Research was deemed exempt by the institutional review board.  A simulated Mars research environment was utilized on Devon Island in the Canadian Arctic.  Electronic communications including audio and video were established between the Arctic base and Henry Ford Hospital serving as Mission Control and incorporated the 15-minute communications lag into all communication.  Ultrasound and laparoscopic capabilities were integrated into communications for remote guidance.  Remote guidance methods and technology utilized has been previously published in communication with the international space station.

A simulated scenario involving a young female astronaut developing right lower quadrant pain was developed and utilized for this demonstration.  An anatomical appendectomy model was utilized for the ultrasound and laparoscopic portions.  Reference aids describing background technical aspects were developed.  A set of confirmation milestones was used to generate a hard stop and mandated remote review.

We report a successful remote guidance demonstration from a simulated mars environment with clinical control from a terrestrial base utilizing appropriate delay and consistent bandwidth and technology.  Reference aids were appropriate for non-surgical personnel and hard stops for milestones with remote approval and go ahead were shown to be feasible.  The appendicitis was appropriately diagnosed utilizing remote guidance of ultrasonography and the appendix removed laparoscopically using stapled technique with remote guidance as well.

We identified the critical maneuver during a laparoscopic cholecystectomy, as the identification and division of the cystic duct. Consequently, we captured a short video segment of this decisive stage of the surgery, during multiple subsequent Cholecystectomies.  Video was captured from laparoscopic camera input and sent via DVI2USB Solo frame grabber to a video recording application on laptop. Seven-second video clips of the presumed cystic duct were recorded, converted, and emailed to physician consultants on their PDAs: Blackberry(R), Apple iPhone, and PlayStation(R) Portable devices.

We were able to successfully transmit three video clips to to all three devices and present them to expert physicians, each of whom believed consulting advice could be offered based on the image quality.
Although formal validity has yet to be established, this represents proof-of-concept.  We succeeded in establishing a reproducible method of accurately transmitting sufficient video for telementoring and pursuit of increased patient safety utilizing primarily existing infrastructure.

Ultrasound:
Also known as diagnostic sonography, medical sonography, and medical ultrasonography, ultrasound is a diagnostic medical imaging technique used to visualize muscles, tendons, and many internal organs, their size, structure and any pathological lesions with real time tomographic images. It is also used to visualize a fetus during routine and emergency prenatal care. Ultrasound scans are performed by medical health care professionals called sonographers. Obstetric sonography is commonly used during pregnancy. Source.

Laparoscopy:
Also referred to by the medical term laparoscopic surgery, or the less medical terms minimally invasive surgery (MIS), bandaid surgery, keyhole surgery, and pinhole surgery. Laparoscopy is the process of surgery using a telescopic rod lens system connected to a camera to perform operations in the abdomen through small incisions, using the camera/lens system as a guide. Source.

VGA:
VGA stands for Video Graphics Array and is the most common connector for analog video on computer equipment and various electronics with an analog video output. VGA carries a RGB (red-green-blue) signal and is also referred to as D-Sub due to its’ 15-pin connector. Source.

DVI:
DVI stands for Digital Visual Interface and is a digital video format used on most modern computer monitors. It is forward compatible with HDMI video in digital mode and fully compatible with VGA video in analog mode.

The DVI connector carries both a digital and analog video signal. It is of rectangular form and comes in a variety of flavors dependant on its pin layout. Source.

Neil S. Shah

Visual input from a surgical site can be transmitted over the Internet from a laparoscopic tower to personal handheld device, utilizing off-the-shelf solutions.

Real-time video display is provided by the laparoscope camera input and sent to a DVI2USB Solo frame grabber (700.00 USD, manufactured by Epiphan Systems Inc), which can capture single-link Digital Video Interface (DVI) video signals via a male-to-male DVI cable connected to the laparoscopic tower. A frame grabber obtains a large amount of visual data, converts it to RGB format at the highest color depth it can support, then compresses and optimizes the data for transmission. This particular frame grabber model was chosen for its ability to acquire video signals from DVI sources (in this case, the laparoscopic tower), and the Solo specifically because it can support the output of the video source. The frame grabber dimensions are highly compact (5” x 3.2” x 1.2”) and itself is commercially available to any consumer at a price of approximately 700.00 USD. The Solo package comes with the DVI2USB solo box, DVI cable, USB cable, power adapter and easy-to-apply user’s installation guide.

The output from the frame grabber connects to any standard laptop with USB 2.0 standard port via USB mini type B cable, and is compatible with Windows 2000, Windows XP, Windows Vista (x86, amd64), Mac OS X, or Linux (x86, amd64) operating systems. DVI2USB solo transfers substantial amounts of data for each captured frame (30 frames per second at any resolution up to 1920x1200) and as such is not compatible with the slower USB 1.0 and 1.1 buses. The advantage of this is DVI2USB solo does not reduce the resolution of the images it captures in order to transfer it over USB.

The captured data can be sent by the Epiphan USB device driver to the video capture application as well as to Microsoft DirectShow (on Windows) or Epiphan QuickTime component (on Mac OS X). The Epiphan video capture application receives and processes the data so that users can display, modify, and record images. In Windows, data can be sent to a video codec in order to save as Windows AVI files, and Mac OS X can record video using QuickTime software. This capability is highly valuable for the purpose of data storage and quality control.

