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Telemedicine for Trauma, Emergencies, and Disaster Management

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  • To end my talk...I like to describe the use of telemedicine in a rewarding and fun event...the swim of Martin Strel in the Amazon river! Give personal story of event :)
  • So, how can telemedicine help with events such as the Syrian refugee crisis, the earthquake of Haiti, and many more of the disasters, trauma, and injuries we see on a daily basis? First, organization and coordination. Telemedicine offers the assistance of wireless technologies to reach people in remote locations, remote access to experts, and relief to disaster management teams who are on location
  • Innes Crawford and colleagues were able to successfully conduct a lung ultrasound remotely by allowing remote experts in Aberdeen to view real-time PLUS images displayed on a smartphone, A portable ultrasound Sonosite 180, in Calgary was interfaced to a laptop computer (Acer) via an analogue-to-digital converter (VC-211V, ActionStar LinXcel, Taiwan). Xsplit Broadcaster (SplitMediaLabs ltd, Hong Kong) allowed video-streaming of both an inexpensive head-mounted webcam (LifeCam VX-2000, Microsoft, Washington) and ultrasound over Skype (Skype, Luxembourg), easily viewed on any smartphone. The remote experts were thereafter able to easily view both the Calgary examiners hands and probe and resultant ultrasound images and to audibly bidirectionally communicate during the conducting of PLUS, with the iphone images deemed of diagnostic quality demonstrating clear evidence of real-time lung sliding.
  • Boniface and colleagues conducted a study with untrained paramedics to determine if using radio communication they could be instructed to perform ultrasounds. The study demonstrated that paramedics with no prior ultrasound experience could obtain FAST images under remote guidance from experienced EPs in less than 5 minutes. This technology has applicability in battlefield, remote, and rural prehospital settings.
  • Telepointer technology is a recent technology that allows for an inexpensive remote-site interaction between the parties in the field and off-site parties to give advice and relay needed information that may not be accessible in disaster situations.
  • People often assume that all militaries have the same protocols and procedures. That everything is standardized simply because they are militaries. This is not the case. Different countries have different priorities regarding business processing.
  • NATO has key rules that it follows regarding standardization: 1) Standardization is voluntary – no nation should be forced 2) Standardization is not an end in and of itself – is should be useful and efficient 3) Some degree of standardization is essential for implementing plans. 4) higher degrees of standardization may be necessary to enhance resource management or implementation of plans 5) interoperability is the minimum level that is desirable 6) Training and equipment are national responsibilities...not NATO. NATO decentralizes 7) common terminology is essential THESE RULES OFFER GREAT GUIDANCE FOR IMPLEMENTATION OF TELEMEDICINE PROGRAMS FOR DISASTER MANAGEMENT
  • AIMS participates as a Tertiary multi-speciality hospital as part of a country wide network linked through VSAT connectivity of 384 KBPS) addressing specialist consultation and diagnostics requirements of patients referred from other hospitals in the network. The Indian Space Research Organization is the technical partner managing the network and providing a bio-medical kit, to measure patients vital signs, the associated computer hardware and Tele-medicine software across the member hospitals as well as satellite connectivity, completely free of cost. Using this infrastructure, Amrita collaborates with over 60 hospitals from near and far flung areas, such as the islands of Lakshadweep and Andaman, the hilly terrains of Kashmir are part of the routine consultation and continued medical education programs that run on the network.
  • Pakistan has recently seen major developments in the telemedicine industry. Telmedpak is an organization that is leading the efforts to involve government and industry in telemedicine innovation in Pakistan. SUPARCO, an autonomous research entity under the federal government has recently launched Pakistan’s First Satellite based telemedicine network. It has connected JPMC hospital in Karachi with remote medical center at Shikarpur for patient Evaluation and consultation. This network has been established in Sindh province. The next step is development of satellite based telemedicine centers at holy family hospital, Rawalpindi in Punjab province and primary care centers in Muzaffarabad keeping in view the geographical isolation of northern areas and the role which space technology can play in these health care inaccessible areas. (www.telmedpak.com)
  • The Armenian Association of Telemedicine recently developed a mobile ECG telemonitoring device. ECG (electrocardiogram) is registered using a modern lightweight ultra-portable sensor and a smartphone with special application and mobile Internet (3G) • ECG can thus be registered regardless of the patient’s location, both indoors and outdoors – anywhere with good mobile coverage • ECG-monitoring (live streamed) is provided by specialized personnel, regardless of the time, if needed – 7 days a week, 24 hours per day • ECG is stored in the patients’ database, and can be viewed and analyzed both live streamed and recorded by authorized personnel anytime and anywhere, from any computer with Internet access
  • The growth of telemedicine is leading to a great surge in corporate interest. In turn, the greater availability of new gadgets is promoting more use of telemedicine. Needs to be addressed: management of healthcare records, dissemination of information quickly, adoption of strategies to provide highest quality care at lowest cost, laws and legal infrastructure to catalyze growth of this industry LEGAL BARRIERS!!
