated elements  136 . The armature  138  is mounted between the first plate  132  and the second plate  134 . The armature  138  comprises a frame  140  and a solenoid  142  wound adjacent a periphery of the frame  140 . A rod  144  is attached to the frame  140  of the armature  138 . The rod  144  extends through an opening  146  in the second plate  134 .  
      The transducer  130  further comprises a first magnet  148  and a second magnet  150 . The first magnet  148  and the second magnet  150  are disposed between the first plate  132  and the second plate  134  facing each other and substantially perpendicular to the first plate  132  and the second plate  134 . The first magnet  148  comprises two juxtaposed first and second sub-magnets  148 A and  148 B. The second magnet  150  comprises two juxtaposed first and second sub-magnets  150 A and  150 B.  FIG. 15  is a lateral cross-section of the transducer  130  showing the relative position of the different magnets, according to an embodiment of the present invention. The two sub-magnets  148 A and  148 B have magnetic fields oriented substantially in opposite directions. For example as shown in  FIGS. 13 and 15 , sub-magnet  148 A is oriented north (N) facing armature  138  and sub-magnet  148 B is oriented south (S) facing armature  138 . Similarly, the two sub-magnets  150 A and  150 B have magnetic fields oriented substantially in opposite directions. For example, sub-magnet  150 A is oriented south (S) facing armature  138  and sub-magnet  150 B is oriented south (N) facing armature  138 .  
      In addition, the first magnet  148  and the second magnet  150  are positioned such that the first sub-magnet  148 A of the first magnet  148  is oriented (S to N) substantially in a same direction as the first sub-magnet  150 A of the second magnet  150 . Furthermore, the first magnet  148  and the second magnet  150  are positioned such that the second sub-magnet  148 B of the first magnet  148  is oriented (S to N) substantially in a same direction as the second sub-magnet  150 B of the second magnet  150 . Because the sub-magnets  148 A and  150 A face each other, the resultant magnetic field B 1  created by the two sub-magnets  148 A and  150 A is oriented S to N from the sub-magnet  150 A to the sub-magnet  148 A. Similarly, because the sub-magnets  148 B and  150 B face each other, the resultant magnetic field B 2  created by the two sub-magnets  148 B and  150 A is oriented S to N from the sub-magnet  148 B to the sub-magnet  150 B. Hence, the magnetic field B 1 , between sub-magnets  148 A and  150 A, and the magnetic field B 2 , between sub-magnets  148 B and  150 B, are substantially parallel but oriented in opposite directions.  
      When the solenoid  142  is energized by applying a current to electrodes  151  (shown in  FIGS. 13 and 14 ), the current produces an electromagnetic field B in the solenoid  142 . The direction of the current flow in the solenoid is shown in  FIG. 15  with an “X” to show that the current flows perpendicular to the plane of  FIG. 15  in a direction facing away from the viewer and with a “O” to show that the current flows perpendicular to a plane of the  FIG. 15  in a direction facing the viewer. As a result, the electromagnetic field B produced by the current has a same direction as the magnetic field B 1  and has an opposite direction to magnetic field B 2 .  
      The electromagnetic field B interacts with the respective magnetic fields B 1  and B 2  to generate a force F (indicated by an arrow in  FIGS. 13 and 15 ) that moves the armature  138  along the elongated elements  136 . In other words, the magnetic field B being opposite to magnetic field B 2  and in the same direction as magnetic field B 1 , would force the solenoid  142  (hence the armature  138 ) to move such that the magnetic field B “leaves” the space between sub-magnets  148 B and  150 B covered by magnetic field B 2  (which is opposite to magnetic field B) to substantially align with magnetic field B 1  (which is in the same direction as magnetic field B). Explained differently, electromagnetic field B interacts with the magnetic field B 1  to generate a first force component and interacts with the magnetic field B 2  to generate a second force component. The first force component and the second force component are compounded to form the force F that moves the armature.  
      The generated force F is substantially perpendicular to the electromagnetic field B generated by the application of current in the solenoid  142 . By providing two magnets  148  and  150 , each having two sub-magnets, respectively,  148 A and  148 B and  150 A and  150 B positioned in the manner discussed above, the generated force F has a magnitude twice a magnitude of a force generated by a conventional transducer.  
      In an embodiment of the invention, the first magnet  148  and the second magnet  150  are permanent magnets. However, it must be appreciated that electromagnets can be used instead or in combination with permanent magnets. In an embodiment of the invention, the frame  140  of the armature  138  is formed from a plastic. However, other materials are also within the scope of the present invention. In an embodiment of the invention, the first and second plates  132  and  134  are made of a metal such as aluminum. However, other suitable materials may be used instead or in combination with aluminum. The frame  140  of armature  138  has a U-like shape and the rod  144  is mounted on a base of the U-like shape. However, other shapes, such as frame-like shapes, are also contemplated.  