Currently, there is no easy way to stream the video live to a BlackBerry®, iPhone, or PSP® device due to the large size of captured video and need to convert to the correct handheld format. Consequently, using video recording software such as TechSmith Camtasia Studio or HackTV Carbon, the stream can be recorded to the computer’s hard drive in any resolution desired (up to the maximum capacity of the DVI signal). One can then convert the video using eRightSoft SUPER© or other free video conversion software to the correct format for the handheld device desired, compressed to a smaller output size. This new video file is ready to be emailed as an attachment to the desired handheld device, and can be played directly using the mobile device’s internal media player. These steps, with practice, can be performed such that the time delay will not exceed 5-10 minutes before appearing on the recipient’s viewing screen.

Neil S. Shah

Visual input from a surgical site can be transmitted real-time over the Internet from a laparoscopic tower to personal computer or laptop situated in a remote location, with cost-effective and easy-to-use materials.

Real-time video display is provided by the laparoscope camera input and sent to a DVI2USB Solo frame grabber (700.00 USD, manufactured by Epiphan Systems Inc), which can capture single-link Digital Video Interface (DVI) video signals via a male-to-male DVI cable connected to the laparoscopic tower. A frame grabber obtains a large amount of visual data, converts it to RGB format at the highest color depth it can support, then compresses and optimizes the data for transmission. This particular frame grabber model was chosen for its ability to acquire video signals from DVI sources (in this case, the laparoscopic tower), and the Solo specifically because it can support the output of the video source. The frame grabber dimensions are highly compact (5” x 3.2” x 1.2”) and itself is commercially available to any consumer at a price of approximately 700.00 USD. The Solo package comes with the DVI2USB solo box, DVI cable, USB cable, power adapter and easy-to-apply user’s installation guide.

The output from the frame grabber connects to any standard laptop with USB 2.0 standard port via USB mini type B cable, and is compatible with Windows 2000, Windows XP, Windows Vista (x86, amd64), Mac OS X, or Linux (x86, amd64) operating systems. DVI2USB solo transfers substantial amounts of data for each captured frame (30 frames per second at any resolution up to 1920x1200) and as such is not compatible with the slower USB 1.0 and 1.1 buses. The advantage of this is DVI2USB solo does not reduce the resolution of the images it captures in order to transfer it over USB.

The captured data can be sent by the Epiphan USB device driver to the video capture application as well as to Microsoft DirectShow (on Windows) or Epiphan QuickTime component (on Mac OS X). The Epiphan video capture application receives and processes the data so that users can display, modify, and record images. In Windows, data can be sent to a video codec in order to save as Windows AVI files, and Mac OS X can record video using QuickTime software. This capability is highly valuable for the purpose of data storage and quality control.

Next, using Skype™, a free-to-use consumer market videoconferencing software, one must set the DVI2USB Solo Driver as the primary webcam. For transmission to a remote laptop or projection workstation, the user only has to sign in with a user account, and make a video call to a recipient available for contact, and the stream is captured live by the recipient’s computer.

For any application in which a video signal is sent to a wireless device, the correct video codecs and parameters must be set in order ensure the highest possible quality while maintaining a reasonable bandwidth for the wireless device to handle. This article explains the video formats to be used for the transmission of video to the Sony PSP, Apple iPhone, and BlackBerry Pearl internet-capable wireless handheld devices.

Neil S. Shah

Sony PSP®

For transmission to a Sony PlayStation® Portable device, real-time video broadcast over the Internet is not currently feasible. Using TechSmith Camtasia Studio 5.1 on a Windows-based computer, digital video was captured (1 min.) and produced into an uncompressed, typically large-sized AVI file format. Next, it was converted to a format (MPEG-4, 320x240 QVGA, 535 Kbps, 15.00 fps) compatible with the PSP® device using XviD4PSP 5.034. This resulted in a small-sized, compatible video file that was then emailed as an attachment to the recipient. Analogous capture and conversion programs exist for the Macintosh operating system. For retrieval of video from a Sony PlayStation® Portable, the recipient turned on the device, accessed the Internet using a local Wi-Fi connection, and signed into the email account. The attachment was then downloaded directly to the Video folder of the PSP, from which it could be played by the recipient.

Apple iPhone

For transmission to an Apple iPhone device, real-time video broadcast over the Internet is not currently feasible. Capture and conversion steps were the same as for the Sony PSP® device, using iPhone video format settings (MPEG-4, 320x240 QVGA, 531 Kbps, 15.00 fps). This resulted in a small-sized, compatible video file that was then emailed as an attachment to the recipient. For retrieval of video from an Apple iPhone, the recipient turned on the device, accessed the Internet using the cellular service, and signed into the email account. The attachment was then downloaded and played by the recipient.

BlackBerry® Pearl™ 8130 or BlackBerry® 8830

For transmission to a BlackBerry® wireless handheld device, real-time video broadcast over the Internet is not currently feasible. Capture and conversion steps were the same as for the Sony PSP® and Apple iPhone devices, using BlackBerry® format settings (MPEG-4, 320x240 QVGA, 387 Kbps, 15.00 fps). However, these models of BlackBerry® do not currently support opening or downloading of these video attachments directly from emails. Consequently, the video file was uploaded to a dedicated website, and a text link to the website was emailed to the recipient. For retrieval of video from a BlackBerry® wireless handheld device, the recipient accessed the personal email account and clicked on the Web hyperlink, then downloaded and saved the clip to the Video Media folder. Since this used the BlackBerry® server and not the local area network to download, it was the most time consuming aspect of the process. Once saved, the video was easily viewed by the recipient.

Neil S. Shah
June 19, 2008

Background and Significance

With rising healthcare complexity, costs and diminishing supply of resources available for high physician demand, there is an escalating need for leveraging assets across boundaries [Lai]. Most institutions do not possess the capital and assets necessary to provide authoritative specialist opinion locally on hand.  Rather than being concentrated at a particular setting, expert resources need to be allocated across multiple locations and environments. With increasing specialization and mounting general surgeon shortage, there is rising fear that resource insufficiency will lead to diminished quality of patient care [Cofer].

