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Pamplin JC, Veazey SR, Barczak S, Fonda SJ, Serio-Melvin ML, Ross KS, Colombo CJ. Randomized Controlled Trial of Telementoring During Resource-Limited Patient Care Simulation Improves Caregiver Performance and Patient Survival. Crit Care Explor 2024; 6:e1090. [PMID: 38736901 PMCID: PMC11086961 DOI: 10.1097/cce.0000000000001090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/14/2024] Open
Abstract
OBJECTIVES To determine the impact of telementoring on caregiver performance during a high-fidelity medical simulation model (HFMSM) of a critically ill patient in a resource-limited setting. DESIGN A two-center, randomized, controlled study using a HFMSM of a patient with community-acquired pneumonia complicated by acute respiratory distress syndrome. SETTING A notional clinic in a remote location staffed by a single clinician and nonmedical assistant. PARTICIPANTS Clinicians with limited experience managing critically ill patients. INTERVENTIONS Telemedicine (TM) support. MEASUREMENTS The primary outcome was clinical performance as measured by accuracy, reliability, and efficiency of care. Secondary outcomes were patient survival, procedural quality, subjective assessment of the HFMSM, and perceived workload. MAIN RESULTS TM participants (N = 11) performed better than non-TM (NTM, N = 12) in providing expected care (accuracy), delivering care more consistently (reliability), and without consistent differences in efficiency (timeliness of care). Accuracy: TM completed 91% and NTM 42% of expected tasks and procedures. Efficiency: groups did not differ in the mean (± sd) minutes it took to obtain an advanced airway successfully (TM 15.2 ± 10.5 vs. NTM 22.8 ± 8.4, p = 0.10) or decompress a tension pneumothorax with a needle (TM 0.7 ± 0.5 vs. NTM 0.6 ± 0.9, p = 0.65). TM was slower than NTM in completing thoracostomy (22.3 ± 10.2 vs. 12.3 ± 4.8, p = 0.03). Reliability: TM performed 13 of 17 (76%) tasks with more consistent timing than NTM. TM completed 68% and NTM 29% of procedural quality metrics. Eighty-two percent of the TM participants versus 17% of the NTM participants simulated patients survived (p = 0.003). The groups similarly perceived the HFMSM as realistic, managed their patients with personal ownership, and experienced comparable workload and stress. CONCLUSIONS Remote expertise provided with TM to caregivers in resource-limited settings improves caregiver performance, quality of care, and potentially real patient survival. HFMSM can be used to study interventions in ways not possible with real patients.
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Affiliation(s)
- Jeremy C Pamplin
- The U.S. Army Telemedicine and Advanced Technology Research Center, Frederick, MD
- Department of Medicine, Department of Emergency and Operational Medicine, The Uniformed Services University, Bethesda, MD
- Department of Emergency and Operational Medicine, The Uniformed Services University, Bethesda, MD
- The U.S. Army Institute of Surgical Research, San Antonio, TX
- The Geneva Foundation, Tacoma, WA
| | - Sena R Veazey
- The U.S. Army Institute of Surgical Research, San Antonio, TX
| | | | | | | | | | - Christopher J Colombo
- Department of Medicine, Department of Emergency and Operational Medicine, The Uniformed Services University, Bethesda, MD
- The U.S. Army Institute of Surgical Research, San Antonio, TX
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Thierry S, Jaulin F, Starck C, Ariès P, Schmitz J, Kerkhoff S, Bernard CI, Komorowski M, Warnecke T, Hinkelbein J. Evaluation of free-floating tracheal intubation in weightlessness via ice-pick position with a direct laryngoscopy and classic approach with indirect videolaryngoscopy. NPJ Microgravity 2023; 9:73. [PMID: 37684267 PMCID: PMC10491756 DOI: 10.1038/s41526-023-00314-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 08/02/2023] [Indexed: 09/10/2023] Open
Abstract
Long duration spaceflights to the Moon or Mars are at risk for emergency medical events. Managing a hypoxemic distress and performing an advanced airway procedure such as oro-tracheal intubation may be complicated under weightlessness due to ergonomic constraints. An emergency free-floating intubation would be dangerous because of high failure rates due to stabilization issues that prohibits its implementation in a space environment. Nevertheless, we hypothesized that two configurations could lead to a high first-pass success score for intubation performed by a free-floating operator. In a non-randomized, controlled, cross-over simulation study during a parabolic flight campaign, we evaluated and compared the intubation performance of free-floating trained operators, using either a conventional direct laryngoscope in an ice-pick position or an indirect laryngoscopy with a video-laryngoscope in a classic position at the head of a high-fidelity simulation manikin, in weightlessness and in normogravity. Neither of the two tested conditions reached the minimal terrestrial ILCOR recommendations (95% first-pass success) and therefore could not be recommended for general implementation under weightlessness conditions. Free-floating video laryngoscopy at the head of the manikin had a significant better success score than conventional direct laryngoscopy in an ice-pick position. Our results, combined with the preexisting literature, emphasis the difficulties of performing oro-tracheal intubation, even for experts using modern airway devices, under postural instability in weightlessness. ClinicalTrials registration number NCT05303948.
