Edgar B. Rodas

Use of mobile low-bandwith telemedical techniques for extreme telemedicine applications

BACKGROUND Telemedicine is traditionally associated with the use of very expensive and bulky telecommunications equipment along with substantial bandwidth requirements (128 kilobytes per second [kbps] or greater). Telementoring is an educational technique that involves real-time guidance of a less experienced physician through a procedure in which he or she has limited experience. This technique has been especially dependent on the aforementioned requirements. Traditionally, telemedicine and telementoring have been restricted to technically sophisticated sites. The telemedicine applications through the existing telecommunication infrastructure has not been possible for underdeveloped parts of the world. STUDY DESIGN Telemedicine and telementoring were applied using low-bandwidth mobile telemedicine applications to support a mobile surgery program in rural Ecuador run by the Cinterandes Foundation and headed by Edgar Rodas, MD. A mobile operating room traveled to a remote region of Ecuador. Using a laptop computer equipped with telemedicine software, a videoconferencing system, and a digital camera, surgical patients were evaluated and operative decisions were made over low-bandwidth telephone lines. Similarly, surgeons in the mobile unit in Ecuador were telementored by an experienced surgeon located thousands of miles away at Yale University School of Medicine. RESULTS Five preoperative evaluations were conducted from Sucua to Cuenca, Ecuador, with excellent clinical correlation. Additionally, a laparoscopic cholecystectomy was successfully telementored from the department of surgery at Yale University School of Medicine to the mobile surgery unit in Ecuador. The telementored surgery was performed using a telephone line with a baud rate of 12 kbps. CONCLUSIONS Mobile, low-bandwidth telemedicine applications used in the proper technical and clinical algorithms can be very effective in supporting remote health care delivery efforts. Advantages of such applications include increased cost-effectiveness by limiting travel, expanding services to patients, and increased patient quality assurance.

Real-Time Internet Connections: Implications for Surgical Decision Making in Laparoscopy

ObjectiveTo determine whether a low-bandwidth Internet connection can provide adequate image quality to support remote real-time surgical consultation. Summary Background DataTelemedicine has been used to support care at a distance through the use of expensive equipment and broadband communication links. In the past, the operating room has been an isolated environment that has been relatively inaccessible for real-time consultation. Recent technological advances have permitted videoconferencing over low-bandwidth, inexpensive Internet connections. If these connections are shown to provide adequate video quality for surgical applications, low-bandwidth telemedicine will open the operating room environment to remote real-time surgical consultation. MethodsSurgeons performing a laparoscopic cholecystectomy in Ecuador or the Dominican Republic shared real-time laparoscopic images with a panel of surgeons at the parent university through a dial-up Internet account. The connection permitted video and audio teleconferencing to support real-time consultation as well as the transmission of real-time images and store-and-forward images for observation by the consultant panel. A total of six live consultations were analyzed. In addition, paired local and remote images were “grabbed” from the video feed during these laparoscopic cholecystectomies. Nine of these paired images were then placed into a Web-based tool designed to evaluate the effect of transmission on image quality. ResultsThe authors showed for the first time the ability to identify critical anatomic structures in laparoscopy over a low-bandwidth connection via the Internet. The consultant panel of surgeons correctly remotely identified biliary and arterial anatomy during six laparoscopic cholecystectomies. Within the Web-based questionnaire, 15 surgeons could not blindly distinguish the quality of local and remote laparoscopic images. ConclusionsLow-bandwidth, Internet-based telemedicine is inexpensive, effective, and almost ubiquitous. Use of these inexpensive, portable technologies will allow sharing of surgical procedures and decisions regardless of location. Internet telemedicine consistently supported real-time intraoperative consultation in laparoscopic surgery. The implications are broad with respect to quality improvement and diffusion of knowledge as well as for basic consultation.

Telemedicine and Electronic Health Information for Clinical Continuity in a Mobile Surgery Program

IntroductionAn intermittent surgical services program in rural Ecuador was able to benefit from close collaboration between surgeons and primary care physicians through the use of telemedicine technologies.MethodsInexpensive telemedicine workstations capable of patient documentation, imaging, and video-conferencing at extremely low bandwidth were established in collaborative primary care sites in rural Ecuador. Patients were screened for intermittent surgical services by primary caregivers according to the surgeons’ guidelines. Real-time and store-and-forward telemedicine allowed appropriate collaborative, informed decision-making. Surgery was performed, and postoperative care was similarly handled by on-site, familiar primary caregivers.ResultsTo date, this system has been used in more than 124 patient encounters (74 preoperative and 50 postoperative visits). The system allowed advance screening of patients on the part of the surgeons, leading to cancellations for 9 patients. Postoperatively, the system allowed 100% concurrence in postoperative diagnoses between the primary caregivers and the surgeons.ConclusionsInexpensive, low-bandwidth telemedicine solutions can support intermittent surgical services by providing patients to have contact with specialist care through their familiar, local primary caregivers.

