For the last five years, Chicago-based studio Level Ex has been making mobile games to help medical professionals hone their skills. With an audience of approximately 600,000 medical professionals already playing its games and over 150 physicians on its advisory council, Level Ex found itself in a distinctive position to aid the coronavirus fight.

Level Ex has built four mobile titles, each for specialized areas of medicine: pulmonology, gastroenterology, anesthesiology and cardiology. Now, the team is updating two of its games, “Pulm Ex” (a pulmonology game) and “Airway Ex” (an anesthesia game), with coronavirus content to help medical professionals treat covid-19 patients in emergency situations. These new levels are available now for free through Google Play and arriving later to other platforms.

“Level Ex has a unique contribution and calling in all of this, which is to help frontline medical professionals,” Level Ex CEO and founder Sam Glassenberg said. “We’ve seen a huge need in the medical community for better solutions to disseminate information. And we know coming from games [development], the best way to learn and the best way to retain, the best way to develop skills, is through play.”

Level Ex games have hyper-realistic simulations that help medical professionals hone their skills virtually, such as practicing surgical procedures. In addition to these simulations, “Pulm Ex” and “Airway Ex” now include fictitious, simulated emergency room experiences based on the pandemic, designed to help medical professionals administer patient care safely and efficiently. Divided into nine cases, the covid-19 content takes the form of a situational strategy game about best practices in “Airway Ex” and a puzzle game about diagnostics in “Pulm Ex.”

Success in the strategy game depends on the effectiveness of your decision-making skills, such as whether to don personal protective equipment for a patient who has tested negative for coronavirus. Different gauges evaluate your progress, including your risk level of spreading covid-19, a points system that increases or decreases depending the efficacy of your choices and a patient’s fluctuating oxygen saturation level (if it falls too low, you have to retry).

Dr. Eric Gantwerker, Level Ex vice president and medical director, likens the diagnosis game within “Pulm Ex” to the board game “Guess Who,” in which you need to eliminate and narrow down your options to find the correct answer. Within the game, a patient presents with a chief complaint, such as being short of breath, and every decision (such as asking about medical history or ordering tests) is broken down into action points you can spend each turn.

“The whole goal of [this game] is we don’t want [medical professionals] to do what we call the shotgun approach,” Gantwerker said. “The shotgun approach in medicine is essentially asking all the questions, doing all the exams, doing all the tests possible and then coming down, but that’s not a proper use of resources."

Some levels are so realistic that they caused a stress response and increased the heart rate of a physician who helped test the game before release. In the level the physician played, a patient is admitted to the hospital for injuries related to a car accident and tests positive for coronavirus. It’s a “really difficult case,” Gantwerker said. The patient’s oxygen drops significantly, and little can be done. The emotional response experienced by the physician is encouraging on the education front, Gantwerker explained.

“Emotion and processing information are very strongly tied,” Gantwerker said. “When you have a very strong emotional response during the information, during the experience, there’s a much higher likelihood that you’re going to retain that information.”

Development for “Pulm Ex” and “Airway Ex’s” coronavirus updates began in early March, as cases started to grow within the United States. When development kick-started, resources on best practices for emergency care were slim, and Glassenberg turned to “a bunch of disparate PDFs in Italian” that had been put together by SIAARTI, the Italian Anesthesia Society. At the time, Italy was the world’s epicenter for the virus. Later came guidelines from the Centers for Disease Control and Prevention, the World Health Organization, the American Society of Anesthesiologists and more, all of which were used to build these new coronavirus updates.

And while Level Ex’s team felt an ethical responsibility to help during the pandemic, Glassenberg and Gantwerker also cite personal reasons. Much of Glassenberg’s family works within the medical world, and he recently had to build makeshift personal protective equipment out of a snorkel and C-PAP filters for his wife, who works as a pediatrician. Gantwerker, who is also a practicing ear, nose and throat doctor, felt a call to action as he examined the bleak situation his colleagues and friends were facing.

“I have lots of friends that are on the front lines and I have friends who have colleagues that are dying,” he said. “I am personally invested in this. And I really think that the way we represent information is better than traditional educational methods.”

But teaching doctors and nurses how to best approach coronavirus is difficult, Glassenberg explained, because the virus is so new and best practices are rapidly evolving. Resources and medical professionals are continuously reallocated to help hard-hit areas during the pandemic.

“Doctors, nurses, ENTs and respiratory therapists are getting pulled in to deal with scenarios either they’ve never dealt with before or they haven’t dealt with since their residency,” Glassenberg said. “So everyone’s scrambling to get some practice."

Glassenberg explained that creating a game mechanic is the most challenging, but when that framework is already there, adding additional updates should be easier to accomplish regularly.

To keep up with the rapidly changing information, Level Ex plans to bring regular updates to the coronavirus content. Players can access guidelines from health organizations like the American Society of Anesthesiologists and others directly through the apps, to corroborate what they’ve learned and stay up to date. Medical professionals can easily reach out to add to the growing research available to Level Ex, too, by emailing them through the official website.

The United States may experience a second wave of coronavirus in the fall, top infectious-disease expert Anthony S. Fauci has warned. It could be particularly severe if coronavirus and influenza patients combine to overwhelm hospitals. With this in mind, Gantwerker and Glassenberg are considering adding “co-infection” cases to the diagnosis game, as well as cardiology-based coronavirus levels as cardiac-related coronavirus symptoms become more prominent.

“There’s actually people who are getting influenza and covid-19,” Gantwerker said. “A lot of [physicians] say, ‘Oh, they have covid-19, let’s stop the workup.’ And that’s actually not the case. There’s actually a fair number of co-infections. As we build more cases, but this is definitely a topic area that we are going to try to address.”

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