Telemedicine for Trauma, Emergencies and Disaster Management

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, 2013

2. Disclosure

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 Most importantly Pre Event Media Effect, research papers… During the Event Chaotic situation, difficult to create “de novo” programs, short term, ?? utility Post Event

6. Vital Signs

7. Store and Forward

8. 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

9. So what is the all the fuss about ?

10. 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, 2004

11. 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

12. 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

13. Disasters • Natural

16. Disasters…

18. 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)

19. 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)

20. CASE PRESENTATION Pull the ET tube back, decompress the stomach… Results: Clinical Improvement Better SBP Improvement of Saturation Small intervention Initial Chest x-ray of the patient managed by telemedicine 11/21/2004

21. Patient at the UMC Trauma center being attended by trauma team

22. 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

25. 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 Extreme Conditions: Low-bandwidth Portable Satellite

26. Conclusion • Telemedicine in acute phase injury : works and it is beneficial • Cost effective • Save lives

27. Telemedicine for Trauma: • Safety and practicality has been demonstrated • Vastly underutilized • It’s time has come

28. Telemedicine for Trauma, Emergencies and Disaster Management The Greatest Unused Tool !

29. What we need to do?

30. Create • Infrastructure and Connectivity • Policies, procedures, protocols (both clinical and technical) • Credentialing process • Quality control

31. Telemedicine for Trauma and Emergencies Non- Disruptive-Very helpful Improving Quality of Patients Care Cost effective Partnership Between healthcare providers Virtual Participation

32. 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

33. 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!

34. 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

35. 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

36. 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.

37. 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.

38. 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.

39. 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

40. 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. The Military Approach 2

41. 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.

42. 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

43. 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

44. Recent Developments – ArmeniaMobile 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

45. 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. Keeping up with Industry Development

46. Telemedicine for Emergency and Disaster Most importantly Pre Event Media Effect, research papers… During the Event Chaotic situation, difficult to create “de novo” programs, short term, ?? utility Post Event

47. 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

48. SUMMARY Preparedness Organization Coordination Communication technology Telemedicine Saving lives!

49. “There are no more excuses for any critically ill or trauma patient to die in any emergency room of any country just because there was no specialist available on site to help with the resuscitation.”

50. 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