Technical innovations that may facilitate real-time telementoring of damage control surgery in austere environments: a proof of concept comparative evaluation of the importance of surgical experience, telepresence, gravity and mentoring in the conduct of damage control laparotomies

Developing a Comparative Effective Methodology for Technology Usability During a Simulated Casualty Event

INTRODUCTION

Future combat environments will be complex, making effective care for multi-domain battlefield injuries more challenging. Technology and resources are essential to reduce provider burden enabling more accurate assessments, decision-making support, expanded treatment, and outcome improvements. Experimentation exercises to evaluate concepts and technologies to incorporate into the Army's future force ensure rapid and continuous integration across air, land, sea, space, and cyberspace domains to overmatch adversaries. A medical lane was first integrated on the communications networks for experimentation in 2022. We describe a project to develop a method for empirically comparing devices intended to support combat casualty care through high-fidelity simulation in preparation for an Army experimentation exercise.

METHODS

Six medics participated in a series of high-fidelity simulation medical casualty injury scenarios with and without technology devices. The participants provided usability information about their care delivery experiences using the System Usability Scale and Adapted Telehealth Usability Questionnaire-Telemedicine and Advanced Technology Research Command and qualitative feedback.

RESULTS

A comparative effectiveness design compared the devices regarding their usability, size, weight, and power with the addition of cost, connectivity, and cyber security, and the qualitative feedback this methodology holistically assessed the technologies as they were applied in the combat casualty care scenario.

CONCLUSIONS

Results were used by decision makers to determine technology inclusion in experimentation exercise, develop proof of concept methodology to scale for the exercise, and provide technology developers feedback for iterative updates of their devices before participation in experimentation exercise. This project supports the body of simulation studies conducted to understand combat casualty care. It is one of few empirical medical technology assessments with medical personnel end user input that has been reported. The methodology incorporates a user-centered design for rapid technology improvements before fielding.

Remote Training for Medical Staff in Low-Resource Environments Using Augmented Reality

This work aims to leverage medical augmented reality (AR) technology to counter the shortage of medical experts in low-resource environments. We present a complete and cross-platform proof-of-concept AR system that enables remote users to teach and train medical procedures without expensive medical equipment or external sensors. By seeing the 3D viewpoint and head movements of the teacher, the student can follow the teacher's actions on the real patient. Alternatively, it is possible to stream the 3D view of the patient from the student to the teacher, allowing the teacher to guide the student during the remote session. A pilot study of our system shows that it is easy to transfer detailed instructions through this remote teaching system and that the interface is easily accessible and intuitive for users. We provide a performant pipeline that synchronizes, compresses, and streams sensor data through parallel efficiency.

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.

Prolonged, High-Fidelity Simulation for Study of Patient Care in Resource-Limited Medical Contexts and for Technology Comparative Effectiveness Testing

Most high-fidelity medical simulation is of limited duration, used for education and training, and rarely intended to study medical technology. U.S. caregivers working in prehospital, resource-limited settings may need to manage patients for extended periods (hours to days). This "prolonged casualty care" occurs during military, wilderness, humanitarian, disaster, and space medicine. We sought to develop a standardized simulation model that accurately reflects prolonged casualty care in order to study caregiver decision-making and performance, training requirements, and technology use in prolonged casualty care.

DESIGN

Model development.

SETTING

High-fidelity simulation laboratory.

SUBJECTS

None.

INTERVENTIONS

We interviewed subject matter experts to identify relevant prolonged casualty care medical challenges and selected two casualty types to further develop our model: a large thermal burn model and a severe hypoxia model. We met with a multidisciplinary group of experts in prolonged casualty care, nursing, and critical care to describe how these problems could evolve over time and how to contextualize the problems with a background story and clinical environment with expected resource availability. Following initial scenario drafting, we tested the models with expert clinicians. After multiple tests, we selected the hypoxia model for refinement and testing with inexperienced providers. We tested and refined this model until two research teams could proctor the scenario consistently despite subject performance variability.

