Telemedicine for Trauma, Emergencies and Disaster Management

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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
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Disclosure
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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

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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
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Vital Signs
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Store and Forward
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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 2000284
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So what is the all the fuss about ?
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Trauma Toll

• 16,000 X 3655,800,000
• Up to 50 million are significantly injured or
  disabled

Mock C et al. Guidelines to Essential Trauma
Care, 2004
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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

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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

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Disasters

• Natural

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Disasters
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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)

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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)

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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
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Patient at the UMC Trauma center being attended
by trauma team
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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

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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

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Conclusion

• Telemedicine in acute phase injury works and
  it is beneficial
• Cost effective
• Save lives

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Telemedicine for Trauma

• Safety and practicality has been demonstrated
• Vastly underutilized
• Its time has come

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Telemedicine for Trauma, Emergencies and Disaster
Management

• The Greatest Unused Tool !

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• What we need to do?

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Create

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

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

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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!

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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

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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

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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.

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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.

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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.

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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.

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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.

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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.

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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

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RECENT DEVELOPMENTS - PAKISTAN

• Pakistan - Telmedpak
• SUPARCO, an autonomous research entity under the
  federal government has recently launched
  Pakistans First Satellite based telemedicine
  network.

Telmedpak.com. Www.suparco.gov.pk
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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

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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.

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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
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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

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SUMMARY

• Preparedness
• Organization
• Coordination
• Communication technology
• Telemedicine
• Saving lives!

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• 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.

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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

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THE VACUUM OF KNOWLEDGE AND THE Vacuum of hope

• Digital divide was getting bigger and wider

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INTEGRATED MIDDLE EASTERN TELEMEDICINE AND
E-HEALTH PROGRAM FOR PREVENTION, TREATMENT AND
REHABILITATION OF LANDMINE INJURIES AND OTHER
TRAUMAS
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INTEGRATED MIDDLE EASTERN TELEMEDICINE AND
E-HEALTH PROGRAM FOR PREVENTION, TREATMENT AND
REHABILITATION OF LANDMINE INJURIES AND OTHER
TRAUMAS
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What we do
Change the delivery of existing medical care
Bring together new coalition of partners with
innovative boundaries and clear vision
Create a modern and efficient medical system that
will prevent morbidity and death, and improve
lives
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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
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Disasters

• Landmines Unexploded Devices

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Telemedicine in the Balkans

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• Thank You!
• latifi_at_iveh.org
• rlatifi_at_email.arizona.edu