Requirements

Overview
Pinned Items
Jonathan McLaughlin

Proposed Flows
Sean Kelleher
Shoukri Kattan
Jonathan Devine

Notable Comments

Hard Requirements

Suggestions/Long-term

Nice-to-haves

Outstanding Issues (with the Wiki approach)

Required Clarification

Appendix
Medical Info
References/Resources
Overview
This document is designed to outline and clarify the requirements of the project. This is
currently a dump of the major items outlined in the Slack channel and should be structured
more appropriately as clarification is added.

Project Design Document is a related document (TODO Define difference).

Pinned Items

Jonathan McLaughlin
I think a simple responsive webpage that is designed from a mobile-first
perspective (as this is how frontline medical staff will access the information
contained in the page) is the way to go.
There could be 3 tabs:
Operating a ventilator: (General information) FAQs and common
charts relating to flow rates etc
Branching a ventilator: Show how it can be done and all the risks
associated with the procedure (see #branched_ventilation_sop for
more detail)
Contribute: This is where Medical Staff can offer insights, hacks,
things that work or don't work, that they wish to share with other
medical staff around the world.
As I see it, we need 3 things:
Content [this MUST be provided by a Medical professional]
Design [Simplicity of the UI is key here. This will be accessed in a high stress
environment and on a phone]
The Tech [This should be simple and something that most tech savvy people
can edit and contribute to] Perhaps someone could create a poll on this?
What is everyone's thoughts on this as a strategy to get something live that
will be of almost immediate value and get around the need to immediately
add content:
○ The site has an input section for questions that frontline staff may need
answered. (The idea here is that the site will be a resource for less
experienced staff when more senior staff are unavailable as resources get
more stretched.)
○ A signup for medical professionals, medical professors or ventilator
specialists who are willing to answer these sorts of questions.
○ The questions could be grouped into 3 tabs, Operating a ventilator,
branching a ventilator and useful Calculations/Tables
The questions will be sent to the panel of medical professionals who will then
post their answer on the site.
As a simple moderation criteria for the medical professional who will answer
these questions they will need to send an email from a verified medical or
educational email address?
Proposed Flows
Sean Kelleher
1. Public (unauthenticated) can submit questions.
2. Trusted moderators will filter, categorise and batch questions for review.
3. Frequently-asked and high priority questions will get added to a list to be given to
medical professionals.
4. Medical professionals can be emailed with question digests (see “Considerations”,
below)
5. Responses can be proofed for grammar, etc. by trusted moderators. Responses
should be tagged with the name and contact details of people that gave the
response.
6. Moderators can forward proofed answers to a tech team, who will upload the
response to the appropriate section on the site.
Considerations:
● Accessing the answers and topics shouldn’t require authentication.
● We don’t want to inundate medical professionals with questions, they’re overworked
as is; I would propose sending digest emails of maybe 3 questions that they could
answer at a time.
TODO:
● How to define “trusted moderators” and “trusted medical professionals”.
● Define the process by which moderators will filter, categorise and batch questions.
● Define how questions will be submitted.
Shoukri Kattan
Media Wiki using AWS, provided by Shoukri Kattan; contact for login details
Link to live version
Jonathan Devine

Marion Rose McFadden:

How to Use Emergency Medical

Field Ventilators Professional
Adapt to multi- Un-trained
Help Me use(Ventilator
Local Resources/
machines) Medical Profesional
Contact
Redirect to
website Medical Expertise
Medical validation,
ExpertiseVolunteer feedback and info.
Volunteer Support
Via Website confirmation
Engineering/
I Can Help via Website Production
Design/ Project
(Engineering/ mgt/ resource
Production/ other) mapping, etc
DONATE Medical
UPDATED LINK
Available Information
on Covid19/
Info
Emergency Field
Vents
Wireframe Document

Sign-Up Workflow
1 Call to Action --> 2 Explainer and Form --> 3 Email validation --> 4 Identity validation --> 5
[approval process]
Editor Workflow
1 Sign in --> 2 Navigate to page in editor --> 3. Edit Page --> 4 Submit for review

