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Introduction

Emergency situations involving multiple victims require efficient decisions about medical care. The use of modern telecommunications allows improved support for disaster medicine. This includes monitoring of the medical situation, communications about patient transportation problems, and consultative support for the medical stuff working in the disaster area. Teleconsulting may be useful in disaster medicine in a number of ways:

• efficient transfer of information about the nature of the emergency, which is needed to plan the order and scale of evacuation measures
  
  
• consultations with medical specialists to support the physicians on site
  
  
• optimization of the choice of specialized hospitals for further treatment of the victims.

Modern telecommunications were used for the first time in disaster medicine by the US National Aeronautics and Space Administration (NASA) in 1985 after the earthquake in Mexico City. This allowed better estimation of the medical consequences of the earthquake and facilitated proper rescue measures.¹

In the former Soviet Union, the first use of teleconsultations in an emergency situation was after the Armenian earthquake of 1988. Telemedical ‘space bridges’ (i.e. video connections) were established by NASA between Russian and American specialists. This was the first experience of international telemedical collaboration in an emergency situation.² The project included audio–video and fax communication between the disaster area in Armenia, clinics in Moscow and four medical centres in the USA.

In 1999, after a train crash in Bashkiria, teleconsultations took place between a hospital in Ufa (Bashkiria), a surgical clinic in Moscow and the Yerevan Diagnostic Centre in Armenia. Dedicated telephone lines were used to provide audio communication and slow-scan black-and-white video images. When connected to the ‘space bridge’, the system enabled consultations about patients in Ufa with conditions such as burns and psychological trauma, involving specialists at medical centres in Moscow and the USA.

In 1993, the US Department of Defense started using telemedicine to support a peacekeeping force (IFOR) undertaking humanitarian missions in a number of countries. The telemedicine system was called PrimeTime. Physicians at field hospitals in Macedonia, Croatia and Bosnia were connected to hospital specialists in Germany, Hungary and the USA.^3,4

The most recent use of telemedicine in an emergency situation in Russia was to support the Children’s Field Hospital of the All-Russia Centre of Disaster Medicine in the Chechen Republic in 2001. The doctors of the field hospital had to provide care for patients with various conditions resulting from explosion trauma and from fire-arms, as well as providing diagnosis and treatment for children with a wide range of pathologies, including acute and chronic diseases (e.g. congenital, malignant, neurological and cardiovascular). This situation required distant medical support, which was realized by installing a telemedicine unit at the field hospital.

Remote decision support for the Children’s Field Hospital

By 2001, medical services in Chechnya had been almost completely destroyed owing to long-term military conflict. Paediatric care was almost unavailable. The Children’s Field Hospital in the Gudermes district of the Chechen Republic included an admission and consultation department, a surgery department, a department of internal medicine and an intensive therapy unit, as well as laboratory and radiology services (Figure 25.1). The hospital was equipped for X-ray imaging, ultrasound scanning and basic laboratory investigations.

The field hospital was admitting not only wounded children, but also children with various diseases from a number of districts of the Chechen Republic. This created serious problems for the relatively small medical staff of the hospital. It was not realistic to refer all the complicated cases to clinics in Moscow or to other Russian cities.

Figure 25.1 Structure of the field hospital

Besides, in a number of cases, urgent consultations with specialists were required, including multispecialist consultations. Therefore, even from the start of the hospital’s work, there was a need for support from specialist institutions. Telephone consultations were impractical in Chechnya in 2001, owing to the very poor quality of telephone connections, and their complete absence in a number of areas. An efficient means of communication was required to support the physicians working in emergency situations, including urgent support from specialists. The consultations had to be provided both in store-and-forward mode and in real-time, using videoconferencing.