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Affiliation(s)
- Séamus Thierry
- Anaesthesiology Department, South Brittany General Hospital, 56100, Lorient, France.
- Space Medicine Group, European Society of Aerospace Medicine (ESAM), Cologne, Germany.
- Medical Simulation Centre B3S, 56100, Lorient, France.
- Laboratoire Psychologie, Cognition, Communication, Comportement, Université Bretagne Sud, 56000, Vannes, France.
| | - François Jaulin
- Sorbonne Medical University, Assistance Publique des Hôpitaux de Paris, Paris, France
- Human Factor in Healthcare Association, Group FHS, Paris, France
| | - Clément Starck
- Space Medicine Group, European Society of Aerospace Medicine (ESAM), Cologne, Germany
- Anaesthesiology and Intensive Care Department, University Hospital of Brest, 29200, Brest, France
| | - Philippe Ariès
- Anaesthesiology and Intensive Care Department, University Hospital of Brest, 29200, Brest, France
| | - Jan Schmitz
- Space Medicine Group, European Society of Aerospace Medicine (ESAM), Cologne, Germany
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital and Medical Faculty, Cologne, Germany
- German Society of Aerospace Medicine (DGLRM), Munich, Germany
| | - Steffen Kerkhoff
- Space Medicine Group, European Society of Aerospace Medicine (ESAM), Cologne, Germany
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital and Medical Faculty, Cologne, Germany
- German Society of Aerospace Medicine (DGLRM), Munich, Germany
| | - Cécile Isabelle Bernard
- Laboratoire Psychologie, Cognition, Communication, Comportement, Université Bretagne Sud, 56000, Vannes, France
| | - Matthieu Komorowski
- Space Medicine Group, European Society of Aerospace Medicine (ESAM), Cologne, Germany
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Tobias Warnecke
- Space Medicine Group, European Society of Aerospace Medicine (ESAM), Cologne, Germany
- Department of Anaesthesiology, Critical Care, Emergency Medicine and Pain Therapy, Hospital of Oldenburg, Medical Campus University of Oldenburg, Oldenburg, Germany
| | - Jochen Hinkelbein
- Space Medicine Group, European Society of Aerospace Medicine (ESAM), Cologne, Germany
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital and Medical Faculty, Cologne, Germany
- German Society of Aerospace Medicine (DGLRM), Munich, Germany
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Thoolen SJJ, Kuypers MI. External Hemorrhage Control Techniques for Human Space Exploration: Lessons from the Battlefield. Wilderness Environ Med 2023; 34:231-242. [PMID: 36906432 DOI: 10.1016/j.wem.2023.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 01/11/2023] [Accepted: 01/12/2023] [Indexed: 03/11/2023]
Abstract
The past few decades of military experience have brought major advances in the prehospital care of patients with trauma. A focus on early hemorrhage control with aggressive use of tourniquets and hemostatic gauze is now generally accepted. This narrative literature review aims to discuss external hemorrhage control and the applicability of military concepts in space exploration. In space, environmental hazards, spacesuit removal, and limited crew training could cause significant time delays in providing initial trauma care. Cardiovascular and hematological adaptations to the microgravity environment are likely to reduce the ability to compensate, and resources for advanced resuscitation are limited. Any unscheduled emergency evacuation requires a patient to don a spacesuit, involves exposure to high G-forces upon re-entry into Earth's atmosphere, and costs a significant amount of time until a definitive care facility is reached. As a result, early hemorrhage control in space is critical. Safe implementation of hemostatic dressings and tourniquets seems feasible, but adequate training will be essential, and tourniquets are preferably converted to other methods of hemostasis in case of a prolonged medical evacuation. Other emerging approaches such as early tranexamic acid administration and more advanced techniques have shown promising results as well. For future exploration missions to the Moon and Mars, when evacuation is not possible, we look into what training or assistance tools would be helpful in managing the bleed at the point of injury.