      In an embodiment of the invention, magnet backing plates  154  and  156  are provided to hold, respectively, the first magnet  148  and the second magnet  150  between the first and second plates  132  and  134 . In an embodiment of the invention, the magnet backing plates  154  and  156  are made of nickel plated steel. Nickel plating is used as a rust inhibitor. However, it must be appreciated that other materials (e.g., high permeability materials) are also contemplated herein. The backing plate  154  and magnets  148 A and  148  B effectively create a horseshoe magnet with twice the field of the magnets taken individually. Similarly, the backing plate  156  and magnets  150 A and  150 B create a second horseshoe magnet oppositely polarized. In this way, the magnetic field to which the solenoid  142  is exposed is increased over that of individually paired magnets. In addition by providing the backing plates  154  and  156 , the backing plates help to channel the lines of magnetic field and the magnetic field is contained within the area where the solenoid is disposed.  
      The transducer  130  further includes a resilient member  152 A disposed around the rod  144  between the second plate  134  and the frame  140  of the armature  138 . The transducer  130  also includes a resilient member  152 B disposed around the rod  144  between the second plate  134  and a stop  143  coupled to the rod  144 . In this embodiment, the resilient members  152 A and  152 B are springs. However, it must be appreciated that other resilient members, such as flexible rubbers or plastics or the like, may be used instead or in combination with a spring. A washer  153 A is provided so that the resilient member  152 A does not escape through the hole  146  in plate  134  to bias the frame  140  of the armature  138  toward the first plate  132 . A washer  153 B is also provided so that the resilient member  152 B does not escape through the hole  146  in plate  134  to bias the frame  140  of the armature  138  toward the second plate  134 . When a current is applied to the solenoid  142 , the force F generated by the current overcomes the biasing force of the resilient member  152 A which acts in opposite direction to force F. The force generated by the solenoid  142  is equal to the number of turns in the solenoid times the current flowing through the solenoid  142  (F=n.i). Since the number of turns (n) is fixed, the force F is directly proportional to the current (i). On the other hand, the force generated by a spring is equal to the constant of the spring times the displacement (F′=k.A, where k is the constant of the spring and A is the displacement). Therefore, the force of the springs varies directly proportionally with the displacement A. Because spring  152 A provides a force F′ opposite the force F generated by the solenoid, a bipolar current may not be needed to return the solenoid to its neutral position. If the current in the solenoid  142  is interrupted or is diminished to a certain level, the force generated by the spring  152 A overcomes the force generated (if any) by the solenoid  142 . The spring  152 B is provided to counteract the force generated by spring  152 A so as to establish a neutral position in which armature  138  is slightly displaced from frame  132 . Hence, the combination of the two resilient members  152 A and  152 B serve to maintain the frame  140  of the armature  138  at a desired neutral position when the solenoid  142  is not energized. This allows, among others, a consistent initial position of the armature with each application of current. As a result, a better control the movement of the armature  138  during the application of a current to the solenoid  142  can be achieved.  
      When a current is applied to the solenoid  142 , the armature  138  and associated rod  144  move in a direction of force F to push against the flexible skin area of the wall of the manikin. When the current in the solenoid  142  is diminished, armature  138  and associated rod  144  move in a direction away from the flexible skin area of the wall of the manikin. When the current in the solenoid  142  is interrupted, the force F generated by the interaction of electromagnetic field in the solenoid  142  with the magnetic fields of magnets  148  and  150  ceases. As a result, the biasing force of the resilient member  152 A takes over and pushes the armature  138  back towards the neutral position, guided by the elongated elements  136 . Because the rod  144  is attached to the armature  138 , the rod follows the translating movement of the armature  138 . As a result, the next time a current is applied to the solenoid  142 , the armature  138  and associated rod  144  would move from the neutral position.  
      This back and forth movement of the armature  138  and coupled rod  144  allows to simulate, for example, cardiovascular pulses in specific areas in the manikin  10  (for example, areas shown in  FIG. 1 ). Hence, by controlling the intensity and frequency of the current in the solenoid  142 , the magnitude, the direction and repetition of the resultant force F can be controlled and as a result the shape and/or frequency of, for example, the cardiovascular pulses can be controlled.  
      An end-piece or bumper member  155  and  107 L and  107 R (shown, for example, in  FIGS. 7 and 10 ) are provided at the end of the rod  144 . The shape of any of the bumper members  155 ,  107 L and  107 R can be selected depending on desired parameters. For example, the shape of the bumper member can be selected depending on its location and/or its function so as to approximate the size and shape of the pulse it mimics. The bumper member is positioned in a hole portion (for example, hole  22 R) in the wall  12  of the manikin  10  so as to be in contact with the flexible skin area. When the transducer is energized, the rod  144  moves back and forth against the flexible skin area to simulate cardio-vascular pulses (for example, carotid pulses). The bumper member  155  provides a cushion so that when the rod pushes against the skin portion in a hole portion corresponding to a specific cardio-vascular area, the rod does not perforate or damage the skin area.  