MEASUREMENTS AND MAIN RESULTS

We developed a 6-8-hour simulation model that represented a 14-hour scenario. This model of pneumonia evolved from presentation to severe hypoxia necessitating advanced interventions including airway, breathing, and shock management. The model included: context description, caregiver orientation scripts, hourly progressive physiology tracks corresponding to caregiver interventions, intervention/procedure-specific physiology tracks, intervention checklists, equipment lists, prestudy checklists, photographs of setups, procedure, telementor, and role player scripts, business rules, and data collection methods.

CONCLUSIONS

This is the first standardized, high-fidelity simulation model of prolonged casualty care described in the literature. It may be used to assess caregiver performance and patient outcomes resulting from that performance during a complex, 14-hour prolonged casualty care scenario. Because it is standardized, the model may be used to compare differences in the impact of new technologies upon caregiver performance and simulated patient outcomes..

Telemedicine for Patient Management on Expeditions in Remote and Austere Environments: A Systematic Review

Telemedicine potentially offers enormous value to expeditions to remote environments. For healthcare professionals, telemedicine can provide access to specialist advice. Where no healthcare professionals are present, telemedicine may be the sole source of expert care. This systematic review appraises and summarizes the current literature regarding telemedicine in patient management on expeditions to remote locations and identifies areas for future research. MEDLINE and EMBASE were systematically searched for relevant articles from 1980 through February 2018. Data were handled according to the PRISMA process and analyzed using type-specific critical appraisal checklists where possible. Two hundred twenty-five articles were identified, 33 of which were included in this systematic review. They encompassed a variety of remote environments, including maritime (13), polar (9), mountainous (5), jungle (1), and multiple austere environments (6). Although some environments were better reported than others, many overarching concepts were generalizable. Through channels of communication that included telephone, radio, videoconferencing, and email, telemedicine has been used effectively in a range of environments to initiate treatment, follow up with patients, and determine the appropriateness of evacuation. Telementoring, in which a remote expert guides a local care provider in performing a procedure or task, is a promising aspect of telemedicine that is currently being developed. As technology advances, the scope of telemedicine will continue to expand. However, each new telemedical development must be shown to do more than simply function in a remote environment. Instead, new technologies should be tested for improved patient, practitioner, or expedition outcomes, within a telemedical system.

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.

Resuscitation and Evacuation from Low Earth Orbit: A Systematic Review

INTRODUCTION

Provision of critical care and resuscitation was not practical during early missions into space. Given likely advancements in commercial spaceflight and increased human presence in low Earth orbit (LEO) in the coming decades, development of these capabilities should be considered as the likelihood of emergent medical evacuation increases.

METHODS

PubMed, Web of Science, Google Scholar, National Aeronautics and Space Administration (NASA) Technical Server, and Defense Technical Information Center were searched from inception to December 2018. Articles specifically addressing critical care and resuscitation during emergency medical evacuation from LEO were selected. Evidence was graded using Oxford Centre for Evidence-Based Medicine guidelines.

RESULTS

The search resulted in 109 articles included in the review with a total of 2,177 subjects. There were two Level I systematic reviews, 33 Level II prospective studies with 647 subjects, seven Level III retrospective studies with 1,455 subjects, and two Level IV case series with four subjects. There were two Level V case reports and 63 pertinent review articles.

DISCUSSION

The development of a medical evacuation capability is an important consideration for future missions. This review revealed potential hurdles in the design of a dedicated LEO evacuation spacecraft. The ability to provide critical care and resuscitation during transport is likely to be limited by mass, volume, cost, and re-entry forces. Stabilization and treatment of the patient should be performed prior to departure, if possible, and emphasis should be on a rapid and safe return to Earth for definitive care.

