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

Smarter faster just-in-time hemorrhage control: A pilot evaluation of remotely piloted aircraft system delivered STOP-THE-BLEED equipment with just-in-time remote telementored deployment

Introduction

Remotely Piloted Aircraft Systems (RPAS) can access patients inaccessible to traditional rescue. Just-in-time remote telementoring (RTM) of naïve users to self-care could potentially address challenges in salvaging exsanguination in remote environments.

Methods

An exsanguination self-application task was established in a wilderness location. Three volunteers-initiated distress calls to prompt RPAS precision delivered STOP-THE-BLEED kits, after which a remote mentor directed the volunteers how to self-care.

Results

Limited connectivity prevented video, however each volunteer delivered images and initiated conversation with the mentor pre-RPAS arrival. Thereafter, all subjects were able to unpack and deploy hemorrhage control adjuncts under verbal direction, and to simulate self-application. All subjects were able to successfully apply wound-clamps, tourniquets, and pack wounds although one had insufficient pressure.

Discussion

RPASs can deliver supplies long before human rescuers, and communication connectivity might allow remote mentoring in device application. Further development of technology and self-care paradigms for exsanguination are encouraged.

The use of drones for the delivery of diagnostic test kits and medical supplies to remote First Nations communities during Covid-19

BACKGROUND

Health care inequity in remote and rural Indigenous communities often involves difficulty accessing health care services and supplies. Remotely Piloted Aircraft Systems, or drones, offer a potentially cost-effective method for reducing inequity by removing geographic barriers, increasing timeliness, and improving accessibility of supplies, equipment, and remote care.

METHODS

We assessed the feasibility of drones for delivery of supplies, medical equipment, and medical treatment across multiple platforms, including drone fleet development and testing; payload system integration (custom fixed-mount, winch, and parachute); and medical delivery simulations (COVID-19 test kit delivery and return, delivery of personal protective equipment, and remote ultrasound delivery and testing).

RESULTS

Drone operational development has led to a finalized, scalable fleet of small to large drones with functional standard operating procedures across a range of scenarios, and custom payload systems including a fixed-mount, winch-based and parachute-based system. Simulation scenarios were successful, with COVID-19 test swabs returned to the lab with no signal degradation and a remote ultrasound successfully delivered and remotely guided in the field.

DISCUSSION/CONCLUSIONS

Drone-based medical delivery models offer an innovative approach to addressing longstanding issues of health care access and equity and are particularly relevant in the context of SARS-CoV-2.

To Watch Before or Listen While Doing? A Randomized Pilot of Video-Modelling versus Telementored Tube Thoracostomy

BACKGROUND

New care paradigms are required to enable remote life-saving interventions (RLSIs) in extreme environments such as disaster settings. Informatics may assist through just-in-time expert remote-telementoring (RTM) or video-modelling (VM). Currently, RTM relies on real-time communication that may not be reliable in some locations, especially if communications fail. Neither technique has been extensively developed however, and both may be required to be performed by inexperienced providers to save lives. A pilot comparison was thus conducted.

METHODS

Procedure-naïve Search-and-Rescue Technicians (SAR-Techs) performed a tube-thoracostomy (TT) on a surgical simulator, randomly allocated to RTM or VM. The VM group watched a pre-prepared video illustrating TT immediately prior, while the RTM group were remotely guided by an expert in real-time. Standard outcomes included success, safety, and tube-security for the TT procedure.

RESULTS

There were no differences in experience between the groups. Of the 13 SAR-Techs randomized to VM, 12/13 (92%) placed the TT successfully, safely, and secured it properly, while 100% (11/11) of the TT placed by the RTM group were successful, safe, and secure. Statistically, there was no difference (P = 1.000) between RTM or VM in safety, success, or tube security. However, with VM, one subject cut himself, one did not puncture the pleura, and one had barely adequate placement. There were no such issues in the mentored group. Total time was significantly faster using RTM (P = .02). However, if time-to-watch was discounted, VM was quicker (P = .000).

CONCLUSIONS

Random evaluation revealed both paradigms have attributes. If VM can be utilized during "travel-time," it is quicker but without facilitating "trouble shooting." On the other hand, RTM had no errors in TT placement and facilitated guidance and remediation by the mentor, presumably avoiding failure, increasing safety, and potentially providing psychological support. Ultimately, both techniques appear to have merit and may be complementary, justifying continued research into the human-factors of performing RLSIs in extreme environments that are likely needed in natural and man-made disasters.

Procedural Telementoring in Rural, Underdeveloped, and Austere Settings: Origins, Present Challenges, and Future Perspectives

Telemedicine is perhaps the most rapidly growing area in health care. Approximately 15 million Americans receive medical assistance remotely every year. Yet rural communities face significant challenges in securing subspecialist care. In the United States, 25% of the population resides in rural areas, where less than 15% of physicians work. Current surgery residency programs do not adequately prepare surgeons for rural practice. Telementoring, wherein a remote expert guides a less experienced caregiver, has been proposed to address this challenge. Nonetheless, existing mentoring technologies are not widely available to rural communities, due to a lack of infrastructure and mentor availability. For this reason, some clinicians prefer simpler and more reliable technologies. This article presents past and current telementoring systems, with a focus on rural settings, and proposes aset of requirements for such systems. We conclude with a perspective on the future of telementoring systems and the integration of artificial intelligence within those systems.

The Potential for Remotely Mentored Patient-Performed Home Self-Monitoring for New Onset Alveolar-Interstitial Lung Disease

Purpose: Coronavirus disease 2019 (COVID-19) caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and is an acute respiratory illness. Although most infected persons are asymptomatic or have only mild symptoms, some patients progress to devastating disease; such progression is difficult to predict or identify in a timely manner. COVID-19 patients who do not require hospitalization can self-isolate at home. Calls from one disease epicenter identify the need for homebased isolation with telemedicine surveillance to monitor for impending deterioration. Methodology: Although the dominant approach for these asymptomatic/paucisymptomatic patients is to monitor oxygen saturation, we suggest additionally considering the potential merits and utility of home-based imaging. Chest computed tomography is clearly impractical, but ultrasound has shown comparable sensitivity for lung involvement, with major advantages of short and simple procedures, low cost, and excellent repeatability. Thoracic ultrasound may thus allow remotely identifying the development of pneumonitis at an early stage of illness and potentially averting the risk of insidious deterioration to severe pneumonia and critical illness while in home isolation. Conclusions: Lung sonography can be easily performed by motivated nonmedical caregivers when directed and supervised in real time by experts. Remote mentors could thus efficiently monitor, counsel, and triage multiple home-based patients from their "control center." Authors believe that this approach deserves further attention and study to reduce delays and failures in timely hospitalization of home-isolated patients.