Brendan Doyle:
Notable Comments
● Shoukri Kattan (paraphrased)
○ There isn’t likely to be the time/resources to build a custom solution,
particularly taking into consideration the definition of build and QA cycles, etc.
■ As such, the current approach is to find a robust Open Source project
that can meet our needs.
○ The current approach is to use MediaWiki.
○ Load: The MediaWiki installation will have a CDN put in front of it to handle
load issues.
○ TODO
■ Consider performance
■ Consider localisation
○ Section 1 : operating ventilator : instructions on how to operate , FAQ, charts
etc.
■ it has to be accessible on Mobile and Web
○ Section 2 - Branching a ventilator
■ both sections will see edits, but not by everyone
■ most likely a select group of moderators etc
○ Section 3 - contribute ; this is where people can login and contribute
■ or just contribute anonymously
■ but we will need some sort of moderation around that
● Mary Battlebury
○ Thread:
○ Mary Battlebury: I think wiki well when I look at wikipedia ,has a very vanilla
interface.
○ Sean Kelleher: I feel like this would help make sure there's no distraction from
the content; what are your thoughts?
○ Mary Battlebury: True that is definitely valid, as long as the basics are here
from a UX perspective like hierarchy in term of content, accessibility in terms
of our end users within a busy ER. So for this especially we’ll really want to
have enough contrast with content, and very clear call-to-actions.
● Mark Leyden
○ If I can re-state my original thoughts on this project: The UCC site offers a
'cheat sheet' for using / setting a ventilator. It is where I have been trying to
extract Ventilator operating requirements from. So I focused on the ARDS
Vent Mgmt PDF Page 6. This requires a bunch of lookups in tables, and then
a number of calculations. There are also 'gotchas' where is X value is < Y, do
Z etc etc
○ I believe we can produce something that will make all of the calculations
somewhat 'foolproof' and have built in alerts for operators to look out for.
● Jonathan Devine
○ My highest concern currently is the the Mediawiki interface is very much a
user-last approach. Look at the delta between these two concepts. If your
 device was 3 inches wide and someone is failing to breathe next to you,
which would you rather have?

○ To be clear, I'm proposing not the exact image I posted above, but it's to
make the point that we need to define just some rudimentary things before we
really commit. Like who our users are, what their workflow might be (maybe
we're talking about 5 gray boxes of process in a row, that's architecture), then
we'll actually have the confidence and clarity to start making platform and
interface decisions.
○ This group has had one barely a whiff of a conversation about user needs. I
would live to crystalize in the google doc what the user needs are. Here we
haven't even agreed on who the user groups are.
○ I suggest
■ 1. Medical Professionals who write content
■ 2. Medical Professionals using the device
■ 3. Non-Professionals using the device
○ If #3 is in the scope of OSV... I'm not sure.
○ So the critical distinction between user #2 and #3 is the pro is asking ``how do
I get this peculiar machine to work`` and the latter is ``my friend is slowly
suffocating to death and I don't know what to do``
○ Marion Rose McFadden: I propose for now we split the objectives from
designing a portal for all Users
■ To design a portal for Medical feedback , literature and illustrations
● Use this Material for creating
● Group 2: Medical PROs
● Group 3: ANY Lay User
○ So really, rethinking this at the "who" level:
■ 1. Professional Medical Content Editors
■ 2. Professional Medical Device Users
■ 3. Non-Professional Device Users
■ 4. Device Makers
 ■ 5. Donors/Supporters
○ Marion Rose McFadden: Great! Now I'd split that into those who:
■ CAN HELP
● Prof Medical Content Editors
● Device Makers ( Engineers & Producers)
● Donors / Supporters / designers / project mgt. / etc...
■ NEED HELP
● Medical Pro Users
● Non-pro Device Users
○ We could then take those groups, and let them self-select by need.
○ Yeah... well you can have them select by who they are, or by what they need

○ The next steps would be important to improve the self-selection.

