Michael Czaplik

Technical and organisational feasibility of a multifunctional telemedicine system in an emergency medical service – an observational study

We evaluated the technical and organisational feasibility of a multifunctional telemedicine system in an emergency medical service (EMS) from the users perspective. The telemedicine system was designed to transmit vital signs data and 12-lead-ECG data, send still pictures and allow voice communication and video transmission from an ambulance. The data were sent to a teleconsultation centre staffed with EMS physicians (tele-EMS physician). The system was used in 157 EMS missions. The applications were used successfully on 80% of missions for real-time vital signs transmission and on 97% for video transmission. The quality of the transmitted still images (n = 64) was: 23% excellent, 50% good, 17% moderate, 9% rather poor and 0% unusable. The quality of the video streaming (n = 36) was: 33% excellent, 56% good, 6% moderate, 6% rather poor and 0% unusable. The tele-EMS physician was able to assist the EMS team in several cases and provided the preliminary information for the hospital in nearly all missions. Use of the telemedical system in EMS is feasible and the quality of the transmitted images and video was satisfactory. However, technical reliability and availability need to be improved prior to routine use.

Implementation phase of a multicentre prehospital telemedicine system to support paramedics: feasibility and possible limitations

BackgroundLegal regulations often limit the medical care that paramedics can provide. Telemedical solutions could overcome these limitations by remotely providing expert support. Therefore, a mobile telemedicine system to support paramedics was developed. During the implementation phase of this system in four German emergency medical services (EMS), the feasibility and possible limitations of this system were evaluated.MethodsAfter obtaining ethical approval and providing a structured training program for all medical professionals, the system was implemented on three paramedic-staffed ambulances on August 1st, 2012. Two more ambulances were included subsequently during this month. The paramedics could initiate a consultation with EMS physicians at a teleconsultation centre. Telemedical functionalities included audio communication, real-time vital data transmission, 12-lead electrocardiogram, picture transmission on demand, and video streaming from a camera embedded into the ceiling of each ambulance. After each consultation, telephone-based debriefings were conducted. Data were retrieved from the documentation protocols of the teleconsultation centre and the EMS.ResultsDuring a one month period, teleconsultations were conducted during 35 (11.8%) of 296 emergency missions with a mean duration of 24.9 min (SD 12.5). Trauma, acute coronary syndromes, and circulatory emergencies represented 20 (57%) of the consultation cases. Diagnostic support was provided in 34 (97%) cases, and the administration of 50 individual medications, including opioids, was delegated by the teleconsultation centre to the paramedics in 21 (60%) missions (range: 1–7 per mission). No medical complications or negative interpersonal effects were reported. All applications functioned as expected except in one case in which the connection failed due to the lack of a viable mobile network.ConclusionThe feasibility of the telemedical approach was demonstrated. Teleconsultation enabled early initiation of treatments by paramedics operating under the real-time medical direction. Teleconsultation can be used to provide advanced care until the patient is under a physician’s care; moreover, it can be used to support the paramedics who work alone to provide treatment in non-life-threatening cases. Non-availability of mobile networks may be a relevant limitation. A larger prospective controlled trial is needed to evaluate the rate of complications and outcome effects.

Xenon consumption during general surgery: a retrospective observational study

BackgroundHigh costs still limits the widespread use of xenon in the clinical practice. Therefore, we evaluated xenon consumption of different delivery modes during general surgery.MethodsA total of 48 patients that underwent general surgery with balanced xenon anaesthesia were retrospectively analysed according to the mode of xenon delivery during maintenance phase (ECO mode, AUTO mode or MANUAL mode).ResultsXenon consumption was highest during the wash-in phase (9.4 ± 2.1l) and further decreased throughout maintenance of anaesthesia. Comparison of different xenon delivery modes revealed significant reduced xenon consumption during ECO mode (18.5 ± 3.7L (ECO) vs. 24.7 ± 11.5L (AUTO) vs. 29.6 ± 14.3L (MANUAL); p = 0.033). No differences could be detected with regard to anaesthetic depth, oxygenation or performance of anaesthesia.ConclusionThe closed-circuit respirator Felix Dual offers effective reduction of xenon consumption during general surgery when ECO mode is used.

