Patent Grant
11690781
This invention relates to resuscitation systems incorporating defibrillation therapy and resuscitation prompts.
Resuscitation can generally include clearing a patient's airway, assisting the patient's breathing, chest compressions, and defibrillation.
The American Heart Association's Basic Life Support for Health Care Providers textbook provides a flow chart at page 4-14 of Chapter 4 that lists the steps of airway clearing, breathing, and circulation (known as A, B, and C), for situations in which there is no defibrillator readily accessible to the rescuer.
Defibrillation (sometimes known as step D) can be performed with the use of an automatic external defibrillator (AED). Most automatic external defibrillators are actually semi-automatic external defibrillators (SAED), which require a clinician to press a start button, after which the defibrillator analyzes the patient's condition and provides a shock to the patient if the electrical rhythm is shockable and waits for user intervention before any subsequent shock. Fully automatic external defibrillators, on the other hand, do not wait for user intervention before applying subsequent shocks. As used below, automatic external defibrillators (AED) include semi-automatic external defibrillators (SAED).
Both types of defibrillators typically provide an oral stand clear warning before the application of each shock, and then the clinician is expected to stand clear of the patient and may be required to press a button indicating that the clinician is standing clear of the patient. The controls for automatic external defibrillators are typically located on a resuscitation control box.
AEDs are used typically by trained providers such as physicians, nurses, fire department personnel, and police officers. There might be one or two people at a given facility that has an AED who have been designated for defibrillation resuscitation before an ambulance service arrives. The availability of on-site AEDs along with rescuers trained to operate them is important because if the patient experiences a delay of more than 4 minutes before receiving a defibrillation shock the patient's chance of survival can drop dramatically. Many large cities and rural areas have low survival rates for defibrillation because the ambulance response time is slow, although many suburbs have higher survival rates because of the faster ambulance response time due to lack of traffic and availability of hospitals and advanced life support.
Trained lay providers are a new group of AED operators, but they rarely have opportunities to defibrillate. For example, spouses of heart attack victims may become lay providers, but these lay providers can be easily intimidated by an AED during a medical emergency. Consequently, such lay providers can be reluctant to purchase AEDs, or might tend to wait for an ambulance to arrive rather than use an available AED, out of concern that the lay provider might do something wrong.
There are many different kinds of heart rhythms, some of which are considered shockable and some of them are not. For example, a normal rhythm is considered non-shockable, and there are also many abnormal non-shockable rhythms. There are also some abnormal non-viable non-shockable, which means that the patient cannot remain alive with the rhythm, but yet applying shocks will not help convert the rhythm.
As an example of a non-shockable rhythm, if a patient experiences asystole, the heart will not be beating and application of shocks will be ineffective. Pacing is recommended for asystole, and there are other things that an advanced life support team can do to assist such patient, such as the use of drugs. The job of the first responder is simply to keep the patient alive, through the use of CPR and possibly defibrillation, until an advanced life support team arrives. Bradycardias, during which the heart beats too slowly, are non-shockable and also possibly non-viable. If the patient is unconscious during bradycardia, it can be helpful to perform chest compressions until pacing becomes available. Electro-mechanical dissociation (EMD), in which there is electrical activity in the heart but it is not making the heart muscle contract, is non-shockable and non-viable, and would require CPR as a first response. Idio-ventricular rhythms, in which the normal electrical activity occurs in the ventricles but not the atria, can also be non-shockable and non-viable (usually, abnormal electrical patterns begin in the atria). Idio-ventricular rhythms typically result in slow heart rhythms of 30 or 40 beats per minute, often causing the patient to lose consciousness. The slow heart rhythm occurs because the ventricles ordinarily respond to the activity of the atria, but when the atria stop their electrical activity, a slower, backup rhythm occurs in the ventricles.
The primary examples of shockable rhythms, for which a first responder should perform defibrillation, include ventricular fibrillation, ventricular tachycardia, and ventricular flutter.
After using a defibrillator to apply one or more shocks to a patient who has a shockable electrical rhythm, the patient may nevertheless remain unconscious, in a shockable or non-shockable rhythm. The rescuer may then resort to chest compressions. As long as the patient remains unconscious, the rescuer can alternate between use of the defibrillator (for analyzing the electrical rhythm and possibly applying a shock) and performing cardio-pulmonary resuscitation (CPR).
CPR generally involves a repeating pattern of chest compressions followed by a pause. CPR is generally ineffective against abnormal rhythms, but it does keep some level of blood flow going to the patient's vital organs until an advanced life support team arrives. It is difficult to perform CPR over an extended period of time. Certain studies have shown that over a course of minutes, rescuers tend to perform chest compressions with less-than-sufficient strength to cause an adequate supply of blood to flow to the brain. CPR prompting devices can assist a rescuer by prompting each chest compression and breath.
PCT Patent Publication No. WO 99/24114, filed by Heartstream, Inc., discloses an external defibrillator having PCR and ACLS (advanced cardiac life support) prompts.
In a general aspect, a system includes a processor coupled to a memory, the processor and memory configured to determine a proficiency level of a user of a rescue application based on stored data indicative of the user's history of use of the rescue application, select a level of operation for the rescue application. The rescue application is executed on a mobile device and configured to control operation of a AED. Each of multiple levels of operation for the rescue application allows the user a different degree of control over the operation of the AED. The processor and memory are configured to present, to the user, a set of instructions associated with the selected level of operation. A different set of instructions is associated with each of the multiple levels. The processor and memory are configured to enable control of the AED according to the selected levels of operation.
In a general aspect, a system includes a processor coupled to a memory, the processor and memory configured to determine a proficiency level of a user of a rescue application based on stored data indicative of the user's proficiency level, and based on the user's proficiency level, select a level of operation for the rescue application. The rescue application is executed on a mobile device and configured to control operation of an AED. Each of multiple levels of operation for the rescue application allows the user a different degree of control over the operation of the AED. The processor and memory are configured to present, to the user, a set of instructions associated with the selected level of operation. A different set of instructions is associated with each of the multiple levels. The processor and memory are configured to enable control of the AED according to the selected levels of operation.
In a general aspect, a system includes a processor coupled to a memory, the processor and memory configured to, based on a proficiency level of a user of a rescue application, select a level of operation for the rescue application. The rescue application is executed on a mobile device and configured to control operation of a treatment unit. The processor and memory are configured to enable control of the treatment unit according to the selected level of operation.
Embodiments can include one or more of the following features.
Each of multiple levels of operation allows the user a different degree of control over the operation of the treatment unit.
The treatment unit includes an AED.