Rubrum Coelis: The Contribution of Real-Time Telementoring in Acute Trauma Scenarios-A Randomized Controlled Trial

Background: Most deaths in military trauma occur soon after wounding, and demand immediate on scene interventions. Although hemorrhage predominates as the cause of potentially preventable death, airway obstruction and tension pneumothorax are also frequent. First responders caring for casualties in operational settings often have limited clinical experience. Introduction: We hypothesized that communications technologies allowing for real-time communications with a senior medically experienced provider might assist in the efficacy of first responding to catastrophic trauma. Methods: Thirty-three basic life saving (BLS) medics were randomized into two groups: either receiving telementoring support (TMS, n = 17) or no telementoring support (NTMS, n = 16) during the diagnosis and resuscitation of a simulated critical battlefield casualty. In addition to basic life support, all medics were required to perform a procedure needle thoracentesis (not performed by BLS medics in Israel) for the first time. TMS was performed by physicians through an internet link. Performance was assessed during the simulation and later on review of videos. Results: The TMS group was significantly more successful in diagnosing (82.35% vs. 56.25%, p = 0.003) and treating pneumothorax (52.94% vs. 37.5%, p = 0.035). However, needle thoracentesis time was slightly longer for the TMS group versus the NTMS group (1:24 ± 1:00 vs. 0:49 ± 0:21 minu, respectively (p = 0.016). Complete treatment time was 12:56 ± 2:58 min for the TMS group, versus 9:33 ± 3:17 min for the NTMS group (p = 0.003). Conclusions: Remote telementoring of basic life support performed by military medics significantly improved the medics' ability to perform an unfamiliar lifesaving procedure at the cost of prolonging time needed to provide care. Future studies must refine the indications and contraindications for using telemedical support.

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.

Damage control surgery in weightlessness: A comparative study of simulated torso hemorrhage control comparing terrestrial and weightless conditions

BACKGROUND

Torso bleeding remains the most preventable cause of post-traumatic death worldwide. Remote damage control resuscitation (RDCR) endeavours to rescue the most catastrophically injured, but has not focused on prehospital surgical torso hemorrhage control (HC). We examined the logistics and metrics of intraperitoneal packing in weightlessness in Parabolic flight (0g) compared to terrestrial gravity (1g) as an extreme example of surgical RDCR.

METHODS

A surgical simulator was customized with high-fidelity intraperitoneal anatomy, a "blood" pump and flowmeter. A standardized HC task was to explore the simulator, identify "bleeding" from a previously unknown liver injury perfused at 80 mm Hg, and pack to gain hemostasis. Ten surgeons performed RDCR laparotomies onboard a research aircraft, first in 1g followed by 0g. The standardized laparotomy was sectioned into 20-second segments to conduct and facilitate parabolic flight comparisons, with "blood" pumped only during these time segments. A maximum of 12 segments permitted for each laparotomy.

RESULTS

All 10 surgeons successfully performed HC in both 1g and 0g. There was no difference in blood loss between 1g and 0g (p = 0.161) or during observation following HC (p = 0.944). Compared to 1g, identification of bleeding in 0g incurred less "blood" loss (p = 0.032). Overall surgeons rated their personal performance and relative difficulty of surgery in 0g as "harder" (median Likert, 2/5). However, conducting all phases of HC were rated equivalent between 1g and 0g (median Likert, 3/5), except for instrument control (rated slightly harder, 2.75/5).

CONCLUSION

Performing laparotomies with packing of a simulated torso hemorrhage in a high-fidelity surgical simulator was feasible onboard a research aircraft in both normal and weightless conditions. Despite being subjectively "harder," most phases of operative intervention were rated equivalently, with no statistical difference in "blood" loss in weightlessness. Direct operative control of torso hemorrhage is theoretically possible in extreme environments if logistics are provided.

Abbreviated closure for remote damage control laparotomy in extreme environments: A randomized trial of sutures versus wound clamps comparing terrestrial and weightless conditions

INTRODUCTION

Far-Forward Damage Control Laparotomies (DCLs) might provide direct-compression of visceral hemorrhage, however, suturing is a limiting factor, especially for non-physicians. We thus compared abbreviated skin closures comparing skin-suture (SS) versus wound-clamp (WC), on-board a research aircraft in weightlessness (0g) and normal gravity (1g).

METHODS

Surgeons conducted DCLs on a surgical-simulator; onboard the hangered-aircraft (1g), or during parabolic flight (0g), randomized to either WC or SS.

