Every day, the critical care transport team at Cincinnati Children’s Hospital Medical Center brings seriously ill infants and children from community hospitals to the Medical Center’s emergency department, intensive care unit and specialty care facilities. With the health of so many of their tiny patients so fragile, physicians were looking for a way to better monitor and treat preemies and critically ill kids while en route.
With the help of a $75,000 state grant, Children’s Hospital became one of the first in the nation to make use of a new generation of high-definition digital video cameras and digital stethoscopes that transmit information via 3G (third generation) telecommunications networks to enable physicians to see patients, listen to their breath sounds and heartbeat, and direct the critical care team—made up of a paramedic, nurse and respiratory therapist—remotely. The program was launched earlier this year.
“Even for experienced clinicians, there are little things that are difficult to paint a 100 percent accurate picture of over the phone,” says Hamilton Schwartz, M.D., pediatric medical director for the Cincinnati Fire Department and medical director for Statline, the hospital’s critical care transport dispatch system. “Sometimes just being able to see the patient for a few seconds can make a difference in your impression of the severity of their illness. Little things can sometimes translate to big decisions.”
The program in Cincinnati is the latest attempt to bring telemedicine to prehospital care—a trend many believe will one day be commonplace. “At some point, it will become the standard of care,” Schwartz says.
Yet for now, such programs are rare. Affordability is one barrier: The device used in Cincinnati—the Transport AV telemedicine system, made by Scottsdale, Ariz.-based Global Media—costs about $30,000 per unit, plus a monthly fee to license the software. That puts a similar system out of reach for most municipal fire departments and EMS agencies, Schwartz says, although Global Media has worked with the hospital to make the program work given its budget. Plus, telemedicine requires a level of coordination between hospitals and EMS that doesn’t always exist.
Yet some systems are findings ways to overcome that—with encouraging results. In 2007, in what is believed to be the first such undertaking in the nation, Tucson Fire Department ambulances were equipped with video cameras to communicate with doctors at the local Level 1 trauma center. Tucson was followed in 2009 by East Baton Rouge Parish EMS’ BR Med Connect, which is also using video cameras to link its ambulances and several area hospitals via the city’s Wi-Fi network.
Telemedicine in ambulances: a work-in-progress
Being a pioneer in the use of telemedicine on ambulances has been a learning process, says Rifat Latifi, M.D., a professor of surgery at the University of Arizona and director of telemedicine services at University Medical Center in Tucson.
The Tucson program was launched with a $1.6 million federal grant to improve police and fire communications and upgrade the city’s Wi-Fi network, a portion of which was allocated for improving trauma care through telemedicine. Initially, there were concerns that firefighters would object to the “Big Brother” aspect of being watched, but this never became an issue. “Most of the feedback we got was that firefighters were glad to be part of this new revolution we were doing together,” Latifi says. “And the leadership was extremely supportive of it.”
Today, 17 Fire Department ambulances have video equipment installed on board that enables firefighter/paramedics and EMTs to communicate with the trauma team at University Medical Center, the city’s only Level 1 trauma center. Initially, it was thought that the video cameras would be used routinely, Latifi says, but as it turns out, that hasn’t been necessary. For many types of routine emergency calls, paramedics and EMTs are able to do all that’s needed, and physician input can wait until the patient arrives at the hospital.
But for stabbings, shootings and other life-threatening injuries, when doctors want to know as much as they can right away, the video cameras have been critical. “Sometimes all you hear is ‘25-year-old victim, stab wound to left chest, BP 100 over 55.’ As a trauma surgeon, you hear that and think the worst,” Latifi says. “What you really want to see is, do they have a distended jugular vein? Are they gasping for air? Are they diaphoretic? Sometimes things are obvious and sometimes they’re not. But trauma surgeons are trained to interpret those things.”
The video cameras have also led to an unexpected result: cost savings. By enabling hospital staff to see a patient before arrival, they can better determine the seriousness of the injury and whether it’s really necessary to activate the trauma team, which includes surgical staff, radiology staff and emergency medical staff, among others.
To do that costs a minimum of $5,000. “Making sure we are only activating the trauma team when necessary saves the health care system a tremendous amount of money,” Latifi says.
Telemedicine system will be deployed in disasters
In Cincinnati, Schwartz sees another use for the Transport AV system: disasters and mass casualty events.
To get his system operational, Schwartz used a state grant for disaster and mass casualty preparedness. If such an event were to occur, the Transport AV devices—which are mounted on gurneys and are easily transported—would be dispatched into the field, enabling doctors back at the hospital to triage and give orders remotely. Since the devices are fully mobile, responders could take the system into high-rises, to the site of a disaster or wherever they needed to go.
The devices include a high-resolution video camera that can zoom in on parts of the body as small as a hair follicle and can take either still images or send real-time, live video; a second camera about the size of a pen light that can be easily slipped into the portholes of the incubators that preemies are transported in; a digital stethoscope that enables doctors to listen to the heartbeat and respirations; a microphone; and a headset. Doctors can control the position of the cameras, leaving the critical care team’s hands free to work.
While using wireless communications can mean interruptions in communications, Schwartz says that hasn’t posed much of a problem, as doctors aren’t interested in observing the patient during the entire ride. “You just need a good quality signal for a few minutes at the right time,” he says.
For now, telemedicine in ambulances remains, to a certain extent, unproven. As part of his program, Schwartz is collecting data about whether the hospital’s telemedicine program changes the way doctors treat patients and affects their decisions, with the eventual goal of determining if having that added ability to intervene remotely improves patient outcomes.
“With mobile telemedicine, we can now interact with the ambulance crews to customize critical care for each individual patient from the minute the patient is transferred into their care,” Schwartz says. “We can immediately diagnose and begin critical care treatment, and we can monitor the patient’s condition and reactions to treatment throughout the transport.”
Knowing exactly what the patient’s condition is at all times not only improves care during transport, but also provides vital information to the teams back at the hospital so they can prepare for the patient’s arrival. While much of the focus of the video cameras was the potential to intervene sooner in patients who are very ill, the converse is also true: Being able to determine that the patient’s condition is not dire means there’s no need for lights and sirens. “Lights and sirens use really affects very little other than increasing the chances that the ambulance crew and the public is going to get in an accident,” Schwartz says. “The benefits of that could go far beyond the patients.”