Training to serve unmet surgical needs worldwide

In 1999, our world’s population passed the six billion mark. An estimated one-third to one-half of our world’s population—2 to 3 billion people—still lack basic surgical care! In this paper we attempt to address the question, “How best can surgical needs be met in a sustainable manner within resources available for training in less-developed populations?” Our goal is to raise awareness of the enormous unmet needs for surgical care in less-developed regions and to suggest ways in which Fellows of the American College of Surgeons may assist in helping meet the needs. In many developing countries, surgical training programs are patterned after North American or European programs. This tends to encourage subspecialization and might not produce surgeons adequately trained to manage the broad spectrum of surgical needs for which people attend their local district hospitals. A complete roster of surgical specialists cannot be made available in most district hospitals throughout the world. So surgeons serving in these hospitals require training and experience that encompass a broader range of surgery than is provided by the usual programs for training general surgeons. We will describe the needs, define the spectrum of surgery in most district hospitals, and outline some affordable and innovative options for surgical care. Our emphasis is on training and sustainability.

Telemedicine to Integrate Intermittent Surgical Services into Primary Care

Assessment of the logistics, economic feasibility, and accuracy of presurgical and postsurgical telemedicine consultations is reported. Virtual patient-surgeon consults were achieved through the use of desktop and laptop computers, digital video, and still cameras using two communications modalities. Patients were selected from rural clinics in the southern Oriente region and from communities located in the Andes Mountain range outside of Cuenca, Ecuador. Patients were evaluated preoperatively and postoperatively by general surgeons working with the Cinterandes Foundation, a not-for-profit organization providing surgical care in remote regions of Ecuador in cooperation with the Ministry of Healths primary care program. Preoperative and postoperative telemedicine consultations had a high measure of clinical accuracy and some economic value. Data were collected from several sites throughout the country during the course of the project. Formidable challenges were encountered and are reported here.

Low-bandwidth telemedicine for pre- and postoperative evaluation in mobile surgical services

Low-bandwidth telemedicine was used for the pre- and postoperative evaluation of patients treated by a mobile surgery service in remote Ecuador. Realtime and store-and-forward telemedicine was employed, using PCs connected via the ordinary telephone network. Between February 2002 and July 2003, 144 patients were studied preoperatively and 50 postoperatively. It was possible to establish 20 satisfactory preoperative realtime connections, which allowed good-quality, simultaneous audiovisual transmission. Thus, there were 124 preoperative assessments done by store-and-forward telemedicine and 50 postoperative assessments. Diagnoses and management plans made by a surgeon using telemedicine were compared with those made independently by a second surgeon, who saw the patient face to face. Due to poor quality of the transmitted images, 43 patients were excluded from the preoperative study and 13 from the postoperative study. In the 101 preoperative evaluations, there was agreement in 78 cases (77%); in the 37 postoperative evaluations, there was agreement in 36 cases (97%). Telemedicine may reduce the time required on site for preoperative planning, and may provide reliable postoperative surveillance, thus improving the efficiency of mobile surgery services.

Intermittent and Mobile Surgical Services: Logistics and Outcomes

A program of intermittent surgical services utilized a mobile facility to support multiple primary care sites in Ecuador. The fiscal and clinical outcomes of the program were analyzed. From 1994 to 2003 the mobile program responded to requests from 15 of 22 provinces of Ecuador for surgical care. The sites served could not offer permanent surgical care. Criteria for inclusion and follow-up were set. Medical records were kept in accordance with standards of the Ministry of Health. Standards of care and critical care pathways were instituted. The program had a permanent staff supplemented by volunteers. Cases were recorded and outcomes noted with respect to complications. The cost of the surgical aspect of the program was entirely covered by a foundation through donations and public service contracts. Financial records of the foundation were reviewed and the costs analyzed. A total of 4545 operations were done largely in general surgery specialties. The program made 40 to 50 excursions each year and proved to be a stable element of medical care delivery. There were no deaths, four major complications, and three minor complications. The cost per operation was less than

International trauma teleconference: evaluating trauma care and facilitating quality improvement.

100. Comparison to U.S. and international volunteer organizations are reported. This program of intermittent mobile surgical services in coordination with fixed primary care constitutes a sustainable, high quality clinical program fully integrated into existing care of a national health ministry. In-country resources may provide greatly enhanced services at low cost and should be considered as an alternative.

