Patent Publication Number: US-9905135-B2

Title: Medical device and procedure simulation and training

Description:
CROSS-REFERENCE TO RELATED APPLICATIONS 
     This application is a continuation-in-part of and claims priority in U.S. patent application Ser. No. 14/165,485, filed Jan. 27, 2014, which is a continuation-in-part of U.S. patent application Ser. No. 13/597,187, filed Aug. 28, 2012, which is a continuation-in-part of U.S. patent application Ser. No. 11/751,407, filed May 21, 2007, now U.S. Pat. No. 8,251,703, issued Aug. 28, 2012. The contents of all of the aforementioned applications are incorporated by reference herein in their entireties. 
    
    
     BACKGROUND OF THE INVENTION 
     1. Field of the Invention 
     The present invention relates to healthcare simulation, and in particular to a portable, dedicated display device, such as a touch-screen monitor, for displaying simulated, noninvasively-obtained vital signs from a healthcare instructional scenario programmed into a computer for conducting the scenario and controlling the monitor display and the simulated physiological functions of a mannequin or other patient model corresponding to the displayed vital signs. The present invention also relates to medical devices and procedures, and more particularly to medical device and procedure simulation and training systems and methods. 
     2. Description of the Related Art 
     The field of patient monitoring with electronic display devices, such as bedside monitors, is well-developed and standard for critical (intensive) care units (ICUs) at many institutions and for many surgical procedures. Patient rooms in critical care units and operating rooms (ORs) at many institutions are equipped with monitors, which receive inputs from electrodes and other input instruments connected invasively and noninvasively to patients. The monitors commonly provide displays corresponding to patient data, such as blood pressure, pulse rate, temperature, electrocardiographic heart rhythm strips, central venous pressure, pulmonary artery pressure, cardiac output, intracranial pressure, pulmonary pressure and other signals from catheters and transducers. Ventilator pressure can be utilized in connection with ventilator monitoring. Gas content analyzers can directly display gas partial pressures for anesthesiology and measured and calculated ventilator pressures for pulmonary functions. 
     Patient physiological instrumentation and monitoring equipment can provide output in a wide variety of formats corresponding to instantaneous (real-time) and historical patient data and vital signs. Analog (e.g., continuous wave-form) and digital readout displays and graphical user interfaces (GUIs) are utilized in existing equipment. Physiological variables can be sampled at predetermined intervals for tracking and displaying trends whereby healthcare practitioners can identify and appropriately respond to improving and deteriorating patient conditions. 
     Computer systems are currently used in the field of patient simulation for healthcare training and education. Mannequins are currently used for training exercises in which they are programmed to automatically model various lifelike symptoms and physiological responses to trainees&#39; treatments, such as normal and abnormal cardiac and respiratory physiology and functions. They can be programmed with various scenarios for instructional simulation of corresponding physiological conditions and specific healthcare problems. For example, Medical Education Technology, Inc. (METI) of Sarasota, Fla.; Gaumard Scientific Company of Miami, Fla.; and Laerdal Medical Corporation (U.S.) of Wappingers Falls, N.Y. all provide patient simulator mannequins, which are adapted for simulating cardio-pulmonary performance with simulated electrocardiogram (EKG) outputs. Such simulation systems enable students to train and learn in settings that closely resemble actual clinical settings and enable practicing on inanimate mannequins. Training under conditions which closely approximate actual clinical patient scenarios will improve patient care and outcomes. Students will have increased levels of skill and competency prior to providing care to actual patients by training under conditions which closely approximate actual clinical patient scenarios. Such automated simulation systems have been successfully utilized in training for specialized procedures and settings, such as cardio-pulmonary, intensive care, anesthesiology, pilot training in flight simulation, etc. 
     More basic mannequins have been employed for instructing students on a wide range of procedures and treatment scenarios, and provide an alternative to instruction on “live” patients or “standard” patients (e.g., actors, other students and instructors). Thus, the patient models adaptable for use with the present invention range from such “live” patients acting roles to abstract, virtual patients, including avatars and holograms. 
     The use of glucometers measuring blood sugar (glucose) levels from blood samples has increased dramatically as the incidence and prevalence of diabetes has increased. Because of this trend, the need for a simulation model for a glucometer for teaching at all levels of care for diabetic patients has increased correspondingly. Simulation of testing blood sugar levels with a glucometer can be extremely valuable for training medical practitioners as well as for training diabetic patients to use a glucometer at home. 
     As the sophistication of simulation scenarios for healthcare teaching has increased in realism and fidelity, the perceived need to train in conditions closely simulating actual medical situations has become more generally recognized. The importance of and the need for these types of portable simulation adjuncts and auxiliaries has become more critical. For example, glucometers represent an example of a medical diagnostic instrument used routinely worldwide for the benefit of large numbers of patients. Diabetic patients tend to use glucometers frequently and regularly. They are also used for monitoring, diagnosing and facilitating the treatment of other blood-glucose level related conditions. Many glucometer users lack formal medical education and would benefit from practical, hands-on training. Anatomically and physiologically accurate simulation of pricking a finger, obtaining a blood droplet, and testing with a glucometer would be extremely valuable medical training. 
     Effective medical training in the use of glucometers and other devices could improve the overall quality of healthcare universally. The training systems and methods of the present invention are adapted for effective training in scenarios closely mimicking actual patient conditions and physiological responses. Such training scenarios can be reliably replicated for universally consistent training and for standardizing the medical training experiences of students and practitioners. For example, new procedures and treatment techniques can be quickly and easily distributed to all users of the present invention. Such distribution and appropriate software upgrades could occur wirelessly over the Internet “in the cloud.” Training and testing results could also be efficiently distributed using the Internet. Student evaluations and training certifications can be handled remotely and efficiently via high-speed Internet connections and cloud-based computing, including data storage and transfer. 
     Medical device simulation can also benefit from current modeling technology, including 3-D printing. Equipment, medical device components and patient interfaces can be accurately and efficiently created and replicated using such technology. Customizable devices and patient-specific interfaces can be produced in 3-D model form for simulation and training. For example, patient-specific templates can be used by appropriate computer technology for producing customized medical devices. Patient fittings and adjustments can thus be handled efficiently and accurately. Equipment components can also be modeled for familiarizing students with their general configurations and operational characteristics. 
     SUMMARY OF THE INVENTION 
     In the practice of an aspect of the present invention, a portable healthcare simulation system and method are provided that utilize a mannequin, from a passive doll to a high-fidelity simulator for displaying certain physiological characteristics obtained noninvasively. A display device comprising a monitor displays vital signs in continuous (real-time) or digital time line modes of operation. The system is controlled by a computer, which can be programmed with various scenarios including outputs responding to various treatment procedures and mannequin control signals. Alternative aspects of the invention include a finger cot or finger splint for providing simulated blood serum and a wide variety of tools for interconnecting participants, components and information, all for use in connection with the present invention. 
     In the practice of other aspects of the present invention, a medical device simulation and training system includes a computer programmed with medical scenarios, including the inputs and outputs corresponding to a variety of patient conditions. Time-varying parameters can correspond to patient condition improvement and deterioration. Moreover, changes in patient conditions can be time-compressed, time-expanded and paused for training purposes. For example, students can observe immediate patient responses to various treatments, which might develop over hours or days in real-time. Instructors can pause exercises and training procedures as needed to emphasize certain patient physiological condition trends and revise treatments as necessary to affect and determine outcomes. 
     In the practice of alternative aspects of the present invention, a computer simulation can be implemented via a mannequin or a live subject, such as a volunteer. “Standard Patient” (“SP”) physiological parameters and conditions can be preprogrammed. Student interface can be accomplished via devices for conveying the simulated patient conditions. Actual diagnostic and monitoring devices can be employed for realism. For example, a stethoscope can be modified with speakers for simulating the audible indicators of physiological parameters, including cardio, pulmonary, gastro-intestinal (“GI”), etc. 
     Controllers, e.g., instructors, can remotely manipulate the training exercises via touch-screen inputs and other control devices. Patient models can be projected on screen for activating touch-screen selection of particular patient conditions. Intensity, timing and other variables can likewise be instructor-controlled. 
     In other aspects of the present invention, simulated substances, such as blood serum, can be extracted for analysis with actual devices, such as glucometers. The aspects and embodiments discussed below can accommodate punctures by lancets with corresponding extraction of simulated blood serum. In an embodiment of the invention, a finger splint is utilized with a blood serum-filled bleb on each of the right and left sides of the finger splint for simulation of testing blood-glucose levels without actually puncturing a mannequin or subject&#39;s finger. Student participants can thus experience the procedures in nearly real-time conditions. The timing of such condition changes can simulate patient conditions and provider inputs. 