○ For example, bearing in mind we're talking about user groups right now... do
we follow How to use with a division by symptoms?
○ Its a classic how to get them to the most relevant information in the fewest
steps, but the most relevant information depends on who they are and what is
happening.
○ And we don't want to burden the Pro with more information than they need,
and we don't want to burden the layman with more information than they can
handle.
○ Definitely. And even my statement about sectionalized content, WP would
support that. You can define multiple content area within a single page, or
treat a page as it's own content area.
○ The challenge is, a good writing experience is a poor consuming experience.
Editors sit at a computer calm and ready. Readers use their phone while busy
or stressed.
○ So we need to solution for each. One size will not fit all.
 ○
● Ryan Carlson
○ Hi team, I’ve been lurking in the conversation trying to build my understanding
of the requirements and objectives. While things still seem fuzzy, the over
arching goal is to deliver static informational content in a multitude of
languages to ventilator users around the world. Is that decent, at a high level?
○ I don’t like to jump to solutioning, but One idea that keeps coming to mind is
an app I helped build in my previous developer role which is meant to do just
this.
○ https://apps.apple.com/us/app/godtools/id542773210
○ It’s called GodTools and it’s meant to share content and facilitate
conversations around the Christian faith. I’m wondering if this same platform
could be cloned/forked to also meet this need? Imagine this content replaced
with the ventilation details
○ Would some take a look and see what you think. The current app is available
for both iOS and Android and the content it has is in 50+ languages already.
○ If there is interest or possibility I can reach out to the app product team and
try to set up some conversations
○ Multi lingual is supported, as is offline viewing. Content can be uploaded
through an admin tool, but it is a custom xml format
○ Images :ballot_box_with_check: , videos I think so, tables I don’t think so. Will
have to check
○ Both iOS and Android
● Gill
○ Also I have different challenges up that may compliment yours including
streamline documentation also consider dictation anything that breaks the
chain of Infection, and prevent Don and doffing PPE etc
● Marion Rose McFadden
○ Considering what the aims perhaps consider a wordpress as the CDN
offering multilingual translations of the *HELP US* requirement
○ [SECTION 1=Emergency Ventilator] and [SECTION 2= Branching Ventilator]
○ And [SECTION 3 = Contribute] involves a redirection to the *Can Help* Wiki
○ Anything that needs moderation and validation and processing before that
information is useful.
○ And In terms of design I’d suggest that this is used to create
○ [SECTION 4 = Latest Information]
○ Which could include updates
 ○ Including where Emergency Ventilators are … at what stage or where they
are available… or if there is go-funding active… or where to go for local
resources or volunteer.
○ I’m suggesting a WP website as frontend Content because I believe there are
two very distinct objectives:
○ 1. Delivering Information
○ 2 Crowdsourcing solutions, validating and moderating content.
■ Jonathan Devine good suggestions. I worry about WP because it has
so many security issues. But it does have good multi-language
support. We haven't really done a clean pros-cons list for it (or any
platform for that matter).
○ The Content and Validation of best practice
○ Should be a login - moderated and validated process so that the information
being provided is sound
○ Group 2: Could be very much simplified with a way for them to report a need
for OS Vents or supplies
○ Group 3: Are we going to be helping geo-locate resources or simply how to
use basic OS device?
○ -
○ So before we discuss the NEED help group can we go back to the CAN help
group
○ And my reason for saying this is that I believe that the design of information
will be based largely on their input
○ The Medical Content editors should have a simple way to access, share,
assess, validate and agree on content to be delivered
○ I know engineers are talking to 3d prototyping and there are scrums
happening within that.
○ But in terms of medical profession - My medical practice doesn't even accept
email for repeat prescripts. I say that simply to illustrate that many don't deal
with anything other that the most basic software packages and wouldn't know
how to help - or contribute unless there are simple solutions in place.

● Matthew Connorton
○ I've read up on the the requirements doc and some of the conversation here
and here are some thoughts and opinions (from web dev)
○ I agree we need to walk a line between getting something stable up fast but
also future proofing. I think a headless CMS is going to be a good choice here
but that doesn't mean we can't get some boilerplate up first and the integrate
cms content later. As far as headless cms I think we can look at contentful or
strapi. If we think we need full CMS then I would propose Drupal over
something like wordpress to futureproof.
○ I agree that we want something simple and clean as far as ui. The photo of
the screenshot with three clear call to actions vs a wiki navigation more or
less proves that point.
○ It isn't quite clear what the roles and responsibilities are. It would be nice to
see a document showing that "this person" is leading the OSV project, "This
 person" is leading the web dev initiative and "these people" are the volunteers
and their skill sets.

Hard Requirements
● Mobile-first support
● Scalability
● Localisation support
● Simple UI with high-contrast text/background
● Simple navigation
● No authentication required to read content

Suggestions/Long-term
● Matt Dumler
○ “Q/A functionality service workers could greatly increase the chances workers
with little connection could get their questions submitted. If they don't have
connection it could send in the background later, and even pull answers to
their questions while they have service but before they open the app.”
● @rad_val
○ I'd personally go with a headless CMS for the admin/editor part and a React
app that consumes the resulting API.

Nice-to-haves
● Offline support
○ This would ideally use PWA functionality, as users won’t need to pm change
their approach, but they’ll be able to access the knowledge base while offline.

