For many years, medical communications has been a fairly primitive affair. It started with the BioCom, a low-power, short range UHF radio for sending voice communications and ECGs. Then came the APCOR and later examples of basically smaller versions of the same thing; limited range radio-technology ECG transmission. Then came Cellular and now we have wireless broadband data networks building out across the country. However, we have done little to exploit them.
It remains the case today that when most people hear the word “Biotelemetry,” they are thinking about sending ECGs. But it could be so much more. How much more is painfully obvious every time I watch a YouTube video with my Toshiba netbook on a 4G wireless card.
It’s a real strange thing — we have the technology but apparently little desire to use it. Maybe one of the reasons why is the common belief that we don’t need it; the doctor in the destination ER “should trust our impressions.” I understand these thoughts and have in earlier years shared them. But my mind has slowly changed to a new perspective. This is not what EMS is supposed to do. We are the eyes and ears of the physician.
Original vision of our role
Our role was originally envisioned as “physician extender”, a way for doctors to practice outside the hospital. Using our eyes they “see” the patient, while using our hands they can deliver care. The idea was not that “we need a new allied health professional to independently deliver care.” The idea was for us to help a physician to deliver care. So why wouldn’t you obviously want him or her to actually see the patient if they could? Of course, with today’s technology, they really could.
Sometimes a picture tells the whole story. I wish the physician could actually see all the vital signs, ECG, SAO2, End-Tidal, right on their screen with a live video-picture of the patient, streaming with sound. Rather than feel threatened by the intrusion into my private space, I’d appreciate the opportunity for better collaboration.
You never know what these tools could do to improve pre-hospital care. They are already commercially available, and are even being used in other specialties such as home care and military medicine. Cops have had dashcams for years, but we are still talking our vital signs over the radio or cell-phone.
I’ll bet 10 bucks most patient report are still Johnny & Roy-style incomplete narratives. We have come almost nowhere in 30 years. I can pull money straight from my bank account from the other side of the world instantly, but can’t transmit an SAO2 and respiratory rate to the hospital. I’m old; I used all my birth-right allocated luck up years ago. I want some fresh, recently and well-trained eyes and ears seeing exactly what I see and hearing what I hear. I’m ready for some real help and as a result, a little less stress.
We are still fighting about how best to transmit a simple ECG. I have been astonished at the number and variety of different costs involved for an EMS system just to send ECGs. It’s even worse for the larger urban hospitals. The end result is no standardization, high costs, and pretty dismal performance with limited capabilities.
While most EMS systems only use one brand of cardiac monitor, a busy urban ER could receive patients from a dozen different systems in a single day, which can result in a nightmarish challenge. The ECG is just one small part of the picture. We’re still fiddling with one piece of the puzzle while the board stands mostly empty.
Models of broadband mobile telemetry have been trialed in various places around the country. The technology is ready; I think the main obstacles are privacy concerns. This is a lot of confidential data flying around, and how to best control its release while it broadcasts to every nook and cranny could be a challenge. I imagine these challenges all have ready solutions. If I can swipe a credit card on a hand-held at a trade show, I can send patient information safely.
On the patient data side, several firms have already explored obvious parts of the solution. Highly sophisticated and compact multi-parameter monitors have been introduced, like the Philips IntelliVue MP2, which can acquire all the physiological data with one compact instrument. The MP2 is FDA-cleared for use in road ambulance, aircraft and helicopter transport, and it’s designed to withstand harsh out-of-hospital environments, including rain, shock, vibration, high humidity, and extreme temperatures.
The MP2 is a very compact and easily carried monitor weighing just over 3 pounds. It offers a customizable display of ECG, SpO2, and NIBP. It does have a computer data port on the back so it should be possible to export everything.
A lot of the development in medical data systems has come from the leading EMS defibrillator companies. The dominant trend has been for EMS providers to prefer having more and more parameters of patient diagnostics built right into the defibrillator. The ZOLL M CCT Series features a three-channel display for ECG and up to two invasive pressures, with ranges covering arterial, pulmonary arterial, central venous or intracranial pressure as well as two temperature channels. Of course, it also provides you all the non-invasive parameter options of the M Series including SpO 2, EtCO 2, NIBP, and fully interpretive 12-lead ECG.