Laparoscopic-assisted surgery provides a minimally invasive technique by which a wide range of operations spanning many subspecialties can be performed with camera guidance. It has many potential applications for traumatic as well as non-traumatic abdominal injuries. The advantages are numerous as laparoscopy allows for organ-specific diagnosis and treatment provision, thus avoiding unnecessary laparotomy, minimizing morbidity, shortening hospital stay, and hastening recovery for the patient [Gorecki, Schulam].  However, the learning curve for the technique is quite high because the two-dimensional working field requires some familiarization [Pokorny, Rosser]. Due to the cost and intricacy of operating the laparoscopic instruments and tower, training surgeons are finding it difficult to practice skills in a nonsurgical setting [Pokorny]. Although some hospitals now have laparoscopic simulators for trainees, most institutions do not due to the high costs. With the difficulty of training surgeons in laparoscopic procedures, the ability to inexpensively teleconference with an expert physician becomes highly valuable.

Telemedicine involves the transfer of medical information for the purpose of remote medical consultation, assessment or procedure. Telementoring entails not only healthcare delivery to a patient, but also educational guidance of a physician by a remote surgeon [Pande, Rosser]. Telesurgical consultation and telementoring provide means by which a patient can be treated at a distance by allowing an expert to educate, assist, and supervise the operating surgeon [Pande]. In many cases, telementoring is considered by primary surgeons to be a highly useful tool to have at hand [Sebajang]. Previous telesurgical mentoring studies have demonstrated viability of such an endeavor using high-cost professional teleconferencing tower cameras that can transmit live video to fixed, predetermined and specially equipped central consultation sites [Schulam, Rogers]. These cameras are often fixed and as such, may not even be able to provide a complete view of the patient. In addition, they are complex to implement and use, such that non-technical physicians would have a difficult time setting such a system up without outside help and an additional expense.

Currently, there has been much press about the “Remote Presence Robot” (InTouch Health®) and its ability to enhance telemedicine. The advantage of the robot over traditional stationary video conferencing equipment is mobility that fixed cameras cannot provide and ease of operation via remote joystick. In Michigan, on-call hospital specialists have used laptops and the Internet to connect to a robot stationed at the patient’s bedside and provide live consultation for emergent situations. They have also been used in hospitals to take the place of physician rounds. However, although the robot has mobility, it nevertheless requires constant monitoring and a real assistant in order to carry out most tasks such as note-taking. The RP-7® model Robot carries a high cost (~$150,000) for the simple telepresence it provides, with RP Connectivity Service ($10,000/mo.) from InTouch Health® required to constantly monitor it.

We will describe the development of an internet-based telemedical system that makes use of low-cost and practical alternatives while providing equivalent and improved services. Studies have already publicized that telemedicine endeavors are more successful when the user interface is simplified and easy to implement [Zahedi]. In addition, real time multimedia data transfer to handheld computers/PDAs via institutional wireless network has also been demonstrated [Gandsas, Georgiadis, Banitsas]. Laparoscopic-assisted cholecystectomy and other procedures have also been sent in real time to remote locations for surgical consultation over low cost, low bandwidth Internet connections [Broderick]. However, in each case the technology was not easy to implement, nor was it highly economical. With the intention of establishing a practical and cost-effective method of providing remote real-time intraoperative consultation, we propose to design, employ, and assess an easily adaptable telecommunications system for the purpose of mentoring clinicians while promoting patient safety.

Hypothesis/Expected Outcomes

We expect to be able to successfully integrate the teleconsultation system into a variety of settings and situations, and initiated by personnel with any type of technological background, substantiating the claims of convenience and ease of implementation. We hope to fulfill all proposed aims and expect the utilization of this new method of surgical healthcare strategy will result in enhanced patient safety and care.

Overall Aims

Specific Aims

Research Design and Methods

Specifically, we will assemble an initial prototypical scheme that will include 3 major components: visual input from the surgical site, a telecommunications link, and a visual output to the desired consulting physician.

Real-time video display is provided by the laparoscope camera input and sent to a DVI2USB Solo frame grabber (manufactured by Epiphan Systems Inc), which can capture single-link Digital Video Interface (DVI) video signals via a male-to-male DVI cable connected to the laparoscopic tower. A frame grabber obtains a large amount of visual data, converts it to RGB format at the highest color depth it can support, then compresses and optimizes the data for transmission. This particular frame grabber model was chosen for its ability to acquire video signals from DVI sources (in this case, the laparoscopic tower), and the Solo specifically because it can support the output of the video source.

The frame grabber dimensions are highly compact (5” x 3.2” x 1.2”) and itself is commercially available to any consumer at a price of approximately 700.00 USD. The Solo package comes with the DVI2USB solo box, DVI cable, USB cable, power adapter and easy-to-apply user’s installation guide:

DVI2USB Solo                DVI Cable                      USB cable                Power Adapter

The output from the frame grabber connects to any standard laptop with USB 2.0 standard port via USB mini type B cable, and is compatible with Windows 2000, Windows XP, Windows Vista (x86, amd64), Mac OS X, or Linux (x86, amd64) operating systems. DVI2USB solo transfers substantial amounts of data for each captured frame (30 frames per second at any resolution up to 1920x1200) and as such is not compatible with the slower USB 1.0 and 1.1 buses. The advantage of this is DVI2USB solo does not reduce the resolution of the images it captures in order to transfer it over USB.

