vigilcare-clinical/docs/simulator-guide.md

# VigilCare Clinical Simulator -- User Guide

Welcome! The VigilCare Simulator lets you replay realistic hospital patient scenarios against the VigilCare Clinical API. You can watch a patient's vitals change over time, see alerts fire (NEWS2, SIRS/qSOFA, sepsis bundles), and observe how the system detects clinical deterioration -- all without real patients.

Think of it as a flight simulator, but for clinical decision support.

---

## Table of Contents

1. [Prerequisites](#1-prerequisites)
2. [Quick Start](#2-quick-start)
3. [Available Commands](#3-available-commands)
4. [Understanding Scenarios](#4-understanding-scenarios)
5. [Available Scenarios](#5-available-scenarios)
6. [Controlling Replay Speed](#6-controlling-replay-speed)
7. [Reading the Output](#7-reading-the-output)
8. [Creating Your Own Scenarios](#8-creating-your-own-scenarios)
9. [Troubleshooting](#9-troubleshooting)
10. [Ward Outage Scenario (Climate Resilience)](#10-ward-outage-scenario-climate-resilience)

---

## 1. Prerequisites

You need two things installed:

- **.NET 8 SDK** -- Download from [dotnet.microsoft.com](https://dotnet.microsoft.com/download/dotnet/8.0)
- **The VigilCare API running locally** -- The simulator sends data to the API, so it must be up first

### Starting the API

From the project root directory, run:

```bash
docker compose up -d
dotnet run --project VigilCare.Api
```

The API starts on `http://localhost:5270` by default.

> See [docker-compose-usage-and-troubleshooting.md](docker-compose-usage-and-troubleshooting.md) if you have trouble with Docker.

---

## 2. Quick Start

Open a terminal in the project root and run:

```bash
dotnet run --project VigilCare.Simulator -- replay \
  VigilCare.Simulator/Scenarios/List/uti-sepsis-elderly-01.json \
  --speed 60 --poll
```

This replays a 4-hour UTI-to-sepsis progression in about 4 seconds, showing alerts as they fire.

That's it! Read on for more detail.

---

## 3. Available Commands

The simulator has four commands. All are run with `dotnet run --project VigilCare.Simulator -- <command>`.

### replay -- Run a scenario against the API

```bash
dotnet run --project VigilCare.Simulator -- replay <scenario-file> [options]
```

**Options:**

| Option | Default | Description |
|--------|---------|-------------|
| `--speed <number>` | 60 | How fast to run (see [Speed](#6-controlling-replay-speed)) |
| `--base-url <url>` | `http://localhost:5270` | API address (change if your API runs elsewhere) |
| `--poll` | off | Show alerts and scores after each set of vitals |
| `--poll-interval <seconds>` | 5 | How often to check for alerts when polling |
| `--username <name>` | `physician.demo` | API login username |
| `--password <secret>` | (demo default) | API login password |
| `--gateway` | off | Target the ward gateway API at `http://localhost:5081` |
| `--encounter-id <guid>` | — | Use an existing encounter (required with `--gateway`; also used with `--skip-setup`) |
| `--skip-setup` | off | Skip patient/encounter registration — requires `--encounter-id` |
| `--gateway-token <jwt>` | `$GATEWAY_JWT` | Bearer token for gateway replay (required with `--gateway`; use `./scripts/mint-gateway-jwt.sh`) |

**Example -- run the stable baseline scenario in real-time with polling:**

```bash
dotnet run --project VigilCare.Simulator -- replay \
  VigilCare.Simulator/Scenarios/List/stable-baseline-01.json \
  --speed 1 --poll
```

### replay-all -- Run every scenario in a folder

```bash
dotnet run --project VigilCare.Simulator -- replay-all <directory> [options]
```

Runs all `.json` scenario files in the given directory, one after another. Accepts `--speed` and `--base-url`.

**Example:**

```bash
dotnet run --project VigilCare.Simulator -- replay-all \
  VigilCare.Simulator/Scenarios/List --speed 60
```

### validate -- Check a scenario file for errors

```bash
dotnet run --project VigilCare.Simulator -- validate <scenario-file>
```

Checks that the JSON is well-formed and all fields are valid. Does **not** contact the API.

**Example:**

```bash
dotnet run --project VigilCare.Simulator -- validate \
  VigilCare.Simulator/Scenarios/List/stable-baseline-01.json
```

### dry-run -- Preview the timeline without touching the API

```bash
dotnet run --project VigilCare.Simulator -- dry-run <scenario-file>
```

Prints exactly what *would* happen (every vital sign, medication, and order) without sending anything.

