Telemedicine and Trauma Care.

ABSTRACT: Advances in technology have made it possible for telemedicine to be used in multiple areas of medicine, including trauma care. Teleradiology and teleconsultation are becoming standard operating procedure for many rural facilities. Future uses of telemedicine include teleproctoring and telepresence surgery. The medicolegal and financial impact of telemedicine remains to be determined. The potential influence of telemedicine in the care of future trauma patients will likely be important and may alter patterns of referral, consultation, and treatment.

ADVANCES IN RADIO COMMUNICATION, electronics, and computer technology have greatly improved care of the trauma patient over the past several decades. In fact, it is unusual for prehospital providers not to communicate with medical personnel at the hospital base station long before a trauma or emergency patient arrives in the resuscitation suite. Such prehospital reports are usually the basis for activating the trauma team and making preparations for the care of the patient, not only in the emergency department, but also in the radiology department, the operating room, and the intensive care unit. Unfortunately, in remote locations, the usual modes of communication, such as very high frequency radio and cellular telephone, may be ineffective or unavailable. Satellite-based telephony, which is now available from companies such as Iridium (Tempe, Ariz) and Globaistar (San Jose, Calif), or satellite-based radio communication, such as the Inmarsat system (London, England), are potential solutions to this common pr oblem. [1-3] Additionally, recent proposals to use these same low-earth-orbit satellites for 64-kilobyte (kb) Internet access could facilitate data and telemetry transmission for patients in rural hospitals or faraway locations. [4] These readily available, "off the shelf" solutions to the communications dilemmas of rural or isolated health care providers may be the most cost-effective method of correcting the deficiencies of the current system.

UTILIZATION OF TELECONFERENCING

The use of teleconferencing and teleconsultation already plays an important role in providing educational programs and real-time medical consultation. Presently, one third of rural hospitals in the United States have at least limited capability to link with at least one tertiary care facility. An excellent example of the utility of remote teleconsultation is the system presently supported by St. Francis Hospital of Tulsa. [5] In addition to providing teleradiology services, emergency medicine practitioners at this tertiary care facility are immediately available for consultation with physicians, nurse practitioners, and physicians' assistants at small rural hospitals. Early experience with this system has documented many areas of improved patient care, including early triage of seriously ill patients, a decreased rate of transfer of patients who did not require treatment at a tertiary care facility, and more effective utilization of ground and air ambulance services. A similar experience has been reported fr om several rural treatment facilities in the United Kingdom. [6,7]

Multisite teleconferencing for the purpose of providing education to a variety of medical professionals has become routine. It is unusual for the practicing physician not to receive monthly invitations to attend such teleconferences. To date, most of these conferences have been sponsored by pharmaceutical companies or instrument manufacturers and contain a significant marketing component. However, these industry-sponsored sessions have shown the potential for high-quality education programs via available satellite communications systems.

TYPES OF AVAILABLE SYSTEMS

Most of the available telemedicine systems are distinctly "low tech" and slow. At present, most teleconferencing is dependent on communication via a conventional phone line, a T-1 line (a 24-channel, high-capacity circuit for data, voice, and video transmission), or in rare cases an OC3 fiberoptic cable connection (a 243-channel, high-capacity fiberoptic circuit for data, voice, and video transmission). Unfortunately, the T-1 communications link is inadequate for high-resolution, real-time clinical interactions. A conventional telephone line and modem provide data transmission at a maximum rate of 64 kb/sec. A T-1 line will provide maximum data transmission rates of from 1.5 to 2.0 megabytes (Mb) per second, and a fiberoptic OC3 line is capable of supporting rates of up to 155 Mb/sec under optimal circumstances. Unfortunately, these rates of data transmission are seldom achieved in routine daily use. A good example of the problems inherent with current telemedicine systems is the interpretation of clinical r adiographic films. Using a currently available teleradiology system and a T-1 line takes approximately 11 minutes to transmit a digital mammogram, which contains only 128 Mb of data. Transmission of a more complex imaging study, such as magnetic resonance imaging (MRI) that contains as much as 1 gigabyte of data, will require 1 1/2 hours! These time requirements are clearly unacceptable for most clinical activities, particularly in an emergency or trauma setting. In contrast, the same digital mammogram and MRI data would require only 6.4 seconds and 52 seconds, respectively, using an OC3 line. Transmission of the same data sets over an OC48 line would require only 0.4 seconds and 3.3 seconds, respectively. High-speed land lines, such as OC3 fiberoptic cables, are not widely available at this time. Current availability is limited primarily to large urban areas. Unfortunately, patients receiving care in rural hospitals who could benefit most from teleconferencing are not likely to be eligible for these services due to lack of fiberoptic infrastructure.

