Teletrauma
The University of Miami Miller School of Medicine’s William Lehman Injury Research Center located in the internationally recognized Ryder Trauma Center is studying how telemedicine capabilities can be utilized to improve the efficiency and effectiveness of the delivery of care in a trauma setting. The Lehman Center TeleTrauma Department has a number of unique and exciting research projects on going.
Telemedicine for Trauma Resuscitation
The Lehman Center has partnered with the US Army and the Army Trauma Training Center (ATTC) to research the effectiveness of telemedicine in the trauma environment. Funded by the Telemedicine and Advanced Technology Research Center (TATRC)—an organization under the US Army Medical Research & Materiel Command, Fort Detrick, Maryland—the research team is conducting a 12-month clinical trial to study the usability and clinical effectiveness of the InTouch Health Remote Presence (RP-7) robot in trauma care. The RP-7 robot is operated using a wireless connection from a control station using a joystick. The control station is on a laptop computer that allows a trauma specialist to operate the robot from any location with a wireless connection. Specifically, trauma physicians at the level-1 Ryder Trauma Center located in Miami, Florida remotely support their on-site team and care of patients in Ryder’s resuscitation and operating room as part of this research effort. It is hoped that this research will help us to better understand the feasibility of the RP-7 robot for use in trauma care and its implications on the battlefield. Telemedicine technology could virtually bring world class trauma physicians to the battlefield to support and mentor deployed military physicians who are treating injured soldiers.
Figure 1. Dr. Antonio Marttos, Director of TeleTrauma at the William Lehman Injury Research Center, poses with the RP-7 robot. Dr. Jeffrey Augenstein, Director of the Ryder Trauma Center, is located remotely and operating the robot.
Figure 2. Dr. Antonio Marttos demonstrates use of the RP-7 robot control station in his office at the Ryder Trauma Center.
Figure 3. The RP-7 robot is being utilized in the Ryder Trauma Center operating room.
Telemedicine for Trauma Triage
Effective response to a disaster situation (e.g., an airplane crash involving multiple casualties) requires that healthcare systems be able to manage the ‘surge capacity’ created by the sudden increase in demand for care. Surge capacity has been a problem throughout history for emergency response systems and healthcare providers faced with man-made and natural disasters. Surge capacity involves three major elements—facilities, supplies and equipment, and personnel. While there has been a great deal of research conducted on the first two aspects (i.e., facilities and equipment), ensuring that well-trained personnel are available to meet the surge capacity is a more complicated and relatively neglected issue. Simply addressing the quantity of personnel on hand in case of a disaster is not sufficient; expertise, knowledge, skills and attitudes (KSAs) must also be sufficient and appropriate to the problem, and workers must be organized into effective units and given contextually relevant tasks.
The use of telemedicine can help to alleviate this concern. Specifically, using audio and video feeds transmitted via the internet, the UM/Lehman Center’s TeleTrauma Department is testing the ability of trauma specialists to respond to and triage victims resulting from a disaster, albeit remotely. Using telemedicine, these experts can be “on hand” to determine the severity of injuries, make clinical assessments and determine whether those injured must be evacuated for necessary care. Our initial testings have proven successful in that remotely located trauma specialists can make the same clinical assessment and plan of care as a trauma specialist who is located with the patient.
Telemedicine for TICU Rounds
Telemedicine is also being used in the Trauma Intensive Care Unit (TICU) at the Ryder Trauma Center to reduce the spread of infections. Typically, rounds at hospitals across the country are conducted with a team of 10 or so attendings, fellows, residents and other clinicians who move from bed to bed in a unit, discussing each patient. This is not only useful for the handoff of patients from the night shift to the morning shift, but also serves as an educational experience for new residents to the team. At the Ryder TeleTrauma Center, we are doing things differently. Rather than the TICU team physically moving from bed to bed, the team now conducts rounds from a conference room. By using a videoconferencing system developed by the UM/Lehman Center TeleTrauma Department, the trauma attending, residents, fellows, nurses, nurse practitioners, and pharmacists are able to watch a live video stream from the patient’s bedside, see the vital signs on the monitor, view the settings on the respiratory ventilator, and see any wounds the patient has. This capability also allows the remote viewers to ask the clinician at the bedside (e.g., the nurse) to do a clinical examination which they can also witness. Using this cart only requires that one additional person be at the bedside—the cart’s operator—rather than a team of 10.
Fig 4. A clinician at the UM/Ryder Trauma Center tests the ability to communicate with clinicians at the bedside and view patient information using the TICU rounds cart.
Fig 5. The TICU rounds cart developed at the Ryder Trauma Center.
Teletrauma Network in the State of Florida
Recent national and international disasters such as attacks on the World Trade Center in 2001, Hurricane Katrina in 2005, and the 2008 typhoon in Myanmar, have shed light on the importance of coordinated response efforts, and how a lack of coordination and resources can have devastating consequences. Natural (e.g., hurricanes, earthquakes) and man-made (e.g., physical, chemical or biological acts) disaster response presents unique barriers and limitations on relief efforts due to the fact that there may be interruptions to commonly used land-based communications (e.g., internet, land-line and cellular telephones), insufficient transportation means (e.g., airport closures, road blockage), an increase in surge capacity (i.e., those needing medical attention), health threats to relief workers (e.g., secondary exposure to a biological or chemical agent), and many others.
