Cost-Effective Remote iPhone-Teathered Telementored Trauma Telesonography

Patient Self-Performed Point-of-Care Ultrasound: Using Communication Technologies to Empower Patient Self-Care

Point-of-Care ultrasound (POCUS) is an invaluable tool permitting the understanding of critical physiologic and anatomic details wherever and whenever a patient has a medical need. Thus the application of POCUS has dramatically expanded beyond hospitals to become a portable user-friendly technology in a variety of prehospital settings. Traditional thinking holds that a trained user is required to obtain images, greatly handicapping the scale of potential improvements in individual health assessments. However, as the interpretation of ultrasound images can be accomplished remotely by experts, the paradigm wherein experts guide novices to obtain meaningful images that facilitate remote care is being embraced worldwide. The ultimate extension of this concept is for experts to guide patients to image themselves, enabling secondary disease prevention, home-focused care, and self-empowerment of the individual to manage their own health. This paradigm of remotely telementored self-performed ultrasound (RTMSPUS) was first described for supporting health care on the International Space Station. The TeleMentored Ultrasound Supported Medical Interventions (TMUSMI) Research Group has been investigating the utility of this paradigm for terrestrial use. The technique has particular attractiveness in enabling surveillance of lung health during pandemic scenarios. However, the paradigm has tremendous potential to empower and support nearly any medical question poised in a conscious individual with internet connectivity able to follow the directions of a remote expert. Further studies and development are recommended in all areas of acute and chronic health care.

Prehospital Ultrasound: A Narrative Review

Background: Point-of-care ultrasound is rapidly becoming more prevalent in the prehospital environment. Though considered a relatively new intervention in this setting, there is growing literature that aims to explore the use of prehospital ultrasound by EMS personnel.Methods: To better understand and report the state of the science on prehospital ultrasound, we conducted a narrative review of the literature.Results: Following a keyword search of MEDLINE in Ovid from inception to August 2, 2022, 2,564 records were identified and screened. Based on review of abstracts and full texts, with addition of seven articles via bibliography review, 193 records were included. Many included studies detail usage in air medical and other critical care transport environments. Clinicians performing prehospital ultrasound are often physicians or other advanced practice personnel who have previous ultrasound experience, which facilitates implementation in the prehospital setting. Emerging literature details training programs for prehospital personnel who are novices to ultrasound, and implementation for some study types appears feasible without prior experience. Unique use scenarios that show promise include during critical care transport, for triage in austere settings, and for thoracic evaluation of patients at risk of life-threatening pathology.Conclusion: There is a growing mostly observational body of literature describing the use of ultrasound by prehospital personnel. Prehospital ultrasound has demonstrated feasibility for specific conditions, yet interventional studies evaluating benefit to patient outcomes are absent.

Telemedicine for Patient Management in Remote Areas and Underserved Populations

Access to care services in remote areas is challenging. The use of telemedicine technology in these areas facilitates access to health care. This study aimed to summarize the current research on telemedicine in remote areas such as mountains and forests. A systematic search was conducted in databases including Medline (through PubMed), Scopus, IEEE Xplore Digital Library, and ISI Web of Science to identify relevant studies published until May 12, 2021. Screening of retrieved articles for selection and inclusion in the study was performed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyzes extension for Scoping Reviews (PRISMA-ScR) checklist. A total of 807 articles were identified after removing duplicates, from which 20 studies meeting our inclusion criteria were selected. Challenges, opportunities, and equipment required to use telemedicine in remote areas were extracted from the selected studies. The results revealed that telemedicine implementation in remote areas had many challenges, including harsh weather conditions, Internet connectivity problems, difficult equipment transportation, and ethical issues. Telemedicine also has many benefits, such as cost and time savings for patients, improving patients' quality of life, and improving patient satisfaction. Telemedicine for inhabitants of forested and mountainous areas facilitates rapid access to health care and enhances patient satisfaction. Distinguishing advantages and barriers as well as reducing restrictions will have an essential role in accelerating the use of this technology.