Hardware system requirements for the video capture workstation for the DVI2USB solo are 2.66 GHz processor speed, USB 2.0 port, 256 MB DDR2 RAM memory, and 5 MB hard disk space. Software system requirements consist of installation of DVI2USB drivers and application, which can easily be accomplished by following the frame grabber install guide.

Installing the Windows DVI2USB drivers and application compatible with the Microsoft DirectShow application programming interface (adapted from Epiphan Systems frame grabber install guide http://www.epiphan.com/pdf/frame_grabber_install_guide.pdf):

Installing the MAC OS X DVI2USB drivers and application compatible with the Apple QuickTime application programming interface (adapted from Epiphan Systems frame grabber install guide http://www.epiphan.com/pdf/frame_grabber_install_guide.pdf):

Connecting a DVI2USB Solo Device (adapted from Epiphan Systems frame grabber install guide http://www.epiphan.com/pdf/frame_grabber_install_guide.pdf):

The captured data can be sent by the Epiphan USB device driver to the video capture application as well as to Microsoft DirectShow (on Windows) or Epiphan QuickTime component (on Mac OS X). The Epiphan video capture application receives and processes the data so that users can display, modify, and record images. In Windows, data can be sent to a video codec in order to save as Windows AVI files, and Mac OS X can record video using QuickTime software. This capability is highly valuable for the purpose of data storage and quality control.

The video capture workstation can then be used as a server to stream the video over the internet via consumer market software internet video conferencing software (ooVoo and Skype™) and can be accessed by the consulting physician, who is notified of the assistance needed by a telephone call from the operating room. The telephone line is used as the primary means of two-way communication from consulting physician to the intraoperative setting, while video display characteristics can only be visually delineated by the operating surgeon in a unidirectional manner. Both ooVoo and Skype™ have the ability to detect the DVI2USB Solo Driver and set it as the primary webcam for the software. For privacy issues, the software can be set up to only be accessible to users that are verified by the person transmitting the video feed.

After initial intra-hospital studies, the equipment can be expanded to the inter-hospital setting, with increasingly compact mobile devices such as personal digital assistants like Apple’s iPhone or the Sony PlayStation Portable. In order to judge the quality of consultation opportunity this system provides, the physicians can be surveyed for satisfaction and utility, comparing the use of video image to the previous methods of consultation.

Discussion

Standard hospital laparoscopes offer the advantage of having in-house, sterile means by which a video image can be captured real-time without the additional expense of purchasing expensive camera equipment for operative situations. Laparoscopic equipment carries an expense, however most major institutions carry them for laparoscopic-assisted surgical procedures anyway, and rarely are all the laparoscopes carried by the hospital in simultaneous use.

This system will not require highly special electronic wiring or extensive cabling of the working areas, and will use free or low-cost, commercially available internet video conferencing software (ooVoo and Skype™) to connect to and collaborate with any consulting expert desired by the operating surgeon. Additionally, the organization of this system is highly adaptable to a diverse array of situations, with increased implementation convenience and portability over previous methods and practices. By streaming the video over internet via an “off the shelf” personal laptop, it has potential to be accessed by technology ranging from lecture hall projectors to desktop workstations to personal digital assistants and smart phones.

The advantages over the “Remote Presence Robot” (InTouch Health®) are numerous, as this system provides many equivalent services at a much lower cost and easier learning curve due to the “off the shelf” components. Currently, the remote presence robot cannot be connected to a laparoscope tower or ultrasound station, nor can it provide written notes. It is simply a telepresence.

This telemedical system also provides an efficient means by which satellite stations of the same hospital health system can intra-institutionally avoid unnecessary duplication of services and leverage subspecialty availability in a beneficial manner for both parties. An affordable and adaptable teleconsultation system incorporating laparoscopic visualization presents many benefits to physicians, and more importantly to the patient due to the accessibility of expert opinion by operating surgeons at any moment necessary. Consulting physicians and mentors are not burdened by the inconvenience of having to travel to confer with colleagues or teach.

A subject of significance is how to decide which situations this consultation system should be employed in. For easily diagnosed disorders, there is typically no need for a consultation. However, a complicated case would benefit from another physician’s opinions, and a video feed of the situation would greatly assist the remote consultation. In most instances, a wise physician gathers as much information as possible in order to make the best and most accurate diagnosis possible. A visual depiction of the patient as well as the treating physician offers additional indications and cues that one otherwise may never have realized. Another example of appropriate use of this system is during transfer of care of patients. In this situation, rather than simply having a telephone description of a patient’s circumstances, it would help to have a video image to aid the new physician in making a better association and providing more patient-centered care.

Shortcomings and Alternatives

Currently there is a one-second latency between real-time and transmission to the consulting physician, however we do not foresee any major difficulties caused by this issue. In addition, the image quality is compressed and reduced when transmitted over the internet, thus for diagnostic purposes it must be studied further to determine if it is sufficient to make an accurate consultation. Finally, with the current methods the surgeon in the operating room must reach the consulting physician via telephone and can point out particular aspects of the image one-way, but the consultant has no means to indicate characteristics visually for the operating surgeon.