       FIG. 16  is another rear elevational view of the manikin  10  with a cutaway in the lower section of opening  54  to show an arm assembly  160  used to hold an abdominal plate  162  (shown also in  FIG. 3 ). The arm assembly  160  comprises a lever  164  and a hinge  166 . The lever  164  is rotatably connected at one end to the hinge  166  via connector  167 . The hinge  166  is fastened to base portion  170  of manikin  10  using fasteners  171 . The base portion  170  closes the cavity  14  of manikin  10  around the thigh part of the manikin  10 . The lever  164  is shown in  FIG. 16  having a cylindrical shape. However, it must be appreciated that lever  164  can have any other suitable shape including, for example a parallelepiped shape and a hexagonal shape. The lever  164  is fastened at its other end to abdominal plate  162 . In an embodiment of the invention, the abdominal plate  162  is a cut portion of wall  12  of manikin  10 . The abdominal plate  162  is cut from the wall  12  so as to permit a movement in the area  46  of the skin of the manikin (shown in  FIG. 1 ) to simulate a breathing movement in the abdomen. Because the plate  162  is not attached to the wall  12 , the plate  162  is held in place by using arm assembly  160 .  
      A breathing mechanism  174  is provided in the cavity  14  of manikin  12  to move the plate  162  in a direction generally perpendicular to the plate  162 . The breathing mechanism  174  is attached to a support plate  176  with fasteners  177 . The support plate  176  is fastened to wall  12  of manikin  10 . The breathing mechanism  174  comprises a pulley assembly  178  and a motor  179 .  
       FIGS. 17, 18  and  19  are various views of the breathing mechanism  174 , according to an embodiment of the invention. The pulley assembly  178  comprises a plurality of pulleys  180 A,  180 B and  180 C.  FIG. 17  is a perspective view of the breathing mechanism  174  showing the position of various pulleys  180 A,  180 B and  180 C in the pulley assembly  178  and the motor  179 .  FIG. 18  is a top view of the pulley assembly  178  showing the relative positioning of the various pulleys  180 A,  180 B and  180 C. The motor  179  is mounted onto a first plate  182 . The first plate  182  has a hole  183  (shown in  FIG. 18 ) through which a drive shaft  184  of the motor  179  penetrates. The pulley  180 A is mounted to the drive shaft  184  of the motor  179 . The pulley  180 B is fixedly mounted onto a rod  186 . The rod  186  is rotatably mounted to plate  182  and is spaced apart from drive shaft  184 . A serpentine belt  188  links pulley  180 A to pulley  180 B so that a rotation of the drive shaft  184  of motor  179  is transferred to the pulley  180 B. The pulley  180 C is fixedly mounted onto a rod  189 . The rod  189  is rotatably mounted to plate  182  and is spaced apart from drive shaft  184  and the rod  186 . A serpentine belt  190  links rod  186  to pulley  180 C. Hence, a rotation of the pulley  180 B, which translates into a rotation of the rod  186 , transfers via the serpentine belt  190  to pulley  180 C. The rotation of pulley  180 C translates into a rotation of rod  189 . Tightening belt devices or idler rollers  192 A and  192 B are provided in the pulley assembly  178  to tense the serpentine belts  188  and  190  or to hold the serpentine belts  188  and  190  against the various pulleys. The pulley assembly  178  is enclosed between the first plate  182  and a second plate  192 . The second plate  192  is mounted spaced apart from the first plate using spacer rod  191 . The rod  189  penetrates through a hole (not shown) in the second plate  192  to link with a crank  194  (Shown in  FIG. 19 ).  
       FIG. 19  is a top perspective view of the breathing mechanism  174  showing an end  195  of the rod  189  linked with the crank  194 . The end  195  of rod  189  has a double-D configuration which intimately fits into a first hole  193 A in crank  194 . With this configuration, a rotation of the rod  189  is transmitted to the crank  194 . The crank  194  has a second hole  193 B through which a crank shaft  196  is mounted. The crank shaft  196  is allowed to freely rotate in the second hole  193 B. C-clips  198  are used around grooves at each end of the crank shaft to rotatably mount the crank shaft  196  onto crank  194 . An arm  200  is mounted to crank shaft  196  through a hole  199  provided at an end of the crank shaft  196 .  