**Example:**

```bash
dotnet run --project VigilCare.Simulator -- dry-run \
  VigilCare.Simulator/Scenarios/List/cardiac-arrest-post-mi-01.json
```

---

## 4. Understanding Scenarios

Each scenario is a JSON file that tells a clinical story. It contains:

- **Patient** -- Name, date of birth, gender
- **Encounter** -- Department, encounter type, attending physician, room/bed
- **Events** -- A timeline of observations (vitals, labs), medications, and orders

Here is what a simplified scenario looks like:

```json
{
  "scenario": {
    "id": "stable-baseline-01",
    "name": "Stable Baseline -- Routine Inpatient Monitoring",
    "description": "52-year-old female admitted for elective cholecystectomy...",
    "durationMinutes": 480,
    "tags": ["stable", "baseline", "control", "surgery"]
  },
  "patient": {
    "firstName": "Linda",
    "lastName": "Weston",
    "dateOfBirth": "1974-02-18",
    "gender": "Female"
  },
  "encounter": {
    "department": "Surgery",
    "encounterType": "Inpatient",
    "attendingPhysician": "Dr. James Nakamura",
    "roomBed": "SURG-204B",
    "admissionReason": "Elective laparoscopic cholecystectomy"
  },
  "events": [
    {
      "offsetMinutes": 0,
      "type": "observation",
      "data": {
        "code": "HEART_RATE",
        "value": 72,
        "unit": "bpm"
      },
      "note": "Post-op arrival, patient alert and comfortable"
    },
    {
      "offsetMinutes": 60,
      "type": "medication",
      "data": {
        "drugName": "acetaminophen",
        "dose": 1000,
        "doseUnit": "mg",
        "route": "PO",
        "administeredBy": "RN Davis"
      }
    }
  ]
}
```

The key concept is **offsetMinutes** -- each event happens at a certain number of minutes after the scenario starts. The simulator waits the appropriate amount of time (adjusted by your speed setting) before sending each event.

### Event Types

| Type | What It Represents | Example |
|------|--------------------|---------|
| `observation` | A vital sign or lab result | Heart rate 110 bpm, Temperature 39.2 C |
| `medication` | A drug being administered | Ceftriaxone 1g IV |
| `order` | A clinical order being placed | "Blood cultures", "Chest X-ray" |
| `order_result` | Result of a prior order | "Positive for E. coli" |
| `alert_ack` | Acknowledgement of an open alert | RN acknowledges critical potassium alert |

`alert_ack` events require `alertType` and `clinicianId` in `data`; optional `note`. On **gateway** replay (`--gateway`), the simulator sends `clinicianId` in the acknowledge request so the ward records the bedside nurse label (e.g. `RN-Wu`) and syncs it to central. On **central** replay, attribution comes from the logged-in API user.

### Vital Sign Codes

These are the observation codes used in scenarios:

| Code | What It Measures | Unit | Normal Range |
|------|-----------------|------|-------------|
| `HEART_RATE` | Heart rate | bpm | 51--90 |
| `RESP_RATE` | Respiratory rate | /min | 12--20 |
| `SYSTOLIC_BP` | Systolic blood pressure | mmHg | 111--219 |
| `DIASTOLIC_BP` | Diastolic blood pressure | mmHg | 60--90 |
| `TEMP_C` | Temperature | C | 36.1--38.0 |
| `SPO2` | Oxygen saturation | % | 96--100 |
| `AVPU` | Consciousness level | score | 0 = Alert |
| `SUPPLEMENTAL_O2` | On supplemental oxygen? | flag | 0 = No |
| `WBC_K_UL` | White blood cell count | x10^3/uL | 4.5--11.0 |
| `LACTATE_MMOL_L` | Serum lactate | mmol/L | 0.5--1.5 |
| `POTASSIUM_MEQ_L` | Potassium | mEq/L | 3.5--5.0 |
| `GLUCOSE_MG_DL` | Blood glucose | mg/dL | 70--140 |

---

## 5. Available Scenarios

The simulator ships with 8 scenarios covering different clinical situations:

| Scenario | Clinical Story | Duration |
|----------|---------------|----------|
| **stable-baseline-01** | Post-op cholecystectomy, all vitals normal. Control case -- no alerts should fire. | 8 hours |
| **uti-sepsis-elderly-01** | 78-year-old with UTI progressing to sepsis. SIRS criteria met, sepsis bundle triggered. | 4 hours |
| **cardiac-arrest-post-mi-01** | Post-MI patient deteriorating into cardiogenic shock. Rapid HR/BP changes. | Varies |
| **post-op-hemorrhage-01** | Surgical patient with internal bleeding. Rising HR, falling BP and SpO2. | Varies |
| **respiratory-failure-asthma-01** | Asthma exacerbation progressing to respiratory failure. Falling SpO2, rising RR. | Varies |
| **dka-electrolyte-01** | Diabetic ketoacidosis with potassium and glucose derangement. | Varies |
| **hypothermia-elderly-01** | Elderly patient with severe hypothermia. Slow HR, dropping temperature. | Varies |
| **medication-false-alarm-01** | Beta-blocker causing bradycardia. Tests whether the system correctly handles medication-induced vital changes. | 3 hours |
| **ward-outage-reconnect-01** | ICU patient with critical hyperkalemia during simulated central outage. Validates gateway-local alerting and alert acknowledgement sync. | 90 minutes |