  • In summary: it is important to realize the urgency of establishing an effective, global disaster management telemedicine program. The goal of this talk today was to discuss the usefulness of the technology in telemedicine. The bottom line, I believe, for all of us is the saving of lives. Better preparedness, organization, coordination, use of advanced communication technologies, and standardization can help us to respond to disasters and incidences of trauma more effectively.
  • Transcript

    • 1. Telemedicine for Trauma, Emergencies, and Disaster Management Rifat Latifi, MD, FACS Professor of Surgery, University of Arizona, Tucson, Arizona President and Founder International Virtual e-Hospital Foundation Hyderabad, September 7, 2013Hyderabad, September 7, 2013
    • 2. DisclosureDisclosure
    • 3. Current Telemedicine Programs Elective Telemedicine Program Inter-hospital telemedicine and telepresence and network- Emergency and Trauma Digital ambulances and monitored patient transport; EMS, Trauma Deployable mobile telemedicine systems- Disasters, Medical Missions
    • 4. Telemedicine for Emergency and Disaster Telemedicine for Emergency and Disaster Pre EventPre Event During the Event During the Event Post EventPost Event Most importantlyMost importantly Chaotic situation, difficult to create “de novo” programs, short term, ?? utility Chaotic situation, difficult to create “de novo” programs, short term, ?? utility Media Effect, researc h papers … Media Effect, researc h papers …
    • 5. Vital Signs
    • 6. Store and Forward
    • 7. Need for telepresence: “Patients involved in MVC in rural America have twice the rate of mortality with those in an urban settings with the same ISS” JAMA 2000;284
    • 8. So what is the all the fuss about ? So what is the all the fuss about ?
    • 9. Trauma Toll •16,000 X 365=5,800,000 •Up to 50 million are significantly injured or disabled Mock C et al. Guidelines to Essential Trauma Care, 2004Mock C et al. Guidelines to Essential Trauma Care, 2004
    • 10. Natural Disasters ● 327 Natural disasters in 2009 ● Earthquakes, floods, extreme temperature, storms ● 2010 Haiti earthquake, roughly 230,000 died ● Death tolls due to construction, infrastructure, and overcrowding
    • 11. Trauma & Disasters as a Worldwide Problem ● “Disaster – Serious event where needs exceed the local capacity to respond” –WHO ● Most victims of disaster are usually also trauma victims
    • 12. Disasters ● Natural ●
    • 13. Disasters…
    • 14. Published Evidence • Australia: Smith et al (2004), Kumar et al (2006) • Canada :Dyer et al ( 2008) • China: Wong et al (2006) • France: Knobloch et al (2009), Dulou et al (2010) • Germany: Kreutzer et al (2008), Juhra et al (2009) • Israel: Ashkenazi et al (2007) Todder et al (2007) • Italy: Do Paolo et al (2009)
    • 15. Published Evidence • Taiwan: Hsieh et al (2004),Tsai et al (2007) • Thailand: Chandhanayingyon et al (2007) • United Kingdom: Keane (2009), Noble et al (2005), Benger et al (2004) • USA: Sposaro and Tyson (2009), Saffle et al (2006, 2009), Latifi et al (2007, 2009), Waran et al (2008), Duchesne et al (2008), Ma et al (2007), Kwon et al (2007), Ngyuen et al(2004), Marcin et al (2004)
    • 16. Pull the ET tube back, decompress the stomach… Results: Clinical Improvement Better SBP Improvement of Saturation Initial Chest x-ray of the patient managed by telemedicine 11/21/2004 Small interventio n CASE PRESENTATION
    • 17. Patient at the UMC Trauma center being attended by trauma team
    • 18. Interventions (routine for trauma) Intubate the patient Reposition the ET tube from the right main bronchus Sedate, paralyze the patient Obtain femoral vein/arterial access Resuscitate with lactated ringer Obtain a blood gas, CBC Blood transfusion, antibiotics Suction the ET tube Place the orogastric tube to decompress stomach
    • 19. Extreme Conditions: Low- bandwidth Portable Satellite  The Amazon Swim Expedition  Martin Strel and virtual physicians  Lessons learned: telepresence 24 hours day, 7 days week, 66 days – usage of mobile satellite, BGAN
    • 20. Conclusion • Telemedicine in acute phase injury : works and it is beneficial •Cost effective •Save lives
    • 21. Telemedicine for Trauma: •Safety and practicality has been demonstrated •Vastly underutilized •It’s time has come
    • 22. Telemedicine for Trauma, Emergencies and Disaster Management The Greatest Unused Tool !