Remote Evaluation of a Wireless Ultrasound Probe

Objective:

To determine whether an evaluation of a wireless ultrasound transducer could be completed remotely.

Materials and Methods:

Video conferencing was used for communication between a sonographer and a minimally trained operator to allow evaluation of a flat linear array transducer that communicated via Wi-Fi with a smartphone and the probe vendor’s software. A tissue-mimicking phantom was used for quantitative testing, while scanning human models allowed qualitative assessments. Video conferencing using a tablet camera directed at the smartphone screen or transducer allowed the sonographer to view images, and guide the operator on probe positioning, and image optimization techniques.

Results:

All tests were completed during three 60-minute video conferences. Assessments of models were more challenging than tests using the phantom. The glare from ambient lighting sometimes made it difficult to view the smartphone screen. A connectivity limitation, which has since been resolved, prevented simultaneous use of video conferencing and the transducer software on the smartphone.

Conclusion:

This study confirmed that an evaluation of a wireless ultrasound transducer can be successfully performed remotely.

Remote Real-Time Ultrasound Supervision via Commercially Available and Low-Cost Tele-Ultrasound: a Mixed Methods Study of the Practical Feasibility and Users' Acceptability in an Emergency Department

Minor emergency departments (ED) struggle to access sufficient expertise to supervise learners of lung and cardiac point-of-care ultrasound (POCUS). Using tele-ultrasound (tele-US) for remote supervision may remedy this situation. We aimed to evaluate the feasibility of real-time supervision via tele-US when applied to an everyday ED clinic. We conducted a mixed methods study that assessed practical feasibility, determined performance, and explored users' acceptability of supervision via tele-US. Technical performance was assessed quantitatively by the ratio in mean gray value between images on site and as received by the supervisor, and by after-compression frame rate. Qualitatively, 12 exploratory semi-structured interviews were conducted with exposed junior doctors and supervisors. Remote supervision via tele-US was performed with 10 junior doctors scanning 45 included patients. During performance assessment, neither alternating internet connection nor software significantly changed the mean gray value ratio. The lowest median frame rate of 4.6 (interquartile range [IQR]: 3.1-5.0) was found by using a 4G internet connection; the highest of 28.5 (IQR: 28.5-29.0) was found with alternative computer and local area network internet connection. In interviews, supervisors stressed the importance of preserving frame rate, and junior doctors emphasized a need for shared ultrasound terminology. In the qualitative analysis, setup mobility, accessibility, and time consumption were emphasized as being of key importance for future clinical implementations. Remote supervision via a commercially available and low-cost tele-US setup is operational for both junior doctors and supervisors when applied to lung and cardiac POCUS scans of hospitalized patients.

Offshore telementored ultrasound: a quality assessment study

Background

Telementored ultrasound (US) connects experts to novices through various types of communication and network technologies with the overall aim to bridge the medical imaging gap between patients’ diagnostic needs and on-site user experience. The recurrent theme in previous research on remote telementored US is the limited access to US machines and experienced users. This study was conducted to determine whether telementored US was feasible in a remote offshore setting. The aim was to assess if an onshore US expert can guide an offshore nurse through focused US scanning protocols by connecting an US machine to existing videoconference units at the offshore hospitals and to evaluate the diagnostic quality of the images and cineloops procured.

Results

The diagnostic quality of cineloops was scored on a five-point scale. The percentage of cineloops suitable for interpretation (score 3 ≥) for the FATE and e-FAST protocols was 96.4 and 79.1. Lung sliding and seashore sign could be identified in all volunteers. The scan time for the FAST protocol (n = four scanning positions), FATE protocol (n = six scanning positions) and both lungs (n = two scanning positions) was 1 min 20 s, 4 min 15 s and 32 s, respectively.

Conclusion

A novice US user can be guided by a remote expert through focused US protocols within an acceptable time frame and with good diagnostic quality using existing communication and network systems found onboard offshore oil rigs.