All scenario files are in: `VigilCare.Simulator/Scenarios/List/`

---

## 6. Controlling Replay Speed

The `--speed` option controls how fast simulated time passes:

| Speed | Meaning | A 4-hour scenario takes... |
|-------|---------|---------------------------|
| `0` | Instant -- no waiting, all events fire immediately | < 1 second |
| `1` | Real-time -- 1 simulated minute = 1 real minute | 4 hours |
| `10` | 10x -- 1 simulated minute = 6 real seconds | 24 minutes |
| `60` | 60x (default) -- 1 simulated minute = 1 real second | 4 minutes |
| `120` | 120x -- 1 simulated minute = 0.5 real seconds | 2 minutes |

**Recommendations:**
- **For demos / presentations:** Use `--speed 10` with `--poll` so people can follow along
- **For quick testing:** Use `--speed 60` or `--speed 0`
- **For the most realistic experience:** Use `--speed 1` (real-time, a 4-hour scenario takes 4 hours)

---

## 7. Reading the Output

When you run a `replay`, the simulator prints a colored timeline. Here's what to look for:

```
────────────────── Stable Baseline -- Routine Inpatient Monitoring ──────────────────
52-year-old female admitted for elective cholecystectomy...

Patient registered: 3fa85f64-... (MRN-12345)
Encounter opened: 7c9e6679-... (active)

  [00:00] HEART_RATE 72 bpm
  [00:00] RESP_RATE 14 /min
  [00:00] SYSTOLIC_BP 124 mmHg
  [00:00] SPO2 98 %

  ... waiting 60m simulated (1.0s real) ...

  [01:00] HEART_RATE 74 bpm
  [01:00] medication: acetaminophen 1000 mg PO
```

**With `--poll` enabled, you also see clinical scoring:**

```
  [01:30] NEWS2 = 5 (Medium)
  [01:30] ALERT SEPSIS_WARNING (Critical)
  [01:30] SEPSIS BUNDLE InProgress (2/4 completed)
```

**At the end, a summary table appears:**

```
Metric                    Value
-----------------------------------
Scenario                  uti-sepsis-elderly-01
Observations sent         42
Medications sent          2
Orders placed             3
Wall-clock time           12.3s
```

### What the Alerts Mean

| Alert | Meaning |
|-------|---------|
| `NEWS2_LOW` | NEWS2 score 1--4: Low risk, routine monitoring |
| `NEWS2_MEDIUM` | NEWS2 score 5--6 or single parameter score of 3: Urgent review needed |
| `NEWS2_HIGH` | NEWS2 score 7+: Emergency response needed |
| `SEPSIS_WARNING` | SIRS criteria met (2+ of: temp, HR, RR, WBC abnormal) |
| `QSOFA_WARNING` | qSOFA criteria met (2+ of: altered mentation, RR >= 22, SBP <= 100) |
| `RAPID_DETERIORATION` | Sudden significant change in vital signs |

---

## 8. Creating Your Own Scenarios

You can create new clinical scenarios by writing a JSON file. There are two ways:

### Option A: Write it manually

1. Copy an existing scenario from `VigilCare.Simulator/Scenarios/List/` as a template
2. Modify the patient, encounter, and events to match your clinical story
3. Make sure `offsetMinutes` values are in ascending order
4. Validate it:

```bash
dotnet run --project VigilCare.Simulator -- validate ./my-scenario.json
```

### Option B: Use AI to generate it

There is a generation prompt file at `VigilCare.Simulator/Scenarios/GENERATE_PROMPT.md`. You can paste its contents into ChatGPT, Claude, or another AI assistant, describe the clinical case you want, and it will generate a valid scenario JSON file for you.