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Affiliation(s)
- Stijn J J Thoolen
- Neural Systems Group, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA; Centre for Human and Applied Physiological Sciences, King's College London, United Kingdom.
| | - Maybritt I Kuypers
- European Astronaut Centre, European Space Agency, Cologne, Germany; Department of Emergency Medicine, Amsterdam UMC, University of Amsterdam, the Netherlands
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Levin DR, Steller J, Anderson A, Lemery J, Easter B, Hilmers DC, Lehnhardt KR. Enabling Human Space Exploration Missions Through Progressively Earth Independent Medical Operations (EIMO). IEEE OPEN JOURNAL OF ENGINEERING IN MEDICINE AND BIOLOGY 2023; 4:162-167. [PMID: 38274774 PMCID: PMC10810302 DOI: 10.1109/ojemb.2023.3255513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 03/01/2023] [Accepted: 03/06/2023] [Indexed: 01/27/2024] Open
Abstract
Goal: Current Space Medicine operations depend on terrestrial support to manage medical events. As astronauts travel to destinations such as the Moon, Mars, and beyond, distance will substantially limit this support and require increasing medical autonomy from the crew. This paper defines Earth Independent Medical Operations (EIMO) and identifies key elements of a conceptual EIMO system. Methods: The NASA Human Research Program Exploration Medical Capability Element held a 2-day conference at Johnson Space Center in Houston, TX with NASA experts representing all aspects of Space Medicine. Results: EIMO will be a process enabling progressively resilient deep space exploration systems and crews to reduce risk and increase mission success. Terrestrial assets will continue to provide pre-mission screening, planning, health maintenance, and prevention, while onboard medical care will increasingly be the purview of the crew. Conclusions: This paper defines and describes the key components of EIMO.
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Affiliation(s)
- Dana R. Levin
- Department of Emergency MedicineBaylor College of MedicineHoustonTX77030USA
- Department of Preventive Medicine Division of Aerospace MedicineUniversity of Texas Medical BranchGalvestonTX77555USA
| | - Jon Steller
- Department of Maternal Fetal Medicine and Obstetrics and GynecologyUniversity of California IrvineIrvineCA92697USA
| | - Arian Anderson
- Department of Emergency MedicineSchool of Medicine, University of Colorado Anschutz Medical CampusAuroraCO80045USA
| | - Jay Lemery
- Department of Emergency Medicine, School of MedicineUniversity of Colorado Anschutz Medical CampusAuroraCO80045USA
- NASA Johnson Space CenterHoustonTX77058USA
| | - Benjamin Easter
- Department of Emergency Medicine, School of MedicineUniversity of Colorado Anschutz Medical CampusAuroraCO80045USA
- NASA Johnson Space CenterHoustonTX77058USA
| | - David C. Hilmers
- Department of Internal Medicine and PediatricsBaylor College of MedicineHoustonTX77030USA
- Center for Space Medicine, Baylor College of MedicineHoustonTX77030USA
| | - Kris R. Lehnhardt
- Department of Emergency MedicineBaylor College of MedicineHoustonTX77030USA
- Center for Space Medicine, Baylor College of MedicineHoustonTX77030USA
- NASA Johnson Space CenterHoustonTX77058USA
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Resuscitation and Evacuation from Low Earth Orbit: A Systematic Review. Prehosp Disaster Med 2019; 34:521-531. [PMID: 31462335 DOI: 10.1017/s1049023x19004734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
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.
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Panesar SS, Ashkan K. Surgery in space. Br J Surg 2018; 105:1234-1243. [DOI: 10.1002/bjs.10908] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Revised: 03/12/2018] [Accepted: 05/11/2018] [Indexed: 01/17/2023]
Abstract
Abstract
Background
There has been renewed public interest in manned space exploration owing to novel initiatives by private and governmental bodies. Long-term goals include manned missions to, and potential colonization of, nearby planets. Travel distances and mission length required for these would render Earth-based treatment and telemedical solutions unfeasible. These issues present an anticipatory challenge to planners, and novel or adaptive medical technologies must therefore be devised to diagnose and treat the range of medical issues that future space travellers will encounter.
Methods
The aim was to conduct a search of the literature pertaining to human physiology, pathology, trauma and surgery in space.
Results
Known physiological alterations include fluid redistribution, cardiovascular changes, bone and muscle atrophy, and effects of ionizing radiation. Potential pathological mechanisms identified include trauma, cancer and common surgical conditions, such as appendicitis.
Conclusion
Potential surgical treatment modalities must consist of self-sufficient and adaptive technology, especially in the face of uncertain pathophysiological mechanisms and logistical concerns.