The implementation of this telemedical support – the first Russian system for disaster telemedicine – was performed by specialists of the Moscow Research Institute for Paediatrics and Children’s Surgery, the All-Russia Centre of Disaster Medicine, the Dorodnicyn Computing Centre of the Russian Academy of Sciences, the State Central Air-Carried Rescue Team and a company called Web Media Service.⁵

It was decided that the Medical Centre for New Information Technologies of the Moscow Research Institute for Paediatrics and Childen’s Surgery would act as the head telemedicine centre of the system. The telemedicine centre was equipped with a videoconferencing system and modern telecommunication equipment, including fibre-optic cables enabling ISDN connection at 2.048 Mbit/s and IP connection at 1.024 Mbit/s.

Emergency and scheduled teleconsultations were provided by the telemedicine centre, as well as multispecialty videoconference consultations.⁶ The Medical Centre for New Information Technologies provided technical support for the field hospital, initially acting as the sole consulting centre. Later on, regular working contacts were established between the field hospital and the Scientific Institute of Medical and Biological Problems in Northern Ossetia, the Fund for Development and Dissemination of New Medical Technologies in Stavropol, the Stavropol Area Hospital and the Republican Children’s Hospital in Vladikavkaz.

System architecture

It was clear from the beginning that only satellite communication would be appropriate for telemedicine (Figure 25.2). One satellite channel was used to provide the connection between the consultants in the telemedicine centre and the physicians in the field hospital, and a second channel was used to send requests to the telemedicine centre. Both store-and-forward and real-time traffic were sent by satellite.

Originally, the equipment at the telemedicine unit in the field hospital included:

• a VSAT terminal, including a computer for information transfer at a bandwidth of 1.0 Mbit/s through the satellite system HeliosNet
  
  
• a satellite phone system (GlobalStar) to transfer the date to the telemedicine centre at a bandwidth of 9.6 kbit/s
  
  
• a videoconference system
  
  
• a workstation for the preparation of medical documents (in digital form)
  
  
• peripheral devices, including a digital camera, digital videocamera and flatbed scanner.

Figure 25.2 Comunication architecture for disaster telemedicine

The telemedicine unit was set up in one of the tents of the field hospital. The telemedicine unit included work places for videoconferencing and for data preparation (e.g. review of case material and digitizing of documents). A satellite dish was installed near the telemedicine unit tent.

Because of technical limitations on videoconferencing with the GlobalStar communication system, other solutions were sought. A duplex satellite terminal (AT&T) was installed at the field hospital. It provided a bandwidth of 12–16 kbit/s for data transfer. It was also less expensive to use than GlobalTel or INMARSAT.

The satellite link enabled real-time consulting using an asymmetrical IP connection between the field hospital and the telemedicine centre. The experience demonstrated that any reliable communication channel with a transfer rate of 9.6 kbit/s for audio and 56 kbit/s for video could be used as a request channel (provided that no fast movements needed to be demonstrated to the remote party). For the response channel, from the telemedicine centre to the field hospital, a high-rate satellite channel was used.

Experimental use of the telemedicine system began in August 2001. By the beginning of September 2001, operational usage had begun. Between October 2001 and July 2002, the telemedicine system was operational 24 hours a day.

Telemedicine in the field hospital

Teleconsultations were based on asymmetrical access, with a high-speed channel from the telemedicine centre to the field hospital and a low-speed channel in the other direction. The process included:

1. preparation of the patient’s data
   
   
2. digitizing any graphical material
   
   
3. forming the request
   
   
4. transfer of the request and digitized medical documents
   
   
5. real-time consultation.

Receipt of the request and the documents was done by a coordinator at the telemedicine centre, who checked the quality of the received data, referred the documents to a consultant, made journal records about the nature of the consultation and recorded the subsequent consultant’s recommendation. The scheme included two main phases: a preliminary phase and the consultation itself.

During the preliminary phase at the field hospital, the patient documentation was assembled and then sent to the telemedicine centre with the consultation request using the low-bandwidth communications channel. The documentation included textual materials and graphical data (e.g. X-ray and ultrasound images and photographs). The total file size was on average about 3–5 Mbyte per patient.