Impact of telemedicine on diagnosis, clinical management and outcomes in rural trauma patients: A rapid review

Introduction

Rural trauma patients are at increased risk of morbidity and mortality compared to trauma patients treated in urban facilities. Factors contributing to this disparity include differences in resource availability and increased time to definitive treatment for rural patients. Telemedicine can improve the early management of these patients by enabling rural providers to consult with trauma specialists at urban centres. The purpose of this study was to assess the impact of telemedicine utilisation on the diagnosis, clinical management and outcomes of rural trauma patients.

Materials and Methods

A rapid review of the literature was performed using the concepts 'trauma', 'rural' and 'telemedicine'. Fifteen electronic databases were searched from inception to 29^th June 2018. Manual searches were also conducted in relevant systematic reviews, key journals and bibliographies of included studies.

Results

The literature search identified 187 articles, of which 8 articles were included in the review. All 8 studies reported on clinical management, while the impact of telemedicine use on diagnosis and outcomes was reported in 4 and 5 studies, respectively. Study findings suggest that the use of telemedicine may improve patient diagnosis, streamline the process of transferring patients and reduce length of stay. Use of telemedicine had minimal impact on mortality and complications in rural trauma patients.

Conclusions

The evidence identified by this rapid review suggests that telemedicine may improve the diagnosis, management and outcomes of rural trauma patients. Further research is required to validate these findings by performing large and well-designed studies in rural areas, ideally as randomised clinical trials.

Point-of-care resuscitation research: From extreme to mainstream: Trauma Association of Canada Fraser Gurd Lecture 2019

The Gurd Family surgical legacy was deeply intertwined with National service in both World Wars. My own personal research mission has attempted to emulate such service, by enhancing the tools and techniques available to facilitate point-of-care diagnosis and resuscitation in extreme and adverse environments. Our efforts involving point-of-care diagnosis/resuscitation and the telementored guidance of those remotely responding to catastrophic injury have included collaborations with National Aeronautics and Space Administration (NASA) the Canadian Space Agency, the Canadian Forces, its democratic allies, and non-governmental surgical organizations. Research has been conducted in resuscitative suites and operating theaters, research laboratories, parabolic flight aircraft, on humanitarian surgical missions, and from ski-hills and firehalls. The initial phases of these efforts involved inaugural studies in resuscitative sonography including defining the Extended Focused Assessment with Sonography for Trauma (EFAST) examination. Although the original work was commissioned for Space Medicine, generalization to mainstream practice further justifies space medicine research. Iterative steps in advancing telementored resuscitation have subsequently involved the maturation of space-mandated telementored ultrasound support (TMUS), exploration of TMUS in terrestrial clinical practice, and the creation of increasingly mobile (hand-held) TMUS solutions. Subsequently it was recognized that teleultrasound is simply one informatic dimension of remote telemedicine, and current efforts are focused in a Program known as TeleMentored Ultrasound Supported Medical Interactions (TMUSMI) of remote responders required to intervene with catastrophic trauma. While this research program has yielded many techniques and findings that have benefited mainstream terrestrial practice, these investigations are currently ongoing, and we hope to demonstrate that TMUSMI may benefit all Canadians especially those in remote areas, as well as potentially every global inhabitant without immediate access to care. Further, we propose that to fully utilize these techniques, a new specialty, that of the remote medical mentor will be required, a new specialty that will require the creation and scientific validation of its principles and techniques.

