Telemedicine in Disaster Medicine

Technical Support by Smart Glasses During a Mass Casualty Incident: A Randomized Controlled Simulation Trial on Technically Assisted Triage and Telemedical App Use in Disaster Medicine

Andreas Follmann, MD, Marian Ohligs, MSc, Nadine Hochhausen, MD, Stefan K Beckers, MD, Rolf Rossaint, MD, and  Michael Czaplik, MD, PhD

 DOI: 10.2196/11939

Disclaimer: This is a summary of the highlights of this article, I do not own any or endorse any of the findings within this article. This is for educational purposes only and a full link for further review is included.

Key Points:

• Background: When you are lacking personnel resources, triage is important in disaster medicine. One potential problem solving approach is to support triage with Smart Glasses.

• Objective: In this study, augmented reality was used to display a triage algorithm and telemedicine assistance was enabled to compared duration and quality of triage with a conventional one.

• Methods: Used a specific Android app that was designed to be used with Smart Glasses – this added information in the augmented reality through 2 different methods.

  • Displaying triage algorithm in data glasses.

  • Telemedical connection to a senior emergency physician realized by the integrated camera.

• A randomized simulation study was created with 31 paramedics carried out a triage for 12 patients in 3 groups.

  • Without technical support (control)

  • Triage algorithm display and technical support

  • Telemedical contact while wearing data glasses

• Results: 362 assessments were performed.

  • Control Group:

    • Accuracy was 58%

    • Assessments took about 16.6 seconds

  • Technical support with triage algorithm displayed:

    • Accuracy was 92%

    • Assessments took about 37.0 seconds

  • Triage group wearing data glasses and being telemedically connected:

    • Accuracy was 90%

    • Assessments took about 35.0 seconds

• Conclusion: Smart glasses lead to digital capture of the triage results which could be useful but they did take a significantly longer time. The authors expected that these Smart Glasses in disaster scenarios and augmented reality could improve the quality of the triage.

Overview:

• Major challenges to emergency physicians involved in disaster settings include:

  • Lack of information about affected and injured

  • Initial difference between available and necessary resources require quick overview of overall situation

• Disaster medicine has some strategies to deal with assisting with management of mass casualties and prioritization of injured persons depending on the need and available resources. A system of triaging the varying severity degree is necessary in order to prioritize treatment and transport to a hospital.

  • Serious injuries need urgent treatment and immediate life-saving measures might be required.

  • Slightly injured patients need to be cared for but transportation from damaged areas can be postponed if resources are limited

• Different countries around the world have different triage algorithms to help rescue personnel and emergency physicians in categorizing patients. These algorithms are different for doctors and non-medical staff that do the “pretriage”.

• There are times when the various triage algorithms are not used correctly or just not used at all – this leads to incorrect categorization of triage and incorrect prioritization.

  • As a result, the already scarce resources are used incorrectly, treatment priorities are neglected and treatments are delayed.

• Seems like technical support for triage is really needed. The authors developed the idea of using augmented reality and the potential of data glasses.

  • A triage app that runs on Smart Glasses within the framework of the project Augmented Disaster Medicine.

  • Data is displayed on a small monitor on the Smart Glasses with a video stream of the integrated camera that is used for tele medical support.

  • Simple operating gestures are provided on an optical touchpad on the Smart Glasses, menu items can be selected, and simple manual entries can be made.

• The study aims to determine how feasible various technical methods are for triage support using these Smart Glasses.

  • Target parameters:

    • Average duration of screen process.

    • Accuracy of the assignment.

Methods:

• Android App:

  • Using the different menu levels, information is displayed to task forces so that the correct support can be offered.

  • Simple hand movements above the optical touchpad allow a decision tree to be processed and allow the result of the triage to be displayed.

  • The result is recorded digitally and assigned to the individual ID of the patient appendix card through a photo.

• Telemedical Support:

  • In Aachen, Germany: this has been used for many years in individualized medical emergency care in the routine prehospital rescue service

  • A telemedical-connected emergency medical service physician can offer medical assistance to the ambulance staff when it comes to making difficult decisions

    • Has not been used in disaster medicine as of yet.

  • The camera of the Smart Glasses was used to provide information about the mass casualty incidents (MCI) site through a live video transmission to a tele-EMS-physician.

  • Allows the physician to get an impression of the situation and carry out triage collaboratively with the on-site team and assign each patient to a triage category.

  • Access the full article in order to get details of the triage technical support system components.

Study Design

• A simulation was set up for evaluation in a randomized triage study on the grounds of the Fire Brigade and Rescue Training Center in Frankfurt.

  • Total of 12 professional actors mimed patients with different injuries. 2 of each injury were identical and the actors were told to exaggerate the case once and then understate it once.

    • refer to article for details of the injury patterns

• Total of 31 paramedics were subjects in the simulation study

  • Each had at least 2 years of being practicing EMS personnels

  • Inclusion criteria:

  • Requisite vocational training

  • Sufficient eyesight with contact lenses or without visual aids

  • Can’t wear Smart Glasses with prescription or reading glasses

• Participants were randomly assigned to 1 of the 3 groups

• Individual triage without further aids and document the results in a tally (Control)

• PRIOR algorithm provided by the Smart Glasses app

• Contact a tele-senior EMS physician collaboratively to carry out the triage of an injured patient through video streaming through the integrated camera of the data glasses

• To make sure all paramedics had the same level of knowledge regarding triage algorithms, everyone (including the control group) was trained for 1/2 hour before the simulation. No one was trained from before.

• Subjects completed the screening process according to their group assignment.

  • They were unobtrusively accompanied by someone that documented the duration of the triage and the selected category.

  • Primary targets were assessed: duration and accuracy of the triage.

