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

"Can differences in hospitalised mild traumatic brain injury (mTBI) outcomes at 12 months be predicted?"

OBJECTIVES

To identify risk factors for poor outcome one year post-mild traumatic brain injury (mTBI).

DESIGN

This study was a prospective observational study using consecutive adult hospital admissions with mTBI.

SUBJECTS

A total of 869 consecutive mTBI patients were enrolled in this study.

METHODS

All patients were reviewed by the specialist TBI rehabilitation team at six weeks and one year following mTBI. Demographic and injury data collected included: age, gender, TBI severity and Glasgow Coma Scale (GCS). At twelve months, global outcome was assessed by the Extended Glasgow Outcome Score (GOSE) and participation restriction by the Rivermead Head Injury Follow-up Questionnaire (RHFUQ) via semi-structured interview. An ordinal regression (OR) was used to identify associated factors for poor GOSE outcome and a linear regression for a poor RHFUQ outcome.

RESULTS

In the GOSE analysis, lower GCS (p < 0.001), medical comorbidity (p = 0.027), depression (p < 0.001) and male gender (p = 0.008) were identified as risk factors for poor outcome. The RHFUQ analysis identified: lower GCS (p = 0.002), female gender (p = 0.001) and injuries from assault (p = 0.003) were variables associated with worse social functioning at one year.

CONCLUSION

mTBI is associated with a significant impact upon the physical health and psychosocial function of affected individuals. The results of this study demonstrate that differences in mTBI outcome can be identified at twelve months post-mTBI and that certain features, particularly GCS, are associated with poorer outcomes.

Pioneering Remotely Piloted Aerial Systems (Drone) Delivery of a Remotely Telementored Ultrasound Capability for Self Diagnosis and Assessment of Vulnerable Populations-the Sky Is the Limit

Remotely Piloted Aerial Systems (RPAS) are poised to revolutionize healthcare in out-of-hospital settings, either from necessity or practicality, especially for remote locations. RPAS have been successfully used for surveillance, search and rescue, delivery, and equipping drones with telemedical capabilities being considered. However, we know of no previous consideration of RPAS-delivered tele-ultrasound capabilities. Of all imaging technologies, ultrasound is the most portable and capable of providing real-time point-of-care information regarding anatomy, physiology, and procedural guidance. Moreover, remotely guided ultrasound including self-performed has been a backbone of medical care on the International Space Station since construction. The TeleMentored Ultrasound Supported Medical Interventions Group of the University of Calgary partnered with the Southern Alberta Institute of Technology to demonstrate RPAS delivery of a smartphone-supported tele-ultrasound system by the SwissDrones SDO50 RPAS. Upon receipt of the sanitized probe, a completely ultrasound-naïve volunteer was guided by a remote expert located 100 km away using online video conferencing (Zoom), to conduct a self-performed lung ultrasound examination. It proved feasible for the volunteer to examine their anterior chest, sides, and lower back bilaterally, correlating with standard recommended examinations in trauma/critical care, including the critical locations of a detailed COVID-19 lung diagnosis/surveillance examination. We contend that drone-delivered telemedicine including a tele-ultrasound capability could be leveraged to enhance point-of-care diagnostic accuracy in catastrophic emergencies, and allow diagnostic capabilities to be delivered to vulnerable populations in remote locations for whom transport is impractical or undesirable, speeding response times, or obviating the risk of disease transmission depending on the circumstances.

Strategies to improve communication in telementoring in acute care coordination: a scoping review

Background

Telementoring facilitates the coordination of advanced medical care in rural, remote or austere environments. Because the interpersonal element of telementoring has been relatively underexplored, we conducted a scoping review to identify strategies to improve communication in telementoring.

Methods

Two independent reviewers searched all English-language articles in MEDLINE and Scopus from 1964 to 2017, as well as reference lists of relevant articles to identify articles addressing telementored interactions between health care providers. Search results were gathered in June 2017 and updated in January 2018. Identified articles were categorized by theme.

Results

We identified 144 articles, of which 56 met our inclusion criteria. Forty-one articles focused on improving dispatcher-directed cardiopulmonary resuscitation (CPR). Major themes included the importance of language in identifying out-of-hospital cardiac arrest and how to provide instructions to enable administration of effective CPR. A standardized approach with scripted questions was associated with improved detection of out-of-hospital cardiac arrest, and a concise script was associated with improved CPR quality compared to no mentoring, unscripted mentoring or more complex instructions. Six articles focused on physician-physician consultation. Use of a handover tool that highlighted critical information outperformed an unstructured approach regarding transmission of vital information. Nine articles examined telementoring in trauma resuscitation. A common theme was the need to establish an understanding between mentor and provider regarding the limitations of the provider and his or her environment.