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Affiliation(s)
- S S Panesar
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - K Ashkan
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, UK
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Ball CG, Kirkpatrick AW, Williams DR, Jones JA, Polk JD, Vanderploeg JM, Talamini MA, Campbell MR, Broderick TJ. Prophylactic surgery prior to extended-duration space flight: is the benefit worth the risk? Can J Surg 2012; 55:125-31. [PMID: 22564516 PMCID: PMC3310768 DOI: 10.1503/cjs.024610] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/05/2011] [Indexed: 01/04/2023] Open
Abstract
This article explores the potential benefits and defined risks associated with prophylactic surgical procedures for astronauts before extended-duration space flight. This includes, but is not limited to, appendectomy and cholecystesctomy. Furthermore, discussion of treatment during space flight, potential impact of an acute illness on a defined mission and the ethical issues surrounding this concept are debated in detail.
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Affiliation(s)
- Chad G Ball
- Department of Surgery, University of Calgary, Calgary, Alta.
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Kirkpatrick AW, Ball CG, Campbell M, Williams DR, Parazynski SE, Mattox KL, Broderick TJ. Severe traumatic injury during long duration spaceflight: Light years beyond ATLS. J Trauma Manag Outcomes 2009; 3:4. [PMID: 19320976 PMCID: PMC2667411 DOI: 10.1186/1752-2897-3-4] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2009] [Accepted: 03/25/2009] [Indexed: 11/14/2022]
Abstract
Traumatic injury strikes unexpectedly among the healthiest members of the human population, and has been an inevitable companion of exploration throughout history. In space flight beyond the Earth's orbit, NASA considers trauma to be the highest level of concern regarding the probable incidence versus impact on mission and health. Because of limited resources, medical care will have to focus on the conditions most likely to occur, as well as those with the most significant impact on the crew and mission. Although the relative risk of disabling injuries is significantly higher than traumatic deaths on earth, either issue would have catastrophic implications during space flight. As a result this review focuses on serious life-threatening injuries during space flight as determined by a NASA consensus conference attended by experts in all aspects of injury and space flight.In addition to discussing the impact of various mission profiles on the risk of injury, this manuscript outlines all issues relevant to trauma during space flight. These include the epidemiology of trauma, the pathophysiology of injury during weightlessness, pre-hospital issues, novel technologies, the concept of a space surgeon, appropriate training for a space physician, resuscitation of injured astronauts, hemorrhage control (cavitary and external), surgery in space (open and minimally invasive), postoperative care, vascular access, interventional radiology and pharmacology.Given the risks and isolation inherent in long duration space flight, a well trained surgeon and/or surgical capability will be required onboard any exploration vessel. More specifically, a broadly-trained surgically capable emergency/critical care specialist with innate capabilities to problem-solve and improvise would be desirable. It will be the ultimate remote setting, and hopefully one in which the most advanced of our societies' technologies can be pre-positioned to safeguard precious astronaut lives. Like so many previous space-related technologies, these developments will also greatly improve terrestrial care on earth.
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Affiliation(s)
| | - Chad G Ball
- Foothills Medical Centre, 1403 29Street NW, Calgary, Alberta, T2N 2T9, USA
| | - Mark Campbell
- Paris Regional Medical Center, 820 Clarksville St., Paris, Texas, 75460, USA
| | - David R Williams
- NASA Johnson Space Center, 2101 NASA Pkwy #1, Houston, Texas, 77058, USA
| | - Scott E Parazynski
- NASA Johnson Space Center, 2101 NASA Pkwy #1, Houston, Texas, 77058, USA
| | - Kenneth L Mattox
- Baylor College of Medicine, Dept. of Surgery, One Baylor Pl., Houston, Texas, 77030, USA
| | - Timothy J Broderick
- University of Cincinnati, Dept. of Surgery, 222 Piedmont Ave, #7000, Cincinnati, Ohio, 45219, USA
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Abstract
Military operations, mass casualty events, and remote work sites present unique challenges to providers of immediate medical care, who may lack the necessary skills for optimal clinical management. Moreover, the number of patients in these scenarios may overwhelm available health care resources. Recent applications of closed-loop control (CLC) techniques to critical care medicine may offer possible solutions for such environments. Here, feedback of a monitored variable or group of variables is used to control the state or output of a dynamic system. Some potential advantages of CLC in patient management include limiting task saturation when there is simultaneous demand for cognitive and active clinical intervention, improving quality of care through optimization of the titration of medications, conserving limited consumable supplies, preventing secondary insults in traumatic brain injury, shortening the duration of mechanical ventilation, and achieving appropriate goal-directed resuscitation. The uses of CLC systems in critical care medicine have been increasingly explored across a wide range of therapeutic modalities. This review will provide an overview of control system theory as applied to critical care medicine that must be considered in the design of autonomous CLC systems, and introduce a number of clinical applications under development in the context of deployment of such applications to austere environments.
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