A Feasibility Study of Smartphone-Based Telesonography for Evaluating Cardiac Dynamic Function and Diagnosing Acute Appendicitis with Control of the Image Quality of the Transmitted Videos

Our aim was to prove the feasibility of the remote interpretation of real-time transmitted ultrasound videos of dynamic and static organs using a smartphone with control of the image quality given a limited internet connection speed. For this study, 100 cases of echocardiography videos (dynamic organ)-50 with an ejection fraction (EF) of ≥50 s and 50 with EF <50 %-and 100 cases of suspected pediatric appendicitis (static organ)-50 with signs of acute appendicitis and 50 with no findings of appendicitis-were consecutively selected. Twelve reviewers reviewed the original videos using the liquid crystal display (LCD) monitor of an ultrasound machine and using a smartphone, to which the images were transmitted from the ultrasound machine. The resolution of the transmitted echocardiography videos was reduced by approximately 20 % to increase the frame rate of transmission given the limited internet speed. The differences in diagnostic performance between the two devices when evaluating left ventricular (LV) systolic function by measuring the EF and when evaluating the presence of acute appendicitis were investigated using a five-point Likert scale. The average areas under the receiver operating characteristic curves for each reviewer's interpretations using the LCD monitor and smartphone were respectively 0.968 (0.949-0.986) and 0.963 (0.945-0.982) (P = 0.548) for echocardiography and 0.972 (0.954-0.989) and 0.966 (0.947-0.984) (P = 0.175) for abdominal ultrasonography. We confirmed the feasibility of remotely interpreting ultrasound images using smartphones, specifically for evaluating LV function and diagnosing pediatric acute appendicitis; the images were transferred from the ultrasound machine using image quality-controlled telesonography.

The Damage Control Surgery in Austere Environments Research Group (DCSAERG): A dynamic program to facilitate real-time telementoring/telediagnosis to address exsanguination in extreme and austere environments

Hemorrhage is the most preventable cause of posttraumatic death. Many cases are potentially anatomically salvageable, yet remain lethal without logistics or trained personnel to deliver diagnosis or resuscitative surgery in austere environments. Revolutions in technology for remote mentoring of ultrasound and surgery may enhance capabilities to utilize the skill sets of non-physicians. Thus, our research collaborative explored remote mentoring to empower non-physicians to address junctional and torso hemorrhage control in austere environments. Major studies involved using remote-telementored ultrasound (RTMUS) to identify torso and junctional exsanguination, remotely mentoring resuscitative surgery for torso hemorrhage control, understanding and mitigating physiological stress during such tasks, and the technical practicalities of conducting damage control surgery (DCS) in austere environments. Iterative projects involved randomized guiding of firefighters to identify torso (RCT) and junctional (pilot) hemorrhage using RTMUS, randomized remote mentoring of MedTechs conducting resuscitative surgery for torso exsanguination in an anatomically realistic surgical trainer ("Cut Suit") including physiological monitoring, and trained surgeons conducting a comparative randomized study for torso hemorrhage control in normal (1g) versus weightlessness (0g). This work demonstrated that firefighters could be remotely mentored to perform just-in-time torso RTMUS on a simulator. Both firefighters and mentors were confident in their abilities, the ultrasounds being 97% accurate. An ultrasound-naive firefighter in Memphis could also be remotely mentored from Hawaii to identify and subsequently tamponade an arterial junctional hemorrhage using RTMUS in a live tissue model. Thereafter, both mentored and unmentored MedTechs and trained surgeons completed resuscitative surgery for hemorrhage control on the Cut-Suit, demonstrating practicality for all involved. While remote mentoring did not decrease blood loss among MedTechs, it increased procedural confidence and decreased physiologic stress. Therefore, remote mentoring may increase the feasibility of non-physicians conducting a psychologically daunting task. Finally, DCS in weightlessness was feasible without fundamental differences from 1g. Overall, the collective evidence suggests that remote mentoring supports diagnosis, noninvasive therapy, and ultimately resuscitative surgery to potentially rescue those exsanguinating in austere environments and should be more rigorously studied.

Trauma in Canada: a spirit of equity & collaboration

BACKGROUND

The delivery of equitable trauma care in Canada is not without challenges within our universal health care system. Notably, the tyranny of geography is intermittently at odds with adequate access for our rural, indigenous, and impoverished populations. Other differences exist when compared with neighbouring trauma systems, for example in the United States.