CASMED has built multi-parameter patient monitors for years. They have been putting them on EMS units for two decades, so they understand the rigors of the environment. It’s easy to make a non-invasive BP device work at a health fair. It’s not so easy to make one that will work in a moving ambulance. CASMED has proven that they know how.
Athena GTX has just received regulatory clearance for the WVSM , a compact monitor attached to a BP cuff. The WVSM is a medical monitoring unit that wirelessly collects patient vital signs data from a blood pressure cuff, pulse oximeter clip and a lead II ECG. It can wirelessly beam BP, Pulse, SAO2 continuously to a remote receiver.
ZOLL has also just received FDA clearance — on July 30 — to market their hotly anticipated Propaq MD. The Propaq MD is a new, ultra-lightweight compact device with highly sophisticated, advanced capabilities that combine the well-accepted and proven features of the Propaq monitors with the clinically superior therapeutic capabilities of ZOLL defibrillation and non-invasive pacing technologies. The Propaq MD is 60 percent smaller and 40 percent lighter than other similar monitor/defibrillators. It is two pounds lighter than the current military vital signs monitor, the Propaq 206, even with defibrillation and pacing added.
The Propaq MD provides an unmatched combination of capabilities that include a large, high-contrast color LCD display capable of viewing up to four waveforms simultaneously, as well as a full 12-lead ECG for on-screen review. It also offers a unique night vision goggle (NVG) mode for military and air medical night time operation.
All physiological monitoring parameter values, including heart rate, SpO2, ETCO2, respiration, non-invasive blood pressure, two temperatures, and three invasive pressures, are shown in large color-coded numeric formats. The device is capable of monitoring all patients, whether adult, pediatric or neonatal. Alarms are provided for all parameters. It is the only FDA-cleared airworthy defibrillator to provide monitoring of three invasive pressures necessary for treating critical patients during long transports.
With all the physiological data we have available nowadays, we need a way to send all this to the hospital. It’s already been done and proven technologically viable. I think the biggest challenge is us. For years it was common for me to hear “we don’t send ECGs anymore, the doctor trusts our interpretations”. Fine —but how about we trust their years of education and experience, and quit being so easily threatened?
I’d love to invite every ER nurse and physician into the back of my ambulance virtually. We could really do amazing things in collaboration. That’s the higher calling of pre-hospital health care.
We could have all types of collaborating professionals helping to create new and innovative solutions to stubborn problems. Imagine having a cardiologist take a look at your MI patient or an orthopedic surgeon helping direct management of an athlete’s shattered limb. Less guessing and more help sounds like a long overdue stress-reliever to me.
Ultimately, the physicians are the ones signing for responsibility. That is not to minimize our responsibility, only to acknowledge their “buck stops here” responsibility. We should trust their, let’s face it, superior diagnostic skills.
If we could stop clogging up the airwaves with a long monologue of basic data orally, we’d free up valuable time. It should all be right there, on the screen, all of it, by the time you press the button to link or send. That’s how we redistribute expensive staff time to extract new and meaningful value out of a system already strapped for cash.
Yes it means we will have to polish our language and demeanor being on camera so much, but the payoff is worth it. Excellence will be shared and incompetence revealed. I think it will help move our industry and patient care forward. But it won’t happen until we all start asking for it to happen and why it hasn’t happened already.
It’s easy for any of us to see in our mind’s eye how it would look:
- A big monitor in the ER displaying the incoming units P, R, SAO2, ETCO2, Temp, BP, with all numeric clinical data across the bottom of the screen
- The upper sections would have ECG, and a real-time streaming video view of the patient
- Next to the image would be smaller alternate views that could be blown up to full view at a tap or click
- All audio, everything that is said, even your stethoscope, would be pumped out of the hospital’s speakers
- All the data, audio and video, gets written to backup and digitally recorded
Less talk, better patient care, and improved quality assurance and research would be the benefits. When will we get it? Only when we are ready to ask for it.