Telemedicine for

Trauma, Emergencies,
and Disaster
Management
Rifat Latifi, MD, FACS
Professor of Surgery, University
of Arizona, Tucson, Arizona
President and Founder
International Virtual e-Hospital
Foundation
Hyderabad, September 7, 2013

Disclosure

Current Telemedicine
Programs
Elective Telemedicine Program
Inter-hospital telemedicine and
telepresence and networkEmergency and Trauma
Digital ambulances and monitored
patient transport; EMS, Trauma
Deployable mobile telemedicine
systems- Disasters, Medical
Missions

Telemedicine for Emergency

and Disaster

Pre
Event
Chaotic situation,
difficult to create de
novo programs,
short term, ?? utility

Most importantly

During
the Event

Media
Effect,
resear
ch
paper
s

Post
Event

Vital Signs

Store and Forward

Need for
telepresence:

Patients involved in
MVC in rural America
have twice the rate of
mortality with those in
an urban settings with
the same ISS

JAMA 2000;284

So what is
the all the
fuss about ?

Trauma Toll

16,000 X
365=5,800,000
Up to 50 million are
significantly injured
or disabled
Mock C et al. Guidelines to Essential Trauma
Care, 2004

Natural Disasters

327 Natural disasters in 2009

Earthquakes, floods, extreme

temperature, storms

2010 Haiti earthquake, roughly

230,000 died

Death tolls due to

construction, infrastructure,
and overcrowding

Trauma & Disasters as a

Worldwide Problem

Disaster

Serious event
where needs exceed the
local capacity to
respond WHO
Most victims of disaster
are usually also trauma
victims

Disasters

Natural

Disasters

Published Evidence
Australia: Smith et al (2004), Kumar et al
(2006)
Canada :Dyer et al ( 2008)
China: Wong et al (2006)
France: Knobloch et al (2009), Dulou et al
(2010)
Germany: Kreutzer et al (2008), Juhra et al
(2009)
Israel: Ashkenazi et al (2007) Todder et al
(2007)
Italy: Do Paolo et al (2009)

Published Evidence
Taiwan: Hsieh et al (2004),Tsai et al
(2007)
Thailand: Chandhanayingyon et al (2007)
United Kingdom: Keane (2009), Noble et al
(2005), Benger et al (2004)
USA: Sposaro and Tyson (2009), Saffle et
al (2006, 2009), Latifi et al (2007, 2009),
Waran et al (2008), Duchesne et al (2008),
Ma et al (2007), Kwon et al (2007),
Ngyuen et al(2004), Marcin et al (2004)

CASE PRESENTATION

Small
interventio
n

Pull the
ET tube back,
decompress
the stomach
Results:
Clinical
Improvement
Better SBP
Improvement
of Saturation

Initial Chest x-ray of the patient managed by telemedicine 11/21/2004

Patient at the UMC Trauma center

being attended by trauma team

Interventions (routine for trauma)

Intubate the patient
Reposition the ET tube from the right
main bronchus
Sedate, paralyze the patient
Obtain femoral vein/arterial access
Resuscitate with lactated ringer
Obtain a blood gas, CBC
Blood transfusion, antibiotics
Suction the ET tube
Place the orogastric tube to
decompress stomach

Extreme Conditions:
Low-bandwidth Portable
Satellite

The Amazon Swim Expedition

Martin Strel and virtual physicians
Lessons learned: telepresence 24 hours day, 7 days
week, 66 days usage of mobile satellite, BGAN

Conclusion

Telemedicine in
acute phase injury :
works and it is
beneficial
Cost effective
Save lives

Telemedicine for Trauma:

Safety and
practicality has
been demonstrated
Vastly
underutilized
Its time has come

Telemedicine for Trauma,

Emergencies and Disaster
Management

The Greatest
Unused Tool !

What we
need to do?

Create

Infrastructure and
Connectivity
Policies, procedures, protocols
(both clinical and technical)
Credentialing process
Quality control

Telemedicine for Trauma

Emergencies
NonDisruptiveVery helpful

Cost
effective

Partnership
Between
healthcare
providers
Virtual Participation

Improving
Quality of
Patients
Care

Inaccuracy of Measurement of
Trauma & Injury
Unreliable measurement globally

Lack of consistency in coding and

gathering of data

www.emdat.be : contains 18,000

natural & technological disasters
since 1900

PROBLEMS FACING MEDICAL

AND EMERGENCY EXPERTS
DURING DISASTERS AND
EMERGENCY

The largest problem is

accessing people affected by
disasters and emergency
situations and being adequately
prepared to respond!

Wireless Technologies: Potential Use

In Emergencies and Disasters

Multi-patient monitoring systems

using wireless technologies in
disaster situations

Long-range data transmission

Connect among regions of experts

GPS technology/satellite

Useful for monitoring multiple

patients in disasters

PROBLEMS FACING MEDICAL AND

EMERGENCY EXPERTS DURING
DISASTERS AND EMERGENCY

Wireless technologies
Remote access to experts
Communications
Organization &
Coordination
Provide relief to disaster
management teams on
location

Potential Uses of Remote Technologies

in Remote Settings
FAST, Focused Assessment with
Sonography for Trauma = real-time
remote physician guidance for trauma
examination
Teleultrasound as a transformational
technology for under-resourced settings
Crawford, I. et al., (2011). Telementorable, just-in-time lung ultrasound on an
iPhone. Journal of Emergencies, Trauma, and Shock, 4, pp. 526-527.
Pian, L.. et al. (2013). Potential use of remote telesonography as a
transformational technology in underresourced and/or remote settings.
Emergency Medicine International.