     However, heretofore there has not been available an automated, portable simulation system and method utilizing a passive or semi-active mannequin with a dedicated monitor and a computer for conducting scenarios with concurrent (real-time) or time-delay display of basic vital sign physiological information, which can be obtained noninvasively, with the advantages and features of the present invention, nor has there been available a glucometer simulation and training system and method with the advantages and features of the present invention. 
    
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
         FIG. 1  is a block diagram of a healthcare training system embodying a first aspect of the present invention. 
         FIG. 2  is a view of a display of a monitor thereof, particularly showing digital display outputs corresponding to patient vital signs. 
         FIG. 3  is a view of a display of an alternative monitor thereof, particularly showing patient vital sign parameters at programmable intervals. 
         FIG. 4  is a flowchart showing a simulation scenario embodying an aspect of the method of the present invention, which can be adapted to various condition-specific and patient-specific scenarios. 
         FIG. 5  is a flowchart showing another simulation scenario involving an initial student trainee assessment of the conditions associated with the mannequin. 
         FIG. 6  is a block diagram of a healthcare training system embodying a second aspect of the present invention. 
         FIG. 7  is a flowchart showing a training session variable initialization procedure therefor. 
         FIG. 8  shows the instructor controls and display therefor. 
         FIG. 9  shows the student display therefor. 
         FIG. 10  shows a typical prior art glucometer, which can be used in connection with an alternative aspect of the present invention. 
         FIG. 11  shows a finger cot, which can optionally be used for simulated patient blood serum modeling in connection with an alternative aspect of the present invention. 
         FIG. 12  shows the finger cot being punctured by a lancet instrument for obtaining a simulated blood serum sample on a reagent strip. 
         FIG. 13  shows a simulated blood serum sample being drawn for application to the reagent strip. 
         FIG. 14  shows the simulated blood serum sample on the reagent strip. 
         FIG. 15  shows a prior art monitor/defibrillator adapted for use in connection with an alternative aspect of the present invention. 
         FIG. 16  is a block diagram of multiple applications, equipment, participants and configurations of various aspects of the present invention. 
         FIG. 17  is a schematic diagram of a device and procedure simulation and training system embodying another aspect of the present invention, with instructor and student touch-screen monitors. 
         FIG. 18  is an enlarged diagram of an instructor touch-screen monitor comprising an input/output (I/O) device for use with the system, taking generally within area  18  in  FIG. 17 . 
         FIGS. 19-27  show additional alternative embodiments of the present invention with finger cots, puncture-resistant shields and serum-filled blebs for glucometer training simulations embodying additional alternative aspects of the present invention. 
         FIG. 28  shows a top, perspective view of an embodiment of a blood serum interface including a simulated finger with two fluid-holding blebs and a common fillable reservoir for training with a fluid analyzer. 
         FIG. 29  is a side, elevational view of the blood serum interface including a simulated finger with two fluid-holding blebs and a common fillable reservoir. 
         FIG. 30  is a front, elevational view of the blood serum interface including a simulated finger with two fluid-holding blebs and a common fillable reservoir. 
         FIG. 31  is a back, elevational view of the blood serum interface including a simulated finger with two fluid-holding blebs and a common fillable reservoir. 
         FIG. 32  is a top, plan view of the blood serum interface including a simulated finger with two fluid-holding blebs and a common fillable reservoir. 
         FIG. 33  is a bottom, plan view of the blood serum interface including a simulated finger with two fluid-holding blebs and a common fillable reservoir. 
         FIG. 34  is an XY-plane cross-sectional, top, perspective view of the back portion of the blood serum interface including a simulated finger with two fluid-holding blebs and a common fillable reservoir. 
         FIG. 35  is a XZ-plane cross-sectional, top, perspective view of the bottom portion of the blood serum interface including a simulated finger with two fluid-holding blebs and a common fillable reservoir. 
         FIG. 36  is a YZ-plane cross-sectional, top, perspective view of one side of the blood serum interface including a simulated finger with two fluid-holding blebs and a common fillable reservoir. 
         FIG. 36 a    shows a perspective view of a protective shield for clipping over a finger under the interface. 
         FIGS. 37-43  show another modified embodiment of a blood serum interface including a finger splint mounting two fluid-holding blebs and a common fillable reservoir for training with a fluid analyzer. 
         FIGS. 44-49  show another modified embodiment of a blood serum interface. 
         FIGS. 50-52  show another modified embodiment of a blood serum interface. 
         FIG. 53  shows another modified embodiment of a blood serum interface. 
     
    
    
     DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS 
     As required, detailed embodiments of the present invention are disclosed herein; however, it is to be understood that the disclosed embodiments are merely exemplary of the invention, which may be embodied in various forms. Therefore, specific structural and functional details disclosed herein are not to be interpreted as limiting, but merely as a basis for the claims and as a representative basis for teaching one skilled in the art to variously employ the present invention in virtually any appropriately detailed structure. 
     Certain terminology will be used in the following description for convenience in reference only and will not be limiting. For example, up, down, front, back, right and left refer to the invention as oriented in the view being referred to. The words “inwardly” and “outwardly” refer to directions toward and away from, respectively, the geometric center of the embodiment being described and designated parts thereof. Said terminology will include the words specifically mentioned, derivatives thereof and words of similar meaning. 
     Referring to the drawings in more detail, the reference numeral  2  generally designates a portable healthcare simulator system embodying aspects of the present invention. Without limitation on the generality of useful applications of the system  2 , it is particularly adapted for training healthcare practitioners in assessing and treating various patient conditions under replicated clinical conditions using programmed “scenarios” with a human-like patient simulator or mannequin  4  exhibiting vital signs and life-like physiological responses in an educational environment. The scenarios can be programmed into a system computer  6 , which controls the mannequin  4  and provides output to system output devices  10 . 
     The system  2  can be configured with various components and can operate standalone or be connected to other systems, e.g., via a server  3  connected to the Internet (worldwide web)  5  whereby multiple mannequins  4  can be linked and controlled in multiple institutions, which can be widely geographically distributed. The term “computer” is broadly used to encompass logic automated control devices, including microprocessors, personal computers, mainframes, etc. The computers disclosed herein typically include such components as memory, inputs and outputs for connection to various peripheral devices, such as the output devices  10 , which can include monitors, printers, telecommunications, data storage, etc. The system computer  6  accepts inputs from various sources, including the mannequin  4  and various input devices, such as keyboards. Moreover, the scenarios and their corresponding patient condition sets can be programmed into the system computer  6  or downloaded to its memory via suitable media, such as CDs or DVDs, or via an Internet (worldwide web) connection. 
     One or more of the components of the system  2  can be portable for accommodating training needs in various locations, e.g. different rooms in particular facilities and in multiple facilities. Interconnections can be hardwired or wireless using various interconnectivity technologies, as appropriate. 
     The mannequin  4  can be provided with its own computer  14 , which can be programmed to provide various, life-like physiological functions and corresponding outputs in response to corresponding inputs. For example, pulmonary and cardiac functions such as breathing and pulse can be programmed to vary as appropriate for various patient physiological “conditions.” Other physiological functions, such as eye movement, can also be provided. Still further, the mannequin  4  can be interactive and can include an audio output source for speaking monologue patient comments and complaints concerning various symptoms. Such mannequins are capable of providing simulated EKG (electrocardiogram) output through lead attachment points to a suitable, external cardiac monitor. In addition to the EKG output, other “patient” physiological information comprising part of the outputs of the mannequin  4  can preferably be obtained noninvasively using sensors and equipment  8  for such physiological condition parameters as blood pressure, pulse, SpO 2 , TCpO 2 , temperature and others. Alternatively, such simulated patient physiological information can be generated and output to the output devices  10 ,  18  by the system computer  6 , and in a training scenario would be virtually indistinguishable from comparable equivalent outputs from the mannequin  4  and its computer  14 . 
     The mannequin  4  can also include a calibrated fluid pressure control pump mechanism capable of delivering fluid pressure corresponding to the patient blood pressures for the programmed scenarios. Various other physiological functions can be simulated with the mannequin  4  and incorporated in the scenarios. The mannequin computer  14  can control its various functionalities, e.g. in a standalone mode of operation or in conjunction with the system computer  6 . Multiple mannequins  4  can be provided and their computers  14  networked to the system computer  6 , which can function as a server in this system architecture. As noted above, the system computer  6  can be networked with other computers, including a server  3 , and ultimately networked to the Internet  5 . Components of the system  2  can be linked in an appropriate network, i.e. LAN or WAN, whereby scenarios can be shared among students, including remotely for virtual classroom types of applications. 