The second phase was information exchange between the telemedicine unit of the field hospital and the telemedicine centre in Moscow using an asymmetrical duplex IP connection. The high-speed channel was used for transfer of large volumes of information, including multimedia data, from the Moscow centre to the hospital, while the low-speed channel was used to transfer relatively limited volumes of information (text, sound, graphical data and, rarely, video data) from the hospital to the telemedicine centre.

On establishing the connection, the participants decided which case to start with. The consultant then opened the relevant document on the screen of a PC in Moscow. Within 5–15 seconds, the same document automatically opened on the screen of the computer in the field hospital. The hospital physician could ask questions orally; if needed, the physician could use a White Board option to show the consultant some part of an opened document (or image). All the consultant’s comments (audio, text and graphics) were presented at the field hospital, being transferred via the satellite channel. All the consultations were recorded, which allowed them to be reviewed afterwards, if required.

The subsequent course of a consultation was defined by the situation. Four main variants were possible:

1. A physician could ask another question on the case or document being discussed.
   
   
2. The parties could begin the discussion of a new case.
   
   
3. The parties could move to a decision about organizational matters.
   
   
4. The discussion could be stopped.

Clinical aspects of telemedicine support

During a 14-month period ending in 2002, the Children’s Field Hospital delivered care for over 30 000 patients from 17 districts of Chechnya. A total of 2700 inpatients were treated. Telemedicine provided valuable long-term support for the physicians of the field hospital. A total of 179 consultations were conducted (including those in the trial period). The main result was that over 40% of patients were able to continue their treatment in the field hospital after the consultation, instead of being transported to other medical centres. The severity of the conditions of the consulted patients can be seen from the two lethal outcomes in children for whom urgent consultations were requested.

During the period of maximum activity (April–June 2002), there were 64 teleconsultations. The most common consultations (23%) were for children with trauma and orthopaedic problems. Other groups had multiple birth defects (six cases) or congenital hip dislocation (three cases). Trauma consultations were required in six cases: three with complicated ankle fractures, two with leg wounds due to mine explosions and one with hip pseudoarthrosis. Teleconsultations in plastic surgery were required for ten patients: three with cleft palate, three with nerve and tendon trauma, three with burn scar contracture, and one with post-traumatic alopecia. Neurosurgeons conducted consultations for two cases of spinal cord hernia, two of cranial hernia and one of severe cranial trauma. Burn surgeons were consulted about three patients with severe burns. There were teleconsultations in medical genetics: two cases of acrocephalosyndactylia, one of Noonan’s syndrome and one of distal acromelia. Cardiologists were consulted about three patients: two with myocarditis and one with rheumatoid arthritis. Two consultations were conducted for children with Hodgkin’s lymphoma. Lung diseases were found in two patients: bilateral pneumonia complicated by pyopneumothorax and a severe case of bronchial asthma. Children with portal hypertension and haemocolitis were consulted by a hepatologist and a gastroenterologist.

A number of medical institutions participated in the teleconsultations, including six medical research institutes and five large hospitals. Most of the consultations were conducted by surgical (32) or paediatric (11) departments of the Moscow Research Institute for Paediatrics and Children’s Surgery. Ten consultations involved other medical centres of Moscow, while 11 consultations were conducted in the hospitals of the northern Caucasus. The results of teleconsultations during the last three months of the hospital’s work are shown in Table 25.1.

The ages and numbers of patients were as follows:

• under 1 year: 11 patients
  
  
• 1–3 years: 8 patients
  
  
• 4–7 years: 9 patients
  
  
• 8–11 years: 10 patients
  
  
• 12–15 years: 9 patients
  
  
• over 15 years: 8 patients.

During the first months of operation of the telemedicine system, the age distribution of the patients remained similar.

Of the 54 patients who received teleconsultations, 8 were transported to other clinics for further treatment: to Moscow (4), Makhachkala (2) and Stavropol (2). Thirty-seven patients were referred for further examination and treatment. For 16 patients, the treatment initiated at the field hospital was changed. Diagnoses were not made in three cases (one patient died and two consultations were not completed owing to the closure of the hospital). In terms of performance, there were 35 scheduled teleconsultations, 19 deferred and 10 urgent. In addition, five emergency consultations were carried out for critical care.