The processor and memory are is configured to, based on the level of operation, select a particular set of instructions from multiple sets of instructions to present to the user.
The processor and memory are configured to receive data about a patient being treated by the treatment unit. The processor and memory are configured to select at least some of the data for display on a display interface based on the level of operation. In some cases, the data is received from a multiple lead ECG.
The processor and memory are configured to receive an indication to execute the rescue application in either a rescue mode or a training mode. In some cases, when the rescue application is executed in training mode, enabling control of the treatment unit includes enabling simulation of the operation of the treatment unit. In some cases, when the rescue application is executed in rescue mode, enabling control of the treatment unit includes establishing a connection with an AED; and sending a control signal to the AED.
The proficiency level of the user is based on the user's history of using the rescue application.
The processor and memory are configured to increase the user's proficiency level when the user satisfies a metric associated with the rescue application.
The memory is configured to store data indicative of the user's history of using the rescue application. The processor and memory are configured to, based on the stored data, determine when the user has satisfied the metric. In some cases, the metric includes a metric associated with a particular one of the levels of operation of the rescue application.
Enabling control of the treatment unit includes automatically controlling the treatment unit.
Enabling control of the treatment unit includes controlling the operation of the treatment unit according to a command received from the user.
Enabling control of the treatment unit includes controlling the treatment unit to analyze a condition of a patient, to deliver a shock to the patient, or both.
In a general aspect, a computer readable medium stores instructions for causing a computing system to, based on a proficiency level of a user of a rescue application, select a level of operation for the rescue application; and enable control of the treatment unit according to the selected level of operation. The rescue application is executed on a mobile device and configured to control operation of a treatment unit.
Embodiments can include one or more of the following features.
Each of multiple levels of operation allows the user a different degree of control over the operation of the treatment unit.
The treatment unit includes an AED.
The instructions cause the computing system to, based on the level of operation, select a particular set of instructions from multiple sets of instructions to present to the user.
The instructions cause the computing system to receive data about a patient being treated by the treatment unit; and select at least some of the data for display on a display interface based on the level of operation. In some cases, the data is received from a multiple lead ECG.
The instructions cause the computing system to receive an indication to execute the rescue application in either a rescue mode or a training mode. In some cases, when the rescue application is executed in training mode, enabling control of the treatment unit includes enabling simulation of the operation of the treatment unit. In some cases, when the rescue application is executed in rescue mode, enabling control of the treatment unit includes establishing a connection with an AED; and sending a control signal to the AED.
The proficiency level of the user is based on the user's history of using the rescue application.
The instructions cause the computing system to increase the user's proficiency level when the user satisfies a metric associated with the rescue application. In some cases, the instructions cause the computing system to store data indicative of the user's history of using the rescue application; and based on the stored data, determine when the user has satisfied the metric. In some cases, the metric includes a metric associated with a particular one of the levels of operation of the rescue application.
The instructions for causing the computing system to enable control of the treatment unit include instructions for causing the computing system to automatically control the treatment unit.
The instructions for causing the computing system to enable control of the treatment unit include instructions for causing the computing system to control the operation of the treatment unit according to a command received from the user.
The instructions for causing the computing system to enable control of the treatment unit include instructions for causing the computing system to control the treatment unit to analyze a condition of a patient, to deliver a shock to the patient, or both.
In a general aspect, a method includes determining a proficiency level of a user of a rescue application based on stored data indicative of the user's proficiency level. The rescue application is executed on a mobile device and configured to control operation of a AED. The method includes, based on the user's proficiency level, selecting a level of operation for the rescue application. Each of multiple levels of operation for the rescue application allows the user a different degree of control over the operation of the AED. The method includes presenting, to the user, a set of instructions associated with the selected level of operation, wherein a different set of instructions is associated with each of the multiple levels; and enabling control of the AED according to the selected levels of operation.
The techniques described herein can have one or more of the following advantages. Providing control of a treatment unit, such as an AED, from a mobile computing device is convenient and allows users to deliver rescue treatments through a familiar interface. Users can practice treatment delivery using the mobile computing device as a simulator to gain experience outside of real emergency situations. Mobile computing devices can offer capabilities for powerful control of AEDs and other treatment and monitoring techniques. The capabilities that are accessible to a given user are tailored to the user's level of experience, thus helping to ensure that the user is provided with tools to deliver safe and effective treatment to a patient.
A portable ECG package allows medical personnel to carry around complex multiple lead ECG equipment, e.g., a 12-lead ECG, without the danger of damaging the ECG electrodes or tangling the ECG cables.
The details of one or more embodiments are set forth in the accompanying drawings and the description below. Other features and advantages will be apparent from the description, drawings, and claims.
With reference to
A low-profile button panel 20 is provided on the electrode assembly. Button panel 20 has buttons 22, including buttons A (Airway Help), B (Breathing Help), C (Circulation Help) and PAUSE, and may also include adjacent light emitting diodes (LEDs) 24 that indicate which button has been most recently pressed. Button panel 20 is connected by a cable 23 to a remote resuscitation control box 26, shown in
A pulse detection system based on shining light through the patient's vascular bed, e.g., a pulse oximetry system 52, is incorporated into defibrillation electrode pad 10. Pulse oximetry system 52 includes a red light-emitting diode, a near-infrared light-emitting diode, and a photodetector diode (see
In another implementation, the pulse detection system is a phonocardiogram system for listening to the sound of the victim's heart, rather than a pulse oximetry system. The phonocardiogram system includes a microphone and an amplifier incorporated within the electrode pad. Because a heart sound can be confused with microphone noise, the signal processing that must be performed by the microprocessor inside the control box will be more difficult in connection with a phonocardiogram system than in connection with a pulse oximetry system. Nevertheless, there are programs available that can enable the microprocessor to determine whether an ECG signal is present as opposed to microphone noise.
Pulse oximetry is a well-developed, established technology, but it requires good contact between the light sources and the victim's skin so that light can shine down into the victim's vascular bed. Many victims have lots of chest hair, which can interfere with good contact. It may be desirable for different types of electrode pads to be available at a given location (one having a pulse oximetry system and one having a phonocardiogram system) so that a rescuer can select an appropriate electrode pad depending on the nature of the victim.
In another implementation, instead of providing a low-profile button panel, a button housing can be provided that is affixed to an edge of the defibrillation electrode. The housing may be in the form of a clamshell formed of single molded plastic element having a hinge at an edge of the clamshell around which the plastic bends. The two halves of the clamshell can be snapped together around the electrode assembly.