      A back and forth rotation of the motor  179  would transfer to a rotation of the rod  189 . A back and forth rotation of the rod  189  would result in a back and forth rotation of the crank  194 . Because the crank shaft  196  is allowed to freely rotate in the second hole  193 B of the crank  194 , the back and forth rotation of the crank  194  is transmitted as a back and forth translation of the arm  200 . A universal joint  202  is mounted at an end  204  of arm  200 . The universal joint  202  is attached to the abdominal plate  162  (shown in  FIGS. 3 and 16 ). Hence, a back and forth translation of the arm  200  would result in the joint  202  moving the abdominal plate  162 . The universal joint  202  is a joint with a certain flexibility. The universal joint  162  can accommodate a large angular variation between its input at a connecting end with the extremity  204  of rod  200  and its output end attach to the abdominal plate  162 . The universal joint  202  serves to transmit the motion of arm  200  to the abdominal plate  162  even in instances where the arm  200  is not perpendicular to the abdominal plate  162 .  
      The breathing mechanism  174  further comprises a position sensor  210  such as a linear potentiometer. The position sensor  210  is configured to sense the movement and thus the position of abdominal plate  162  using adjustable sensing tip  212 . The position sensor  210  provides a feedback electrical signal via a feedback loop to an input of motor  179  to control the rotation of the driving shaft  184  of motor  179  and hence control the transfer of movement of arm  200  to abdominal plate  162 .  
      The cardiopulmonary simulator (CPS) further comprises a controlling device.  FIG. 20  is an electronic diagram of the controlling device and other devices and systems used in the CPS, according to an embodiment of the present invention. In an embodiment of the invention, the controlling device  300  is housed in a housing of table top  50  (shown in  FIGS. 2 and 16 ). The controlling device  300  electrically communicates with the plurality of electromechanical transducers  302 , for example, right and left carotid transducers  59 R,  59 L, right and left jugular transducers  60 R,  60 L, right and left femoral transducers  68 R and  68 L, pulmonary transducer  98 , right ventricle transducer  99 , left ventricle transducer  100 , displaced left ventricle transducer  101  and brachial and radial transducers  110  described above. The controlling device  300  is configured to control the plurality of electromechanical transducers  302  by applying a plurality of sets of electrical signals. Each set of electrical signals corresponding, respectively, to one of a plurality of health conditions. The plurality of sets of electrical signals are generated by inputting a corresponding plurality of data sets via user interface  303 , for example user interface  52  (shown  FIG. 2 ), into a memory device  304  of the controlling device  300  and running a computer program using computer processing unit (CPU)  306  in the controlling device  300 . The computer program comprises a set of instructions to generate the plurality of sets of electrical signals. In an embodiment of the invention, the user interface  303  may include a keypad, a mouse, a joystick, etc. The user interface  303  may further include a display device, such as an electro-fluorescent display or a liquid crystal display to display the status of the CPS.  
       FIG. 21  is an electronic diagram of the chain of components used for controlling the electromechanical transducers  302 , according to an embodiment of the present invention. The controlling device  300  sends an electric signal to a pulse driver module  400 . The pulse driver module  400  is connected to a digital-to-analog converter  402  for converting the digital signal provided by the controlling device  300  into an analog signal. The analog signal is multiplied for amplitude scaling by multiplier  404 . The amplitude scaled analog signal is sent to 6 th  order Butterworth filter  406  for frequency filtering. A Butterworth filter is a lowpass filter designed to have a flat frequency response in the passband range. The filtered analog signal is then sent to power amplifiers  408  for amplifying the power of the analog signal. The amplified signal is transferred to a current servo  410  for driving pulse transducers such as, for example, carotid transducers  59 R,  59 L and jugular transducers  60 R,  60 L and/or sent to position servo  412  for driving the breathing mechanism  174 .  
      As stated above, the plurality of electromechanical transducers  302  are disposed in the cavity  14  of manikin  10 . The plurality of electromechanical transducers  302  comprise mechanical components (for example actuators or studs  69 R,  69 L,  106 R and  106 L), coupled to selected parts of the wall  12  of the manikin  10  (for example, carotid areas  22 R and  22 L and jugular areas  20 R and  20 L). As described above, the plurality of electromechanical transducers  302  are configured to produce simulated movements of the selected parts of the wall  12  of the manikin  10 . The plurality of transducers  302  are configured to move the selected parts of the wall  12  in a predetermined manner. In an embodiment of the invention, the controlling device  300  controls the plurality of transducers  302  such that the relationship between corresponding bilateral movements of the selected parts of the wall  12  of the manikin  10  is different from one health condition to another health condition in the plurality of health conditions. In an embodiment of the invention, an intensity of an electrical signal in the set of electrical signal is controllable relative to other intensities of other electrical signals in the set of electrical signals.  
      The set of data in the plurality of sets of data can be selected using the user interface  303  for processing by the computer program using CPU  306  at any given moment during the progress of a simulation. The set of data is sampled from a desired curve-function corresponding, for example, to a shape of heart beat or a certain cardiovascular pulse.  