In summary, telemedicine was highly effective in diagnosis, choice of treatment and transportation of patients to specialized medical institutions in a complicated situation due to the military conflict in Chechnya.

Monitoring during treatment and rehabilitation

In large-scale disasters, disruption of the regional health care system and population migration often occur, which lead to difficulties with patient transfer and medical data recording. Monitoring of the victims during all stages of medical care is essential. In the Russian system, information on the health condition of disabled persons is integrated into a special registry.⁷ In the USA, the TRAC2ES system is designed to control the handling of victims evacuated from military operations.⁸

The Russian registry was created for centres of disaster medicine. The users of the registry are health care and social security authorities. Electronic medical records include personal data of a child, data about the parents/guardians, life history, diagnoses, treatment, disability and need for rehabilitation.

The registry was developed to support decision making on the scale and duration of rehabilitation of disabled children involved in disasters, to improve the monitoring of their health status, and rational planning and control of medical and social measures. The database includes:

• assessment of functional capabilities, pathological conditions and social adaptation of the child
  
  
• analysis of the child’s level of disability
  
  
• control of rehabilitation at different stages of medical care
  
  
• assessment of the nature of the child’s disability
  
  
• analysis of the social adaptivity of the disabled child
  
  
• the need for prosthetics and special equipment.

Transfer of the information between the centres providing the care for the victims of disasters takes place through the Internet.

Discussion

The experience of regular telemedicine support for physicians at the Children’s Field Hospital has demonstrated high efficiency in diagnosis and treatment, as well as in solving the problems of patient evacuation to specialized institutions. Unlike conventional mobile military hospitals, the Children’s Field Hospital provided medical care for a wide range of diseases.

It is interesting to compare the results of teleconsulting in the traditional practice of the telemedicine centre and in emergency situations. According to the data from the Moscow Research Institute for Paediatrics and Children’s Surgery (2003–2007), transportation from the Russian regions to Federal (Moscow) clinics was required in 17–37% of the consulted patients, depending on the type of pathology. In comparison, 58% of the Children’s Field Hospital patients required transportation to specialized clinics in Moscow and other regions. This difference can be explained by the greater severity of the cases and the limited means of diagnosis and treatment at the Children’s Field Hospital. Nevertheless, the treatment of 42% of patients was continued in the field hospital, while previously most such patients had to be transported to other medical institutions. The decrease in the need for patient transportation due to the use of videoconsultations has been mentioned previously.^3,4

Our experience of teleconsultations in Chechnya was somewhat similar to the situation in Somalia during the United Nations humanitarian mission in 1993. During the long civil war in that country, the communication and transport infrastructure was almost completely destroyed. Medical care was limited, and not all medical specialties were represented on the staff of the US military field hospital. However, during 13 months of operation in Somalia, 74 cases involving 248 images were transmitted. For several patients, air evacuation or on-site surgical intervention was avoided because of the teleconsultations.³

In other humanitarian operations, a teleradiology (DEPRAD) system was installed by the Georgetown Medical Center to support PrimeTime III.^9,10 In Russia, specialists of the Russian Antarctic Expedition, the Institute of Influenza of the Russian Academy of Medical Sciences, the Baltic Technical University and the company SVIT developed a modular station for diagnosis, the Ambulance-071 YS.¹¹ The station enables distant delivery of urgent consultations. It enables:

• automatic and semi-automatic recording of electrophysiological, tactile, descriptive and other data
  
  
• preparation and transfer of documents
  
  
• automatic and semi-automatic processing and analysis of the received data
  
  
• expert assessment of patients’ functional status
  
  
• provision of recommendations for correction of patients’ functional status based on expert assessment
  
  
• monitoring of patients’ functional status.

This station is used in Antarctica. The results obtained demonstrate the value of the approach,¹² which can also be employed in emergency situations.