FAST
Emergency situations:
EMT lack of training
FAST technology applications

Boniface, K.S., Shokoohi, H., Smith, E.R., & Scantelbury, K. (2011). Teleultrasound and paramedics: real-time remote phyisician guidance of
the Focused Assessment with Sonography for Trauma examination.
American Journal of Emergency Medicine, 29, pp 477-481.

Telepointer Technology
Interaction style presentation system
interactive television, and other systems,
where the user is positioned at a remote
site from the display. The main function of a
telepointer is to point at the specific display
so that its motion could represent the
human gesture. Meanwhile, display devices
allow the collaborator to view the same
scene as seen by the other parties
Abdul Karim, R., Farizan Zakara, N. et al., (2013). Telepointer technology in
telemedicine: A review. Biomedical Engineering Online.

The Military Approach

Establishing Clinical Protocols &
Standards
Standardization may not always be
necessary
Not all military's follow the same
approach!!
Lam, D.M. (2011). Establishing clinical protocols and standards: The
military approach. pp. 147-160. In Telemedicine for Trauma,
Emergencies and Disaster Managment, R. Latifi, Ed.

The Military Approach 2

NATO successful international
standardization
Clinical, Technical, Business Standards
NATO: 1) standardization voluntary, 2)
Not an end of itself, only done if useful
and makes process more efficient, use of
common terminology
Lam, D.M. (2011). Establishing clinical protocols and standards: The
military approach. pp. 147-160. In Telemedicine for Trauma,
Emergencies and Disaster Managment, R. Latifi, Ed.

U.S. Army Telemedicine in Iraq

& Afghanistan

Can telemedicine effectively be used across national

boundaries?
U.S. Army Theater Teleconsult program
Online management of consultation requests
Consultant is primary responder
7,255 consultations over 6 year period
Avoided 90 medical flight evacuations ($2 million cost
savings)
Considerations for NATO operations lessons learned
Poropatich, R.K., Lappan, C., & Lam, D.M. (2011). Operational use of U.S.
Army telemedicine information systems in Iraq and Afghanistan
Considerations for NATO operations.pp. 173-182. In Telemedicine for
Trauma, Emergencies and Disaster Managment, R. Latifi, Ed.

INDIA Disaster Management

Amrita
Amrita Institute of Medical
Sciences and Indian Space
Research Organization (ISRO)
partnering to provide remote
care to over 60 hospitals in
preparation for disaster
management

RECENT DEVELOPMENTS PAKISTAN

Telmedpak.com.
Www.suparco.gov.pk

Pakistan Telmedpak
SUPARCO, an
autonomous
research entity
under the federal
government has
recently launched
Pakistans First
Satellite based
telemedicine
network.

Recent Developments
Armenia
Mobile ECG Telemonitoring

Armenia recent development of Mobile ECG

telemonitoring device
Lightweight ultra-portable sensor &
smartphone
ECG registered regardless of patient's location
ECG monitoring is live streamed, provided by
specialized personnel
Data stored in patient databased, viewed
anywhere
Www.armtelemed.com

Keeping up with
Industry Development
Dissolving legal barriers to industry
growth and development are key to
unlocking potential of the use of
telemedicine in disaster and trauma
management
Gupta, A. & McHugh, M. (2011). Keeping up with industry
development. pp. 373-388. In Telemedicine for Trauma,
Emergencies and Disaster Managment, R. Latifi, Ed.

Telemedicine for
Emergency
and Disaster

Pre
Event
Chaotic situation,
difficult to create
de novo programs,
short term, ?? utility

Most importantly

During
the Event

Media
Effect,
research
papers

Post
Event

Reconstruction

The entire medical

infrastructure and human capacity destroyed
No medical standards
Infant mortality
51.2 per 1000
In-efficient and broken
medical system
Crowded hospitals
Not a single scientific journal in
any library

SUMMARY
Preparedness
Organization
Coordination
Communication
technology
Telemedicine
Saving lives!

There

are no more excuses

for any critically ill or trauma
patient to die in any
emergency room of any
country just because there
was no specialist available on
site to help with the
resuscitation.

What do we needed was and

still is:
Radical changes of the
configuration of medical care
Coalition of new partners with
innovative boundaries
Penetrating eyes of revolutionary
and champions of the
unconventional
The rebels of the hospital as we
know it

THE VACUUM OF KNOWLEDGE AND

THE

Vacuum of hope
Digital divide was
getting bigger and
wider

INTEGRATED MIDDLE EASTERN TELEMEDICINE AND E-HEALTH PROGRAM

FOR PREVENTION, TREATMENT AND REHABILITATION OF LANDMINE
INJURIES AND OTHER TRAUMAS

INTEGRATED MIDDLE EASTERN TELEMEDICINE AND E-HEALTH PROGRAM

FOR PREVENTION, TREATMENT AND REHABILITATION OF LANDMINE
INJURIES AND OTHER TRAUMAS

What we do:
Change the delivery of existing medical care

Bring together new coalition of partners

with innovative boundaries and clear vision

We Demand
A new generation of leaders with
different intellectual capital and a new
direction

Global and not focused on

self limited projects, or
driven by institutional
and/or national interest

Universal Thinking and Actions

Disasters
Landmines & Unexploded Devices

Telemedicine in the Balkans

57

Thank You!
latifi@iveh.org
rlatifi@email.arizona.edu