Telemedicine in trauma care

Advances in technology have made it possible for telemedicine to be used in multiple areas of medicine, including trauma care. Teleradiology and teleconsultation are becoming standard operating procedure for many rural facilities.

Future uses of telemedicine include teleproctoring and telepresence surgery. The medicolegal and financial impact of telemedicine remains to be determined. The potential influence of telemedicine in the care of future trauma patients is likely to be important and may alter patterns of referral, consultation, and treatment.

Advances in radio communication, electronics, and computer technology have greatly improved care of the trauma patient over the past several decades. In fact, it is unusual for prehospital providers not to communicate with medical personnel at the hospital base station long before a trauma or emergency patient arrives in the resuscitation suite. Such prehospital reports are usually the basis for activating the trauma team and making preparations for the care of the patient, not only in the emergency department, but also in the radiology department, operating room, and the ICU. Unfortunately, in remote locations, the usual modes of communication, such as very high frequency radio and cellular telephone, may be ineffective or unavailable.

Utilisation of teleconferencing
Currently, one third of rural hospitals in the US have limited capability to link with at least one tertiary care facility. An excellent example of the utility of remote teleconsultation is the system presently supported by St. Francis Hospital of Tulsa. In addition to providing teleradiology services, emergency medicine practitioners at this tertiary care facility are immediately available for consultation with physicians, nurse practitioners, and physicians’ assistants at small rural hospitals. Early experience with this system has documented many areas of improved patient care, including early triage of seriously ill patients, a decreased rate of transfer of patients who did not require treatment at a tertiary care facility, and more effective utilisation of ground and air ambulance services. A similar experience has been reported from several rural treatment facilities in UK.

Multisite teleconferencing for the purpose of providing education to a variety of medical professionals has become routine. To date, most of these conferences have been sponsored by pharmaceutical companies or instrument manufacturers and contain a significant marketing component. However, these industry-sponsored sessions have shown the potential for high-quality education programs via available satellite communications systems.

Types of available systems
Most of the available telemedicine systems are distinctly “low tech” and slow. At present, most teleconferencing is dependent on communication via a conventional phone line, a T-1 line (a 24-channel, high-capacity circuit for data, voice, and video transmission), or in rare cases an OC3 fibreoptic cable connection (a 243-channel, high-capacity fibreoptic circuit for data, voice, and video transmission). Unfortunately, the T-1 communications link is inadequate for high-resolution, real-time clinical interactions. A conventional telephone line and modem provide data transmission at a maximum rate of 64 kb/sec. A T-1 line will provide maximum data transmission rates of from 1.5 to 2.0 megabytes (Mb) per second, and a fibreoptic OC3 line is capable of supporting rates of up to 155 Mb/sec under optimal circumstances. Unfortunately, these rates of data transmission are seldom achieved in routine daily use. A good example of the problems inherent with current telemedicine systems is the interpretation of clinical radiographic films. Using a currently available teleradiology system and a T-1 line takes approximately 11 minutes to transmit a digital mammogram, which contains only 128 Mb of data. Transmission of a more complex imaging study, such as MRI that contains as much as 1 gigabyte of data, will require 1 1/2 hours!

These time requirements are clearly unacceptable for most clinical activities, particularly in an emergency or trauma setting. In contrast, the same digital mammogram and MRI data would require only 6.4 seconds and 52 seconds, respectively, using an OC3 line. Transmission of the same data sets over an OC48 line would require only 0.4 seconds and 3.3 seconds, respectively. High-speed land lines, such as OC3 fibreoptic cables, are not widely available at this time. Current availability is limited primarily to large urban areas. Unfortunately, patients receiving care in rural hospitals who could benefit most from teleconferencing are not likely to be eligible for these services due to lack of fibreoptic infrastructure.

Developing technology
As technology continues to improve, substantial efforts have been directed toward development of telepresence as an adjunct to having physicians on site, or in some instances, as replacement for on-site physician expertise. Telepresence may be described as the ability to perform a “virtual examination or intervention” for a patient over a distance, made possible by telecommunication technology. While the potential for telepresence to improve patient care is obvious, caution must be exercised, since this concept remains in its developmental infancy. To date, the greatest obstacle to routine use of telemedicine and, particularly, telepresence interventions such as operations has been the lack of cost-effective, dependable, broad-bandwidth communication and data links as discussed earlier. Wider availability of high-speed fibreoptic land lines and satellite up-link and down-link services will greatly facilitate further development of telemedicine and telepresence interaction.

Application to trauma management
An area of telemedicine that has already proved moderately successful with present technology is that of trauma management for patients in remote or inaccessible rural medical facilities. Armstrong and Haston recently reported on their initial experience with a telemedicine system that linked a small rural facility in Peterhead, Scotland, with the emergency department of the Aberdeen Royal Infirmary by way of an integrated services digital network land line capable of 128 kb/sec and a satellite link capable of a data transmission rate of 64 kb/sec.

...To be continued

(Source: www.medscape.com)