  • If the selected triage category was not the correct category, it was marked.

  • Paramedics of the 2 technical supported groups completed a usability questionnaire.

  • All the participating teams were asked about their feelings of safety and asked about their individual options.

• Statistical analysis: nonparametric distribution of primary outcome parameters using the Mann-Whitney U test for independent samples

Results:

• User Results:

  • Total of 362 individual triages were performed by 31 paramedics

    • Control group: 20 paramedics that triaged 240 patients

    • PRIOR algorithm in Smart Glasses: 7 paramedics triaged 84 patients

    • Tele-senior EMS physician support: 4 paramedics triaged 38 patients

• Duration of Triage:

  • Control group: 16.6 seconds

  • PRIOR algorithm in Smart Glasses: 37.0 seconds

  • Tele-senior EMS physician support: 35.0 seconds

• Quality of Triage

  • Control group: accuracy of 58%

  • PRIOR algorithm in Smart Glasses: 92%

  • Tele-senior EMS physician support: 90%

  • The usability and sense of safety was sufficiently acceptable among subjects.

  • In paramedics that used the triage algorithm or a telemedicine contact: 73% stated good or very good usability of the Smart Glasses.

  • Several subjects stated that they felt much safer during the triage due to the technical support

  • Only 1 test person thought that the assistance by a tele-senior EMS physician was superfluous and felt the doctor’s contact was intrusive and he’d prefer triage alone in the future.

Discussion

• In the observation of the subjects – many of them were distinctly nervous so this confirmed that the simulation was realistic enough.

• Many went into “tunnel vision” and triages were wrong and in most situations, a higher priority category was selected.

• Control Group:

  • Even though the control group was explicitly instructed to use the algorithm, none of the subjected actually used the pocket card (this is actually also available for real disaster use in many EMS use)

  • Many studies have shown that checklists in medicine aren’t well accepted even though they’re regularly used in other safety related professions (ie. aviation).

• PRIOR triage algorithm on the Smart Glasses:

  • By working through the decision tree, participants were forced to use the PRIOR until the triage result was achieved.

  • This tool was actually used since the direct display of the algorithm was in from of their eyes unlike the pocket card.

  • This also resulted in a much longer duration of triage – doubled compared with the control group.

  • This group also had digitally recorded triage results as compared to a manual tally like the control group.

    • Many advantages with decisive importance in deployment tactics.

    • Allowed digital results to be retrieved from anywhere – in the future, this could help with early knowledge of human and material needs to help plan for rare resources like hospital capacity and ambulances

    • An internet connection isn’t needed to display the PRIOR algorithm in Smart Glasses but is required for the digital acquisition of the triage results.

• Telemedicine assistance in triage through a live video streaming through video in Smart Glasses

  • The better quality of triage is likely attributed to the high level of compliance with the better quality of triage with the guidelines for processing of the screening algorithm

  • Duration was markedly prolonged.

  • Digital acquisition of the triage results was achieved

  • Telephysicial was able to collect and document more information in addition to the trial category (ie. patient name, first diagnoses)

  • There is a longer time required for classification into the category III of the slightly injured is a well-known phenomenon in the PRIOR algorithm in addition to the high rate of over triage

  • The time lag from technical support was the lowest in category I

    • This category identifies severely injured patients with immediate treatment priority so this is pretty significant.

• There is no 100% accuracy in triage which can be explained by the different estimations of qualitative characteristics

• Group triage algorithm display on the data glasses did not achieve full accuracy.

• Other studies

  • Feasibility study was carried on the app of modern telemedicine in disaster to triage where only 2 patients were triaged with telemedicine.

    • No marked differences in quality of triage but the duration did have differences.

• Another study using the optical headhunted displays in disaster missions:

  • this was mentioned to be beneficial but there wasn’t any direct comparisons to a control group

• Another triage algorithm was tested on Google Glass during a full-scale exercise – this was to perform visually guided augmented reality Simple Triage and Rapid Treatment triage. This was used to identify casualties and collected georeferenced notes, photos, and videos to be incorporated into the debriefing.

  • Demonstrated for the first time the controlled randomized comparison between conventional triage, display of triage algorithms as augmented reality and tele medically assisted triage.

• Increased quality of triage using the Smart Glasses was reflected in the questioning of the subjects

  • Majority of subjected that underwent triage with technical support described a increased sense of security

  • This can be pretty important for the emergency services in stressful and unfamiliar situations like a disaster case.

• Sufficient usability of the Smart Glasses was confirmed under realistic conditions.

  • It was feasible to conduct operations with the Smart Glasses optical touchpad for menu control even while wearing protective gloves.

  • Simulation was completed by subjects wearing their own personal protective equipment.

Limitations:

• Different sizes of the study group resulting from the fact that the control group was part of the parallel observational study.

• Originally the 2 technical study groups were supposed to have n=10 however due to the given time slots, not all of the paramedics could participate.

• Lack of compatibility with personal glasses

• Local Wi-Fi connections led to problems

  • In 10 of the triages, no adequate connection could be achieved due to the structural obstacles and so these were excluded from the study results.

  • Probably need a mobile connection with sufficient network coverage and increased battery capacity

Conclusions:

• Technically assisted triage showed better quality than traditional methods

• Smart Glasses have shown to be a useful tool in disaster medicine and they allow EMS responders to continue working with both hands while info is on the monitor and data is collected through the integrated camera.

• Delay of the triage seems acceptable especially in view of the digital coverage of the integrated camera

  • Developments to the system and to the routine operations will likely shorten the duration of the triage markedly.

• Research on screening assistance procedures is still required in order to make sure there is sufficient quality of triage which is critical and can contribute to the targeted and prioritized treatment and support of patients in a disaster.