The resuscitation control box (
The resuscitation control box has printed instructions 32 on its front face listing the basic steps A, B, and C for resuscitating a patient and giving basic instructions for positioning the defibrillation electrode pad on the patient. A speaker 32 orally prompts the user to perform various steps, as is described in detail below.
For example, the resuscitation control box instructs the user, by audible instructions and also through a display 34 on the resuscitation control box, to check the patient's airway and perform mouth-to-mouth resuscitation, and if the patient's airway is still blocked, to press the A (Airway Help) button on the button panel (
During the circulation procedure, the resuscitation control box receives electrical signals from the defibrillation electrodes and determines whether defibrillation or CPR should be performed. If the resuscitation control box determines that defibrillation is desirable, the resuscitation control box instructs the user to press the “ready” button on the resuscitation control box and to stand clear of the patient. After a short pause, the resuscitation control box causes a defibrillation pulse to be applied between the electrodes. If at any point the resuscitation control box determines, based on the electrical signals received from the electrodes, that CPR is desirable, it will instruct the user to perform CPR.
Thus, the key controls for the system are on the electrodes attached to the patient rather than the resuscitation control box. This is important because it enables the rescuer to remain focused on the patient rather than the control box. The resuscitation control box gets its information directly from the electrodes and the controls on the electrodes.
The resuscitation control box can sense electrical signals from the patient's body during pauses between CPR compressions. Also, as is described below, a compression-sensing element, such as an accelerometer or other acceleration sensing element, or a force-sensing element is provided in the region of the defibrillation electrode pad on which the user presses to perform CPR. The purpose of the compression-sensing or force-sensing element is to allow the resuscitation control box to prompt the user to apply additional compression or force, or to prompt the user to cease CPR if the user is performing CPR at an inappropriate point in time.
Referring to
Thus, the ink can be applied as pattern, as opposed to a solid sheet covering the entire polyester base. For example, U.S. Pat. No. 5,330,526 describes an electrode in which the conductive portion has a scalloped or daisy shape that increases the circumference of the conductive portion and reduces burning of the patient. A conductive adhesive gel 38 covers the exposed surface of each electrode.
In addition, electrical circuit components are also be screen printed on the base, in the same manner as flat circuit components of membrane-covered, laminated panel controls.
Referring to
Referring again to
In implementations having a force-sensing element, a polyester laminate 60, and a force-sensing resistor having two layers of carbon-plated material 62 and 64, are laminated between polyester substrate 36 and semi-rigid supporting member 58. A suitable construction of the force-sensing resistor is illustrated in the FSR Integration Guide & Evaluation Parts Catalog with Suggested Electrical Interfaces, from Interlink Electronics. The electrical contact between the two carbon-plated layers of material increases with increased pressure, and the layers of force-sensing resistive material can provide a generally linear relationship between resistance and force. Conductive ink traces 66 and 68 provide electrical connections to the two layers of the force-sensing resistor.
During chest compressions, the rescuer's hands are placed over the extension piece, and the force-sensing resistor of the extension piece is used to sense the force and the timing of the chest compressions. The force-sensing resistor provides information to the resuscitation control box so that the resuscitation control box can provide the rescuer with feedback if the rescuer is applying insufficient force. The resuscitation control box also provides coaching as to the rate at which CPR is performed. In certain situations, the resuscitation control box indicates to the rescuer that CPR should be halted because it is being performed at an inappropriate time, such as immediately prior to application of a defibrillation shock when the rescuer's hands should not be touching the patient, in which case the resuscitation control box will also indicate that the rescuer should stay clear of the patient because the patient is going to experience a defibrillation shock.
As is noted above, during CPR the rescuer pushes on the patient's chest through the extension piece in the vicinity of the electrodes. If the resuscitation control box were to perform analysis during the chest compressions, the chest compressions would be likely to affect the sensed electrical rhythm. Instead, during the pauses between sets of compressions (for example, the pause after every fifth chest compression), the resuscitation control box can perform an electrocardiogram (ECG) analysis. The resuscitation control box might discover, for example, that the patient who is undergoing CPR is experiencing a non-shockable rhythm such as bradycardia, in which case the CPR is required in order to keep the patient alive, but then the resuscitation control box may discover that the rhythm has changed to ventricular fibrillation in the midst of CPR, in which case the resuscitation control box would instruct the rescuer to stop performing CPR so as to allow the resuscitation control box to perform more analysis and possibly apply one or more shocks to the patient. Thus, the rescuer is integrated into a sophisticated scheme that allows complex combinations of therapy.
In another implementation, a compression-sensing element such as an accelerometer may be used in place of a force-sensing element. The accelerometer, such as a solid-state ADXL202 accelerometer, is positioned at the location where the rescuer performs chest compressions. In this implementation, the microprocessor obtains acceleration readings from the accelerometer at fixed time intervals such as one-millisecond intervals, and the microprocessor integrates the acceleration readings to provide a measurement of chest compression. The use of an accelerometer is based on the discovery that it is more important to measure how deeply the rescuer is compressing the chest than to measure how hard the rescuer is pressing. In fact, every victim's chest will have a different compliance, and it is important that the chest be compressed to a recommended depth in a normal sized adult regardless of the victim's chest compliance.
The first thing the rescuer must do upon arriving at the patient is to determine whether the patient is unconscious and breathing. The rescuer opens the patient's airway, administers breaths to the patient if the patient is not breathing, and checks to determine whether a pulse is present. If there is no pulse, rather than perform chest compressions as in standard CPR, the rescuer allows the resuscitation control box to analyze the patient's electrical rhythm, and if the resuscitation control box determines that the rhythm is shockable, the resuscitation control box causes one or more shocks to be applied to the patient, and then the rescuer performs chest compressions. Thus, there is provided a first response system that can keep the patient viable until an advanced life support time arrives to perform advanced techniques including pacing, further defibrillation, and drug therapy.
If the resuscitation control box determines that it should apply one or more defibrillation shocks to the patient, it is important that the rescuer not be anywhere near the patient when the shocks are applied to the patient. Prior to application of each shock, the resuscitation control box instructs the rescuer to please press the “ready” button when everybody is clear of the patient. The pressing of the “ready” button verifies that the rescuer's hands are off of the patient.
When the resuscitation control box detects a shockable rhythm, the resuscitation control box provides shocks of appropriate duration and energy (such as a sequence of shocks of increasing energy from 100 Joules to 150 Joules to the highest setting, 200 Joules, with the resuscitation control box performing analysis after each shock to determine whether another shock is required). If the defibrillation therapy is successful, the patient's rhythm is typically converted from ventricular fibrillation, ventricular tachycardia, or ventricular flutter to bradycardia, idio-ventricular rhythm, or asystole, all of which require CPR. It is rare to convert to a normal rhythm. Once the resuscitation control box has caused defibrillation shocks to be applied to the patient, the resuscitation control box automatically senses the patient's condition, and depending on the patient's condition will either prompt the responder to perform CPR or will not prompt the respond to perform CPR.