     The system output devices  10  can include a monitor connected to the computer  6 . The term “monitor” is used in the broad sense to include various types of displays and GUIs appropriate for the particular applications of the system  2 . Auxiliary output devices  18  can be hardwired (hardwired connections indicated at 25) or wirelessly connected (wireless connections indicated at 27) to the mannequin  4  or to the computer  6  directly as a supplement to or in place of the system computer output devices  10 . For example, the auxiliary output devices  18  can display, print, record, transmit, etc. the simulated outputs of the sensors and equipment  8  corresponding to simulated physiological variables associated with the mannequin  4 , which can include its own computer  14 , or be completely passive. The sensors and equipment  8  can be hardwired or wirelessly connected to the auxiliary output devices  18 , the mannequin computer  14  and/or the system computer  6 . The sensors  8  are adapted to interface with the mannequin  4  and can comprise a wide variety of conventional medical instrumentation, such as: cuffs for blood pressure (BP); pulse oximetry sensors for clipping on a finger of the mannequin  4  and sensing pulse, SpO 2  and TCpO 2 ; thermometers; and other devices. The sensors  8  are preferably of the noninvasive type and either comprise actual medical instrumentation or are adapted for realistically interfacing with the mannequin  4 . 
     An example of an auxiliary monitor  20  is shown in  FIG. 2  and can comprise, for example, a handheld unit with a display screen  22  for receiving the output of the mannequin computer  14  and/or the sensors  8 . By way of example and without limitation on the generality of useful information that can be displayed on the auxiliary monitor  20 , a basic set of vital signs comprising blood pressure (BP), pulse, oxygen saturation in percent (SpO 2 ) and temperature is displayed on the monitor display  22 , as shown in  FIG. 2 . A fifth parameter comprising transcutaneous oxygen tension (TCpO 2 ) can be utilized in place of SpO 2 , particularly for pediatric scenarios. The use of these parameters will be described below. 
     Blood pressure is conventionally represented by systolic over diastolic. Digital readouts are shown for the vital sign parameters, but one or more could be replaced or supplemented with analog displays. The most recent blood pressure reading can be held on the display screen or GUI  22  of the monitor  20  until the next reading is “taken” (or computer-generated via computer simulation). A blood pressure sensing mechanism can be used for reading the actual pressure on the mannequin&#39;s arm or, alternatively, the system computer  6  or the mannequin computer  14  can inflate and deflate a blood pressure cuff, and generate an audible tone (i.e., “beep”) with a simulated pulse in the usual manner, except that the blood pressure signals can be completely controlled and generated by the computers  6  and/or  14 . In this configuration the mannequin  4  is passive, with the computer(s) generating all of the active commands, signals, inputs, outputs, etc. 
     The computer  6  can be programmed to obtain blood pressure values and display same at programmable intervals, e.g. 1-60 minutes. A simplified output would provide the most recent blood pressure readings only. As shown in  FIG. 2 , the BP acquisition time is displayed, along with the current time. The monitor  20  displays patient parameters obtained noninvasively and is preferably coupled to the mannequin  4  and the system computer  6  (e.g., hardwired, wireless or network) for interfacing (graphically and otherwise) with the users for simulation healthcare training. 
     The system  2  provides a “duality” whereby vital sign inputs and outputs can be obtained from the mannequin  4 , the computer  6 , or both. In a classroom setting, an instructor or instructors can oversee training exercises on the monitor output device  10  connected to the system computer  6 , while the students/trainees directly observe mannequins  4  and/or vital sign readings on displays  22 . Student/trainee performances can thus be monitored on site, or even remotely. Record and playback features of the system  2  permit post-scenario evaluations and critiques. Still further, a live subject could be utilized for one or more of the vital sign inputs, with others being computer-generated in order to simulate virtual medical conditions and output simulated virtual patient “responses” to various treatments. 
       FIG. 3  shows a modified or alternative display  24  displaying a digital time line or history  26  indicating patient parameters taken at programmed intervals. For example, blood pressure readings can be “taken” (or generated by the computers  6 ,  14  according to the program or scenario being run) at suitable time intervals, which can be either predetermined or selected by the students as part of a training exercise. Along with the blood pressure readings, instantaneous values corresponding to the other patient parameters can be taken or computer-generated. In the example display  24  shown, the last five readings are displayed digitally at  26  to provide a recent patient history and identify trends, which could be symptomatic and provide indications of various assessment and intervention options. This feature enables detecting and tracking vital sign “trends,” which can provide important information concerning the patient&#39;s improvement or declining condition based on his or her records over periods of time. All of the parameters/vital signs can be tracked with respect to time in this manner and the computer  6  can be programmed for suitable time intervals (t). More or fewer time line entries can be retained and/or displayed. The display  24  can comprise an auxiliary output device  18  ( FIG. 1 ), or it can be incorporated in the system output devices  10 , for example, as an optional screen display or window in a main monitor display accessible through a pull-down menu. The computer  6  can also be programmed to provide digital time lines specific to one or more patient parameters. 
     In addition to normal real-time operation of the display devices  10  and  18 , the computer  6  can be programmed to compress or expand time in order to conduct efficient training exercises. For example, blood pressure readings that might normally change at hourly intervals can be programmed to change at 10-minute intervals in order to accelerate the simulated changes in patient condition and provide students and trainees with appropriate training on assessing and treating unstable patients in response to changes in their vital signs, including compressed reaction times to such trainee treatments. Other vital signs can be programmed to change at corresponding compressed or expanded intervals. Still further, intervals can be extended to provide a “slow-motion” or “freeze-frame” changing-condition experience as appropriate for particular training scenarios. 
     Still further, the computer  6  can perform a record-keeping function whereby such changes are recorded and stored to a patient&#39;s file. Saved data can be recalled and displayed in order to determine the patient&#39;s history and trends and for purposes of comparison with present readings. Users can trigger or initiate repeat vital sign reading procedures for determinations on-demand and in real-time at predetermined or desired time intervals. Predetermined numbers of prior readings can be recalled for comparison with current readings. 
     Although only a limited number of lines of data are displayed at a time, the system computer  6  memory can be designed to store large amounts of data for multiple virtual patients, which can be identified by patient number. Such data can be retrieved and displayed in various formats, including an interactive “scrolling” display whereby an operator can scroll forward and backward while displaying a limited amount of data at a time. The default display can be the current and the most recent values. 
     The computer  6  can store data applicable to different “patients” and scenarios. Thus, for training and education purposes patient profiles can be created and subjected to different scenarios in order to provide instructional variety and realism. Of course, some of the vital signs would change more or less quickly than others, whereby different time references for the different vital signs can be utilized as appropriate. Temperature and SpO 2 , for example, would tend to change relatively gradually, as compared to, for example, pulse and blood pressure. 
     A pulse-oximeter sensor function (mannequin  4 , computer  6  or both) can emulate the performance of a helium-neon (“he-ne”) laser light type of sensor, which is clipped on a fingertip. An intermittent mode of operation can be provided whereby the oximetry result can be displayed and the result recorded. The sensor  8  and the display monitor  10  can then be removed. Temperature, pulse, and SpO 2  could be displayed continuously in real-time, or compared over time with blood pressure (BP) trends. The default timing for pulse, temperature, and SpO 2  recording can be keyed on whenever a blood pressure value is also recorded, but different times for just these other readings can also be used. 
     The monitor display  22  content may be determined, at least in part, by the particular mannequin  4 , which may include software for controlling its operation, i.e., active responses in the form of outputs to various procedures in the form of inputs. The healthcare simulation mannequin  4  preferably provides certain noninvasive patient monitoring functionalities and simulated physiological functions, such as breathing, heartbeat, blood pressure (BP), temperature, audible output, eye/eyelid movement, etc. Input and output signals for the various components of the system  2  can be transferred via connecting cables or wirelessly. Preferred hardwired connections are shown by continuous lines  25  and preferred wireless connections are shown by broken lines  27  in  FIG. 1 , although many other combinations of connections are possible. 