Analysis of regional compliance in a porcine model of acute lung injury

Lung protective ventilation in acute lung injury (ALI) focuses on using low tidal volumes and adequate levels of positive end-expiratory pressure (PEEP). Identifying optimal pressure is difficult because pressure-volume (PV) relations differ regionally. Precise analysis demands local measurements of pressures and related alveolar morphologies. In a porcine model of surfactant depletion (n=24), we combined measuring static pressures with endoscopic microscopy and electrical impedance tomography (EIT) to examine regional PV loops and morphologic heterogeneities between healthy (control group; CON) and ALI lungs ventilated with low (LVT) or high tidal volumes (HVT). Quantification included indices for microscopy (Volume Air Index (VAI), Heterogeneity and Circularity Index), EIT analysis and calculation of regional compliances due to generated PV loops. We found that: (1) VAI decreased in lower lobe after ALI, (2) electrical impedance decreased in dorsal regions and (3) PV loops differed regionally. Further studies should prove the potentials of these techniques on individual respiratory settings and clinical outcome.

Improved technical performance of a multifunctional prehospital telemedicine system between the research phase and the routine use phase – an observational study

Introduction Telemedical concepts in emergency medical services (EMS) lead to improved process times and patient outcomes, but their technical performance has thus far been insufficient; nevertheless, the concept was transferred into EMS routine care in Aachen, Germany. This study evaluated the system’s technical performance and compared it to a precursor system. Methods The telemedicine system was implemented on seven ambulances and a teleconsultation centre staffed with experienced EMS physicians was established in April 2014. Telemedical applications included mobile vital data, 12-lead, picture transmission and video streaming from inside the ambulances. The tele-EMS physician filled in a questionnaire regarding the technical performance of the applications, background noise and assessed clinical values of the transmitted pictures and videos after each mission between 15 May 2014–15 October 2014. Results Teleconsultation was established during 539 emergency cases. In 83% of the cases (n = 447), only the paramedics and the tele-EMS physician were involved. Transmission success rates ranged from 98% (audio connection) to 93% (12-lead electrocardiogram (ECG) transmission). All functionalities, except video transmission, were significantly better than the pilot project (p < 0.05). Severe background noise was detected to a lesser extent (p = 0.0004) and the clinical value of the pictures and videos were considered significantly more valuable. Discussion The multifunctional system is now sufficient for routine use and is the most reliable mobile emergency telemedicine system compared to other published projects. Dropouts were due to user errors and network coverage problems. These findings enable widespread use of this system in the future, reducing the critical time intervals until medical therapy is started.

Analgesia by telemedically supported paramedics compared with physician-administered analgesia: A prospective, interventional, multicentre trial.

In German emergency medical services (EMS), the analgesia is restricted to physicians. In this prospective, interventional, multicentre trial, complications with and quality of telemedically delegated analgesia were evaluated.

Potenzial und Wirksamkeit eines telemedizinischen Rettungsassistenzsystems

BACKGROUND The demographic change and an increasing multimorbidity of patients represent increasing challenges for the adequate prehospital treatment of emergency patients. The incorporation of supplementary telemedical concepts and systems can lead to an improved guideline-conform treatment. Beneficial evidence of telemedical procedures is only known for isolated disease patterns; however, no mobile telemedical concept exists which is suitable for use in the wide variety of different clinical situations. AIM This article presents a newly developed and evaluated total telemedical concept (TemRas) that encompasses organizational, medical and technical components. The use of intelligent and robust communication technology and the implementation of this add-on system allows the telemedical support of the rescue service for all emergencies. METHODS After development of the telemedical rescue assistance system, which includes organizational, medical and technical components, a telemedical centre and six ambulances in five different districts in North-Rhine Westphalia were equipped with this new tool. During the evaluation phase of 1 year in the routine emergency medical service the rate of complications as well as differences between urban and rural areas were analyzed with respect to different target parameters. RESULTS Between August 2012 and July 2013 a total of 401 teleconsultations were performed during emergency missions and 24 during secondary interhospital transfers. No complications due to teleconsultation were observed. The mean duration (±SD) of teleconsultations was longer in rural areas than in urban areas with 28.6±12.0 min vs. 25.5±11.1 min (p < 0.0001). In 63.2% of these missions administration of medications was delegated to the ambulance personnel (52.0% urban vs. 73.6% rural, p < 0.0001). The severity of ailments corresponded to scores of III and VI in the National Advisory Committee for Aeronautics (NACA) classification. CONCLUSION Emergency medical care of patients with support by a telemedical system is technically feasible, safe for the patient and allows medical treatment independent of spatial availability of a physician in different emergency situations.