Defibrillation equipment can be somewhat intimidating to rescuers who are not medical professionals because the equipment can lead the rescuer to feel responsibility for having to save a loved one's life. It is important that the defibrillation equipment reduce this sense of responsibility. In particular, when the rescuer presses the “ready” button, rather than apply a shock immediately that will cause the patient's body to jump dramatically, the resuscitation control box will thank the rescuer and instruct the rescuer to remain clear of the patient and then wait for about two seconds (the resuscitation control box may describe this period to the rescuer as being an internal safety check, even if no substantial safety check is being performed). This process has an effect similar to a conversation that hands responsibility to the resuscitation control box, which makes the decision whether to apply the shock. Thus, the system maintains the rescuer safety features of a semi-automatic external defibrillator, because the rescuer must press the “ready” button before each shock, while appearing to operate more as a fully automatic external defibrillator because the time delay immediately prior to each shock leaves the rescuer with the impression that operation of the equipment is out of the hands of the rescuer. The use of CPR prompts in combination with the defibrillation also adds to the sense that the rescuer is simply following instructions from the resuscitation control box.
With reference to
After a pause, the resuscitation control box then instructs the rescuer that if the patient is breathing the patient should be placed on the patient's side, unless trauma is suspected, and that the rescuer should press the PAUSE button (steps 108-109). Then the resuscitation control box instructs the rescuer to perform mouth-to-mouth resuscitation if the patient is not breathing (steps 110-114). Then the resuscitation control box instructs the rescuer to press an Airway Help button A if the patient's airway is blocked, so that the resuscitation control box can give prompts for clearing obstructed airways (steps 115 of
Next, after a pause (step 116a), if the resuscitation control box does not include pulse oximetry or phonocardiogram capability (step 116b), the resuscitation control box instructs the rescuer to check the patient's pulse (step 117). After another pause, the resuscitation control box instructs the rescuer to press a Breathing Help button B if the patient's pulse is okay but the patient is not breathing, so that the resuscitation control box can give prompts for assisting the patient's breathing (steps 118 and 119 of
If the resuscitation control box does include pulse oximetry or phonocardiogram capability (step and 116b), the resuscitation control box prompts the rescuer to open the patient's shirt or blouse and attach the adhesive pads (steps 121 and 122a). If the pulse oximetry or phonocardiogram system does not provide a valid pulsatile reading (step 122b), then the flow chart proceeds to step 117. If the pulse oximetry or phonocardiogram system does provide a valid pulsatile reading and detects a pulse (steps 122b and 122c), then the resuscitation control box begins the breathing help routine (steps 122d of
The combined defibrillation and CPR resuscitation assembly provided can be less intimidating than conventional AEDs because the assembly is not devoted solely to defibrillation. Moreover, the resuscitation assembly is less intimidating because it accommodates common skill retention problems with respect to necessary techniques ancillary to defibrillation such as mouth-to-mouth resuscitation and CPR, including the appropriate rates of chest compression, the proper location for performing compressions, the proper manner of tilting the patient's head. In addition, because the rescuer knows that it may never even be necessary to apply a defibrillation shock during use of the resuscitation assembly, the rescuer may be more comfortable using the resuscitation assembly for mouth-to-mouth resuscitation and CPR. Unlike previous CPR prompting devices, the rescuer would be required to place the electrode assembly on top of the patient, but the rescuer would do this with the belief that the resuscitation assembly will be sensing the patient's condition and that the likelihood that the resuscitation assembly is actually going to apply a shock is low. If, during this resuscitation process, the resuscitation control box instructs the rescuer to press the “READY” button so that a defibrillation shock can be applied, the rescuer will likely feel comfortable allowing the shock to be applied to the patient. Basically, the resuscitation assembly simply tells the rescuer what to do, and by that point, given that the rescuer is already using the assembly, the rescuer is likely simply to do what the rescuer is told to do. Essentially, the rescuer will be likely to view the resuscitation assembly as simply being a sophisticated CPR prompting device with an additional feature incorporated into it, and since rescuers are less likely to be intimidated by CPR prompting devices than AEDs, they will be likely to use the resuscitation assembly when it is needed.
The first unit could also be incorporated into the electrode pad assembly rather than being a separate box. The electronics could be provided on the rigid substrate 40 of the electrode pad assembly (
Separate batteries 178, 179 and controls 180, 181 may be provided for the first (CPR) and second (therapy) units, thereby allowing the electronics in the first unit to provide CPR prompting to the operator without the need for the second unit. The cable 216 that connects the first and second units may be detachable. Memory 189 is provided in the first unit for storing information such as voice recording, ECG data, chest compression data, or electronic system status such as device failures that occur during daily self checks of the electronics initiated by a real time clock circuit.
The defibrillation electrode pad assembly 10 may incorporate defibrillation electrodes composed of a material that can be held against a patient's skin for extended periods of time (e.g., up to 30 days).
As shown in
In another implementation, the first unit may be adapted to be supported by the patient for long periods of time. The unit could be incorporated into the electrode pad assembly as suggested above, or it could be a separate unit configured to be worn by the patient. In such an implementation, the electronics of the first unit are designed to allow for long term monitoring of the patient's condition via the ECG 177 and physiological monitoring 176 circuitry. If a physiological condition is detected that is deemed hazardous to the patient by the CPR processor 170, based on analysis of the ECG and other physiological parameters, an alarm is sounded to the patient via the speaker 182.
An activity sensor and associated circuitry can inform the CPR processor of whether the patient is moving. For example, accelerometer 76 could serve as the activity sensor, and detect whether or not the patient is moving. Patient motion may be detected using a variety of different algorithms, including, for example the following: The acceleration signal is integrated over one-second intervals to provide an estimate of velocity. Velocity is integrated over the same one-second intervals to provide an estimate of displacement. The root means square velocity is calculated for each one-second interval. If either the RMS velocity exceeds 0.2 cm/s or the peak displacement exceeds 0.5 cm, the patient is determined to be moving.
If the algorithm determines that a cardiac emergency event is occurring, the first unit can send a message directly to a medical emergency response system, such as 911. This can be done using a variety of known communication techniques, e.g., Bluetooth, cellular phone, Ultra Wideband (UWB). If the activity sensor has determined that the patient is still moving during the cardiac emergency, the unit could also issue a prompt indicating, “Call 911 Immediately!”
