1. 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, 2013Hyderabad, September 7, 2013

2. DisclosureDisclosure

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

4. Telemedicine for Emergency
and Disaster
Telemedicine for Emergency
and Disaster
Pre EventPre Event
During the
Event
During the
Event
Post EventPost Event
Most importantlyMost importantly
Chaotic situation,
difficult to create “de
novo” programs, short
term, ?? utility
Chaotic situation,
difficult to create “de
novo” programs, short
term, ?? utility
Media
Effect,
researc
h
papers
…
Media
Effect,
researc
h
papers
…

6. Vital Signs

7. Store and Forward

8. 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

9. So what is the all
the fuss about ?
So what is the all
the fuss about ?

10. 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, 2004Mock C et al. Guidelines to Essential Trauma Care, 2004

11. 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

12. 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

13. Disasters
●
Natural
●

16. Disasters…

18. 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)

19. 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)

20. 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
Small
interventio
n
CASE
PRESENTATION

21. Patient at the UMC Trauma center being attended by
trauma team

22. 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

25. 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

26. Conclusion
• Telemedicine in acute
phase injury : works and it
is beneficial
•Cost effective
•Save lives

27. Telemedicine for Trauma:
•Safety and
practicality has been
demonstrated
•Vastly underutilized
•It’s time has come

28. Telemedicine for Trauma, Emergencies
and Disaster Management
The Greatest
Unused Tool !

29. •What we
need to do?

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

31. Non-
Disruptive-
Very helpful
Cost
effective
Improving
Quality of
Patients
Care
Telemedicine for Trauma and
Emergencies
Partnership
Between
healthcare
providers
Virtual Participation

32. 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

33. 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!

34. 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

35. 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

36. 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.

37. FAST
Emergency situations:
EMT lack of training
FAST technology applications
Boniface, K.S., Shokoohi, H., Smith, E.R., & Scantelbury, K. (2011). Tele-ultrasound 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.

38. 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.

39. 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.

40. 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.

41. 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.

42. 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

43. RECENT DEVELOPMENTS -
PAKISTAN
Pakistan -
Telmedpak
SUPARCO, an
autonomous
research entity
under the federal
government has
recently launched
Pakistan’s First
Satellite based
telemedicine
network.
Telmedpak.com.
Www.suparco.gov.pk

44. 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

45. 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.

46. Telemedicine for Emergency
and Disaster
Telemedicine for Emergency
and Disaster
Pre EventPre Event
During the
Event
During the
Event
Post EventPost Event
Most importantlyMost importantly
Chaotic situation, difficult
to create “de novo”
programs, short term, ??
utility
Chaotic situation, difficult
to create “de novo”
programs, short term, ??
utility
Media
Effect,
research
papers…
Media
Effect,
research
papers…

47. 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

48. SUMMARY
Preparedness
Organization
Coordination
Communication
technology
Telemedicine
Saving lives!

49. ““There are no more excuses forThere are no more excuses for
any critically ill or trauma patientany critically ill or trauma patient
to die in any emergency room ofto die in any emergency room of
any country just because thereany country just because there
was no specialist available on sitewas no specialist available on site
to help with the resuscitation.to help with the resuscitation.””

50. 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

51. THE VACUUM OF KNOWLEDGE AND THE
Vacuum of hope
Digital divide was getting
bigger and wider…

52. INTEGRATED MIDDLE EASTERN TELEMEDICINE AND E-HEALTH PROGRAM
FOR PREVENTION, TREATMENT AND REHABILITATION OF LANDMINE
INJURIES AND OTHER TRAUMAS

53. INTEGRATED MIDDLE EASTERN TELEMEDICINE AND E-HEALTH PROGRAM
FOR PREVENTION, TREATMENT AND REHABILITATION OF LANDMINE
INJURIES AND OTHER TRAUMAS

54. What we do:
Change the delivery of existing medical care
Bring together new coalition of partners
with innovative boundaries and clear vision

55. 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

56. Disasters
• Landmines & Unexploded Devices

57. • =
57
Telemedicine in the Balkans

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