      In an embodiment of the invention, the controlling device  300  comprises a plurality of memory devices  304 , each of which carries a different set of data corresponding to a health condition. The set of data are input into a computer program, via user interface  303 , when executed by the CPU  306  of the controlling device  300  generates the plurality of electrical signals to control the plurality of electromechanical transducers  302 .  
      In another embodiment of the invention, the controlling device  300  comprises a memory device  304  and a plurality of buffers  308 . The memory device  304  is configured to carry a plurality of sets of data corresponding to a plurality of health conditions. Each of the plurality of buffers  308  carries a different set of data corresponding to one of the health conditions. A set of data in one of the plurality of buffers  308  are used by the computer program when executed by the CPU  306  of controlling device  300  to generate the plurality of electrical signals to control the plurality of electromechanical transducers  302  to simulate one of the health conditions. In an embodiment of the invention, the computer program is selectable to run with input data from any one of the plurality of buffers  308  at any desired time. Hence, the computer program can be switched at any time of the simulation to run with a specific input data from any one of the plurality of buffers.  
      The cardiopulmonary simulator further comprises a plurality of electromagnetic switches  310 . The electromagnetic switches  310  are disposed inside the cavity  14  of manikin  10  adjacent a portion of the wall  12  of the manikin  10 . The plurality of electromagnetic switches  310  are in electrical communication with the controlling device  300 . The CPS also includes a sound device  312  in communication with the controlling device  300  and a mock stethoscope (activating device)  314  configured to activate at least one of the electromagnetic switches  310 . When the mock stethoscope  314  is applied on the portion of the wall  12  of manikin  10 , the mock stethoscope  314  interacts with at least one of the plurality of electromagnetic switches  310  to activate the sound device  312  to emit an audio signal selected from a library of audio signals saved in the memory  304  of the controlling device  300 .  
      In an embodiment of the invention, the electromagnetic switches comprise magnetic reed switches. A reed switch is an electric switch which generally consists of a pair of ferrous metal contacts in a hermetically sealed glass envelope. A permanent magnet placed in close proximity to the switch will cause the ferrous metal contacts to pull together, thus completing an electrical circuit hence allowing an electrical signal to be transmitted therethrough.  
      The mock stethoscope  314  in the present case is different from a conventional medical stethoscope used for listening to internal sounds in the body. In the present case, the mock stethoscope  314  is provided with a magnet (e.g., a permanent magnet) so that the mock stethoscope  314  can interact with at least a portion of the reed switches  310  and allow an electrical signal to propagate to the controlling device  300  which activates the sound device  312 . In an embodiment of the invention, the sound device  312  can be incorporated in the ear pieces of the mock stethoscope  314 . In another embodiment, the sound device is separate from the mock stethoscope  314 , for example, the sound device  312  may comprise a set of audio speakers to allow a plurality of students to listen to the audio signal. In an embodiment of the invention, the electromagnetic switches  310  are configured into a grid to cover substantially cardiac ausculatory areas which include aortic area (AOR)  36 , pulmonary area (PUL)  38 , tricuspid area (TA)  40 , mitral area (MA)  42 , mitral radiation area (MR)  44  and breathing pulmonary auscultation which include the right upper quadrant lung field (RUQ)  48 A, the left upper lung quadrant lung field (LUQ)  48 B, the right lower posterior lung field (RLP)  48 C, right lower anterior lung field (RLA)  48 D, the left lower posterior lung field (LLP)  48 E and the left lower anterior lung field (LLA)  48 F (shown in  FIG. 1 ).  
       FIG. 22  is an electronic diagram of a chain of components used to control the sound device  312 , according to an embodiment of the present invention. The controlling device  300  sends an electric signal to a heart/breath sound generation module  420 . The heart/breath sound generation module  420  is connected to a digital-to-analog converter  422  for converting the digital signal provided by the controlling device  300  into an analog signal. The analog signal is multiplied for amplitude scaling by multiplier  424 . The amplitude scaled analog signal is sent to 6 th  order Butterworth filter  426  for frequency filtering. The filtered analog signal is then sent to power amplifiers  428  for amplifying the power of the analog signal. The amplified signal is transferred to sound device  312 . The sound device  312  may include, for example, an audio system  430  such as audio speakers which can be wired or wireless, earphones which can be wired or wireless, stethophones  432  and other auxiliary audio outputs  434 . Stethophones  432  can be, for example, part of the mock stethoscope  314 .  
      In an embodiment of the invention, each audio signal in the library of audio signals corresponds to one of a plurality of health conditions. In an embodiment of the invention, a frequency and/or amplitude of each audio signal in the library of audio signals correlates with a frequency and/or amplitude of each of the plurality of sets of electrical signals in a corresponding health condition in the plurality of health conditions. In an embodiment of the invention, a relationship between corresponding bilateral sounds of selected parts of the wall of the body is different from one health condition to another health condition in the plurality of health conditions. The audio signal includes, for example, a cardiovascular sound such as heart valve closure, breathing sounds, etc.  