The first unit will be able to determine the orientation of the patient, e.g., based on the accelerometer output. It can detect if a patient has fallen down and initiate a message to the emergency system. It can also determine whether the patient is lying on his back, the proper orientation for doing CPR. Thus, a specific prompt can be provided to the rescuer that tells them to roll the patient on their back prior to beginning CPR, should the device detect an improper orientation of the patient.
Other implementations may include signal analysis software for predicting the risk of a heart attack. When a threshold is exceeded in the value of that risk probability, a voice prompt may be provided to the patient via the speaker 182 to contact the medical emergency system. By using the motion detection capabilities of the accelerometer to measure and track a patient's activity level (PAL), and combining the activity level calculation with measurements of the ECG 177, e.g., ST-segment elevation (STE), the first unit is able to provide a predictor of the risk of an impending heart attack or cardiac arrest. An ST segment elevation exceeding a threshold such as 300 microvolts on the ECG provides an indicator of impending heart attack. In the preferred embodiment, ST segment elevation in the presence of increased physical activity is an indication of further risk of potential cardiac arrest. The calculation of risk probability may be accomplished by first performing a logistic regression of variables such as STE and PAL as predictors of cardiac arrest within 24 hours. The calculation may take the form of a linear regression equation such as
0.24 STE+0.12 PAL=RISK.
Alternatively, nonlinear regression may be performed to allow for a multiplicative term such as
0.24 STE+0.12 PAL+0.54(STE*PAL)=RISK.
The multiplicative term heightens the importance of STE in the presence of PAL.
Parameters such as STE, PAL and RISK may additionally be stored in memory and multiple readings and calculations performed over time. The sequence of readings may then be analyzed for trends in the physiological state of the patient that can augment the RISK calculation taken at a single point in time. For instance, if STE is found to be steadily rising over a series of readings, the voice prompt may be triggered sooner than at a fixed threshold of 300 microvolts.
Additionally, the ECG may be analyzed to determine the interval between adjacent R-waves of the QRS complexes and using this interval to calculate heart rate variability as a running difference between adjacent R-R intervals. It is known that the R-R interval will vary following an ectopic beat or ventricular premature contraction (VPC). In a healthy heart, the R-R interval will decrease immediately following the VPC followed by a gradual return to steady state; a heart with an increased risk of heart attack will show a decreased level of variability. This effect is sometimes called heart rate turbulence. Two variables are calculated: (1) the Relative Change in R-R interval (RCRR) between pre- and post-VPB R-R intervals,
RCRR=(R-R pre-VPB−R-R post-VPB)/R-R pre-VPB
and (2) the slope of the change of R-R interval (SRR) while it is undergoing its post-VPB decrease. If the RCRR is non-negative and the slope SRR does not steeper than −2 ms/R-R interval then the patient is considered as at risk. Alternatively, the individual calculations may be included along with STE and PAL to create an integrated measurement vector as discussed in the preceding paragraphs. Other signal analysis algorithms may incorporate analysis of heart rate variability in the frequency domain, wavelet domain or using non-linear dynamics-based methods.
Since VPBs are often rare events, the defibrillation electrode pad 10 may include circuitry to stimulate the patient with a single pulse of low enough amplitude to cause a VPB without undue discomfort to the patient, under the patient's control. An additional control is provided on the low-profile button panel 20 so that the patient may initiate the pulse under their control. Alternatively, the device is programmed to automatically deliver the pulse at regular intervals such as at 24-hour intervals, at a time of day when the patient may conveniently have access to the device, such as in the morning. While the pulse generator 186 may be located in the second (therapy) unit, it is preferably contained as part of the first (CPR) unit.
In another implementation, the activity monitoring capability of the first unit may be utilized so that the activity state of the patient is continuously monitored. Using the activity monitoring capability and a real time clock 187, the first unit may detect when a patient has woken up in the morning. After there has been 10 minutes of regular motion detected, the unit may prompt the patient that it would like to perform a test. If the patient assents to the test indicated by a press of the TEST button on the low-profile button panel 20, the unit will send out a small current pulse, preferably a 40 millisecond pulse of 75 mA amplitude that is synchronized to the patient's ECG so that it occurs approximately 200 mS prior to the R-wave and after the T-wave so as not to introduce any arrhythmias. The pulse will safely cause a VPB in the patient which can then be used to measure the autonomic response to a VPB to provide regular calculations of the autonomic response to a VPB as measured by such parameters, though not limited to, STE and PAL, and providing a daily update to the RISK calculation.
Additional physiological measurement, preferably that of blood pressure, may be incorporated into the RISK calculation. A sudden change in systolic or mean arterial blood pressure of greater than 10-15 points is indicative of an increased risk of cardiac arrest. In the preferred embodiment, the blood pressure measurement device would be a handheld, inflated cuff blood pressure device 188. The blood pressure cuff 188 would have wireless communication capability with the CPR Processor 170 and at the conclusion of each measurement, the blood pressure reading along with a date and time stamp would be stored in memory 189 of the CPR Processor 170 for subsequent use in calculating RISK. This scheme would allow the patient to carry the small blood pressure cuff along with them during their daily activities and take blood pressure measurements at regular intervals without having to return home. Alternatively, the blood pressure measurement device may communicate with the therapy processor and may additionally get power from and be physically connected to the second (therapy) unit by a cable. The patient will then be required to take regular blood pressure readings at the second unit, typically a larger device that may or may not be portable. Communication of the blood pressure readings may be accomplished over a cable between the first (CPR) and second units (therapy) units, e.g., cable 216, or wirelessly, using such technology as Bluetooth.
The second unit 218 may in some implementations be thought of as an energy delivery unit (EDU), in which case it would incorporate a defibrillator 172, pacer 173, or other electrical therapy 174. In some implementations, the EDU would be small and light enough to be worn in a harness or belt to be carried around continuously by the patient. The EDU 218 may in some cases not contain a therapy processor 171, but be a “dumb” device that requires the controls provided by connection to the processor in the first (CPR) unit, e.g., on the defibrillator pad 10, in order to deliver electrical therapy to the patient.