Future Application

This system can be used for many purposes in the future, including resident education by streaming live or stored feeds of surgeries to remote conference rooms, or teleconferencing with a translator for patients who speak a foreign language. The low cost of materials and easy-to-implement features allow for possible future deployment in underserved communities and developing countries [Pande, Zahedi]

References
Banitsas, K. A., et al. "Using Handheld Devices for Real-Time Wireless Teleconsultation." Conference proceedings : ...Annual International Conference of the IEEE Engineering in Medicine and Biology Society.IEEE Engineering in Medicine and Biology Society.Conference 4 (2004): 3105-8.
Broderick, T. J., et al. "Real-Time Internet Connections: Implications for Surgical Decision Making in Laparoscopy." Annals of Surgery 234.2 (2001): 165-71.
Cofer, J. B., and R. P. Burns. "The Developing Crisis in the National General Surgery Workforce." Journal of the American College of Surgeons 206.5 (2008): 790,5; discussion 795-7.
Gandsas, A., K. McIntire, and A. Park. "Live Broadcast of Laparoscopic Surgery to Handheld Computers." Surgical endoscopy 18.6 (2004): 997-1000.
Georgiadis, P., et al. "PDA-BASED TELERADIOLOGY SYSTEM WITH REAL-TIME VOICE CONFERENCING CAPABILITIES." .
Gorecki, Pioter. The Role of Laparoscopy., 2005.
Lai, F. "Robotic Telepresence for Collaborative Clinical Outreach." Studies in health technology and informatics 132 (2008): 233-5.
Pande, R. U., et al. "The Telecommunication Revolution in the Medical Field: Present Applications and Future Perspective." Current surgery 60.6 (2003): 636-40.
Pokorny, M. R., and S. L. McLaren. "Inexpensive Home-made Laparoscopic Trainer and Camera." ANZ Journal of Surgery 74.8 (2004): 691-3.
Rogers, F. B., et al. "The use of Telemedicine for Real-Time Video Consultation between Trauma Center and Community Hospital in a Rural Setting Improves Early Trauma Care: Preliminary Results." The Journal of trauma 51.6 (2001): 1037-41.
Rosser, J. C.,Jr, S. M. Young, and J. Klonsky. "Telementoring: An Application Whose Time has Come." Surgical endoscopy 21.8 (2007): 1458-63.
Schulam, P. G., et al. "Telesurgical Mentoring. Initial Clinical Experience." Surgical endoscopy 11.10 (1997): 1001-5.
Sebajang, H., et al. "Telementoring: An Important Enabling Tool for the Community Surgeon." Surgical innovation 12.4 (2005): 327-31.
Zahedi, E., M. A. M. Ali, and M. J. Gangeh. Design of a Web-Based Wireless Mobile Teleconsultation System with a Remote Control Camera. Vol. 2., 2000.

FAST ultrasound video log transmission via iPhone for overreading

Dan Nguyen

Introduction and Justification

Since the early 1980s, bedside ultrasound by emergency physicians has become increasingly popular [1]. The use of FAST ultrasoungraphy has now become an extension of the physical examination of the trauma patient [2]. It provides effective and timely diagnosis of potentially life-threatening hemorrhages and is a decision making tool to help determine the need for transfer to the operating room, CT scanner or angiography suite. In addition, it is cost effective solution with lower cost in manufacturing, telecommunication, and maintenance. Currently, ultrasound is performed in the trauma room by properly trained and credential staff. However, the protocols for education and varieties of teaching media vary from not only among specialties but within them as well.

As the economic healthcare paradigm continues to shift, we must be cognizant of how healthcare payments are now becoming linked with not only cost-effective but also high quality healthcare. This put the increasing responsibility on physicians, hospital staff, and healthcare facilities to closely monitor quality of care. This is why it is important to monitor and improve the quality of ultrasound training. By creating real-time ultrasound transmissions and an electronic procedure log of video and image recorded ultrasound, residents will be able to further assess their clinical skills individually and with resident training staff. It is the hope of this pilot study to develop future training protocols that will improve FAST ultrasound assessment and review complications. This will in turn, enhance the quality of patient care by improving critical diagnosis and improving the quality of clinical skill by student, residents, and attending physicians.

According to studies by Costantino et al. success in ultrasound education does improve with increased didactic training [3]. However, beyond 15 hours of didactic training there is no improvement in resident performance [3]. This is significantly lower than the 40 hours of recommended didactic training by the SAEM [4]. It is the goal of this study to implement a device that will develop a computer database of digitally procedure log of digitally recorded ultrasound images and video captures. This will improve clinical training by increasing the time and efficiency of ultrasound training to the clinical setting instead of increasing didactic lecture. Durning et al. showed that the number of ultrasound scans under supervision is the most critical predictor of successful ultrasound training [5]. Additionally, electronically recorded ultrasound will include benefits such as eliminating bias in recorded complications and allowing the resident to develop a better critical assessment of clinical skill and deficiencies and plan for a modified individual plan of improving quality of diagnosis. Additionally the use of an electronic database will allow hospital administration, healthcare payers, residency directors, etc. to monitor the quality of ultrasound imaging on an administrative level.

Review of Literature

Optimal training required for proficiency in bedside ultrasound is unknown. Optimal media for ultrasound training is still being reviewed. In 1994 SAEM released formalized guidelines for ultrasound training [4]. This was followed by the American College of Emergency Physician publishing formalized guidelines in 2001 [1]. However there is no translation of protocols to credentialing criteria and quality assurance programs. Some hospitals have started to develop rigorous credentialing policies and ultrasound review committee systems like at the University of California, San Francisco [6]. However these protocols remain to be studied and embraced by the ACEP or SAEM. Other specialties have also started to develop their own ultrasound training protocols. The American College of Surgeons have published their own guidelines for formalized training including specified levels of training and focused modules for various ultrasound techniques [7]. Ultrasound use has also started to spread in newer realms of medicine, such as EMT’s in rapid assessment of left ventricular systolic function in a pacemaker function [8].