Outstanding Issues (with the Wiki approach)

● Better editor (WYSIWIG, etc.)
● Localisation
● Determine roles and responsibilities

Required Clarification
● Who are the different users - medical practitioners, editors, etc. in a purpose doc for
the channel.
● Edit flow for content for different pages. Flows have been proposed, in Thoughts;
these should be investigated further.
Appendix
Medical Info
● Noel Gibney
○ I am an Intensivist/Respiratory physician with many years experience
ventilating critically ill patients in both state of the art ICUs and in developing
countries and would be pleased to answer any questions. There are two
main types of assisted ventilation: (1) Non-invasive and (2( Invasive. During
non-invasive assisted ventilation the patient is ventilated with a tight-fitting
mask attached to a device which generates a gas-flow under pressure which
drives air into the lungs where oxygen is delivered into the blood and carbon
leaves the lungs and is exhaled out through the airways and mouth. This can
be as simple as a bag-mask-valve apparatus during initial resuscitation or
very sophisticated with the patient attached by mask to a fully featured
modern mechanical ventilator. For invasive assisted ventilation, the patient's
airway (trachea) is intubated with an endotracheal tube which has a balloon
close to the end in the airway which can be distended to prevent a leak of the
delivered gas around the tube. This also helps to reduce the risk of gastric
fluids and mouth fluids leaking into the airway and infecting the lungs.
Assisted ventilation is used to breathe for people who can't because their
brain, nerves or muscles don't work adequately to generate a breath but also
to provide a distending pressure for diseased, stiff lungs which tend to want
slowly shrink causing the tiny air sacs (alveoli) to collapse so that oxygen
can't enter and cross into the bloodstream.
○ Continuing ventilator explanation: Mechanical ventilators need to have a
number of controllable features. The oxygen concentration must be
controllable and constantly measured. The volume of inspired gas (Tidal
Volume) should be controllable to ensure the volume is adequate but not so
much that the lungs are damaged which can cause them to burst
(pneumothorax). The pressure changes in the airway caused by delivering
each tidal volume must be constantly measured and the peak pressure
should generally be kept below 30 cm H2O). Ideally, it should be possible to
provide a constant distending pressure to the airway to keep the tiny air sacs
(alveoli) open. There should be alarms for low or high airway pressure,
oxygen concentration etc.
○ Mats description of ventilatory modes and the link to the UK govt ventilator
manufacture documents [below] are very useful. I will try to outline how
ventilators are used to treat critically ill patients with COVID-19. Patients with
severe COVID-19 have a severe viral pneumonia that damages both lungs.
The infection causes severe inflammation of the lung tissues and a leak of
plasma from the bloodstream into the lung air sacs (alveoli) . This has two
effects. The lungs become very stiff and difficult to inflate with each breath.
In addition, the fluid in the alveoli and the stiffness of the lungs cause the
alveoli to close and no longer be available for gas exchange. This causes a
low oxygen level in the blood being pumped around the body. As Mat stated,
 the most common mode of ventilation used in very sick patients with severe
lung injury is assist-control. This mode allows the ventilator to deliver a
breath a specified number of times per minute (frequency or respiratory rate)
if the patient does not trigger a breath. It also allows the patient, when they
feel a need, to trigger the ventilator to deliver a breath consisting of a volume
of gas (tidal volume). Assist-control requires the ability of the ventilator to
recognize when the patient has started to initiate a breath. This can be done
by a pressure transducer recognizing a drop in airway pressure of a specified
amount (usually 2-3 cmH2O or in very sophisticated ventilators by inserting
an electrode into the esophagus and placing it next to the diaphragm where it
senses an electrical discharge in the muscle of the diaphragm and initiates a
breath. There are many other modes of ventilation which I suspect would be
beyond the scope of this project. A critical requirement of a ventilator to
support patients with viral pneumonia from COVID-19 would be the ability to
provide a constant distending pressure to the alveoli to keep them open and
functional. This called positive end-expiratory pressure (PEEP). I expect that
most patients with COVID-19 viral pneumonia would be ventilated on assist-
control mode with a PEEP ranging between 5 and 20 cmH2O. Higher levels
of PEEP are typically required in patients with more severe lung injury to
maintain adequate levels of oxygen (O2) in the blood. The goals of assisted
mechanical ventilation are (1) to provide adequate oxygenation of blood in the
lungs and achieve an oxygen saturation of 92% or greater in the arterial
blood. (2) Provide ventilation to remove appropriate amounts of carbon
dioxide (CO2) and keep the partial pressure of CO2 in arterial blood. The
normal PCO2 level is approx 40 mmHg or 7.5 kPa. In very sick patients with
super stiff lungs it is often necessary to let the PCO2 level rise much higher
by dropping the tidal volume of each breath as our efforts to normalize it in
patients with stiff lungs can cause further serious lung injury. So, when we
prescribe the settings for a patient on mechanical ventilation it looks like this:
Mode: AC (assist-control) ventilation, FiO2: (inspired fraction of oxygen), Vt:
tidal volume (ideally 6 ml/kg for patients with severe lung injury), f (frequency)
or Rate; breaths/min, PEEP. There are other considerations including the
inspiratory time (proportion of the respiratory cycle time occupied by
inspiration - usually 25-30%) and alarms to recognize when the ventilator has
been inadvertently disconnected, high peak airway pressure and low inspired
oxygen levels.
● Mat (MD)
○ ER doc here chiming in, hopefully I can answers some questions or clarify
minimal requirements.
○ The basic mode you need is Assist Control. This mode provides a breath
whenever the patient triggers a breath (by inhaling and creating negative
pressure past a certain threshold) or whenever the patient is due for a breath
(based on the set rate). The breath it provides are either a fixed volume (and
the doc monitors the pressures delivered) or a fixed pressure (and the doc
monitors the volume delivered). AC/volume is often called Volume Control,
and AC/pressure is often called Pressure Control. While I do not have direct
experience ventilating COVID patients yet, these 2 modes will cover 99% of
ICU cases.
 ○ Steve Siebert: Awesome, thanks for your input @Mat (MD)! That's eye
opening for me because although it makes sense that the majority of the
patients aren't so critical they can't use AC - I looked it at as an engineer: AC
being a lower priority requirement because a patient can (theoretically) be
sedated/incubated if the only ventilation option was forced. But, if the number
is something like 99% not requiring intubation, well, that would seem like
excessive waste in both equipment, manpower managing their sedation, and
unnecessary risk.
○ You could sedate someone enough to make them accept "forced ventilation" -
a mode called CMV. But AC is more comfortable, so it requires less use of
sedating drugs (which may also become on short supply.
○ Equally important to putting someone on a vent is getting them back off.
There are a variety of ways to "ween" someone, which is easier to do with
AC, but nearly impossible on CMV because you're sedating them to be
completely dependent on the vent and not breathe in their own.
● Henrik Feldt
○ May I suggest nextjs + https://zeit.co/home?
○ It's very straight forward to change and there are no hosting costs
○ and we can use https://github.com/hanford/next-offline - which uses
https://developers.google.com/web/tools/workbox/modules/workbox-
webpack-plugin#generatesw_plugin
○ If it needs to survive internet blackouts we could further sync offline with
RxDB / WebRTC and IPFS
○ It generates static content
○ You can look at it as an offline generator