     The temperature function is preferably capable of both intermittent and continuous real-time display for this modality. Patient temperature generally corresponds physiologically to the other parameters of the program according to the particular scenario being utilized. In other words, temperature is an important indicator of physiological condition, and trends (both increasing and decreasing) can inform practitioners of changing conditions and treatment efficacies. Like blood pressure, it can be useful to display temperature in relationship to a time line (e.g.,  FIG. 3 ), including an indication of when it was last obtained. Also like blood pressure, the temperature can be controlled by existing scenario software loaded on the computer  6 , which is not always the same as real-time and may be capable of manipulation. The mannequin  4  can be temperature-passive, i.e. providing no output signal corresponding to patient temperature. However, passive instruments, such as dummy tympanic membrane temperature probes can be provided for simulating the temperature-taking procedures in the scenarios. Sensors are available for quickly obtaining measurements (e.g., from the ear canal), which can be simulated by the scenario software and the computer  6 . 
     The system  2  is preferably capable of incorporating continuous temperature displays associated with continuous monitoring, which can be achieved with existing equipment. It will be appreciated that the range of thermometers and temperature sensors is relatively large, whereby the system  2  can be programmed to simulate the operation and outputs associated with such a wide range of temperature input devices. The system  2  can be programmed for simulated temperature readings from different sources, such as axillary, oral, etc., and the scenarios can reflect temperature readings obtained by students from such different sources. Both Centigrade and Fahrenheit readings are available. Pediatric, neonatal, post-anesthesia, sensory depressed, comatose and medicated patients may require and will tolerate continuous temperature sensing from instruments which can be continuously left in place, such as a rectal temperature probe. Continuous temperature sensing in awake or awakening patients can be accomplished with suitable noninvasive surface equipment, such as forehead strips, axillary and skin-surface probes. Just as it is currently possible to use an actual working portable automated blood pressure monitor on existing mannequin models with controlled hydraulic conduits that simulate bronchial arteries, and just as it is possible to use current actual clinical intensive care monitors to pick up cardiac rhythms from predetermined electrical outlets on the mannequin, so it is possible to design a mannequin with vital sign outputs that would enable staff training with their own actual portable automated vinyl signed display devices (VSDD). All output points are controlled by the mannequin and system computer working in concert with the programmed scenario. The blood pressure would be projected by the hydraulic palms in the system as described above. The temperature signal would be transmitted by carefully controlled thermal plates located at strategic points. These can include a plate as the tympanic membrane producing a temperature control chamber in the ear for a scope-type thermal probe, and a plate against the lingual jaw inside and out for an oral probe and a spot on the forehead for a skin surface probe, etc. A specific mannequin model can be equipped with a single play or any combination. The same duality applies to the choices for all the signal output sides for all signals. The SpO 2  output signal could be computer-controlled, synchronized infrared and red light output that would simulate the actual transmitted red signal for a specific level of saturation and pulse. This could be transmitted from the mannequin and a designated spot, e.g., the nailbed level of the ring finger. The sensing clip can be oriented so that the receptor signed his against the output sign of the finger. Alternatively, the output signal could be obtained from both the dorsal and the lingual sides of the mannequin finger so that, as in actual practice, it would not matter with the orientation and it is a “transmitted” through signal. 
     On-demand display of clock time (e.g., 24-hours or other suitable time period) can be coordinated to the time frame chosen for the scenario, or real-time. Preferably the scenario can be started at any chosen time, which “sets the clock” or starts the clock running to set in motion a series of programmed physiological occurrences affected by inputs corresponding to the treatment procedures and scenario plan. The computer  6  also preferably enables “pause” functionalities whereby immediate instruction and feedback can be provided in order to facilitate the instructional aspect of the exercise. Thus, instruction can be timely provided with the simulated patient&#39;s condition suspended in pause mode without further deterioration of the patient&#39;s physiology. Of course, such deteriorating (or improving) patient conditions can be programmed into the scenarios in real-time for greater realism, or even accelerated to demonstrate the consequences to the patient of various conditions and/or treatments. Also, by selecting key moments and running them in sequence, a cycle which would normally occur over several days can be time-compressed into hours. 
     As an alternative or supplement to SpO 2 , transcutaneous oxygen tension (TCpO 2 ) can be modeled by the software. The TCpO 2  value is obtained by determining the actual partial pressure of oxygen in the blood at the skin surface, as opposed to the “saturation” percentage of hemoglobin in the SpO 2 . TCpO 2  is determined by heating the skin surface in a small sealed chamber and reading the change in the oxygen level as the gas escapes the skin. TCpO 2  sensors are therefore noninvasive surface probes. The computer program of the system  2  provides SpO 2  output, for which TCpO 2  can be substituted. The scenarios can include the steps of attaching passive SpO 2  and TCpO 2  detection and monitoring equipment to the mannequin  4 , with the computer  6  providing the actual output signals corresponding to these vital signs. 
       FIG. 4  is a flowchart showing a healthcare educational method of the present invention. Beginning with a start  29 , variables are preset at  30  and correspond to computer inputs and outputs. A time reference is selected at  32  and can be based on continuous (real-time) display  34 , trend display  36 , and most recent  38 . Output is provided to a mannequin at  40 , which in turn provides output to a monitor at  42 . Treatment is initiated at  44 , the mannequin is treated at  46  and the physiological effects of the treatment are computed at  48 . The treatment results are output at  50 , and can include mannequin reactions such as audible output and changes in physical condition at  52 . The treatment results are displayed and mannequin condition is reassessed at  54 . An affirmative decision at “More Treatment?” decision box  56  leads to a repeat of the treat mannequin step and sequence beginning at  46 . A negative decision at  56  leads to recording the scenario at  58 , outputting the scenario at  60  and a decision box for “Another Scenario?” at  62 , with an affirmative decision leading to a repeat of the sequence beginning at  30  and a negative decision leading to a debrief of the simulation results  64  and ending the exercise  66 . 
       FIG. 5  is a flowchart of another procedure or scenario embodying the method of the present invention. Beginning with a start  68 , variables are preset at  70  and the mannequin is programmed at  72 . A trainee or student assesses the mannequin condition at  74  and initiates treatment at  76  by treating the mannequin at  78 . The treatment physiological effects are computed at  80  and output at  82 . The mannequin reacts at  84  and the treatment results are displayed and mannequin condition is reassessed at  86 . An affirmative decision at “More Treatment” decision box  88  repeats the cycle beginning at the “Treat Mannequin” step  78 . A negative decision leads to the record scenario step  90 , the output scenario step  92  and the “Another Scenario” decision box  94 , from which an affirmative decision repeats the cycle beginning at “Preset Variables”  70  and a negative decision leading to a debrief of the simulation results  96  and ends the exercise  98 . 
     An exemplary training exercise practicing the method of the present invention using the system  2  could include wheeling the “patient” (i.e., mannequin  4 ) into a training room, which can consist of or be modeled after a hospital room. The student or trainee can attach noninvasive sensors, such as a blood pressure cuff, thermometer, finger-clip pulse/SpO 2  sensor, etc. If the initial reading is considered ineffective or erroneous, the student/trainee has the option of canceling or deleting it and retaking the initial reading. The computers  6 ,  14  and/or the sensors/equipment  8  can be configured to detect incorrect applications of the sensors/equipment  8  to the mannequin  4 , e.g., improper blood pressure cuff wrappings or SpO 2  sensor placements. The system  2  can provide appropriate outputs alerting the students to the incorrect applications. The computer  6  can initiate a training scenario with programmed outputs and responses to various inputs corresponding to “treatment.” The initial readings obtained by the system  2  can be output on the display  18  ( FIG. 2 ) and can also comprise the first time line entries on the display  18  ( FIG. 3 ). Thereafter the scenario can present predetermined changes in the physiological variables in order to simulate a deteriorating patient condition, prompting the trainee to react with appropriate treatment protocols. As shown in  FIG. 3 , additional memory line values are obtained and displayed at intervals, which can be predetermined or set by the students as part of the training exercises. For example, blood pressure readings taken once an hour can correspond to the updates in the other physiological values whereby trends can be identified from the display  18 . Thus, even if the initial readings are relatively normal, subsequent changes can indicate a deteriorating condition necessitating treatment. 
       FIG. 6  shows a block diagram of a system  102  comprising a second aspect of the invention and including a student computer  104  with a vital signs display device (VSDD)  106 , inputs  108  and memory  110 . A passive mannequin  112  can be placed in proximity to the student computer  104  for simulated “treatment” in response to the VSDD  106  output. These components can operate in a standalone mode. Alternatively, an optional instructor computer  114  can be provided and linked to the student computer  104  by connection  116 . The instructor computer can include a VSDD  118 , inputs  120  and memory  122 . The functionalities of the student and instructor computers  104 ,  114  can be combined and separate VSDDs  106 ,  118  can be provided on opposite sides of an enclosure housing the computer whereby the student&#39;s VSDD  106  is in the student&#39;s field of vision, but the instructor&#39;s VSDD  118  is concealed from the student either by its orientation or by a removable cover. 