METHODS

As a critical review, we chose to compare and critique the overall system of trauma organization and perceived societal expectations of a high-income, North American country (Canada) to assist with discussions on trauma systems for the future.

RESULTS

Tele-technology is providing some early solutions. Trauma systems and delivery of care in Canada differ from the United States due to our single-payer system, regionalization and universal provision. Care for injured Canadians has a long history of being multidisciplinary, with collaborative research programs. Canada also has a history of global surgical endeavours, beginning with Dr. Norman Bethune and his recognition of the political causes of trauma and continuing as a global public health concern for all.

CONCLUSIONS

While challenges continue to exist for the provision of equitable trauma care in Canada, unique multidisciplinary, collaborative and technology-based solutions continue to be developed, both locally and globally, to address this critical public health issue.

Help is in your pocket: the potential accuracy of smartphone- and laptop-based remotely guided resuscitative telesonography

BACKGROUND

Ultrasound (US) examination has many uses in resuscitation, but to use it to its full effectiveness typically requires a trained and proficient user. We sought to use information technology advances to remotely guide US-naive examiners (UNEs) using a portable battery-powered tele-US system mentored using either a smartphone or laptop computer.

MATERIALS AND METHODS

A cohort of UNEs (5 tactical emergency medicine technicians, 10 ski-patrollers, and 4 nurses) was guided to perform partial or complete Extended Focused Assessment with Sonography of Trauma (EFAST) examinations on both a healthy volunteer and on a US phantom, while being mentored by a remote examiner who viewed the US images over either an iPhone(®) (Apple, Cupertino, CA) or a laptop computer with an inlaid depiction of the US probe and the "patient," derived from a videocamera mounted on the UNE's head. Examinations were recorded as still images and over-read from a Web site by seven expert reviewers (ERs) (three surgeons, two emergentologists, and two radiologists). Examination goals were to identify lung sliding (LS) documented by color power Doppler (CPD) in the human and to identify intraperitoneal (IP) fluid in the phantom.

RESULTS

All UNEs were successfully mentored to easily and clearly identify both LS (19 determinations) and IP fluid (14 determinations), as assessed in real time by the remote mentor. ERs confirmed IP fluid in 95 of 98 determinations (97%), with 100% of ERs perceiving clinical utility for the abdominal Focused Assessment with Sonography of Trauma. Based on single still CPD images, 70% of ERs agreed on the presence or absence of LS. In 16 out of 19 cases, over 70% of the ERs felt the EFAST exam was clinically useful.

CONCLUSIONS

UNEs can confidently be guided to obtain critical findings using simple information technology resources, based on the receiving/transmitting device found in most trauma surgeons' pocket or briefcase. Global US mentoring requires only Internet connectivity and initiative.

Potential Use of Remote Telesonography as a Transformational Technology in Underresourced and/or Remote Settings

Mortality and morbidity from traumatic injury are twofold higher in rural compared to urban areas. Furthermore, the greater the distance a patient resides from an organized trauma system, the greater the likelihood of an adverse outcome. Delay in timely diagnosis and treatment contributes to this penalty, regardless of whether the inherent barriers are geographic, cultural, or socioeconomic. Since ultrasound is noninvasive, cost-effective, and portable, it is becoming increasingly useful for remote/underresourced (R/UR) settings to avoid lengthy patient travel to relatively inaccessible medical centers. Ultrasonography is a user-dependent, technical skill, and many, if not most, front-line care providers will not have this advanced training. This is particularly true if care is being provided by out-of-hospital, “nontraditional” providers. The human exploration of space has forced the utilization of information technology (IT) to allow remote experts to guide distant untrained care providers in point-of-care ultrasound to diagnose and manage both acute and chronic illness or injuries. This paradigm potentially brings advanced diagnostic imaging to any medical interaction in a setting with internet connectivity. This paper summarizes the current literature surrounding the development of teleultrasound as a transformational technology and its application to underresourced settings.

Technological advancements in the care of the trauma patient

INTRODUTION

Medical technology has benefited many types of patients, but trauma care has arguably benefited more from technologic development than almost any other field.