      In an embodiment of the invention, an intensity of the audio signal is controllable relative to intensities of other sounds. For example, the intensity of the audio signal can be controllable such that the audio signal is discernible over ambient sounds.  
      In an embodiment of the invention, the mock stethoscope  314  interacts with one or a group in the plurality of electromagnetic switches  310  (for example reed switches) to activate the sound device  312  to emit one sound and interacts with another one or another group in the plurality of electromagnetic switches  310  to activate the sound device  312  to emit another sound which is different from the first mentioned sound.  
      The CPS includes an electromagnetic switch  310  (see  FIG. 20 ) disposed inside the cavity  14  of the manikin  10 . The electromagnetic switch  310 , for example a reed switch, is positioned adjacent a portion of the wall of the arm  18  of manikin  10  (see  FIG. 1 ). The electromagnetic switch  310  is in electrical communication with the controlling device  300 .  
       FIG. 23  is an electronic diagram of a chain of components used to control brachial sounds, according to an embodiment of the present invention. The controlling device  300  sends an electric signal to a brachial sound generation module  440 . The brachial sound generation module  440  is connected to a digital-to-analog converter  442  for converting the digital signal provided by the controlling device  300  into an analog signal. The analog signal is multiplied for amplitude scaling by multiplier  444 . The amplitude scaled analog signal is sent to 6 th  order Butterworth filter  446  for frequency filtering. The filtered analog signal is then sent to power amplifiers  448  for amplifying the power of the analog signal. The amplified signal is transferred to sound device  312  (see  FIG. 20 ). The sound device  312  may include for example an audio system  450  for generating brachial artery blood flow sounds.  
      The CPS further includes a cuff  320  (shown in  FIG. 2 ) disposed around the arm  18  of manikin  10 . The cuff  320  is provided with an inflating device  340  configured to inflate the cuff  320  around the arm  18 . The inflating device is connected to a pressure sensor  321  connected to the controlling device  300  (see  FIG. 20 ). The pressure sensor  321  can be disposed, for example, inside the housing of the table top  50 . The pressure sensor  321  is configured to measure a pressure generated by the cuff  320 .  
      In a real patient, the cuff is wrapped around the upper arm and is inflated to a pressure exceeding that of the brachial artery. This amount of pressure collapses the artery and stops the flow of blood to the arm. The pressure of the cuff is slowly reduced as the pressure in the cuff is monitored by a pressure transducer. As the pressure drops, it will eventually match the systolic (peak) arterial pressure. At this point, the blood is able to “squirt” through the brachial artery. This squirting results in turbulence which creates the Korotkoff sounds. The Korotkoff sounds are detected using a stethoscope, for example. As the cuff pressure continues to drop, the pressure will eventually match the diastolic pressure of the artery. At this point the Korotkoff sounds stop completely, because the blood is now flowing unrestricted through the artery.  
      In the case of the CPS, when the mock stethoscope  314  (see  FIG. 20 ) is applied on the portion of the arm  18  where the electromagnetic switch  310  is disposed and when the pressure measured by the pressure sensor is above a first pressure (diastolic pressure) and below a second pressure (systolic pressure), the mock stethoscope  314  interacts with the electromagnetic switch  310  to activate the sound device  312  (for example, audio system  450  shown in  FIG. 23  which, in one embodiment, may be in the ear pieces of the mock stethoscope  314 ) to emit an audio signal corresponding to Korotkoff sounds. When the pressure measured by the pressure sensor is above the second pressure (systolic pressure), the sound device does not emit Korotkoff sounds. When the pressure measured by the pressure sensor is below the first pressure (diastolic pressure), the sound device does not emit Korotkoff sounds. The diastolic and systolic pressures are selected according to preset health condition(s). The diastolic and systolic pressures are input into the CPS via user interface  303  and are saved in memory  304  of controlling device  300 .  
      As stated above, the plurality of sets of electrical signals are generated by inputting a corresponding plurality of data sets via user interface  303 , into a memory device  304  of the controlling device  300  and running a computer program using computer processing unit (CPU)  306  in the controlling device  300 . The computer program comprises a set of instructions when executed by the CPU  306  generates the plurality of sets of electrical signals. Hence an aspect of the present invention is to provide a method for generating the set of electrical signals.  