       FIG. 7  shows a flowchart for a procedure for setting variables for the system  102 . Beginning with a start  124 , the system then initializes at  126  and proceeds to a select mode step at  128 . The vital signs can be associated with default variables, which are displayed at step  130 . The variables can be accepted at  132 , increased at  134 , or decreased at  136 . Thereafter the method proceeds to selecting the time reference at  138 , which is generally an instantaneous (real-time) or sequential (time history) value. A positive answer at decision box  140  leads to the select mode step at  128 . A negative answer at  140  leads to an end  142 . 
       FIG. 8  shows an instructor controls and display  144  for the optional instructor computer  114  with a controls section  146  and the VSDD  118 . Suitable controls for power  148 , mode (e.g., blood pressure systolic/diastolic, pulse, temperature, SpO 2  and or TCpO 2 ) select  150 , display  152 , start  154 , pause  156 , stop  157 , scroll up  149  and scroll down  151  can be provided as shown. 
     The VSDD  118  includes a temperature module  158  with a start/reset switch  160 , a Fahrenheit/Centigrade switch  162  and a normal/monitor switch  164 . A blood pressure module  166  includes an auto/manual switch  168 , a start switch  170 , and a cancel switch  172 . An alarms module  174  includes a select switch  176 , a silence (mute) switch  178 , a high limit switch  180 , and a low limit switch  182 . The limit switches  180 , 182  permit entry of values corresponding to high and low blood pressure (or other variable) values which, when exceeded, cause an alarm to be output. A blood pressure (BP) cycle module  186  includes an interval select switch  188  for inputting time units (e.g., minutes) between readings. A start switch is provided at  190  and a prior data switch  192  causes prerecorded data to be displayed. 
       FIG. 9  shows the student VSDD  106 , which can be essentially identical to the instructor VSDD  118 . In operation, the instructor can program the system  102  and interactively control its operation while monitoring the instructor VSDD  118 . The student can assess and treat the passive mannequin  112  while observing the student VSDD  106 . 
       FIGS. 10-14  show an alternative aspect of the present invention being used in connection with a glucometer  202 , comprising a standard instrument used for measuring blood glucose levels. Blood sugar concentration or blood glucose level is the amount of glucose (sugar) present in the blood, which is normally tightly regulated as part of metabolic homeostasis. Hyperglycemia is a common indicator of a diabetic medical condition. Long-term hyperglycemia can cause health problems associated with diabetes, including heart disease, eye, kidney, and nerve damage. 
     Conversely, hypoglycemia is a potentially fatal medical condition, which can be associated with lethargy, impaired mental function, muscular weakness and brain damage. Patients with such medical conditions are commonly carefully monitored at frequent intervals in order to avoid serious medical complications. Simulating blood glucose levels can thus be useful in training healthcare providers in the assessment and treatment of various medical conditions indicated by abnormal blood glucose levels. 
       FIGS. 11-14  show a finger cot  204  adapted for placement over a finger  206  of a simulated patient, which can be an individual assuming the role of a patient, or a mannequin. The cot  204  includes a protective, puncture-resistant thimble  208  and a latex-like or rubber-like, penetrable cover  210  placed over the thimble  208  and forming an intermediate space  212  adapted for receiving simulated blood serum  214 , which can be retained by a perimeter seal  216  located at a proximate end of the thimble  208 . The cover  210  can be rolled at its proximate end  218  and unrolled to an appropriate length to cover part of the finger  206  and thus retain the finger cot  204  securely thereon. The finger cot  204  can also be secured with adhesive or tape. 
     In operation the cover  210  is penetrated by an instrument, such as a lancet  220 , and a small quantity, such as a single drop, is applied to a reagent strip  222 . The reagent strip  222  can be placed in the glucometer  202 , which provides a glucose level reading. 
       FIG. 15  shows a monitor/defibrillator  230  adapted for use in connection with an alternative aspect of the present invention. Without limitation on the generality of useful equipment, the monitor/defibrillator  230  can comprise a LifePak model, which is available from Physio-Control, Inc. of Redmond, Wash. The monitor/defibrillator  230  can optionally be connected to the system computer  6  and/or a patient model, such as the mannequin  4 . Alternatively, the monitor/defibrillator  230  can be configured as a “smart” unit with an internal processor programmed for simulating procedures corresponding to patient conditions and responses. Individuals can interact with the monitor/defibrillator  230  by administering simulated treatments in response to simulated patient outputs, such as physiological conditions and vital signs, as described above. 
     Such monitor/defibrillators  230  are commonly used in emergency procedures, and are typical equipment on emergency vehicles, such as ambulances, “Med-Act” vehicles, and “Life Flight” helicopters and other aircraft. For training purposes, students can practice interactive procedures with mannequins or live actors using the monitor/defibrillators  230 . Alternatively, “smart” monitor/defibrillators can be used in a “standalone” mode for interacting with students and displaying appropriate outputs in response to different conditions and treatments. Various other types of equipment can be used in connection with the system and method of the present invention. For example, chest drainage systems can be monitored and/or simulated in operation. Pleur-Evac chest drainage systems are available from Teleflex Medical OEM of Kenosha, Wis. 
       FIG. 16  is a block diagram showing various alternative configurations and functions of the aspects of the present invention. For example, the patient model can be a live actor with a script, a mannequin (interactive or passive), an avatar, a hologram or a virtual patient existing only in computer memory and represented visually as a still photo, a video clip or an animated or graphic image. Still further, student interfaces with both the patient model and the tools can range from direct contact to remote, on-line interaction. Likewise, the instructor interface can assume a wide variety of contact and communication media and methods. Automated interfaces can be substituted for or supplement direct, human interaction. 
       FIG. 17  shows a diagram of a simulation system  302  including instructor and student touchscreen monitors  304 ,  305  for use as input/output (I/O) components. The monitors  304 ,  305  are connected to a system computer(s)  6  ( FIG. 1 ), which can be preprogrammed with various simulation training and educational scenarios. For example, the monitors  304 ,  305  can display anterior and posterior patient images  306 ,  307  with predetermined touch-screen areas  308  for initiating interaction. Additional inputs can be entered via touch-screen buttons  319  ( FIGS. 17 and 18 ). The monitors  304 ,  305  can also be used in conjunction with a student interface configured like a stethoscope  310 , which can comprise a “smart” device providing audible output signals via headphone-type speakers  312 . Input signals can be provided by placing an input  314  of the stethoscope  310  on the touchscreen areas  308 , whereby the computer  6  provides corresponding responses. Alternatively, the stethoscope input  314  can be placed on a mannequin or an individual portraying a patient. The output of the stethoscope  310  can be preprogrammed on the system computer  6 , or controlled in real-time by an instructor. A suitable input/output (I/O) interface component  320  is connected to the system computer  6  for interfacing with the various input and output (I/O) devices. For example, the I/O interface component  320  can include analog-to-digital (A/D) converters, filters, amplifiers, data compression, data storage, etc. The stethoscope  310  output can be “On Demand,” i.e., placement determining the output sounds via the touchscreen whereby variants of chosen heart rates and breathing sounds can be preprogrammed and altered, e.g., by a rheostat-type sliding scale control  318 . 
     By way of example and without limitation, a preprogrammed scenario can involve placing the stethoscope input  314  on lung areas  308  whereby audible output corresponding to patient breathing sounds are delivered via the headphone speakers  312 . The scenarios and the corresponding output signals, including the stethoscope  310  outputs, can be controlled via an instructor monitor  304  displaying a patient image  306 , which is similar to that shown on the student monitor  305 . For example, the instructor monitor  304  can include the rheostat-type sliding scale control  318  for adjusting a parameter of an output signal, such as volume, intensity and frequency. Breathing patterns, i.e., shallow-to-deep, slow-to-rapid, etc. can be controlled by an instructor for simulating various patient medical conditions. Such audio outputs can be made self-sensing by placing a band around the chest of the mannequin or SP which senses the respiration rate and depth and signals this to the controlling computer  6 . These audio signals and pulses can be coupled to an EKG strip displayed on a vital sign monitor control by the controlling computer  6 , which senses all of these effects. The system computer  6  can also interface with and output to a monitor/defibrillator  230  ( FIG. 15 ) and a 2-D/3-D printer modeler  316 . 