In some cases, the patient may not even own an EDU due to the significant costs inherent in the high-voltage components necessary. The patient would only own the first unit and defibrillator pad, as the components incorporated in them are less expensive, e.g., they can be manufactured from less-expensive, consumer-type electronics. In such a case, when the patient did not own the EDU, and had a heart attack, a bystander or family member who encountered the cardiac arrest victim would be prompted to begin CPR. It has been shown now in several studies that performing good CPR for extended periods prior to delivery of a shock is not detrimental to long term survival, and can in some cases increase survival rates. CPR would thus begin with built-in prompting and when the paramedic arrives with the defibrillator it can be connected to the pads to deliver the electrical therapy. If the first (CPR) unit is separate from the electrode pad assembly, the EDU connection to the electrodes could be direct, or via a cable connected to the first (CPR) unit. If the defibrillator is an EDU or other compatible device, patient and performance data stored by the first (CPR) unit may be downloaded to the defibrillator.
Many other implementations of the invention other than those described above are within the invention, which is defined by the following claims. For example, the defibrillation pads 10, 12 may be separable from the CPR-prompting first unit and be connected at the time that the EDU is brought to the scene; the defibrillation pads may be connected both electrically and mechanically to the CPR-prompting first unit at that time. A greater amount of the control functionality may be put into the first unit, leaving essentially only the circuitry for providing the defibrillation pulses in the second unit. The first unit may be incorporated into the defibrillation electrode pad assembly, or made a separate unit connected to the pad assembly by one or more cables. The second unit may connect to the first unit by one or more cables, or by a wireless connection. The defibrillation pulses may pass through the first unit (
In some implementations the second (therapy) unit can provide pacing therapy as well as defibrillation therapy. Pulse detection methods other than pulse oximetry and phonocardiogram may be employed. Any method capable of detecting a victim's pulse can be used for pulse detection.
Referring to
The treatment unit 1402 can act as a power source and can include electronic components, such as a battery, a capacitor, and other electronic components that enable the treatment unit 1402 to provide treatment to the patient 1400. The treatment unit 1402 can also include a communication module 1408, e.g., an antenna, for communicating wirelessly with the control unit 1404. In some examples, the treatment unit 1402 can include basic controls 1410, such as a power switch and a shock/analyze controller, that can be used by a rescuer 1414 to operate the treatment unit 1402 without the control unit 1404.
The control unit 1404 can be a mobile computing device, such as a mobile phone (e.g., an iPhone®), a tablet (e.g., an iPad®), a wearable computing device such as a smart watch or glasses (e.g., a Glass® wearable computing device), or another type of mobile computing device. The control unit 1404 executes a software application 1412 (referred to herein as an “app”) that controls the operation of the treatment unit 1402, provides information and instructions to a user 1414 of the control unit 1404 (e.g., a rescuer), and receives input from the user 1414. In some examples, the app can be a generalized app that enables the control unit 1404 to control various types of treatment units 1402, such as treatment units 1402 produced by various manufacturers. In some examples, the app can be specific to one or more particular brands or models.
The app 1412 can receive status information about the patient from the electrode pad assembly 10. In some examples, the control unit 1404 can receive the status information directly from the electrode pad assembly 10, e.g., through a wired or wireless connection with the electrode pad assembly 10. In some examples, the control unit 1404 can receive the status information from the treatment unit 1402, which receives the status information from the electrode pad assembly 10.
The app 1412 analyzes the status information to determine the condition of the patient 1400. For instance, the app 1412 can determine if the patient's rhythm is shockable. If the rhythm is shockable, the app 1412 can command the treatment unit 1402 to deliver a shock to the patient 1400, e.g., automatically or upon approval by the user 1414. In some cases, the app 1412 can determine the appropriate energy and duration for the shock and the appropriate number of shocks. If the rhythm is not shockable, the app 1412 can instruct the user 1414 to deliver CPR to the patient 1400. In some examples, the app 1412 can command the treatment unit 1402 to analyze the status information and to deliver a shock to the patient 1400 if appropriate, e.g., automatically or upon approval by the user.
The app 1412 communicates information and instructions to the user 1414, e.g., through visual, audio, or tactile communications. The app 1412 can display information and instructions as images and/or text on a display interface of the control unit 1404. In one example, the app 1412 displays step-by-step instructions and simple figures to guide the user in delivering CPR to the patient. The app 1412 can provide audio information through speakers of the control unit 1404. In one example, the app 1412 speaks “Clear: Shocking Patient” prior to commanding the treatment unit 1402 to apply a shock. In one example, the app 1412 sounds a rhythmic tone (e.g., a beep) to assist the user in delivering compressions at the proper rate. The app 1412 can provide tactile information through a vibration component of the control unit 1404. For instance, the app 1412 can cause the mobile device 1404 and/or a unit on the electrode pad assembly 10 to vibrate when a new instruction is displayed on the display interface. Other ways of communicating with the user can also be used.
The app 1412 can also receive input from the user 1414. For instance, the user can tap the screen with his finger or a pointing device, such as a stylus, to input information to the app 1412. In one example, the user can tap an “Approve” button to approve the delivery of a shock to the patient 1400. Information can also be received by other methods. For instance, the user can input information, such as information about the patient, to the app through a keyboard or keypad of the control unit 1404. The user can speak into a microphone and the app 1412 can use voice recognition technology to recognize voice commands. For instance, the user can ask for more information or give a command to the app 1412, such as commanding the app 1412 to dial 9-1-1 to report an emergency. In some examples, the user's speech can be processed by a speech recognition program. Other forms of input can also be used.
In some examples, the app 1412 can operate in either a rescue mode or a training mode. In rescue mode, the control unit 1404 communicates with the treatment unit 1402 to provide treatment to a real patient 1400. In training mode, the user-facing operation of the app 1412 is similar to the rescue mode operation of the app, but the control unit 1404 does not communicate with the treatment unit. That is, the app 1412 acts as a simulator that allows the user 1414 to interact with the control unit 1404 as if he were in a real rescue situation. In some examples, the training mode can include a simulation component, which simulates the operation of the app 1412 in a real rescue situation; and a teaching component, which provides recorded instructions, demonstrations, videos, quizzes, or other approaches to teaching the user about the app 1412 or about rescue techniques in general.
The app 1412 can offer multiple levels of operation to the user 1414. Each successive level can be targeted at users with greater experience. Thus, each successive level can provide access to a wider range of capabilities of the app. In addition, the prompts and instructions that the app 1412 provides to the user can depend on the level. For instance, in a basic mode directed to inexperienced users, only basic functions of the app 1412 can be accessed, and detailed instructions for how to proceed in a rescue situation can be provided. In an advanced mode directed to experienced professional users, a more complete set of functions of the app 1412 can be accessed, and fewer instructions are provided so as not to distract the user. In some examples, training mode can provide a teaching component associated with each level that is designed to teach the user about the capabilities of the app 1412 at that level and associated rescue techniques.