Conclusion

The available data suggest that standardization coupled with short, concise validated scripts could improve efficacy, safety and engagement. Improvements will require multidisciplinary input, practice and deliberate efforts to address barriers.

A Randomized Trial of Mentored vs Nonmentored Military Medics Compared in the Application of a Wound Clamp Without Prior Training: When to Shut Up and Just Watch!

INTRODUCTION

Hemorrhage control is a basic task required of first responders and typically requires technical interventions during stressful circumstances. Remote telementoring (RTM) utilizes information technology to guide inexperienced providers, but when this is useful remains undefined.

METHODS

Military medics were randomized to mentoring or not from an experienced subject matter expert during the application of a wound clamp (WC) to a simulated bleed. Inexperienced, nonmentored medics were given a 30-second safety briefing; mentored medics were not. Objective outcomes were time to task completion and success in arresting simulated bleeding.

RESULTS

Thirty-three medics participated (16 mentored and 17 nonmentored). All (100%) successfully applies the WC to arrest the simulated hemorrhage. RTM significantly slowed hemorrhage control (P = 0.000) between the mentored (40.4 ± 12.0 seconds) and nonmentored (15.2 ± 10.3 seconds) groups. On posttask questionnaire, all medics subjectively rated the difficulty of the wound clamping as 1.7/10 (10 being extremely hard). Discussion: WC application appeared to be an easily acquired technique that was effective in controlling simulated extremity exsanguination, such that RTM while feasible did not improve outcomes. Limitations were the lack of true stress and using simulation for the task. Future research should focus on determining when RTM is useful and when it is not required.

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.

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.

Transoceanic Telementoring of Tube Thoracostomy Insertion: A Randomized Controlled Trial of Telementored Versus Unmentored Insertion of Tube Thoracostomy by Military Medical Technicians

Background: Tension pneumothorax is a frequent cause of potentially preventable death. Tube thoracostomy (TT) can obviate death but is invasive and fraught with complications even in experienced hands. We assessed the utility of a remote international virtual network (RIVN) of specialized mentors to remotely guide military medical technicians (medics) using wireless informatics. Methods: Medics were randomized to insert TT in training mannequins (TraumaMan; Abacus ALS, Meadowbrook, Australia) supervised by RIVN or not. The RIVN consisted of trauma surgeons in Canada and Australia and a senior medic in Ohio. Medics wore a helmet-mounted wireless camera with laser pointer to confirm anatomy and two-way voice communication using commercial software (Skype^®). Performance was measured through objective task completion (pass/fail) regarding safety during the procedure, proper location, and secure anchoring of the tube, in addition to remote mentor opinion and subjective debrief. Results: Fourteen medics attempted TT, seven mentored and seven not. The RIVN was functional and surgeons on either side of the globe had real-time communication with the mentees. TT placement was considered safe, successful, and secure in 100% of mentored (n = 7) procedures, although two (29%) received corrective remote guidance. All (100%) of the unmentored attempted and adequately secured the TT and were safe. However, only 71% (n = 5) completed the task successfully (p = 0.46). Participating medics subjectively felt remote telementoring (RTM) increased self-confidence (strong agreement mean 5/5 ± 0); confidence to perform field TT (agreement (4/5 ± 1); and decreased anxiety (strong agreement 5/5 ± 1). Subjectively, the remote mentors felt in 100% of the mentored procedures that "yes" they were able to assist the medics (1.86 ± 0.38), and in 71% (n = 5) felt "yes" they made TT safer (2.29 ± 0.49). Conclusions: RTM descriptively increased the success of TT placement and allowed for real-time troubleshooting from thousands of kilometers with a redundant capability. RTM was subjectively associated with high levels of satisfaction and self-reported self-confidence. Continued controlled and critical evaluation and refinement of telemedical techniques should continue. Trial Registration: ID ISRCTN/77929274.

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.

The need for a robust 24/7 subspecialty "clearing house" response for telementored trauma care

Traumatic injury is increasing in importance in all settings and environments worldwide. Many preventable deaths are from conditions that are common and treatable. However, as potentially lethal injuries often induce progressive and frequently irreversible physiologic decline, the timing of interventions is critical. Invasive treatments may need to be offered by prehospital care providers who lack extensive training and practice. Telementoring allows experienced experts to guide less experienced providers remotely using information technology (IT). Early experience has shown that these techniques are practical and considered valuable. Their translation to regular practice, however, will require the immediate availability of appropriately trained remote experts willing to serve as mentors. Acute care trauma specialists are acclimatized to responding to out-of-hospital consultations and assuming overall responsibility for critical physiology and transport and may serve as the backbone of such a national/ international call response initiative.

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.