     Other instructor-to-student audio applications include cardiac and gastro-intestinal (G.I.). Instructors can present patient distress indications via the interface monitor  304 , with appropriate condition changes based on treatments administered by the students. The timing of such signal interactions can be varied and paused as appropriate for accomplishing the training objectives. For example, patient condition changes naturally occurring over several days can be compressed into training exercises corresponding to a class period. 
     Of course, many patient condition indicators and physiological parameters are interrelated. Such interrelated relationships and their visible/audible indicators can be programmed and presented to students for training purposes. For example, worsening conditions are often indicated by labored breathing, rapid pulse, fever, etc. Conversely, improving conditions can be indicated by restoring normal breathing patterns, normal heart rate, moderate blood pressure, normal temperature, etc. Visual indicators can include pale versus flushed skin appearance, pupil dilation, perspiration, etc. All of these parameters can be preprogrammed or manually manipulated by the instructors as appropriate for training exercise objectives. 
     It will be appreciated that such training exercises can occur remotely, with the instructors and students connected via the Internet or otherwise by telecommunications. By linking the participants with the Internet and other telecommunications technology, significant training efficiencies can be achieved. For example, instructors and students can be dispersed globally at remote locations with Internet access providing the interaction. Moreover, scenarios and student responses can be digitally stored for later replay and evaluation, e.g., via the I/O interface  320 , in the cloud  322 , etc. 
     Glucometer Applications ( FIGS. 19-53 ) 
     Glucometers, such as the portable example shown at  202 , are frequently used by both trained medical personnel and untrained individuals, including patients. The present invention includes systems and methods for glucometer training. A glucometer training system  402  includes a computer  6 , an I/O interface  320 , software and participants (i.e., instructor, student and/or patient) as described above. The patient/subject role can be filled by an individual, a mannequin, or a device, such as a simulated fingertip  442  ( FIGS. 24-27 ) described below. 
       FIGS. 19 and 20  show a glucometer training system  402  with a blood serum simulation interface  404  including a finger cot  406  placed over a bleb  408 , which can be filled with simulated blood serum  410 . The interface  404  can include a thimble or fingertip shield  412 , which protects an underlying part of the fingertip  426  from penetration by a lancet  414 . The shield  412  can comprise any suitable material conformable to the fingertip. For example, metals and hard plastics can be used for forming the shield  412 . Still further, padded shields can be provided. The bleb  408  is preferably filled with a semi-viscous fluid  410  forming a droplet  416  when discharged. The fluid  410  can include appropriate physiological composition characteristics, such as blood-sugar levels for glucose testing. Alternatively, the fluid  410  can be inert, with the characteristics preprogrammed and simulated by the computer  6 . 
       FIGS. 21-23  show another alternative aspect of the present invention comprising a glucometer training system  420  with a soft, protective gel or latex pad  422  placed on a volar portion  424  of the fingertip  426  with a bleb  428  placed on the pad  422 . A suitable finger cot  430  can be placed over the pad  422  and the bleb  428 , which is adapted for refilling with a syringe  432 . 
       FIGS. 24-27  show another alternative aspect of the present invention comprising a glucometer training system  440  with a simulated fingertip  442  placed over an individual&#39;s fingertip, or used standalone. The simulated fingertip  442  is fitted with a pad  444 , which is similar to the pad  422  described above. A bleb  446  is placed on the pad  444  and can be internally refilled with a syringe  432 , as shown in  FIG. 25 .  FIG. 26  shows the system  440  being placed on an actual fingertip. Optionally, a finger cot  430  can be placed over the system  440 . 
       FIGS. 28-36   a  show an alternative embodiment of a glucometer simulation and training system  502  including a patient, a blood serum interface  504 , and an analyzer. The patient may be an individual or a mannequin, and at least one of the patient&#39;s fingers is required for the glucometer simulation and training system  502 . The analyzer may be a glucometer such as the portable example shown at  202 , a computer programmed to simulate fluid analysis, or another type of fluid analyzer. 
     In this embodiment, the blood serum interface  504  includes a simulated finger  506  configured to hold semi-viscous fluid simulating blood and to slide over a simulated patient or mannequin&#39;s finger  526 . The simulated finger  506  is preferably made of flexible, flesh-like material that is capable of sealing itself after puncture. In this embodiment, a protective shield  534  may optionally be placed on the patient/subject&#39;s finger  526  prior to sliding the simulated finger  506  over the patient/subject&#39;s finger  526  to provide protection from cuts. The protective shield  534  may be made of metals, hard plastics, and/or other materials capable of protecting a finger from being cut, and preferably, the protective shield  534  snaps around the patient/subject&#39;s finger  526 . Alternatively, the protective shield may be built into the inside of the simulated finger  506  to protect the finger  526 . 
     In this application, finger joint is synonymous with knuckle. Additionally, anatomical terms are given their usual meanings. For example, when referring to the hand, dorsal means the top, or back, of the hand, and ventral means the bottom, or palm side, of the hand. Proximal means closer to the trunk of the body, and distal means further from the trunk of the body. So, in reference to a finger, distal is closer to the fingertip, and proximal is closer to the palm and back of the hand. There are two bones that make up the human forearm: the radius and the ulna. With palms facing towards the back of the body, the radius is closer to the torso, and the ulna is further from the torso. The terms radial and ulnar are references to the proximity to the radius and ulna bones, respectively. Thus, with palms facing back, the radial side of a hand or finger is the inside, and the ulnar side is the outside. The bones that make up the fingers are called phalanges, and a single finger bone is called a phalanx. The distal phalanges are the bones from fingertips to the most distal knuckles, the intermediate phalanges are bones between the most distal knuckles and the middle knuckles, and the proximal phalanges are the bones between the middle knuckles and the most proximal knuckles. The most distal knuckle of each finger, between the distal phalanx and the intermediate phalanx, is called the distal interphalangeal (“DIP”) joint. The middle knuckle, between the intermediate phalanx and the proximal phalanx, is called the proximal interphalangeal (“PIP”) joint. The most proximal knuckle is called the metacarpophalangeal (“MCP”) joint. It is preferable for the simulated finger  506  to extend at least as long as halfway between the DIP and PIP joints of the finger, or halfway across the intermediate phalanx. Extension of the simulated finger  506  beyond the DIP joint helps ensure that the simulated finger  506  will stay on the patient/subject&#39;s finger  526  when the finger  526  is handled by a student or trainee. 
     Preferably, the simulated finger  506  has a nail-like indention  518  on its dorsal side or an open nail portion showing the patient/subject&#39;s nail underneath. This nail-like indention  518  or open nail portion gives the simulated finger  506  a more anatomically correct look, and more importantly, it helps with placing the simulated finger  506  on the patient/subject&#39;s finger  526  and using the simulated finger  506  in the proper orientation.  FIGS. 28-36  show an embodiment of the simulated finger  506  having a nail-like indention  518 . The simulated finger  506  can be placed on any finger  526  of a mannequin or simulated patient, with the middle (3rd) finger or ring (4th) finger being the preferred placement. Different sizes of simulated fingers  506  may be utilized to better fit different finger sizes. 
     The simulated finger  506  includes a bleb  508 , or stick site, below the nail on each of the radial and ulnar sides of the simulated finger  506 . A bleb  508  is a cavity or receptacle configured to hold semi-viscous fluid simulating blood. These blebs  508  cover a large portion of each of the radial and ulnar sides of the distal phalanx. In this embodiment, the blebs  508  are formed within the simulated finger  506 .  FIG. 34  shows a cross-sectional view of the blebs  508 . The two blebs  508  share a common reservoir  520  configured to be filled with blood serum. After the common reservoir  520  is filled with simulated blood serum, blood serum can be pushed into the blebs  508  by applying pressure to the reservoir  520 . The common reservoir  520  may be configured for injection with a syringe, or the reservoir  520  may be capable of filling via IV connectors, Leur-Lok hub connectors, or other tubing or bladder connectors. The common reservoir  520  may or may not have a specific fill site  522 , and the common reservoir  520  could either be placed on the dorsal side or the ventral side of the simulated finger  506 .  FIGS. 28-36  show an embodiment including a common reservoir  520  on the ventral side of a simulated finger  506 . This embodiment also has a fill site  522  for filling the reservoir  520  with blood serum.  FIGS. 35 and 36  are cross-sectional views of the simulated finger  506  showing the inside of the common reservoir  520 . 