    • 23. •What we need to do?
    • 24. •Infrastructure and Connectivity •Policies, procedures, protocols (both clinical and technical) •Credentialing process •Quality control Create
    • 25. Non- Disruptive- Very helpful Cost effective Improving Quality of Patients Care Telemedicine for Trauma and Emergencies Partnership Between healthcare providers Virtual Participation
    • 26. Inaccuracy of Measurement of Trauma & Injury ● Unreliable measurement globally ● Lack of consistency in coding and gathering of data ● www.emdat.be : contains 18,000 natural & technological disasters since 1900
    • 27. PROBLEMS FACING MEDICAL AND EMERGENCY EXPERTS DURING DISASTERS AND EMERGENCY ● The largest problem is accessing people affected by disasters and emergency situations and being adequately prepared to respond!
    • 28. Wireless Technologies: Potential Use In Emergencies and Disasters ● Multi-patient monitoring systems using wireless technologies in disaster situations ● Long-range data transmission ● Connect among regions of experts ● GPS technology/satellite ● Useful for monitoring multiple patients in disasters
    • 29. PROBLEMS FACING MEDICAL AND EMERGENCY EXPERTS DURING DISASTERS AND EMERGENCY − Wireless technologies − Remote access to experts − Communications − Organization & Coordination − Provide relief to disaster management teams on location
    • 30. Potential Uses of Remote Technologies in Remote Settings • FAST, Focused Assessment with Sonography for Trauma = real-time remote physician guidance for trauma examination • Teleultrasound as a transformational technology for under-resourced settings Crawford, I. et al., (2011). Telementorable, “just-in-time” lung ultrasound on an iPhone. Journal of Emergencies, Trauma, and Shock, 4, pp. 526-527. Pian, L.. et al. (2013). Potential use of remote telesonography as a transformational technology in underresourced and/or remote settings. Emergency Medicine International.
    • 31. FAST Emergency situations: EMT lack of training FAST technology applications Boniface, K.S., Shokoohi, H., Smith, E.R., & Scantelbury, K. (2011). Tele-ultrasound and paramedics: real-time remote phyisician guidance of the Focused Assessment with Sonography for Trauma examination. American Journal of Emergency Medicine, 29, pp 477-481.
    • 32. Telepointer Technology Interaction style presentation system interactive television, and other systems, where the user is positioned at a remote site from the display. The main function of a telepointer is to point at the specific display so that its motion could represent the human gesture. Meanwhile, display devices allow the collaborator to view the same scene as seen by the other parties Abdul Karim, R., Farizan Zakara, N. et al., (2013). Telepointer technology in telemedicine: A review. Biomedical Engineering Online.
    • 33. The Military Approach Establishing Clinical Protocols & Standards  Standardization may not always be necessary  Not all military's follow the same approach!! Lam, D.M. (2011). Establishing clinical protocols and standards: The military approach. pp. 147-160. In Telemedicine for Trauma, Emergencies and Disaster Managment, R. Latifi, Ed.
    • 34. The Military Approach 2 NATO – successful international standardization  Clinical, Technical, Business Standards  NATO: 1) standardization voluntary, 2) Not an end of itself, only done if useful and makes process more efficient, use of common terminology Lam, D.M. (2011). Establishing clinical protocols and standards: The military approach. pp. 147-160. In Telemedicine for Trauma, Emergencies and Disaster Managment, R. Latifi, Ed.