Ultrasound training has even started to be incorporated earlier in undergraduate medical education with high success rates [9]. Barloon et al. reported that 30 minutes of ultrasound training helped Year 2 medical students more accurately estimate liver size compared with students who did not receive ultrasound training [10]. Current literature has showed numerous studies on different techniques and media for clinical training specific to ultrasound scanning. Proctored examinations have shown significant value to retention of ultrasound knowledge after the introduction of an emergency ultrasound curriculum [11].

Many European countries have already high integrated ultrasound programs [12]. Sweden’s resident physicians are required to submit a portfolio of cases on a DVD format for educational review. Additionally in Germany, there is a national program for ultrasound procedures, especially those performed by obstetricians. In fact there are government guidelines linking reimbursement for obstetrical ultrasound payment [12]. This places pressure on hospitals and physicians to increase the quality of care due to financial incentives, compared to monetary caps on procedures which breed a culture of minimal quality care.

In a study by Dolmans et al. ultrasound procedures logs helped clerkship coordinators by providing a useful overview of the content and nature of the students’ learning experiences in the hospitals. However the logs were not utilized by students, supervisors, and faculty to help improve the structure of student learning [13]. With a video procedure log there would be increased oversight over medical education, where residents and supervisors can readjust the learning experience by catering to individual needs and goals [14, 15]. By embedding the procedure logs into supervision of training, there will be increased importance placed on procedure logs by resident physicians. However the reliability of current logbook data has its pitfall. In a study by Raghoebar-Krieger et al. there were numerous inconsistencies when comparing student procedure logs and feedback data from attending doctors [16]. Diseases were under reported, which lead to a breakdown in clear supervision and feedback, which is important for procedure logs to work

Fung et al. created a similar internet-based learning portfolio in resident education call the KOALA. They created an advanced portfolio of ultrasound images that were link to self-directed hyperlinks [17]. The hope of the study was to reduce the future need for textbooks and CME in favor of creating self-directed study of ultrasound techniques. In addition the internet portfolio provided a media to directly observe ultrasound scans and compare quality of ultrasound scans throughout the hospital [17].

A study by Blaivas et al. published in 2005, compared ultrasound images between commercial cell phone and traditional high-resolution thermal printout in image quality, detail and resolution. There was no statistically significant difference. There was however, a problem with reading measurement and a lower confidence in diagnosis with p-values of .003 and .02 [18]. With the fast developing market of portable cell phone with larger screens and higher resolution, our study reexamines current cell phone technology with real-time ultrasound transmission.

Research Objectives

1. Reduce the cost of current ultrasound technology by developing an “off-the-shelf” solution to an image/video capture system from commercially available technologies
   1. Prove that consumer available technology (iPhone) can be used for ultrasound transmission and oversight with diagnostic quality images.
2. Development of a video/image recorded ultrasound database for the storage of resident procedure logs.
   1. Better utilize procedure logs and clinical supervision to provide more efficient ultrasound education that will improve diagnostic accuracy and increase user confidence of FAST ultrasound scans.
   2. Enhance current credentialing and quality assessment protocol for FAST (Focused Assessment with Sonography for Trauma) ultrasound training in residency training by utilizing real-time ultrasound transmission and video procedure log of FAST ultrasound scans.

Research Methodology

This study is a comparison of ultrasound images and video outputted directly to an Apple iPhone with ultrasound images ultrasound video directly displayed on the portable ultrasound monitor. This study will take place at a level 1 trauma center ED (Henry Ford Health Systems, Detroit) with an accredited emergency medicine residency program and an active emergency ultrasound program. Currently all residents are trained to use ultrasound under the SAEM (Society of Academic Emergency Medicine) guidelines.

10 FAST ultrasound examinations will be randomly selected from approximately 20 computer recorded FAST ultrasound examination. Examination will only be performed on patient medically require a FAST ultrasound examination based on emergency department protocol. The ultrasound scans will be performed in the emergency department during a 2 week period by the on call emergency medicine resident that is trained and credentialed in the use of FAST ultrasound examination in the emergency department. Computer recorded FAST ultrasound will comprised of 10 second video clips and 1 high resolution image capture of each of the 4 primary views: perihepatic, perisplenic, pelvis & pericardium. All images and video that is computer recorded is also saved to the internal hard drive of the portable ultrasound device. All ultrasound scans will be outputted through VGA signal to the VGA2USB LR Frame Grabber. The converted USB signal will then be sent to a computer laptop. We will use a commercial available laptop produced by HP. The laptop will receive data from the portable ultrasound device through a VGA-to-USB converter box. The computer will then record both images and video at the highest possible resolution onto the internal hard drive. Resolution of the computer recorded ultrasound images and video will only be limited by the output capabilities of the VGA-to-USB converter box. Additionally, the ultrasound video will be streamed real-time through a Skype account to an iPhone. Once the video transmission to the iPhone is confirmed by the operating technician, the ultrasound scan is complete.

The premise of this study is to duplicate a scenario where a residency director, ultrasound director, attending, or resident can review recently performed FAST ultrasound scans for the purposes of assessing accuracy of diagnosis, evaluate quality improvement, and improve clinical skills. The 10 computer recorded FAST ultrasound data and the ultrasound recorded data will be graded by a hospital credentialed sonologist with a minimum of 5 years of experience. Approximately 1 week after ultrasound images are randomly selected 2 credentialed emergency sonologists (radiologist stationed with the emergency medicine department) with extensive ultrasound experience including study performance, interpretation and ultrasound education will review ultrasound database. Ultrasound review will include video replayed back on the portable ultrasound device and video replayed back on the iPhone. For practical purpose, real-time transmission via the iPhone will not be reviewed real-time by the sinologist. However, replayed ultrasound transmission will simulate real-time transmission.