Contact-free monitoring of circulation and perfusion dynamics based on the analysis of thermal imagery

Acute circulatory disorders are commonly associated with systemic inflammatory response (SIRS) and sepsis. During sepsis, microcirculatory perfusion is compromised leading to tissue hypoperfusion and potentially to multiple organ dysfunction. In the present study, acute lung injury (ALI), one of the major causes leading to SIRS and sepsis, was experimentally induced in six female pigs. To investigate the progress of body temperature distribution, measurements with a long-wave infrared camera were carried out. Temperature centralization was evidenced during ALI owing to impairments of peripheral perfusion. In addition, statistical analysis demonstrated strong correlations between (a) standard deviation of the skin temperature distribution (SD) and shock index (SI) (p<0.0005), (b) SD and mean arterial pressure (MAP) (p<0.0005), (c) ΔT/Δx and SI (p<0.0005), as well as between (d) ΔT/Δx and MAP (p<0.0005). For clarification purposes, ΔT/Δx is a parameter implemented to quantify the spatial temperature gradient. This pioneering study created promising results. It demonstrated the capacity of infrared thermography as well as of the indexes, SD and ΔT/Δx, to detect impairments in both circulation and tissue perfusion.

In vivo microscopy in a porcine model of acute lung injury.

Regional inhomogeneity and alveolar mechanics in a porcine model of acute lung injury (ALI) was evaluated using confocal laser scanning microscopy (CLSM). CLSM was performed through thoracic windows of the upper and lower lobes. Image quantification was conducted by use of a volume air index (VAI). Twelve anesthetized, mechanically ventilated pigs were randomized to non-injury (control group, n = 6) or ALI induced by surfactant depletion (ALI group, n = 6). CLSM was performed at baseline, after 1 h at 5 mbar and after 2 h at 15 mbar positive end-expiratory pressure (PEEP). Haemodynamics, respiratory mechanics and calculation of pulmonary ventilation-perfusion distribution by MIGET were determined. At baseline, VAI was not different. In the upper lobes, VAI significantly decreased in ALI compared to control group, with no changes after PEEP application. In the lower lobes, VAI significantly decreased in ALI compared to control group. Incremental PEEP significantly increased VAI in ALI, but not in control group. Haemodynamics were significantly compromised in the ALI group. A significant deterioration in oxygenation and ventilation-perfusion distribution could be seen being restored after PEEP adjustment. The VAI may help to assess regional inhomogeneity of the acutely injured lung.

Clinical proof of practicability for an ECG device without any conductive contact

Abstract Heart rhythm disturbances are common symptoms of several heart disorders. One of the most effective screening methods is the traditional electrode-based ECG. However, this examination can be both time- and resource-consuming. Capacitive-coupling ECG (cECG) screening – working without any conductive electrical contact with the patient – might help to shorten the time required for diagnosis. In this study, we examine the practicability of employing a non-contact capacitive ECG in a clinical setting. A total of 30 volunteer patients aged over 50 years without pacemakers were included in our trial, after obtaining their written informed consent and their medical history. A cECG as well as a conventional, conductive ECG were recorded simultaneously. In addition to mathematical analysis, ECG data were manually evaluated by two clinicians blinded to the recording method and patient conditions. Data from 30 patients were collected during our study, seven of whom had experienced myocardial infarction. The obtained cECG signals showed a high correlation with the simultaneously recorded Einthoven lead II of the conventional ECG. The values for heart rate, PQ and QT time periods correlated particularly well. Significant differences were observed with regard to QRS duration. Data recorded in the supine position contained less motion artefacts and, in particular, there were fewer breathing artefacts compared to data collected from those in a sitting position. Owing to the easy and quick application of the cECG system, the feedback from the examined patients was consistently positive. In conclusion, recording cECG data in a sitting position provided sufficient quality for screening purposes. Further studies will be needed for the evaluation of cECG appropriateness in diagnosing heart disease.