Satellite-based telemedicine could rapidly fill the gap now present in the area of high-speed data transmission. The Advanced Communications Technology Satellite (ACTS), which is capable of a 622-Mb/sec transmission rate, was recently used in an experiment that linked physicians at Phoenix Children's Hospital in Phoenix, Ariz, with consultants at the Mayo Clinic in Rochester, Minn. [8] Using ACTS and high-speed fiberoptic land lines, essentially real-time consultative evaluations of 38 patients with congenital heart disease, including review of cineangiograms, were done. These long-distance consultations were believed to be equivalent to in-person, "hands on" consultations. A similar experiment sponsored by the National Aeronautics and Space Administration's Ames Research Center in May 1999 provided a "virtual clinic" that linked several remote or rural hospitals, such as the Northern Navaho Medical Center (Indian Health Service) in Shiprock, NM, with clinical consultants at medical universities, such as Sta nford. This computer-based program used a combination of high-speed fiberoptic land lines and a communications satellite to provide real-time participation of physicians at multiple hospitals who performed activities such as radiographic diagnosis, interpretation of 3-dimensional images, and practice of virtual operations.

DEVELOPING TECHNOLOGY

As technology continues to improve, substantial efforts have been directed toward development of telepresence as an adjunct to having physicians on site, or in some instances, as replacement for on-site physician expertise. Telepresence may be described as the ability to perform a "virtual examination or intervention" for a patient over a distance, made possible by telecommunication technology. While the potential for telepresence to improve patient care is obvious, caution must be exercised, since this concept remains in its developmental infancy. To date, the greatest obstacle to routine use of telemedicine and, particularly, telepresence interventions such as operations has been the lack of cost-effective, dependable, broad-bandwidth communication and data links as discussed earlier. Wider availability of high-speed fiberoptic land lines and satellite up-link and down-link services will greatly facilitate further development of telemedicine and telepresence interaction.

APPLICATION TO TRAUMA MANAGEMENT

An area of telemedicine that has already proved moderately successful with present technology is that of trauma management for patients in remote or inaccessible rural medical facilities. Armstrong and Haston [6] recently reported on their initial experience with a telemedicine system that linked a small rural facility in Peterhead, Scodand, with the emergency department of the Aberdeen Royal Infirmary by way of an integrated services digital network land line capable of 128 kb/sec and a satellite link capable of a data transmission rate of 64 kb/sec. In a 1-year period, teleconsultations were done for 120 patients enrolled in the telemedicine program. Teleradiology was used in 116 consultations, videoconferencing was used in 76 cases, and telepresence was used for 4 patients. In this study, both the emergency medicine consultants in the tertiary care facility and the rural practitioners believed that the use of telemedicine improved care. Use of this rudimentary low-tech telemedicine system obviated the need for transfer of 70 patients and produced estimated savings of [pound]65,000 per year. A similar experience was reported by Tachakra et al, [7] who discussed some of the technical problems associated with the use of early telemedicine systems, such as poor resolution of video images, poor audio quality, poorly designed telepresence examination rooms, and concerns for patient privacy and confidentiality. Broad-bandwidth communication links by satellite would do much to improve the utility of these early systems.

EARLY RESULTS

The initial use of telemedicine systems in the United States and in the United Kingdom has provided valuable expertise from urban trauma centers to rural facilities that only occasionally care for critically ill or injured patients. Unfortunately, initial experiences with these endeavors have pointed out many technologic problems associated with telemedicine, including a significant learning curve for use of video equipment. In many hospitals, telemedicine has been more successful when used for consultation in nonacute cases or for follow-up visits in remote areas. In these instances, patients have been spared the necessity of driving several hours for a routine follow-up appointment.

At this time, the greatest experience with telemedicine exists in the field of teleradiology. In many hospitals, it is now routine for a radiologist to interpret emergency radiographs at home via teleradiology links. While this certainly enhances the life-style of radiologists and, in some instances, speeds the process of film interpretation, caution must be exercised. In a recent series regarding subtle orthopedic injuries, statistically significant differences in accuracy, sensitivity, and specificity were observed when radiologists interpreted studies via teleradiology versus in-person. [9] Similar problems with the identification of subtle fractures utilizing previously available teleradiology systems were recently reported by Wilson and Hodge. [10] However, they reported excellent results when teleradiology was used for the assessment of joint dislocations.