### Validation Rules

The simulator enforces these rules on scenario files:

- **scenario.id** and **scenario.name** are required
- **encounter.department** must be one of: `Icu`, `GeneralMedicine`, `Emergency`, `Cardiology`, `Surgery`, `Pediatrics`
- **encounter.encounterType** must be one of: `Inpatient`, `Outpatient`, `Emergency`
- **events** must be non-empty, with `offsetMinutes` in ascending order
- **observation codes** must match one of the 12 valid codes listed above
- Maximum **10 observations per time point** (API batch limit)
- **order_result** events must reference a matching prior order (or a sepsis bundle auto-order)

### Sepsis Bundle Auto-Orders

When the system detects sepsis (SIRS or qSOFA criteria met), it automatically creates four orders:
- `SEP-1: Blood cultures`
- `SEP-1: Serum lactate`
- `SEP-1: Broad-spectrum antibiotics`
- `SEP-1: IV fluid bolus`

You do **not** need to create `order` events for these. Just add `order_result` events referencing them to simulate bundle completion.

---

## 9. Troubleshooting

### "Connection refused" error

The API is not running. Start it first:

```bash
docker compose up -d
dotnet run --project VigilCare.Api
```

### "scenario.json has N error(s)"

Run `validate` to see what's wrong:

```bash
dotnet run --project VigilCare.Simulator -- validate ./your-scenario.json
```

Common issues:
- Invalid department name (must match exact casing: `Icu`, not `ICU`)
- `offsetMinutes` out of order
- Missing required fields (`scenario.id`, `scenario.name`, `encounter.attendingPhysician`)

### Medications show "skipped"

The medication tracking endpoint may not be available. This is non-fatal -- the scenario continues.

### "dotnet" command not found

Install .NET 8 SDK from [dotnet.microsoft.com](https://dotnet.microsoft.com/download/dotnet/8.0).

### I want to point the simulator at a different API

Use `--base-url`:

```bash
dotnet run --project VigilCare.Simulator -- replay scenario.json \
  --base-url http://192.168.1.50:5270
```

---

## 10. Ward Outage Scenario (Climate Resilience)

The `ward-outage-reconnect-01` scenario validates Tier 1 safety during a central API outage. Observations and alerts continue on the ward gateway; acknowledgements are recorded locally and synced when the uplink returns.

### Automated verification (recommended)

From the repo root, with Docker running:

```bash
./scripts/run-phase24-verification.sh
```

This script runs all three phases automatically: central baseline replay, gateway replay during simulated central outage, and post-reconnect sync checks. Logs go to `/tmp/vigilcare-phase24-*`.

Useful flags:

| Env var | Effect |
|---------|--------|
| `SKIP_DOCKER=1` | Assume `docker compose` stack is already up |
| `SKIP_PHASE_A=1` | Skip central replay; use an existing ICU encounter on the gateway |

Helper for manual gateway API calls (ward gateway has no login endpoint):

```bash
export GATEWAY_JWT=$(./scripts/mint-gateway-jwt.sh nurse.demo NURSE)
```

### Manual procedure

1. Full stack running with the ward gateway profile:

```bash
docker compose --profile ward-gateway up -d
```

2. Central API running and the gateway encounter replica synced
3. Note an active ICU encounter id from the gateway:

```bash
curl "http://localhost:5081/api/v1/encounters?status=ACTIVE&department=ICU" \
  -H "Authorization: Bearer $JWT"
```

### Procedure

**Phase A — Baseline on central (optional):**

```bash
dotnet run --project VigilCare.Simulator -- replay \
  VigilCare.Simulator/Scenarios/List/ward-outage-reconnect-01.json \
  --speed 0 --base-url http://localhost:5270
```

**Phase B — Stop central, replay against gateway:**

```bash
# Stop central API process/container
dotnet run --project VigilCare.Simulator -- replay \
  VigilCare.Simulator/Scenarios/List/ward-outage-reconnect-01.json \
  --gateway --encounter-id <ENCOUNTER-GUID> --speed 60 --poll
```

The `--gateway` flag targets `http://localhost:5081` automatically. `--encounter-id` must reference an encounter already replicated on the gateway. The `alert_ack` event at T+50 min sends `clinicianId: "RN-Wu"` from the scenario; the gateway honors this in `acknowledged_by` and in the sync buffer (login user is only used when `clinicianId` is omitted).

**Phase A note:** Central replay attributes acks to the JWT user (`physician.demo` by default). Use `--username nurse.demo` if you want a nurse role on central; gateway Phase B is the authoritative climate-resilience path for scenario attribution.

**Phase C — Restart central, verify sync:**

- Wait for `SyncUploaderService` to drain the buffer
- Poll `GET /api/v1/operations/gateways` — buffer depth should reach 0
- Confirm observations on central with preserved `recorded_at` timestamps

### Success criteria

- Critical potassium alert created on gateway at T+45 min while central is down
- Ack recorded locally at T+50 min with `acknowledged_by` = `RN-Wu`
- After reconnect: central has observations, alert, and ack; no duplicate paging logs