Status of trauma quality improvement programs in the Andean region: What foundation do we have to build on

BACKGROUND Evaluation, development, and implementation of trauma systems in Latin America are challenging undertakings as no model is currently in place that can be easily replicated throughout the region. The use of teleconferencing has been essential in overcoming other challenges in the medical field and improving medical care. This article describes the use of international videoconferencing in the field of trauma and critical care as a tool to evaluate differences in care based on local resources, as well as facilitating quality improvement and system development in Latin America. MATERIALS AND METHODS In February 2009, the International Trauma and Critical Care Improvement Project was created and held monthly teleconferences between U.S. trauma surgeons and Latin American general surgeons, emergency physicians, and intensivists. In-depth discussions and prospective evaluations of each case presented were conducted by all participants based on resources available. Care rendered was divided in four stages: (1) pre-hospital setting, (2) emergency room or trauma room, (3) operating room, and (4) subsequent postoperative care. Furthermore, the participating institutions completed an electronic survey of trauma resources based on World Health Organization/International Association for Trauma and Surgical Intensive Care guidelines. RESULTS During a 17-month period, 15 cases in total were presented from a Level I and a Level II U.S. hospital (n=3) and five Latin American hospitals (n=12). Presentations followed the Advanced Trauma Life Support sequence in all U.S. cases but in only 3 of the 12 Latin American cases. The following deficiencies were observed in cases presented from Latin America: pre-hospital communication was nonexistent in all cases; pre-hospital services were absent in 60% of cases presented; lack of trauma team structure was evident in the emergency departments; during the initial evaluation and resuscitation, the Advanced Trauma Life Support protocol was followed one time and the Clinical Randomization of an Antifibrinolytic in Significant Hemorrhage protocol on two occasions; it was determined that imaging resources were adequately used in half of the cases; the initial care was mostly provided by emergency room physicians; and a surgeon, operating room, and intensive care unit were not readily available 83% of the time. The ease of patient flow was cumbersome because of a lack of a structured system for trauma care except for one academic urban center. Adequate trauma resources are present in less than 50% of the time. Multidisciplinary resources, quality improvement programs, protocols, and guidelines were deficient. CONCLUSIONS A well-structured international teleconference can be used as a dynamic window of observation to evaluate and identify deficiencies in trauma care in the Latin American region. These findings can be used to formulate specific recommendations based on local resources. Furthermore, by raising local awareness, leaders could be identified to become the executors of more efficient healthcare policies that can potentially affect trauma care.

Trauma Education and Care in the Jungle of Ecuador, Where There is no Advanced Trauma Life Support

INTRODUCTION Trauma quality improvement (QI) programs have been shown to improve outcomes and decrease cost. These are high priorities in low- and middle-income countries (LMICs), where 2,000,000 deaths due to survivable injuries occur each year. We sought to define areas for improvement in trauma QI programs in four LMICs. METHODS We conducted a survey among trauma care providers in four Andean middle-income countries: Bolivia, Colombia, Ecuador, and Peru. RESULTS 336 physicians, medical students, nurses, administrators and paramedical professionals responded to the cross-sectional survey with a response rate greater than 90% in all included countries except Bolivia, where the response rate was 14%. Eighty-seven percent of respondents reported morbidity and mortality (M&M) conferences occur at their hospital. Conferences were often reported as infrequent - 45% occurred less than every three months and poorly attended - 63% had five or fewer staff physicians present. Only 23% of conferences had standardized selection criteria, most lacked documentation - notes were taken at only 35% of conferences. Importantly, only 13% of participants indicated that discussions were routinely followed-up with any sort of corrective action. Multivariable analysis revealed the presence of standardized case selection criteria (OR 3.48, 95% CI 1.16-10.46), written documentation of the M&M conferences (OR 5.73, 95% CI 1.73-19.06), and a clear plan for follow-up (OR 4.80, 95% CI 1.59-14.50) to be associated with effective M&M conferences. Twenty-two percent of respondents worked at hospitals with a trauma registry. Fifty-two percent worked at institutions where autopsies were conducted, but only 32% of those reported the autopsy results to ever be used to improve hospital practice. CONCLUSIONS M&M conferences are frequently practiced in the Andean region of Latin America but often lack methodologic rigor and thus effectiveness. Next steps in the maturation of QI programs include optimizing use of data from autopsies and registries, and systematic follow-up of M&M conferences with corrective action to ensure that these activities result in appreciable changes in clinical care.