Military medicine has been extremely interested in the potential of telemedicine because of the obvious logistic problems associated with fulfilling the medical mission of the armed services. [11,12] Extensive research has been conducted by the military in conjunction with industry for the development of practical telemedicine systems, including development of a personal status monitor for personnel located in combat areas. This wristwatch-sized device transmits vital signs to a central monitoring facility and could greatly enhance the ability of medical officers to carry out battlefield triage and initial treatment. Additionally, valuable medical personnel would not be sent on dangerous missions for the extrication of injured combatants who were known to have already died. Examples of currently successful use of telemedicine include telepresence consultations and Internet-based consultation and referral. A practical system of this nature has been established at Tripler Army Medical Center in Hawaii, in which that hospital is linked to several military medical facilities in the western Pacific. The US Navy has long used radio and satellite-based telemedicine links (in particular, teleradiology) to enhance the treatment of patients on board ships at sea, where medical expertise may be absent or limited.

Perhaps one of the best examples of telemedicine technology that is available for current patient care is the LSTAT (Life Support for Trauma and Transport). The LSTAT is the result of a joint effort of Northrop Grumman Corp (Los Angeles, Calif) and the various military medical services. The LSTAT is a self-contained, stretcher-type platform that is designed to aid in field stabilization and transport of severely injured patients. The LSTAT incorporates a number of on-board devices for ongoing treatment, which include monitors for basic vital signs and blood chemistry; mechanical ventilation and oxygen supplementation for patients requiring endotracheal intubation; a self-contained, battery-powered infusion pump to deliver intravenous fluids; and a self-contained, battery-powered suction pump. An automated external defibrillator is also built into each of the LSTAT units. All patient medical data that is monitored by the on-board devices of the LSTAT can be data-linked to the receiving medical facility while t he patient is being transported by air or ground ambulance. This system provides real-time respiratory and hemodynamic data to receiving physicians without the necessity for frequent radio communication by busy prehospital care providers. The LSTAT system is now being field tested by the military and will also be available for civilian use in the immediate future. [13]

Telepresence trauma surgery is the ultimate development in telemedicine. In fact, experimental studies have been done using a computer-based telemanipulator system for remote operations, including vascular anastomoses and trauma procedures. [14,15] In these series, surgeons used a telesurgery system for vascular reconstruction, organ excision, hemorrhage control, suturing, and knot tying in laboratory animals. Unfortunately, the time required for simple tasks was approximately three to four times greater than when a surgeon performed the techniques in person in the traditional manner. At this time, it appears that while the concept of telepresence surgery for trauma and emergencies is intriguing, technologic limitations, which include the lack of dependable broad-band-width communications links, preclude the widespread use of this technique in the immediate future.

However, in the more controlled realm of elective laparoscopic surgery, remote operations have already taken place. Satava and Green [16] first described a telepresence operating system for laparoscopic procedures in 1992. This system was later manufactured and has been used experimentally. In 1997, Himpens et al [17] in Belgium did the first telepresence laparoscopic cholecystectomy in a human patient. One year later, Carpentier et al [18] reported the use of a telepresence operating system for more than 150 operations on beating hearts. Schlag et al [19] in Berlin have used a telemedicine system that utilizes a satellite link and fiberoptic land lines with data transmission rates of 2 x 17 Mb/sec and 2 x 34 Mb/sec, respectively, to demonstrate stereoscopic telepresence operations between Paris and Berlin and between Chicago and Berlin, as well as to carry out realtime, high-resolution consultations.

PROBLEMS IN USING THIS TECHNOLOGY

One of the problems encountered in teleoperations over great distances is that of latency or delay factor. A surgeon using a telemedicine system that uses a satellite in geosynchronous orbit would observe a period of latency of 1.5 seconds before his tactile inputs would be carried out in his distant patient. Imagine the difficulty of coordinating the delicate movements of surgeons and their assistants if this magnitude of latency was present! Despite these remaining technical problems, the possibilities associated with telepresence operations are exciting.