    • 35. U.S. Army Telemedicine in Iraq & Afghanistan • Can telemedicine effectively be used across national boundaries? • U.S. Army Theater Teleconsult program • Online management of consultation requests • Consultant is primary responder • 7,255 consultations over 6 year period • Avoided 90 medical flight evacuations ($2 million cost savings) • Considerations for NATO operations – lessons learned • Poropatich, R.K., Lappan, C., & Lam, D.M. (2011). Operational use of U.S. Army telemedicine information systems in Iraq and Afghanistan – Considerations for NATO operations.pp. 173-182. In Telemedicine for Trauma, Emergencies and Disaster Managment, R. Latifi, Ed.
    • 36. INDIA – Disaster Management Amrita Amrita Institute of Medical Sciences and Indian Space Research Organization (ISRO) partnering to provide remote care to over 60 hospitals in preparation for disaster management
    • 37. RECENT DEVELOPMENTS - PAKISTAN Pakistan - Telmedpak SUPARCO, an autonomous research entity under the federal government has recently launched Pakistan’s First Satellite based telemedicine network. Telmedpak.com. Www.suparco.gov.pk
    • 38. Recent Developments – Armenia Mobile ECG Telemonitoring Armenia – recent development of Mobile ECG telemonitoring device Lightweight ultra-portable sensor & smartphone ECG registered regardless of patient's location ECG monitoring is live streamed, provided by specialized personnel Data stored in patient databased, viewed anywhere Www.armtelemed.com
    • 39. Keeping up with Industry Development Dissolving legal barriers to industry growth and development are key to unlocking potential of the use of telemedicine in disaster and trauma management Gupta, A. & McHugh, M. (2011). Keeping up with industry development. pp. 373-388. In Telemedicine for Trauma, Emergencies and Disaster Managment, R. Latifi, Ed.
    • 40. Telemedicine for Emergency and Disaster Telemedicine for Emergency and Disaster Pre EventPre Event During the Event During the Event Post EventPost Event Most importantlyMost importantly Chaotic situation, difficult to create “de novo” programs, short term, ?? utility Chaotic situation, difficult to create “de novo” programs, short term, ?? utility Media Effect, research papers… Media Effect, research papers…
    • 41. Reconstruction • The entire medical infrastructure and human capacity destroyed • No medical standards • Infant mortality 51.2 per 1000 • In-efficient and broken medical system • Crowded hospitals • Not a single scientific journal in any library
    • 42. SUMMARY Preparedness Organization Coordination Communication technology Telemedicine Saving lives!
    • 43. ““There are no more excuses forThere are no more excuses for any critically ill or trauma patientany critically ill or trauma patient to die in any emergency room ofto die in any emergency room of any country just because thereany country just because there was no specialist available on sitewas no specialist available on site to help with the resuscitation.to help with the resuscitation.””
    • 44. What do we needed was and still is: • Radical changes of the configuration of medical care • Coalition of new partners with innovative boundaries • Penetrating eyes of revolutionary and champions of the unconventional • The rebels of the hospital as we know it
    • 45. THE VACUUM OF KNOWLEDGE AND THE Vacuum of hope Digital divide was getting bigger and wider…
    • 46. INTEGRATED MIDDLE EASTERN TELEMEDICINE AND E-HEALTH PROGRAM FOR PREVENTION, TREATMENT AND REHABILITATION OF LANDMINE INJURIES AND OTHER TRAUMAS
    • 47. INTEGRATED MIDDLE EASTERN TELEMEDICINE AND E-HEALTH PROGRAM FOR PREVENTION, TREATMENT AND REHABILITATION OF LANDMINE INJURIES AND OTHER TRAUMAS
    • 48. What we do: Change the delivery of existing medical care Bring together new coalition of partners with innovative boundaries and clear vision
    • 49. We Demand A new generation of leaders with different intellectual capital and a new direction Global and not focused on self limited projects, or driven by institutional and/or national interest Universal Thinking and Actions
    • 50. Disasters • Landmines & Unexploded Devices
    • 51. • = 57 Telemedicine in the Balkans
    • 52. Thank You! latifi@iveh.org rlatifi@email.arizona.edu