METHODS

A literature review to identify key technological advances in the care of trauma patients was performed.

RESULTS

The advances in trauma care are in great measure due to the integration of many different systems. Medical technology impacts care in the field at the site of the trauma, in the transport to trauma facilities, and care at the trauma center itself. Once at the hospital, technology has impacted care in the trauma bay, intensive care units, the operating room, and in postoperative and long-term care settings. The integration of advancements, however, needs to be examined in a careful systematic fashion to insure that patients will actually derive benefit.

How to set up a low cost tele-ultrasound capable videoconferencing system with wide applicability

Background

Worldwide ultrasound equipment accessibility is at an all-time high, as technology improves and costs decrease. Ensuring that patients benefit from more accurate resuscitation and diagnoses from a user-dependent technology, such as ultrasound, requires accurate examination, typically entailing significant training. Remote tele-mentored ultrasound (RTUS) examination is, however, a technique pioneered in space medicine that has increased applicability on earth. We, thus, sought to create and demonstrate a cost-minimal approach and system with potentially global applicability.

Methods

The cost-minimal RTUS system was constructed by utilizing a standard off-the-shelf laptop computer that connected to the internet through an internal wireless receiver and/or was tethered through a smartphone. A number of portable hand-held ultrasound devices were digitally streamed into the laptop utilizing a video converter. Both the ultrasound video and the output of a head-mounted video camera were transmitted over freely available Voice Over Internet Protocol (VOIP) software to remote experts who could receive and communicate using any mobile device (computer, tablet, or smartphone) that could access secure VOIP transmissions from the internet.

Results

The RTUS system allowed real-time mentored tele-ultrasound to be conducted from a variety of settings that were inside buildings, outside on mountainsides, and even within aircraft in flight all unified by the simple capability of receiving and transmitting VOIP transmissions. . Numerous types of ultrasound examinations were conducted such as abdominal and thoracic examinations with a variety of users mentored who had previous skills ranging from none to expert. Internet connectivity was rarely a limiting factor, with competing logistical and scheduling demands of the participants predominating.

Conclusions

RTUS examinations can educate and guide point of care clinical providers to enhance their use of ultrasound. The scope of the examinations conducted is limited only by the time available and the criticality of the subject being examined. As internet connectivity will only improve worldwide, future developments need to focus on the human factors to optimize tele-sonographic interactions.

Portable bedside ultrasound: the visual stethoscope of the 21st century

Over the past decade technological advances in the realm of ultrasound have allowed what was once a cumbersome and large machine to become essentially hand-held. This coupled with a greater understanding of lung sonography has revolutionized our bedside assessment of patients. Using ultrasound not as a diagnostic test, but instead as a component of the physical exam, may allow it to become the stethoscope of the 21st century.

2010 Trauma Association of Canada presidential address: why the Trauma Association of Canada should care about space medicine

The Trauma Association of Canada is now 27 years old, having been officially founded in 1983, at the meetings of the Royal College as a maturation of the trauma committee of the Canadian Association of General Surgeons. The first page of the official minutes also stressed the need to welcome other disciplines into the fold. Personally, it has taken me years of involvement, as well as the Presidency, to truly appreciate the depth of our Founding Members commitment. These individuals set lofty mission goals for the organization, namely: to strive to improve the quality of care provided to the injured patient, including prehospital management and transport, acute care hospitalization, and reintegration into society; to support, conduct, and apply basic science and clinical and outcome research related to trauma; to encourage effective and efficient use of healthcare resources in the delivery of trauma care; and to foster professional and community education in the field of injury prevention and in the care of the injured patient. As daunting as these responsibilities are, I am suggesting one more: to overcome the great penalty of geography that challenges our nation and penalizes many of our citizens by aspiring to optimize these four goals, for all Canadians, irrespective of where they live--our potential fifth mission. Furthermore, I believe that lessons from space medicine may offer some strategies to accomplish this goal.