     Alternatively, the simulated finger could have just one bleb with a separate filling reservoir on the dorsal or ventral side of the simulated finger. Another alternative would be for the simulated finger to have two reservoirs, each leading to a separate bleb. With dual reservoirs, one bleb could be filled with a simulated blood serum having one set of characteristics, and the other bleb could be filled with a simulated blood serum having a different set of characteristics. 
     In reality, when using a glucometer to test blood-glucose levels, a patient or subject&#39;s finger is pricked with a lancet on the side of the finger in order to avoid nerve damage to the finger and to minimize pain. Thus, a glucometer training system  502  with stick sites  508  on the sides of the finger provides an anatomically correct simulation for training medical professionals and patients, such as those having diabetes. 
     The simulated blood fluid can include appropriate physiological composition characteristics, such as blood-sugar levels for glucose testing with a glucometer. Alternatively, the fluid, or simulated blood serum, can be inert with characteristics preprogrammed and simulated by a computer  6 . To simulate testing blood glucose levels, an instructor can fill the common reservoir  520  with blood serum and apply pressure to the reservoir  520 , filling the two blebs  508  with blood serum. The protective shield  534 , optionally, and the simulated finger  506  can be placed on a patient or mannequin&#39;s finger  526  either before or after applying pressure to the reservoir  520  to fill the blebs  508 . A student or trainee can then prick one of the blebs  508 , or stick sites, with a lancet, extract a droplet of blood serum, and test the glucose level of the blood serum using a glucometer  202  or simulated glucometer. The simulated blood serum may include a sealant configured to seal off holes poked into the blebs  508 , or the blood serum may include properties causing the blood serum to coagulate, or clot, around holes poked through the blebs  508 . 
     For a simulated finger including two blebs with each having a separate fillable reservoir, the blebs could be filled with different simulated blood serums. The simulated finger can be placed on a patient/subject&#39;s finger, and a student or trainee can prick the radial side bleb with a lancet to test one of the fluids. The simulated finger can then be removed and placed on the corresponding finger of the patient/subject&#39;s other hand. The student or trainee can then prick the radial side bleb with a lancet to test the other fluid. Alternatively, the student or trainee can prick the ulnar side bleb for both tests, switching hands in between, to test the two different fluids, or the simulated finger could remain on the same finger with the student or trainee pricking the radial side bleb for one test and the ulnar side bleb for the other. 
       FIG. 36 a    shows an optional protective shield  534  with and outwardly-convex configuration adapted for placement over a finger. The shield  534  can comprise sheet metal, rigid plastic, puncture-resistant fabric or some other suitable puncture-resistant material. The shield  534  functions to avoid lacerating a test patient or mannequin if a lancet penetrates the interface  504 . Alternatively, a suitable shield can be integrally formed with the interface  504 . 
       FIGS. 37-43  show an alternative aspect of the present invention comprising a glucometer simulation and training system  602  with a patient, a blood serum interface  604 , and an analyzer. The patient may be an individual or a mannequin, and at least one of the patient&#39;s fingers is required for the glucometer simulation and training system  602 . The analyzer may be a glucometer such as the portable example shown at  202 , a computer programmed to simulate fluid analysis, or another type of fluid analyzer. 
     The blood serum interface  604  in this embodiment includes a finger splint  606  with a layer of protective material  612  to protect a patient/subject&#39;s finger  626  and a membrane capable of forming blebs  608 . The blebs  608  form adjacent to the protective layer  612  and are configured for holding semi-viscous fluid  610  simulating blood. The fluid  610  can include appropriate physiological composition characteristics, such as blood-sugar levels for glucose testing with a glucometer. Alternatively, the fluid, or simulated blood serum  610 , can be inert with characteristics preprogrammed and simulated by a computer  6 . 
     The protective layer  612  may consist of metals, hard plastics, and/or other materials capable of protecting a finger from being cut. Existing splints (e.g., DIP splints for ruptured extensor tendons, such as Stax-type splints) are readily available for use as a platform for adding simulated blood blebs. This embodiment of the blood serum interface  604  can be placed on any finger  626  of a mannequin or simulated patient, with the middle (3rd) finger or ring (4th) finger being the preferred placement. Different sizes of finger splints  606  may be utilized to better fit different finger sizes. It is important for the finger splint  606  to extend beyond the DIP joint of the patient/subject&#39;s finger  626  to help ensure that the interface  604  will stay on the finger  626  when the finger  626  is handled by a student or trainee. It is also preferable to have an open nail portion  618  or a nail-like indention on the finger splint  606  to make the simulation more anatomically correct and to aid in placing the finger splint  606  in the correct orientation on the patient/subject&#39;s finger  626 .  FIGS. 37-43  show an embodiment of the blood serum interface  604  having an open nail portion  618 . 
     Preferably, the membrane is made of flexible, self-sealing material, capable of sealing itself after being punctured. In this embodiment, two blebs  608  form adjacent to the protective layer  612 , one on the radial side and one on the ulnar side of the finger. The blebs  608  cover a large portion of the radial and ulnar sides of the distal phalanx, below the nail. In real practice, when using a glucometer to test blood-glucose levels, a patient or subject&#39;s finger is pricked with a lancet on the side of the finger in order to avoid nerve damage to the finger and to minimize pain. Thus, a glucometer training system  602  with blebs  608  on the side of the finger configured for being pricked with a lancet  614  provides an anatomically correct simulation. 
     In this embodiment, the two blebs  608  share a common reservoir  620  capable of being filled with simulated blood serum  610 . The blebs  608  and common reservoir  620  may be adhered to the finger splint  606 , or they may form a separate piece that clips over or attaches to the finger splint  606 . Pressure can be applied to the common reservoir  620  to simultaneously fill both blebs  608  with fluid  610  from the reservoir  620 . Placement of the common reservoir  620  can either be on the dorsal side or the ventral side of the finger splint  606 . The common reservoir  620  can either be injectable with a syringe  632  or configured for filling with blood serum  610  via IV connectors, Leur-Lok hub connectors, or other tubing or bladder connectors. The common reservoir  620  may or may not have a specific fill site  622 .  FIGS. 37-43  show an interface  604  having a common reservoir  620  on the ventral side of a finger splint  606  with a fill site  622  for filling with simulated blood serum  610 . 
     To simulate testing blood glucose levels, an instructor can fill the common reservoir  620  with simulated blood serum  610  and apply pressure to the reservoir  620  to fill the blebs  608  with blood serum  610 . The finger splint  606  can be placed on a patient or mannequin&#39;s finger  626  either before or after applying pressure to the reservoir  620  to fill the blebs  606  with blood serum  610 . A student can then prick a bleb  608  with a lancet  614 , extract a droplet  616  of blood serum  610 , and test the glucose level of the blood serum  610  using a glucometer  202  or simulated glucometer. The simulated blood serum  610  may include a sealant configured to seal off holes poked into the blebs  608 , or the blood serum  610  may include properties causing the blood serum  610  to coagulate, or clot, around holes poked through the blebs  608 . 
     Alternatively, a variation of the glucometer simulation and training system  652  could include a blood serum interface  654  with just one bleb  658  and a separate filling reservoir  670 . In an embodiment having one bleb  658  with a separate filling reservoir  670 , the layer of protective material  662  may only cover the side of the patient/subject&#39;s finger  626  which mounts the bleb  658 , leaving the other side of the distal phalanx open, as shown in  FIGS. 44-49 . This embodiment would also include hard material on the opposite side of the finger  626  from the bleb  658  to provide a cantilever effect for the interface  654 . This embodiment could be achieved by attaching a bleb  658  with a fillable reservoir  670  to the bottom of a Stax-type splint  656 , and placing the splint  656  on a patient/subject&#39;s finger  626  turned 90 degrees. By turning the splint  656  sideways, the bleb  658  is located on the side of the patient/subject&#39;s finger  626  while still having at least part of the patient/subject&#39;s fingernail visible, making the simulation more anatomically correct. 
     Another embodiment of a glucometer simulation and training system  702 , shown in  FIGS. 50-52 , includes a patient, a blood serum interface  704 , and an analyzer. The patient may be an individual or a mannequin, and at least one of the patient&#39;s fingers is required for the glucometer simulation and training system  702 . The analyzer may be a glucometer such as the portable example shown at  202 , a computer programmed to simulate fluid analysis, or another type of fluid analyzer. 
