Stephen W. Cone

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.

Remote anesthetic monitoring using satellite telecommunications and the Internet.

Remote collaboration for anesthesia requires considerable sharing of physiologic data, audio, and images on a consistent data platform. A low-bandwidth connection between Ecuador and the United States supported effective joint management of operative plan, airway, intraoperative decisions, and recovery. Transmission with a 64-Kbps InMarSat satellite telephone (Thrane & Thrane, Denmark) connection from hospitals in Macas and Sucúa, Ecuador, to Richmond, Virginia, included preoperative patient evaluations, video of endotracheal intubations, electrocardiogram waveforms, pulse oximetry measurements, arterial blood pressure readings, capnography readings, and auscultation of breath sounds.

Implementation and evaluation of a low-cost telemedicine station in the remote Ecuadorian rainforest

A clinical workstation was developed to provide basic telemedicine services in a medical clinic in rural Ecuador. The unit cost was less than

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

1000. The system provided videoconferencing and a Spanish language electronic medical record (EMR) for clinic consultations. All partners participated in the development of the EMR. Over a six-month period, almost all new patient encounters and ultrasound studies were entered into the EMR. Of 2387 patient encounters, 572 were recorded in electronic format and 80% were transmitted over the Internet for consultation. Four hundred and eight ultrasound studies were filed with the EMR and 90% were transmitted over the Internet for shared evaluation. During the six months of the study, there were no serious software or hardware problems. The doctor in Ecuador was initially trained at the laboratory in the USA. The two sites were in contact by email almost daily. Without such interaction, the performance of the software and hardware would probably have been worse. When a structured programme of instruction, protocols, EMR and technology support is in place, telemedicine can support remote rural practice.

Snakebites in the Rainforests of Ecuador

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.

Evaluation of a documentation system for airway management training.

Epidemiologic information about snakebites in Ecuador is scarce. Snakebites are more common in the lowlands east of the Andes, in the Amazon basin. In the present study, a retrospective review of all (n = 142) snakebite admissions to Hospital Pio XII, a regional health center/hospital in the canton of Sucúa, Morona Santiago, Ecuador was carried out between the years of 1996 and 2000. Bites occurred more frequently during the months of March to May. The largest group of patients were in the 15- to 49-year-old range (52.5%), and agricultural workers were the most affected of all patients by occupation (> 40%). In most cases of snakebite, patients could not identify the type of snake that had bitten them. A small number of patients (n = 60, 42.3%) received some type of treatment prior to arrival at the hospital. Bites occurred most frequently on the left lower extremity (31.7%). Typical symptoms included pain and local edema at the snakebite site; generalized symptoms such as fever, nausea, and vomiting were less frequent. Most patients (almost 90%) received antivenin during hospitalization in addition to supportive care. The mean hospital stay was 4.3 days. More than 90% of all 142 patients recovered, about 8% with local abscesses. Mortality was 2.9% and occurred as a result of complications, including renal failure, respiratory failure, and disseminated intravascular coagulation.

Telesurgical presence and consultation for open surgery

Introduction: Resuscitation science is a dynamic part of healthcare training, with an expanding role for simulation. Historically, performance measurement and documentation relied upon the presence of an instructor, an expensive and potentially inaccurate assessment tradition that tied performance testing to a fixed facility. We hypothesize that an automated system might be developed and validated to document performance in airway management for self assessment in the absence of a human trainer. The system would also store and transmit data to a central registry to document skill acquisition and maintenance. Methods: Multiple video and pressure inputs captured and documented resuscitation task performance on a readily available standard practice manikin. Bag-valve-mask ventilation (BVM), endotracheal intubation, and ventilation via endotracheal tube (ETT) were studied for accuracy, adequacy, and time. The 12 participants performed each task for 5 repetitions, resulting in 60 total attempts for each skill. Results: Twelve untrained participants performed 3 critical tasks in airway management. Review with the system informed the participant of his/her performance and desired outcome. The system also documented skill performance objectively relative to a standard, recording both successes and failures. Compressed and abstracted performance records populated an average 14-megabyte file size (excluding full motion video). Discussion: This system was successfully used to document student performance of BVM, orotracheal intubation, and ventilation via ETT. The system easily integrates documentation, including text reports, airway pressure readings, still images and videos of task performance. Such digital documentation could guide skill acquisition and quantitatively certify performance with minimal reliance upon an instructor and evaluator.