      In an embodiment of the invention, as illustrated in  FIG. 24 , the method comprises creating a pulse profile, at step S 10 , sampling the pulse profile, at step S 20 , and converting the pulse profile into a two dimensional data, at step S 30 . The method further includes removing any tilt so that a beginning and ending of the two dimensional data are flat, at step S 40  and determining pixel to timing conversion based on timing data using first heart sound time location S 1  and second heart sound time location S 2 , at step S 50 . The method further includes adding dead space (a time interval with zero amplitude) to the beginning and end of the two dimensional data and, for example, making a period of the two dimensional data approximately one second and normalizing an amplitude of the two dimensional data, at step S 60 . The method progresses by performing a Fourier transform and transforming the two dimensional data to a Fourier series at get into the frequency domain, at step S 70  followed by introducing a phase shift for S 1 /S 2  such that the first and second heart sounds S 1  and S 2  are timed properly, at step S 80 . Specifically, the timing of the CPS is shifted so that S 1  occurs at 0. The method further includes performing an inverse Fourier transform, to get back to the time domain, for example, every 0.5 ms at 2 KHz sampling rate and normalize again, for example, to 12-bit scale of 0 to 4095.  
      The pulse profile can be generated, for example, by drawing on a sheet of paper and scanning the drawing in the sheet of paper and saving the drawing as an image file, for example as a bit-map (BMP) file. The profile may also be generated by drawing a pulse profile on an electronic tablet linked to a computer and thus directly saving the drawing as a data file, e.g. a BMP file. By using this method a medical doctor can create any pulse shape and thus provide various sets of health conditions to the CPS.  
      A further aspect of the present invention is to provide a method for generating breathing movement. In an embodiment of the invention, as illustrated in  FIG. 25 , the method includes generating a breathing profile from a breathing timing file, at step S 110 , generating pulse calibration files, at step S 120 . In one embodiment, the breathing rate is set at 5 seconds. However, the breathing rate may be set to any rate. The method progresses by writing generic disease information table into a binary file on a memory, at step S 130 , writing heart and breathing sound maps to a binary file on a memory, at step S 140 , and writing pulse sound and breathing volume tables to a binary file on a memory, at step S 150 . In an embodiment of the invention, the heart pulses are synchronized with the heart sounds. The method further includes writing pulse amplitude table to a binary file on a memory, at step S 160 , and writing disease sound and breath files to a binary file on a memory, at step S 170 . The method further includes, interleaving the pulse profiles (for example  16  pulse profiles) into a single pulse data record, at step S 180  and write interleaved pulse data record to binary file on a memory, at step S 190 . At this stage, a test is performed to determine if all disease data are written, at step S 200 . If all diseases data is written then the method ends. If all the disease data is not written, then there the method repeats starting at step SI  70 .  
      The cardiovascular (e.g. heart) sounds and breathing sounds are recorded and gathered in a database for building a library of sounds for various health conditions and at various locations in a body of one or more patients. In addition or alternatively, some or all the sounds (breathing sounds or cardiovascular sounds) may also be synthesized, i.e. not recorded from a real patient. The sounds may be synthesized using one or more sound generating devices. The sounds can be synchronized with the pulse (e.g. heart beat) by timing S 1  and S 2  relative to the “S 1  and S 2 ” of the sounds. In other words, S 1  and S 2  are used as references in the generation of a breathing and/or heart sound.  
      Therefore, a further aspect of the present invention is to provide a method for generating a pulse and a sound and coordinating and/or synchronizing between the pulse and the sound within the CPS. In an embodiment of the invention, the method includes providing an interrupt timer within CPU  306  for generating the sound and/or pulse, at step S 2   10 . In this embodiment, this occurs every 0.5 msec., but the timing can be varied. The method further includes retrieving a heart sound for an activated stethoscope region, at step S 215 , and weighing and adding sounds using heart and breathing sound amplitudes, at step S 220 . The method progresses by outputting to sound digital-to-analog (D/A) converter, at step S 225  and outputting sound volume in sound multiplying D/A converter, at step S 230 .  
      The method further includes retrieving a pulse profile from an interleaved pulse data stream, at step S 235 , outputting to pulse D/A converter, at step S 240 , and outputting pulse amplitude to pulse multiplying D/A converter, at step S 245 . The method further includes selecting a pulse site on a pulse multiplexer, at step S 250 . Following selecting the pulse site, incrementing a location of the pulse site and reset to overflow, at step S 255  and incrementing the sound counter and reset to overflow, at step  260 . The method may then repeat by returning to step S 210  and starting the timer.  
      The pulses, i.e. the pulse wave forms, are sampled at 2 kilohertz but in reality each pulse is only sampled at one sixteenth ( 1/16) of that. So every time a sound is generated one of sixteen possible pulses is sampled. Each pulse is 0.5 ms in duration and one pulse occurs every 8 ms. However, if one pulse occurs every 8 ms, that translates into a 125 Hz signal. The actual bandwidth of the pulse signal itself is only 20 hertz. To be accurate, i.e. within Nyquist criterion, the signal would need to be sampled at a frequency of 40 hertz. So there is a margin of three higher.  