Although in Chechnya the satellite system provided a relatively simple and reliable connection, this was not mobile communication in the full sense of the term. Recently, fully mobile satellite equipment has become available, and has been used successfully in military and disaster medicine. For real-time consultations, a personal digital assistant (PDA) equipped with a digital camera and telephone has been suggested.¹³ Wireless communication for PDAs enables communication between several sites and the centre in the case of multiple victims.¹⁴ Such a situation occurred occasionally in Chechnya, when multiple patients were admitted to the field hospital. A full-scale decision support system for a field hospital could be based on a WiFi network. A wireless network would allow data transfer from the patient’s bed, as well as interactive videoconferences directly from the operating room or intensive care unit. Mobile telemedicine of this kind would have been useful during our work in the field hospital.

Limited on-site data collection was possible in the field hospital using a mobile ECG recorder. The American system PrimeTime allowed US physicians to establish video telemedicine sessions anywhere within a war zone and to connect with medical centres in the USA.4 Direct interactive contacts with rescue teams, using mobile telemedicine systems, by remote consultants would significantly increase the efficiency of decision making in emergency situations.

Prolonged and severe emergency situations often require special provision for psychological support and rehabilitation of the victims. Such support can be provided through telepsychiatry,¹⁵ although this was not available in the case of children treated at the field hospital.

In summary, the challenges faced during the implementation of the telemedicine system in Chechnya were:

• insufficient bandwidth for communications during the first stage of telemedicine work (subsequently overcome by the use of another satellite)
  
  
• occasional difficulties in finding specialists in certain areas
  
  
• absence of an intra-hospital telemedicine system in the Institute for solving medical problems during videoconsultations
  
  
• satellite limitations precluding observation of the dynamics of patients’ movements during videoconsultations.

Future disaster telemedicine in Russia

To increase the efficiency of teleconsultations provided for Russian field hospitals, the following are required:

• organization of round-the-clock services in the telemedicine centre
  
  
• availability of sufficient medical institutions to provide teleconsulting in emergency situations
  
  
• development of the requisite national telemedicine infrastructure and creation of local information systems in disaster medicine centres.

In 2006, successful training exercises of the disaster medicine service were conducted under field conditions using a new, less expensive mobile telemedicine system. This accords with the government’s concept of developing telemedicine technologies in the Russian Federation,¹⁶ which provides transition to a new level of information support in disaster telemedicine to enable efficient control over medical care and consultative support for medical teams in emergency situations.

The process of equipping field hospitals with mobile telemedicine units continues. A small Q-band satellite station, developed by Web Media Service, successfully passed testing in 2007. This allows data transfer at 128 kbit/s, i.e. at almost the same rate as via ground communication lines.⁵ Mobile telemedicine units have been developed for the needs of space medicine.¹⁷ During the missions of the US Space Shuttle, a mobile set of medical devices for ear, nose and throat and skin imaging, electrocardiography, blood oxygen saturation level, and heart and lung sound auscultation was used.¹⁸ Similar equipment might be used by mobile teams for disaster medicine.

Conclusion

Telemedicine was highly effective in managing paediatric patients at the field hospital in a complicated situation due to the military conflict in Chechnya. The Russian satellite system HeliosNet provided reliable communication, and was not prohibitively expensive. The cost of the equipment in the telemedicine unit of the field hospital was approximately US$5000 in 2001. The cost of operating the satellite system (2008 prices) was approximately US$270 per month (for 10 videoconferences and 15 store-and-forward consultations). In 2001–2002, the estimated cost was some three to four times higher. The costs of the telemedicine work in Chechnya were met by charitable donations from business concerns.

Telemedical support for physicians working in areas of natural disasters, local military conflicts or humanitarian disasters would increase the level of urgent and specialized medical care. An important factor in realizing this will be the presence of a satisfactory telemedicine infrastructure in neighbouring regions and appropriate organization to monitor patients’ health during their transportation to hospitals or other specialized medical centres.