For each ultrasound image, the reviewers will be initially asked for an initial interpretation of the images and video captures. Afterward, each reviewer is given a short clinical vignette of the patient’s complaint in addition to a procedure log of complication from the emergency medicine resident that performed the FAST ultrasound examination. Reviewers are allowed to manipulate the images as needed including increasing image size, changing contrast, etc. Then each image will be graded on the following: (1) total image quality, (2) image resolution, defined as the sharpness and crispness of the image and lack of haziness/blurriness; (3) image detail, defined as the clarity of organ outlines and ease with which boundaries of structures are seen and defined; (4) optimal quality image that is required for optimal review for resident training purposes. Each reviewer will rank their impressions on a 10-point Likert scale with 1 being the worst and 10 the best. All data will be filled out on a standardized data form, which will then be entered into a computerized database. Statistical analysis will include descriptive statistics and a paired t test with 95% intervals. Data will be analyzed using standard statistically

For safety consideration, a separate dedicated portable ultrasound device will still be kept in all resuscitation room in the emergency department according to emergency department protocol. If there are technical problems while scanning a patient with the proposed ultrasound transmission apparatus, the physician will be able to use the standard ultrasound device at the attending or resident physician’s discretion.

Materials

-GE Portable Ultrasound

-iPhone 3G:

3.5 inch (diagonal) widescreen Multi-Touch display, 480-by-320-pixel resolution at 163 ppi, Dimension 4.5 inches (height) x 2.4 inches (width) x 0.48 inch (depth), 16 GB flash drive capacity, UMTS/HSDPA (850, 1900, 2100 MHz), GSM/EDGE (850, 900, 1800, 1900 MHz), Wi-Fi, (802.11b/g), Bluetooth 2.0 + EDR, Video formats supported: H.264 video, up to 1.5 Mbps, 640 by 480 pixels, 30 frames per second,; MPEG-4 video, up to 2.5 Mbps, 640 by 480 pixels, 30 frames per second, Simpler Profile with AAC-LC audio up to 160 Kbps, 48kHz, stereo audio in .m4v, .mp4, and .mov file formats, 2.0 megapixel camera.

-HP Pavilion Laptop dv2700t series

Windows Vista Home Premium, Pentium® Core™ 2 Duo Processor T5750 (2.0 GHz), 14.1” diagonal WXGA HP BrightView Widescreen Display (1280 x 800), 2GB DDR2 System Memory (2 Dimm), 128MB NVIDIA GeForce 8400m GS, Intel® PRO/Wireless 4965AGN Network, 120GM 5400RPM SATA Hard Drive,

-VGA2USB LR Frame Grabber (made by Epiphan Systems Inc.)

-Skype Account (commercial video streaming website)

-Remote Computer Access

-Public Wi-Fi access at the Henry Ford Health Systems Downtown Detroit Main Campus

Limitations/Potential Future Amendments

-Small sampling size may provide a biased analysis for the efficacy of video ultrasound logs

-Development of an all-in-one device for ultrasound recording and transmission will allow for easier mobile setup of ultrasound scans.

-After the release of the iPhone 3G, third party developers will be able to develop higher quality online conferencing clients for use on the iPhone or Apple may develop proprietary video conferencing software.

-Future tests can include computer laptops with an integrated video camera

-Future research should expand on the development of an online database (FTP) for remote access from any Wi-Fi capable device.

-Future research should experiment with using other device that are portable and Wi-Fi capable (PSP®, computer laptops, palm, blackberry, etc).

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Ilan Rubinfeld, MD, MBA, Barbara Joyce, PhD, Sisir Rao, BA, Craig Reickert, MD,  H Mathilda Horst, MD, Ryan Kinnen, BGS, Alex Shepard, MD 
Henry Ford Hospital, Detroit, MI

Authors: Alton Parker, MD; David Kwon, MD; Ilan Rubinfield, MD, MBA. Henry Ford Health System - Detroit, MI.

Abstract

BACKGROUND: Ultrasound is rapidly becoming a more versatile diagnostic tool for use with medical and non-medical personnel. The advent of the Mediphan device has made it possible to transmit ultrasound data in real-time to a remote location via Internet. We proposed that non-medical personnel with minimal training could be remotely guided to obtain diagnostic quality ultrasound images for use on the field by professional athletic teams.

METHODS: A Detroit Lions athletic trainer was given a brief tutorial on the Logic-e portable ultrasound machine and several musculoskeletal exams from an expert ultrasonographer. The trainer then examined Detroit Lions professional football players. The examination data was via internet to the remote expert ultrasonographer. The trainer was then remotely guided by the ultrasonographer via telecommunications.

RESULTS: All examinations were of diagnostic quality.

CONCLUSION: Non-medical personnel can accurately obtain diagnostic quality ultrasound images for musculoskeletal examinations using the Mediphan and remote guidance.

INTRODUCTION

Ultrasound (US) is rapidly becoming a more versatile diagnostic tool in medical applications. It has been found to be both a rapid and accurate method of diagnosis in a wide variety of clinical conditions that were previously reserved for X-Ray or CAT Scan. In recent years, investigations have shown that non-physician operators can reliably perform focused clinical US examinations to facilitate on-site diagnosis of medical conditions such as intra-ocular foreign body, abdominal blunt trauma, as well as muscle, tendon, and bone injuries. In addition, technological advances have improved the portability and quality of the images. In the not too distant past, the ultrasounds were completely immobile. Improved portability, combined with the addition of an ultrasound Ethernet port, has made it possible to send the ultrasound data over a secured network from remote locations. However, no hardware or software had been specifically developed for the ultrasound device, until recently.