In some examples, the app 1412 can access a stored indicator of the user's proficiency on startup, and can run the appropriate level based on the stored indicator. The indicator can be stored locally on the control unit 1404 or in a remote data storage accessible through a communications network, such as the Internet. In some cases, the indicator can be reflective of the user's history of using the app 1412, e.g., in rescue mode, training mode, or both. For instance, the indicator can reflect the level that the user has reached in training mode. In some cases, the indicator can be specified by the user or by a third party, such as the user's supervisor. In some examples, no indicator is stored and the app 1412 can prompt the user to enter his proficiency on startup.
Referring to
If the app runs in rescue mode, the app causes the control unit to establish wireless communication with the treatment unit (1504). In some examples, if the app detects the presence of a treatment unit, a wireless connection can be automatically established. In some examples, the app requests user input, such as user approval to establish the connection or user input to identify the treatment unit.
In both training mode and rescue mode, the user's proficiency is identified by the app (1506). In some examples, the app can retrieve the indicator of the user's proficiency from local data storage on the control unit or from an Internet-accessible remote data storage. In some examples, the app can prompt the user to enter an indicator of his proficiency.
Based on the user's proficiency, the app provides access to the appropriate level of operation (1508). Depending on the level of operation, the user can have access to various capabilities of the app, and instructions and information can be provided to the user as appropriate.
Referring to
In the example of
Referring to
At an appropriate point during CPR, the user is asked if an AED is available (1710). If not, the user is instructed to continue CPR as directed (1712). If an AED is available, the user is provided with detailed instructions for preparing the AED (1714), including turning on the AED, opening the electrode pad package, and applying the electrode pad assembly to the victim.
Once the AED is prepared, the app analyzes the condition of the victim to determine if the victim's rhythm is shockable. When the app determines that the victim's rhythm is shockable (1716), the user is notified to stand clear of the victim (1718) and the app automatically sends a command to the AED to deliver a shock to the victim (1720), e.g., after receiving confirmation that the user is clear of the victim. That is, in this example, the basic level does not provide the user access to the AED controls within the app.
In some examples, the app can command the AED to analyze the condition of the victim to determine if the victim's rhythm is shockable. When the AED determines that the victim's rhythm is shockable, the AED communicates with the app, which notifies the user to stand clear of the victim. The app can then instruct the AED to deliver a shock to the victim, e.g., after receiving confirmation that the user is clear of the victim.
Other information and instructions can also be provided at the basic level. For instance, the app can remind the user about personal safety issues, such as wearing gloves or a face mask. The app can ask the user if there is another person available to help, and can provide instructions to that other person.
Referring again to
Referring to
At an appropriate point during CPR, the user is asked if an AED is available (1808). If not, the user is instructed to continue CPR as directed (1810). If an AED is available, the user is instructed to prepare the AED (1812).
Once the AED is prepared, the app analyzes the condition of the victim to determine if the victim's rhythm is shockable. When the app determines that the victim's rhythm is shockable (1814), the user is notified to stand clear of the victim (1816) and instructed to press the “Shock” button on the AED (1818) when clear of the victim. That is, in this example, the intermediate level does not provide the user access to the AED controls within the app.
In some examples, the intermediate level does not provide the user access to the AED controls within the app; the user is limited to using the controls on the AED itself. When the app detects that a shock should be delivered to the victim, the app notifies the user to stand clear of the victim (1814) and asks the user to press the “Shock” button on the AED (1816) when clear of the victim.
Other information, instructions, and capabilities can also be provided at the intermediate level. For instance, the app can respond to a user request for help by providing additional instructions about a particular technique (e.g., by providing step-by-step instructions for the preparation of the AED).
Referring again to
Referring to
If the user does not turn on the AED, the user can be provided with a prompt to turn on the AED through the app (1904), e.g., by clicking or tapping on a button on the display interface or by speaking a command. The app presents a shock/analyze capability to the user, e.g., as buttons on the display interface or as commands that can be spoken. When the app receives the user's command to analyze, the app analyzes the victim's condition (1906). If the app determines that the victim's rhythm is shockable, the app asks for the user's command to shock the victim (1908), e.g., by presenting a visual, audio, or vibration indicator that the rhythm is shockable. Upon receiving the user's command to shock (e.g., a tap on a button on the display interface or a spoken command), the app sends a command to the AED to deliver a shock to the victim (1910). That is, in this example, the professional level provides the user with access to AED controls within the app.
Referring again to
In addition, the advanced level can allow the user to connect one or more monitors to the control unit to gain a more detailed and accurate overview of the victim's condition. For instance, the user can connect a multiple lead ECG to the control unit, such as a three-lead ECG, a twelve-lead ECG, an eighteen-lead ECG, or another type of ECG. Plots corresponding to each of the leads of the ECG can be displayed on the display interface. In some examples, plots corresponding to all of the leads can be displayed simultaneously and the user can scroll through the plots. In some examples, the user can request a plot, e.g., by a voice command (e.g., speaking the name of the lead) or by selecting the plot from a list of available plots.
Other information, instructions, and capabilities can also be provided at the advanced level. For instance, the advanced level can provide recording and charting capabilities, e.g., a data recorder that records ECG traces or a voice recorder that records a paramedic's ongoing voice narration of an emergency rescue situation.
Referring to
Referring to
In some examples, the ECG package 2200 is provided enclosed in a wrapper, e.g., to protect the integrity and cleanliness of electrode pads therein. For instance, the ECG package 2200 can be packaged in a wrapper that provides a high moisture vapor barrier, such as a high moisture vapor transmission rate (MVTR) material, e.g., a polyfoil substrate. In some examples, the housing itself 2202 is formed of a material that provides a high moisture vapor barrier. In some examples, the slit 2205 can be closed by a gasket material that allows the pull tab 2204 to be accessed but prevents moisture from entering the interior of the housing.
A chip 2214, such as a memory chip or a processor, located in or near the pull tab 2204 can store and/or process ECG data carried by the ECG cables 2206. For instance, the ECG signals transmitted through the ECG cables 2206 can be stored on the chip 2214 so that the signals can later be read and analyzed by a physician at a hospital. By storing the signals on the chip 2214, the stored data can be easily transported to the hospital.
When a rescuer pulls the pull tab, the ECG cables 2206 unwind from their wrapped configuration around the core 2208 and can be pulled out of the housing 2202. For instance, the core 2208 can spin as the pull tab 2204 is pulled, thus releasing the ECG cables 2206. By storing the ECG cables 2206 in this wrapped configuration, the chance of the cables tangling or breaking during transportation and/or unwinding can be minimized.