As with any new technology, implementation of telemedicine techniques will create new problems at the same time it enhances patient care. Use of telemedicine techniques brings up several medicolegal issues and questions. For example, if a remote telemedicine consultation is done, who is actually the attending physician? Who would be subject to medicolegal litigation if it occurred? Another question regards state licensing for physicians providing telemedicine consultations across state or international borders. If a telemedicine consultation is provided for a patient in another state, must the consulting physician be licensed to practice medicine in both states?

CONCLUSION

Telemedicine will certainly enhance the care of the trauma patient in the future. However, many technical, logistical, and medicolegal problems must be addressed before this technology will reach its full potential and significantly affect the care of the trauma patient of the 21st century. Development of this technology creates questions that have previously existed only in science fiction. Greater access to satellite-based data transmission systems with ever-greater data transmission capabilities will be one of the primary components required for the fullest development of this treatment modality.

From the Department of Surgery, University of Kansas School of Medicine-Wichita; and Trauma Services, Via Christi Regional Medical Center-St. Francis Campus, Wichita, Kan.

Reprint requests to R. Stephen Smith, MD, University of Kansas School of Medicine-Wichita, Department of Surgery 929 N St. Francis, Wichita, KS 67214.

References

(1.) Taverna MA: European mergers boost common broadband satellite system plans. Aviation Week and Space Technology November 8, 1999, pp 94-95

(2.) Anselmo JC: Can broadband fix space industry woes? Aviation Week and Space Technology November 8, 1999, p 96

(3.) Anselmo JC: Precursors to broadband. Aviation Week and Space Technology November 8, 1999, p 96

(4.) Anselmo JC: ICO boosts McCaw's satellite empire plan. Aviation Week and Space Technology November 8,1999, p 53

(5.) Swartz D: The Saint Francis emergency room telemedicine system: marriage of technology and business models. Telemed Today 1997; 5:28-29

(6.) Armstrong IJ, Haston WS: Medical decision support for remote general practitioners using telemedicine. J Telemed Telecare 1997; 3:27-34

(7.) Tachakra, S, Sivakumar A, Everard R, et al: Remote trauma management--setting up a system. J Telemed Telecare 1996; 2(suppl 1):65-38

(8.) Julsrud PR, Breen JF, Jedeikin R, et al: Telemedicine consultations in congenital heart disease: assessment of advanced technical capabilities. Mayo Clin Proc 1999; 74:758-763

(9.) Scott WW, Rosenbaum JE, Ackerman SJ, et al: Subtle orthopedic fractures: teleradiology workstation versus film interpretation. Radiology 1993; 187:811-15

(10.) Wilson AJ, Hodege JC: Digitized radiographs in skeletal trauma: a performance comparison between a digital workstation and the original film images. Radiology 1995;196:565-568

(11.) Person DA: Telemedicine in cyberspace. Mil Med Technol 1998; 2:13-15

(12.) LeVec LN: Medics in Reserve. Mil Med Technol 198; 2:32-35

(13.) FDA clears LSTAT for marketing and military evaluation. Mil Med Technol 1998; 2:4

(14.) Bowersox JC, Shah A, Jensen J, et al: Vascular applications of telepresence surgery: initial feasibility studies in swine. J Vasc Surg 1996; 23:281-287

(15.) Bowersox JC, Cordts PR, LaPorta AJ: Use of an intuitive telemanipulator system for remote trauma surgery: an experimental study. J Am Coll Surg 1998; 186:615-621

(16.) Satava RM, Green PS: The next generation: telepresence surgery current status and implications for endoscopy. (Abstract) Gastrointest Endosc 1992;38:277

(17.) Himpens J, Leman G, Cadiere GB: Telesurgical laparo scopic cholecystectomy. (Letter) Surg Endosc 1998; 12:1091

(18.) Carpentier A, Loulmet. D, Aupecle B, et al: Computer-assisted cardiac surgery. (Letter) Lancet 1999; 353:379-380

(19.) Schlag P, Moesta KT, Rakovsky S, et al: Telemedicine: the new must for surgery. Arch Surg 1999; 134:1216-1221

KEY POINTS

* Recent advances in broad-band communication technologies have made real-time telemedicine consultations and interventions practical.

* Telemedicine modalities have the potential to reduce costs and reduce the requirement to transfer patients to tertiary care facilities.

* One area that will likely benefit from telemedicine increasingly in the future is trauma care.

* Currently, teleradiology and teleconsultation are being used, and teleproctoring and telepresence surgery will likely become feasible with further advances in technology.