References/Resources
● First project: Take this info from UCC
https://ucc.instructure.com/courses/22984/pages/critical-care and turn it into the
simplest App that can help tired, stressed-out front-line practitioners to use any
Ventilator
● 53 PNG Images of the source PDF (i.e. UCC link, converted to PNG):
https://files.slack.com/files-pri/T01032CM4CF-
F010F5BFQAG/download/cnv19_ards_docs.zip (Brendan Doyle)
● Ventilation Performance Document from Code Life Ventilator Challenge (Shoukri
Kattan)
○ Issues, according to Mark Leyden: “It is good, however the 'cheat sheet'
from UCD tells an operator what settings to use”.
● Rapidly manufactured ventilator system specification (GOV.UK, Mat (MD))
● Design and Prototyping of a Low-cost Portable Mechanical Ventilator (Gill)
● Ventilators Requirement Document by OSV
● On a separate note - if you have the time might be worth a watch :
● Designing for Crisis by Eric Meyer - An Event Apart video (Brendan Doyle)
● https://www.mantis3dprinter.com/help (Brendan Doyle)
● https://www.ifixit.com/Device/Ventilator list of ventilator manuals (Brendan Doyle)
● https://crowdfightcovid19.org/covid19researchers (Brendan Doyle)
 ○ These guys could be very useful for content - Crowd Sourced Med
Professionals specifically for Covid-19
○ "This is a service for COVID-19 researchers. They only need to state a
wish or a task, which can go from a simple time-intensive task to be
performed (e.g. transcribe data, manually annotate images), to answering
a technical question which is beyond their expertise, or to setting up a
collaboration. They only need to explain their request in a few lines. Then,
another scientist makes the effort of understanding that request and
making it reality."
● Open Source Medical Supplies Document (Gill)