RESULTS

Ten surgeons participated. Two (40%) surgeons randomized to suture in 0g were incapacitated with motion-sickness, and none were able to close in either 1 or 0g. With WC, two completely closed in 1g as did three in 0g, despite having longer incisions (p = 0.016). Overall skin-closure with WC was significantly greater in both 1g (p = 0.016) and 0g (p = 0.008).

CONCLUSIONS

WC was more effective in 1g and particularly 0g. Future studies should address the utility of abbreviated WC abdominal closure to facilitate potential Far-Forward DCL.

TRIAL REGISTRATION

ID ISRCTN/77929274.

Intubation after rapid sequence induction performed by non-medical personnel during space exploration missions: a simulation pilot study in a Mars analogue environment

BACKGROUND

The question of the safety of anaesthetic procedures performed by non anaesthetists or even by non physicians has long been debated. We explore here this question in the hypothetical context of an exploration mission to Mars. During future interplanetary space missions, the risk of medical conditions requiring surgery and anaesthetic techniques will be significant. On Earth, anaesthesia is generally performed by well accustomed personnel. During exploration missions, onboard medical expertise might be lacking, or the crew doctor could become ill or injured. Telemedical assistance will not be available. In these conditions and as a last resort, personnel with limited medical training may have to perform lifesaving procedures, which could include anaesthesia and surgery. The objective of this pilot study was to test the ability for unassisted personnel with no medical training to perform oro-tracheal intubation after a rapid sequence induction on a simulated deconditioned astronaut in a Mars analogue environment. The experiment made use of a hybrid simulation model, in which the injured astronaut was represented by a torso manikin, whose vital signs and hemodynamic status were emulated using a patient simulator software. Only assisted by an interactive computer tool (PowerPoint(®) presentation), five participants with no previous medical training completed a simplified induction of general anaesthesia with intubation.

RESULTS

No major complication occurred during the simulated trials, namely no cardiac arrest, no hypoxia, no cardiovascular collapse and no failure to intubate. The study design was able to reproduce many of the constraints of a space exploration mission.

CONCLUSIONS

Unassisted personnel with minimal medical training and familiarization with the equipment may be able to perform advanced medical care in a safe and efficient manner. Further studies integrating this protocol into a complete anaesthetic and surgical scenario will provide valuable input in designing health support systems for space exploration missions.

Intubation after rapid sequence induction performed by non-medical personnel during space exploration missions: a simulation pilot study in a Mars analogue environment

Background

The question of the safety of anaesthetic procedures performed by non anaesthetists or even by non physicians has long been debated. We explore here this question in the hypothetical context of an exploration mission to Mars. During future interplanetary space missions, the risk of medical conditions requiring surgery and anaesthetic techniques will be significant. On Earth, anaesthesia is generally performed by well accustomed personnel. During exploration missions, onboard medical expertise might be lacking, or the crew doctor could become ill or injured. Telemedical assistance will not be available. In these conditions and as a last resort, personnel with limited medical training may have to perform lifesaving procedures, which could include anaesthesia and surgery. The objective of this pilot study was to test the ability for unassisted personnel with no medical training to perform oro-tracheal intubation after a rapid sequence induction on a simulated deconditioned astronaut in a Mars analogue environment. The experiment made use of a hybrid simulation model, in which the injured astronaut was represented by a torso manikin, whose vital signs and hemodynamic status were emulated using a patient simulator software. Only assisted by an interactive computer tool (PowerPoint^® presentation), five participants with no previous medical training completed a simplified induction of general anaesthesia with intubation.

Results

No major complication occurred during the simulated trials, namely no cardiac arrest, no hypoxia, no cardiovascular collapse and no failure to intubate. The study design was able to reproduce many of the constraints of a space exploration mission.

Conclusions

Unassisted personnel with minimal medical training and familiarization with the equipment may be able to perform advanced medical care in a safe and efficient manner. Further studies integrating this protocol into a complete anaesthetic and surgical scenario will provide valuable input in designing health support systems for space exploration missions.