      A further aspect of the present invention, is to provide a method controlling the control device and generating and/or timing various pulses and/or sounds in various areas of the CPS. In an embodiment of the invention, the method includes initiating CPU  306  of the CPS and initiating all software variables at step S 300  as illustrated in  FIG. 27 ,and reading disease information from memory  304  or other memory in communication with to CPU  306  at step S 310 . For example, at least two diseases can be loaded in buffers  308  so as to be accessible at any time during the progress of the method.  
      The method further includes initializing the sound and/or pulse timer interrupt, at step S 315  and enabling pulse actuator power, at step  320 . The method progresses by updating pulse and sound and perform diagnostic and calibration, at step S 325  and testing if brachial blood pressure timer is greater than 100 ms. If the timer is greater than 100 ms, the brachial blood pressure (BP) is read, at step S 335 . If the timer is less than 100 ms, the reed switches are queried at step S 365 . When the brachial blood pressure is read at step S 335 , the method progresses by performing another test at step S 340  to determine if the brachial blood pressure is between the systolic and diastolic blood pressure. If the brachial pressure is between the systolic and diastolic pressure, the controlling device  300  controls the sound device  312  to generate the Korotkoff sounds, at step S 350 . If the blood pressure is not between the systolic and diastolic pressure (for example higher than the systolic pressure or lower than the diastolic pressure), the controlling device  300  shuts off the Korotkoff sounds.  
      The method further includes inquiring if the cuff-timer is greater than 100 ms, at step S 355 . If the cuff-timer is greater than 100 ms, the scale factor for the radial and brachial pulses is determined and re-initialize the cuff-timer, at step S 360 . If the cuff-timer is less than 100 ms, the method progresses by querying the switches (e.g. Reed switches), at step S 365 . After determining the scale factor for the radial and brachial pulses, at step S 360 , the method also progresses by querying the switches, at step S 365 . At step S 365  a determination is made as to the status of the reed switches. If the brachial switch is activated, i.e. the stethoscope is on the brachial, the method progresses by performing a sub-routine, at step S 370 , to determine a brachial blood pressure and disease correspondence which includes starting the blood pressure timer and which will be discussed in more detail in the following paragraphs. If none of the switches is activated the blood pressure timer is disabled and the sounds are disabled, at step S 375 . For example, if the stethoscope is anywhere but in the right brachial, the blood pressure timer is disabled and the sounds are disabled. If other switches except the brachial switch, are activated, the blood pressure timer is disabled and the sounds are updated, at step S 380 . The sounds are updated by tracking where the stethoscope is positioned, i.e., which switch is activated by the stethoscope, and updating the sound data value. For example, the sound data value is updated if the stethoscope moves from the aortic to the pulmonary so that the sound value corresponds to the pulmonary.  
      In an embodiment of the invention, the subroutine S 370  of the above method, includes the starting the blood pressure timer, at step S 400  (see  FIG. 28 ) and querying the interface  52  (see  FIG. 2 ). If the amplitude of the breath, pulse or heart are changed, at step S 415 , the method progresses by updating variable and updating the display in interface  52 , at step S 420 . If a new disease is entered via interface  52  in  FIG. 2 , the information about the requested disease is transferred from the memory to the RAM of the controlling device  300 . If on the other hand a power off command is entered, the controlling device powers off and thus pulses and sounds are turned off.  
      While various embodiments of the present invention have been described above, it should be understood that they have been presented by way of example, and not limitation. It will be apparent to persons skilled in the relevant art(s) that various changes in form and detail can be made therein without departing from the spirit and scope of the present invention. In fact, after reading the above description, it will be apparent to one skilled in the relevant art(s) how to implement the invention in alternative embodiments. Thus, the present invention should not be limited by any of the above-described exemplary embodiments.  
      Moreover, the method and apparatus of the present invention, like related apparatus and methods used in robotic or simulation arts are complex in nature, are often best practiced by empirically determining the appropriate values of the operating parameters, or by conducting computer simulations to arrive at best design for a given application. Accordingly, all suitable modifications and equivalents should be considered as falling within the spirit and scope of the invention.  
      In addition, it should be understood that the figures, are presented for example purposes only. The architecture of the present invention is sufficiently flexible and configurable, such that it may be utilized in ways other than that shown in the accompanying figures.  
      Further, the purpose of the Abstract of the Disclosure is to enable the U.S. Patent and Trademark Office and the public generally, and especially the scientists, engineers and practitioners in the art who are not familiar with patent or legal terms or phraseology, to determine quickly from a cursory inspection the nature and essence of the technical disclosure of the application. The Abstract of the Disclosure is not intended to be limiting as to the scope of the present invention in any way.