In some examples (e.g.,
In some examples, each ECG cable 2206 can be wound individually around a corresponding core that can rotate relative to the housing, such as a radially oriented core. Other configurations of ECG cables 2206 within the housing are also possible. For instance, each ECG cable 2206 can be contained within a package, such as a pouch, within the housing.
Referring to
In some examples, the electrode pads 2212 are disposed directly on the core 2208, which can be coated with a release liner, such as silicone, to enable the pads 2212 to be removed quickly and easily and with little to no damage to the pads. In some examples, the electrode pads 2212 can be protected by a release liner coating, such as silicone, which can be removed by the rescuer after removing the pads 2212 from the core 2208 and prior to placing the pads on the victim. In some examples, the electrode pads 2212 are encased in a packaging, and the packaged electrode pads 2212 are wound around the core 2208. For instance, the packaging can be an envelope that provides a high moisture vapor transmission rate barrier, such as a polyfoil substrate.
In some examples, the ECG cables 2206 can be different lengths. For instance, in some cases, each individual ECG cable 2206 can be a unique length, such that as the ECG cables 2206 are unwound from the core 2208, each ECG cable 2206 can be pulled off of the core 2208 separately from each other ECG cable 2206. In some cases, two or more groups of ECG cables 2206 can be formed, the ECG cables 2206 in each group having a unique length. The lengths of the ECG cables 2206 can be set based on the order in which each ECG cable 2206 is to be applied to the victim. For instance, the first ECG cables 2206 to be applied, such as the six V cables, can be the shortest cables, and the last ECG cables 2206 to be applied, such as the limb cables, can be the longest cables. In some cases, the electrode pads 2212 of ECG cables 2206 of different lengths are less likely to stick together, thus improving the usability of the ECG housing 2200.
Referring to
In some examples, the ECG package 2200 is a single-use, disposable package. In some examples, new ECG cables 2206 can be wound around the core 2208 to reuse the ECG package.
Referring to
The pull tab 2204 is pulled (2302) away from the housing 2202, causing the ECG cables 2206 connected thereto to unwind from the core 2208. That is, the ECG cables 2206 are unrolled and pulled out of the housing through the slit 2205 (2304).
The electrode pads 2212 at the proximal ends of the ECG cables 2206 are unrolled and removed from the housing 2202 through the slit 2205 (2306). The electrode pads 2212 can be positioned at appropriate positions on the victim (2308), such as on the chest, legs, and/or arms of the victim. The pull tab 2204 can be connected to a control unit, such as a mobile phone or tablet or another type of mobile device, or to another type of ECG-capable device. Once the electrode pads 2204 are positioned and the pull tab 2204 connected to the control unit (2310), ECG readings can be viewed on a display interface of the control unit (2312).
The features described herein can be implemented in digital electronic circuitry, or in computer hardware, firmware, software, or in combinations of them. The apparatus can be implemented in a computer program product tangibly embodied in an information carrier, e.g., in a machine-readable storage device, for execution by a programmable processor; and method steps can be performed by a programmable processor executing a program of instructions to perform functions of the described implementations by operating on input data and generating output. The described features can be implemented advantageously in one or more computer programs that are executable on a programmable system including at least one programmable processor coupled to receive data and instructions from, and to transmit data and instructions to, a data storage system, at least one input device, and at least one output device. A computer program is a set of instructions that can be used, directly or indirectly, in a computer to perform a certain activity or bring about a certain result. A computer program can be written in any form of programming language, including compiled or interpreted languages, and it can be deployed in any form, including as a stand-alone program or as a module, component, subroutine, or other unit suitable for use in a computing environment.
Suitable processors for the execution of a program of instructions include, by way of example, both general and special purpose microprocessors, and the sole processor or one of multiple processors of any kind of computer. Generally, a processor will receive instructions and data from a read-only memory or a random access memory or both. The essential elements of a computer are a processor for executing instructions and one or more memories for storing instructions and data. Generally, a computer will also include, or be operatively coupled to communicate with, one or more mass storage devices for storing data files; such devices include magnetic disks, such as internal hard disks and removable disks; magneto-optical disks; and optical disks. Storage devices suitable for tangibly embodying computer program instructions and data include all forms of non-volatile memory, including by way of example semiconductor memory devices, such as EPROM, EEPROM, and flash memory devices; magnetic disks such as internal hard disks and removable disks; magneto-optical disks; and CD-ROM and DVD-ROM disks. The processor and the memory can be supplemented by, or incorporated in, ASICs (application-specific integrated circuits).
To provide for interaction with a user, the features can be implemented on a computer having a display device such as a CRT (cathode ray tube), LCD (liquid crystal display), or other type of display monitor for displaying information to the user and a keyboard and a pointing device such as a mouse or a trackball by which the user can provide input to the computer.
The features can be implemented on a mobile computing device, such as a mobile phone, a tablet, a watch, glasses, or another type of mobile computing device. The mobile computing device can have a display device such as a touch screen for displaying information to the user and receiving input from the user. The mobile computing device can receive input from the user via the touch screen, a key pad, a microphone, or another type of input device.
The features can be implemented in a computer system that includes a back-end component, such as a data server, or that includes a middleware component, such as an application server or an Internet server, or that includes a front-end component, such as a client computer having a graphical user interface or an Internet browser, or any combination of them. The components of the system can be connected by any form or medium of digital data communication such as a communication network. Examples of communication networks include, e.g., a LAN, a WAN, and the computers and networks forming the Internet.
The computer system can include clients and servers. A client and server are generally remote from each other and typically interact through a network, such as the described one. The relationship of client and server arises by virtue of computer programs running on the respective computers and having a client-server relationship to each other.
It is to be understood that the foregoing description is intended to illustrate and not to limit the scope of the invention, which is defined by the scope of the appended claims. Other embodiments are within the scope of the following claims.
This application is a continuation of U.S. application Ser. No. 16/396,874, filed on Apr. 29, 2019, now issued as U.S. Pat. No. 10,980,706, which is a continuation of U.S. application Ser. No. 15/070,619, filed on Mar. 15, 2016, now issued as U.S. Pat. No. 10,322,060, which is a divisional of U.S. application Ser. No. 14/036,503, filed on Sep. 25, 2013.
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| Number | Date | Country | |
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| 20210308003 A1 | Oct 2021 | US |
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| Parent | 14036503 | Sep 2013 | US |
| Child | 15070619 | US |
| Number | Date | Country | |
|---|---|---|---|
| Parent | 16396874 | Apr 2019 | US |
| Child | 17206204 | US | |
| Parent | 15070619 | Mar 2016 | US |
| Child | 16396874 | US |
