Telemedicine for Trauma, Emergencies, and Disaster
Management
Rifat Latifi, MD, FACSProfessor of Surgery, University of
Arizona, Tucson, ArizonaPresident and Founder
International Virtual e-Hospital Foundation
Hyderabad, September 7, 2013Hyderabad, September 7, 2013
Disclosure Disclosure
Current Telemedicine Programs
Elective Telemedicine ProgramInter-hospital telemedicine and
telepresence and network- Emergency and Trauma
Digital ambulances and monitored patient transport; EMS, Trauma
Deployable mobile telemedicine systems- Disasters, Medical Missions
Telemedicine for Emergency and Disaster
Telemedicine for Emergency and Disaster
Pre Event Pre 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
MediaEffect, researc
h papers
…
MediaEffect, researc
h papers
…
Vital Signs
Store and Forward
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
So what is the all the fuss about ?So what is the all the fuss about ?
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
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
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
Disasters● Natural●
Disasters…
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)
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)
Pull the ET tube back,decompress
the stomach…Results: Clinical
ImprovementBetter SBP
Improvement of Saturation
Initial Chest x-ray of the patient managed by telemedicine 11/21/2004
Small intervention
CASE PRESENTATION
Patient at the UMC Trauma center being attended by trauma team
Interventions (routine for trauma) Intubate the patient Reposition the ET tube from the right main
bronchus Sedate, paralyze the patientObtain femoral vein/arterial accessResuscitate with lactated ringerObtain a blood gas, CBCBlood transfusion, antibioticsSuction the ET tubePlace the orogastric tube to decompress
stomach
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
Conclusion
• Telemedicine in acute phase injury : works and it is beneficial
• Cost effective• Save lives
Telemedicine for Trauma:
•Safety and practicality has been demonstrated •Vastly underutilized •It’s time has come
Telemedicine for Trauma, Emergencies and Disaster Management
The Greatest Unused Tool !
•What we need to do?
• Infrastructure and Connectivity • Policies, procedures, protocols
(both clinical and technical)• Credentialing process• Quality control
Create
Non- Disruptive-
Very helpful Cost
effective
Improving Quality of PatientsCare
Telemedicine for Trauma and Emergencies
Partnership Between
healthcareproviders
Virtual Participation
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
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!
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
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
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 settingsCrawford, 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.
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.
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.
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.
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.
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.
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
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
Recent Developments – ArmeniaMobile ECG Telemonitoring
Armenia – recent development of Mobile ECG telemonitoring device
Lightweight ultra-portable sensor & smartphoneECG registered regardless of patient's locationECG monitoring is live streamed, provided by
specialized personnelData stored in patient databased, viewed anywhereWww.armtelemed.com
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.
Telemedicine for Emergency and Disaster
Telemedicine for Emergency and Disaster
Pre Event Pre 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
MediaEffect,
research papers…
MediaEffect,
research papers…
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
SUMMARYPreparednessOrganizationCoordinationCommunication
technologyTelemedicineSaving lives!
“ “There are no more excuses for There are no more excuses for any critically ill or trauma patient any critically ill or trauma patient to die in any emergency room of to die in any emergency room of any country just because there any country just because there was no specialist available on site was no specialist available on site to help with the resuscitation.” to help with the resuscitation.”
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
THE VACUUM OF KNOWLEDGE AND THE
Vacuum of hope
Digital divide was getting bigger and wider…
INTEGRATED MIDDLE EASTERN TELEMEDICINE AND E-HEALTH PROGRAM FOR PREVENTION, TREATMENT AND REHABILITATION OF LANDMINE INJURIES AND OTHER TRAUMAS
INTEGRATED MIDDLE EASTERN TELEMEDICINE AND E-HEALTH PROGRAM FOR PREVENTION, TREATMENT AND REHABILITATION OF LANDMINE INJURIES AND OTHER TRAUMAS
What we do:
Change the delivery of existing medical care
Bring together new coalition of partners with innovative boundaries and clear vision
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
Disasters
• Landmines & Unexploded Devices
• =
57
Telemedicine in the Balkans