Researchers at the National Aeronautical and Space and Administration (NASA) and the National Space Biomedical Research Institute

(NSBRI) have optimized rapid ultrasound training methods that allow minimally trained, non-physician operators to obtain diagnostic quality ultrasound images, which can be used to diagnose a wide variety of clinical conditions.

We have successfully used portable ultrasound in conjunction with the Epiphan real-time remote guidance hardware and software to rule-out or diagnose injuries in professional athletes on the field. We proposed that non-medical personnel could undergo minimal training and, combined with remote guidance, obtain diagnostic quality ultrasound images.

METHODS

The Procedures described herein were reviewed and approved by the Henry Ford Health (HFH) System Human Investigation Committee. The ultrasound trial was also approved by the Detroit Lions Administration. Team athletic trainers and physicians were interviewed to determine common football player injury patterns, with special emphasis on musculoskeletal injuries. Injury patterns were classified as muscular, ligamentous, or bone.

The Detroit Lions’ athletic trainers were given a brief tutorial on the Logic e portable ultrasound machine from an expert ultrasonographer. In addition, they were provided with the Onboard Proficiency Enhancement (OPE) tutorial interactive CD that is currently used to train NASA astronauts for International Space Station (ISS) ultrasonography. Topographic reference cue cards to facilitate US examinations were developed based on cue cards used aboard the ISS. The cue cards provide locations of ultrasound controls, keyboard shortcuts, as well as examples of transducer placement for various examinations. Trainers had access to this OPE program for review at any time.

Trainers participated in mock sessions performing musculoskeletal US examinations on non-injured subjects. During these tutorials, trainers received hands-on experience including device positioning, remote guidance terminology, and trouble-shooting complex scenarios. In addition, they became familiar with the characteristics of US images that should be obtained during each specific examination.

Twelve Detroit Lions professional football players were enrolled after suspected hamstring muscle and foot. The football players were informed of the NASA research, and potential benefits for injury diagnosis. Informed consent from the players were obtained before each examination.

A GE Logiq e US machine was placed in the locker room of Ford Field in Detroit, Michigan. The 12L (7-13MHz) transducer was used for all examinations.

Video stream from the VGA port of the portable ultrasound device was broadcasted onto the internet utilizing an Epiphan DVI-2USB device (Epiphan, Ottawa, Canada). The real-time video stream was routed to a secure, encrypted web site for viewing by remote guidance experts at Henry Ford Hospital in Detroit, Michigan. Audio communication over a secure phone line between a remote expert ultrasonographer and the trainers was used for all experiments.

The trainers began the examination autonomously using the provided cue cards. The expert ultrasonographer physicians, with remote guidance experience, viewed the transmitted US images. The physician then guided the trainers using previously specified directional language and cues. The trainers were given instructions to obtain, or enhance the images by the physician via real-time, secured telecommunications.

(Table 1).

Table 1. Cue Card used to assist the athletic trainer in ultrasonography.

Figure 1. Diagnostic quality ultrasound image that was obtained by the minimally trained athletic trainer.

Figure 2. Picture of Epiphan DVI-2USB Device -GE Logic-e coupled

Figure 3. Diagram of coupling and information flow.

RESULTS

Equipment setup, operator, and subject positioning was accomplished in less than 5 minutes. Average bandwidth of transmission through the digital subscriber line from each facility to HFH was 300Kbps. There was a 0.5 to 1.0-second transmission delay for video, which did not impact the conduct or quality of ultrasound examinations. All experiments were archived on an offsite, remote server based in Ottawa, Canada, for future examination. Digital Imaging and Communications in Medicine (DICOM) images were saved at intervals during the examination and then downloaded after completion of the experiment. All downloaded DICOMs and video-streams were deemed adequate for professional interpretation by musculoskeletal ultrasound radiologists.

Complete ultrasound examinations of the hamstring were obtained on 12 athletes. One complete exam was obtained of the calcaneous. Examination completeness was evaluated by the remote experts while viewing the real-time ultrasound video stream. The remote-guided examinations were completed by the non-physician operators in less than 15 minutes each.

Musculoskeletal US examinations of the hamstring included (X) muscles and (X) views. Ultrasound examinations of the foot included views (X) bones and (X) ligaments.

Twelve professional athletes were examined using three trainers. Eleven hamstrings and one foot exam were obtained. These exams were labeled either “Diagnostic Quality” or “Non-Diagnostic Quality” by the expert ultrasonographer. All positive injuries were confirmed with the appropriate gold standard examination and compared to the conclusion drawn from the ultrasound exam and the expert interpretation. All exams were correctly diagnosed. All exams were considered “Diagnostic Quality”.

CONCLUSION

Ultrasound is currently readily available, in most urban and rural medical centers. It is also now portable, less expensive, and less cumbersome than X-Ray, CT or MRI technology. It has been shown to be sensitive and specific for musculoskeletal injury diagnosis in other studies, which have focused on minimally trained operators. The ability to provide timely and accurate diagnostic imaging to athletes by operators with limited medical training, although challenging, appears to be a viable option. There was no difference between the remote guidance diagnostic images and those obtained in standard conditions, when evaluated by a musculoskeletal US expert radiologist. Although our experiment has limited power, other investigations show similar results when training non-medical personnel in diagnostic ultrasound technology. With minimal training, non-medical personnel can accurately obtain diagnostic quality ultrasound images in the field for musculoskeletal examinations using the Epiphan remote guidance system. This, and other investigations warrant expansion of the study of remote guidance ultrasonography into other professional, amateur and high school teams as well as community first responder agencies such as paramedics, fire and police departments.

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