     This embodiment of a blood serum interface  704  includes a finger splint  706  with a layer of protective material  712 . The interface  704  also includes a membrane adhered to the inside and to the ventral side of the finger splint  706  with an unadhered portion of the membrane on each of the radial and ulnar sides of the finger splint  706 . The unadhered portions of the membrane are configured to form blebs  708  capable of holding semi-viscous fluid  710  simulating blood. The blebs  708  cover a large portion of the radial and ulnar sides of the distal phalanx of the finger. When really using a glucometer to test blood-glucose levels, a patient or subject&#39;s finger is pricked with a lancet on the side of the finger in order to avoid nerve damage to the finger and to minimize pain. Thus, a glucometer training system  702  with blebs  708  on the side of the finger configured for being pricked with a lancet  714  provides an anatomically correct simulation. 
     The protective layer  712  of the finger splint  706  may consist of metals, hard plastics, and/or other materials capable of protecting a finger from being cut. Existing splints (e.g., DIP splints for ruptured extensor tendons, such as Stax-type splints) are readily available for use as a platform for adding simulated blood blebs. The layer of protective material  712 , in this embodiment, has at least one perforation  713  on each of the radial and ulnar sides of the finger splint  706 , leading to the unadhered portions of the membrane, or blebs  708 . The perforations  713  are large enough to allow a syringe needle to fit through but small enough to not allow a lancet  714  to fit through, protecting the patient/subject&#39;s finger. 
     Prior to training, the blebs  708  of the blood serum interface  704  can be filled with simulated blood serum  710  from the inside of the finger splint  706 , using a syringe. The fluid  710  can include appropriate physiological composition characteristics, such as blood-sugar levels for glucose testing with a glucometer  202 . Alternatively, the fluid, or simulated blood serum  710 , can be inert with characteristics preprogrammed and simulated by a computer  6 . The simulated blood serum  710  may include a sealant configured to seal off holes poked into the blebs  708 , or the blood serum  710  may include properties causing the blood serum  710  to coagulate, or clot, around holes poked through the blebs  708 . 
     The blebs  708  can be filled by placing a syringe needle through the membrane, through a perforation  713 , and into an unadhered portion of the membrane; filling the bleb  708  with blood serum  710  from the syringe  732 ; and removing the syringe  732 . Either one or both of the blebs  708  can be filled with blood serum  710  in this manner in preparation for training. After at least one bleb  708  has been filled with blood serum  710 , the finger splint  706  can be placed on a patient/subject&#39;s finger. A student or trainee can then prick the outside of the bleb  708  with a lancet  714 , obtain a droplet  716  of blood serum  710 , and test the glucose level of the blood serum  710  using a glucometer  202  or simulated glucometer, thus simulating the actual process for checking someone&#39;s blood-glucose level. 
     The finger splint  706  can be placed on any finger of a mannequin or simulated patient, with the middle (3rd) finger or ring (4th) finger being the preferred placement. There may be different sizes of finger splints  706  to better fit different finger sizes. It is important for the finger splint  706  to extend beyond the DIP joint of the patient/subject&#39;s finger to help ensure that the splint  706  will stay on the finger when the finger is handled by a student or trainee. Additionally, it is preferable to have an open nail portion  718  or a nail-like indention on the finger splint  706  to make the simulation more anatomically correct and to aid in placing the finger splint  706  in the correct orientation on the patient/subject&#39;s finger.  FIGS. 50-52  show the finger splint  706  having an open nail portion  718 . 
     Another alternative embodiment of a glucometer simulation and training system  802 , shown in  FIG. 53 , includes a patient, a blood serum interface  804 , and an analyzer. The patient may be an individual or a mannequin, and at least one of the patient&#39;s fingers is required for the glucometer simulation and training system  802 . The analyzer may be a glucometer such as the portable example shown at  202 , a computer programmed to simulate fluid analysis, or another type of fluid analyzer. 
     The blood serum interface  804  includes a finger splint  806  with a layer of protective material  812  and a bleb  808  configured for holding a semi-viscous fluid  810  simulating blood. The protective layer  812  may consist of metals, hard plastics, and/or other materials capable of protecting a finger from being cut. Existing splints (e.g., DIP splints for ruptured extensor tendons, such as Stax-type splints) are readily available for use as a platform for adding a simulated blood bleb. The bleb  808 , in this embodiment, spans both the inside and outside of the protective layer  812  of the finger splint  806 . The protective layer  812  includes perforations  813  large enough for a syringe needle  834  to go through but small enough to prevent a lancet  814  from going through, protecting a patient/subject&#39;s finger  826  from being cut. 
     The bleb  808  can be filled with simulated blood serum  810  from the inside of the finger splint  806  with a syringe  832  by pointing the syringe needle  834  through one of the perforations  813  in the protective layer  812 . The fluid  810  can include appropriate physiological composition characteristics, such as blood-sugar levels for glucose testing with a glucometer. Alternatively, the fluid, or simulated blood serum  810 , can be inert with characteristics preprogrammed and simulated by a computer  6 . The simulated blood serum  810  may include a sealant configured to seal off holes poked into the bleb  808 , or the blood serum  810  may include properties causing the blood serum  810  to coagulate, or clot, around holes poked through the blebs  808 . 
     After being filled with blood serum  810 , the blood bleb  808  sits underneath the patient/subject&#39;s finger. A filled bleb  808  can be pricked with a lancet  814 , and a droplet  816  of the blood serum  810  can be tested for glucose levels using a glucometer  202  or simulated glucometer. The finger splint  806  can be placed on any finger of a mannequin or simulated patient, with the middle (3rd) finger or ring (4th) finger being the preferred placement. There may be different sizes of finger splints  806  to better fit different finger sizes. It is important for the finger splint  806  to extend beyond the DIP joint of the patient/subject&#39;s finger  826  to help ensure that the interface  804  will stay on the finger when the finger is handled by a student or trainee. It is also preferable to have an open nail portion  818  or a nail-like indention on the finger splint  806  to make the simulation more anatomically correct and to aid in placing the finger splint  806  in the correct orientation on the patient/subject&#39;s finger  826 .  FIG. 53  shows the finger splint  806  having an open nail portion  818 . 
     Alternatively, the finger splint  806  could be placed on the patient/subject&#39;s finger rotated 90degrees. Turning the splint  806  sideways places the bleb  808  on the side of the patient/subject&#39;s finger  826 , which is where an actual finger would be pricked when testing for blood glucose levels. With an open-nail  818  finger splint  806  configuration, at least part of the patient/subject&#39;s fingernail would be visible with the splint  806  turned sideways. A visible fingernail helps with training where to stick a finger when obtaining a droplet of blood serum for blood glucose testing. 
     The glucometer training systems  402 ,  420 ,  440 ,  502 ,  602 ,  652 ,  702 , and  802  are adapted for use with a wide variety of training protocols and procedures. Moreover, the components can be customized, e.g. with 3-D printing, for specific individuals and different digits. Still further, other training exercises and protocols within the scope of the present invention can simulate obtaining samples, e.g., fluid and tissue, for extracting medical information from real and virtual patients. Such sampling exercises can be used in conjunction with other training protocols, as described above. Moreover, fluid can be added via various connections, such as IV tubing connected to the bleb. Additionally, fluids simulating other relevant bodily fluids could be used instead of simulated blood serum for different types of medical training. Also, instead of using testing strips and a glucometer, droplets of blood serum could be taken in a capillary tube from the blood serum interface and brought into a lab for microchemistry and/or histology testing. 
     Still further, the fluid and other simulation characteristics can be located at various parts of a mannequin. For example, mannequin arms, elbows, wrists, etc. can be placed within the mannequins for supplying simulated fluid. Still further, the connections can be accomplished via commonly available medical devices, including standard Leur-Lok hub connectors, IV connections, etc. 
     Life-Pak simulation units, such as that shown in  FIG. 15 , can be utilized for simulation and training Dedicated units can be labeled “Simulation Only.” Other functions, such as defibrillator simulations can be provided with such units. Vital sign machines can be simulated with hydraulic models providing pulsing and respiratory simulations, all of which are variable and controllable. Beeps can be utilized to indicate pulse and other functions, including emergency “no pulse” conditions indicating emergency measures. Temperature probes and pulse-oximetry functions can be included. Simulated electronic medical records (EMRs) can be output. The systems described herein can be installed on new “OEM” mannequins, or retrofit onto existing mannequins. 
     It is to be understood that the invention can be embodied in various forms, and is not to be limited to the examples discussed above. Other components and configurations can be utilized in the practice of the present invention. For example, various combinations of mannequins, simulated patients, computers, outputs, signals, sensors, memories, software, inputs, and diagnostic instruments can be utilized in configuring various aspects of the system  2  comprising the present invention.