The Lehman Center and the UM/Ryder Trauma Center has received funding from the Florida Department of Health to develop a teletrauma network in the State of Florida. This network will link two trauma centers and two regional hospitals within the state (initially). This small scale effort will be used to demonstrate a proof of concept, with the hopes of expanding to additional trauma centers and regional hospitals in the near future. This network will promote the synergy and exchange of knowledge between the participating hospitals. In addition, the creation of such a network using satellite technology would improve the ability of the trauma center to manage surges and disasters through real-time medical assistance, education and training, something that the state currently does not have. The feasibility and effectiveness of the teletrauma network will be tested.
Telemedicine for Trauma Education
One of the most important issues facing military medicine today is how to train military medical personnel in peace for the realities of war. Few military physicians, nurses and medics have the opportunity to train in combat scenarios which has led to what some have termed a “training gap” for military medical education. The Lehman Center and the UM/Ryder Trauma Center is trying to close this gap by delivering trauma education to US military hospitals across the world. Known as the Telemedicine Education and Advice for Military Medicine (TEAMM) project, the research team has developed the educational content for a grand rounds lecture series for clinicians. Each lecture provides fundamental principles, firsthand knowledge and evidenced-based methods for critical analysis of established clinical practice standards and comparisons to newer advanced alternatives. For each of these lectures participants can receive Continuing Medical Education Credits (CMEs). The project is a pilot that will last for one year. We hope to expand this project to theater in the near future. In a similar project, Ryder Trauma Center has an agreement with two medical schools in Sao Paulo, Brazil. As a part of this agreement, grand rounds in trauma are conducted jointly each month using video-conferencing capabilities.
Telemedicine in the Operating Room
Timely assessment and treatment of trauma patients are major goals of trauma and critical care. Delays in both patient assessment and physician response can result in lost opportunities to improve patient outcome and can result in increased morbidity and length of stay. In trauma surgery, teams of physicians and other clinicians frequently rely on a flow of information using a multitude of communication modes. Oftentimes the busyness of the trauma center or nature of patients’ injuries requires consultation or communication with a specialist who may not be present at the time. It is at these crucial times that telemedicine may be an appropriate solution.
The Lehman Center and UM/Ryder Trauma Center has developed a mobile telemedicine/tele-education system for use in the operating room. This system uses a high definition camera attached to a retractable arm (which will extend over the operating table) to transmit audio and video capabilities of a surgical procedure to a remote location. Trauma surgeons will thus be able to observe and consult on cases from this remote location. This capability will also allow the attending to review the residents in action and offer teaching, guidance, and support. The remote surgeon will have the capability to control the camera (pan, tilt and zoom) to get the best angle of the procedure while at the same time providing expertise in order to provide the best possible care to the patient. This capability will also allow trauma physicians, fellows, residents, and other staff will be able to view cases from this remote location for educational purposes. Finally, surgical procedures can be recorded using the high definition camera, offering high quality videos which would be made available for educational purposes at a later time. As a part of this research, we are conducting usability and clinical effectiveness tests to understand the system’s functions, capabilities and limitations before implementing it as standard operating procedure.
William Lehman Injury Research Center TeleTrauma Team
Antonio Marttos, M.D. – Director, TeleTrauma (amarttos@med.miami.edu)
Jill Graygo, M.A., M.P.H. – Research Manager (jgraygo@med.miami.edu)
Gabriel Alonso – Telemedicine Network Engineer (galonso@med.miami.edu)
Elana Perdeck – Executive Director, Lehman Center (eperdeck@med.miami.edu)
TeleTrauma Publications/Presentations
Journal articles:
Schulman, C. I., Eisdorfer, S., Graygo, J., & Marttos, A. (in preparation). Cutting costs with telemedicine: Application of potential cost-saving measures at a major metropolitan trauma center. For submission to Telemedicine and e-Health.
Conference presentations:
Eisdorfer, S., Graygo, J., Marttos, A., & Schulman, C. I. (2008). Cutting costs with telemedicine: Application of potential cost-saving measures at a major metropolitan trauma center. Paper presented at the 13th Annual International Meeting & Exposition of the American Telemedicine Association.
Marttos, A., Robinson, D. W., Wilson, K. A., Schulman, C., Alonso, G., Krauthamer, S., Atwood, R., Lynn, M., McKenney, M., & Augenstein, J. S. (2008, September). Use of telemedicine for mass casualty triage. Poster to be presented at the 2008 Annual Meeting of the American Association for the Surgery of Trauma, Maui, Hawaii.
Invited presentations
2nd Annual Remote Presence Clinical Innovations Forum – InTouch Health. Santa Barbara, CA, July 19-21, 2007
American Telemedicine Association - Half-day course: Telehealth Business & Strategic Planning Interactive Workshop. Nashville, TN, May 13-15, 2007.
American Telemedicine Association – Half-day course:Telemedicine for Trauma, Emergency Medical Services and Disaster Management. Nashville, TN, May 13-15, 2007.