Further reading

Hogan DE, Burstein JL. Disaster Medicine, 2nd edn. Philadelphia: Lippincott Williams & Wilkins, 2007.

Llewellyn CH. The role of telemedicine in disaster medicine. J Med Syst 1995; 19: 29–34.

Simmons SC, Murphy TA, Blanarovich A et al. Telehealth technologies and applications for terrorism response: a report of the 2002 coastal North Carolina domestic preparedness training exercise. J Am Med Inform Assoc 2003; 10: 166–76.

Teich JM, Wagner MM, Mackenzie CF, Schafer KO. The informatics response in disaster, terrorism, and war. J Am Med Inform Assoc 2002; 9: 97–104.

References

¹ NASA satellite aids in Mexico City rescue effort. NASA News Release 1985; 85: 133.

² Houtchens BA, Clemmer TP, Holloway HC et al. Telemedicine and international disaster response. Medical consultation to Armenia and Russia via a Telemedicine Spacebridge. Prehosp Disaster Med 1993; 8: 57–66.

³ Crowther JB, Poropatich R. Telemedicine in the US Army: case reports from Somalia and Croatia. Telemed J 1995; 1: 73–80.

⁴ Calcagni DE, Clyburn CA, Tomkins G et al. Operation Joint Endeavor in Bosnia: telemedicine systems and case reports. Telemed J 1996; 2: 211–24.

⁵ Ehrlich AI, Kobrinsky BA, Petlakh VI et al. Telemedicine for a Children’s Field Hospital in Chechnya. J Telemed Telecare 2007; 13: 4–6.

⁶ Kobrinskiy BA, Matveev NV. Teleconsultations at the Moscow Research Institute for Paediatrics and Children’s Surgery. J Telemed Telecare 2006; 12(Suppl 3): 110.

⁷ Kobrinsky BA. Database of disabled children injured in disasters. Prehosp Disaster Med 1997; 12(Suppl 1): 90–1.

⁸ Cook R, Woods D, Walters M, Christoffersen K. The cognitive systems engineering of automated medical evacuation scheduling and its implications. In: Proceedings of the Third Annual Symposium on Human Interaction with Complex Systems, 25–28 August 1996: 202–7.

⁹ Levine BA, Cleary K, Mun SK. Deployable teleradiology: Bosnia and beyond. IEEE Trans Inf Technol Biomed 1998; 2: 30–4.

¹⁰ Mun SK, Levine B, Cleary K, Dai H. Deployable teleradiology and telemedicine for the US military. Comput Methods Programs Biomed 1998; 57: 21–7.

¹¹ Liaskovik AT, Senkevich YuI, Chasnik VG, Yaschin AV. [The concept of health services in regions with low population density and computer stations in the structure of advisory help.] Inform Technol Publ Health Serv 2001; 8/9: 28–9 (in Russian).

¹² Senkevich YuI. [Development of information technologies for medical maintenance of polar expeditions.] Ukr J Telemed Med Telematics 2004; 2: 22–8 (in Russian).

¹³ Garshnek V, Burkle FM Jr. Applications of telemedicine and telecommunications to disaster medicine: historical and future perspectives. J Am Med Inform Assoc 1999; 6: 26–37.

¹⁴ Grasso MA. Handheld computer application for medical disaster management. AMIA Annu Symp Proc 2006: 932.

¹⁵ Mack D, Brantley KM, Bell KG. Mitigating the health effects of disasters for medically underserved populations: electronic health records, telemedicine, research, screening, and surveillance. J Health Care Poor Underserved 2007; 18: 432–42.

¹⁶ [Concepts of Development of Telemedical Technologies in the Russian Federation.] Moscow, 2001 (in Russian).

¹⁷ Grigoriev AI, Orlov OI. [Telemedicine in Russia.] Vestn Ross Akad Med Nauk 2004; 10: 30–5 (in Russian).

¹⁸ Crump WJ, Levy BJ, Billica RD. A field trial of the NASA Telemedicine Instrument Pack in a family practice. Aviat Space Environ Med 1996; 67: 1080–5.

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