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Ambulances to Get Virtual Doctors On Board
nomrniceguy writes "Researchers are developing technology for ambulances to improve communications and perhaps more importantly, place
virtual doctors inside in transit.
A patient's vital signs and other data are beamed in real-time to the closest trauma center, where doctors can not only instruct paramedics in the field, but also prep a room to treat the critically injured once they arrive."
As a doctor I have felt this was silly for a long time... our EMTs are well trained and usually do the right things in transport until they get to us.
However, I have recently changed my mind.
Several new studies have shown in sepsis (severe infections) that the early treatment is the most important treatment. When you combine this with the "early is better" studies in heart attacks and strokes, I think the time has come for this.
Telemedicine is on its way... for better or for worse.
Oh, our poor malpractice fees!
Now I have to be responsible for the transport as well? I can run servers looking at data on a screen just fine... but running a code?
Plus, the EMTs are trained to do their job... and now you are going to have little ole me barking orders to these guys who have been doing it solo for years and years.
Does my extra knowledge better for the patient than their physicial being there? They can touch and physicially examine the poor guy... I can just sit there and look at numbers.
When I see the study that shows that this actually saves lives, then I will believe it. Until then, I believe it's just a another tech company trying to stir up interest in investors.
They talked into this little thing and a doctor's voice came out of it and gave them advice on what to do. The future is here! I've got one of those things, I can't remember what it's called, it's on the tip of my tongue, umm, err, hang on, let me get the box.... ahh here it is, they call it a "Mobile Phone". Amazing.
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I think I agree that telemedicine in the field is a great idea for certain things (especially weird ALS interfacility transfers between hospitals), but the whole point of "prehospital medicine" is to get the patient to definitive care in one piece, correcting life-threatening problems as they go, preferably in better shape than when they found the patient. EMS is there to "fix big problems that can't wait," according to pre-established patient care protocols. Also, just for purposes of clarity, EMT != paramedic.
If you look at the article, it talks about geographical considerations in the rural area around Pittsburgh that prevent them from making contact with physicians with conventional radio and cellular methods. Paramedics routinely call physicians at hospitals and say "this is what the patient looks like, these are the vital signs, this is the treatment i've rendered so far," etc. Rural EMS presents more of a challenge, but if "communications" is where the system breaks down, fix it with improved communications, not an unproven bazillion dollar system that takes more effort and cost to implement than just treating the patient as well as we do now.
The biggest problem with this (as I've mentioned above) is that this isn't really what paramedics are there for in most cases. Paramedics think in terms of chief complaints, not truly in terms of differential diagnoses. There's a much smaller universe of things you can definitively treat in the field versus starting down a path of treatment as one might in the emergency department. Sometimes there are disease processes (heart attack, stroke, and apparently sepsis) that can benefit greatly from definitive early treatment. However, the appropriate way to address this is by changing treatment protocols to tell paramedics "if you see X, Y and Z, treat THIS way" or "contact medical control" or something. Frequently, when there are new meaningful findings that can result in improved patient outcomes, continuing education and common knowledge will tell us to call for online medical control so we can immediately intervene instead of just treating with O2, IV of normal saline, and an EKG.
The second biggest problem with this is the price tag. No EMS system in its right mind is going to pay $250,000 for something that hasn't demonstrated that it's more effective at reducing morbidity and mortality than "conventional" paramedics with existing equipment and a slightly upgraded communications system.
Generally, paramedics are very good at recognizing patients who present as "yikes, this guy is sick, and I don't know why" and calling a physician. We have plenty of tools at our disposal with fancy whistles and bells to help give us a big picture of what's going on with the patient. And to be honest, physicians don't WANT paramedics bothering them at the emergency department for every incoming patient.
Save your tax dollars and mine. Spend it on more staffed ambulances and better training for paramedics, not cooler toys.
Like I said in my earlier comment, this is nothing new. Paramedics can give nitrates for chest pain, draw bloods for analysis at the hospital, administer oxygen, perform endotracheal intubation, interpret life-threatening heart rhythms, etc. In most cases, we can already do this without calling a physician and asking permission.
This is basically "offline medical control" in the form of standing orders. Physicians get together, decide what's best for the patient and a particular geographic area, and allow paramedics to practice under their indirect supervision.
Sometimes, a patient doesn't meet the right criteria for treatment, or a patient needs an intervention that needs a direct physician order (like morphine for chest pain/congestive heart failure) - in these cases, paramedics are very skilled at and comfortable with giving a very fast rundown of what's going on with the patient and asking the physician's permission to give a particular intervention.
That's in place now, it works, and it can be improved by improving the radio/communication system. I'm all for trying new things out, but I fail to see how putting expensive equipment in the back of an ambulance is going to make a difference or improve care from what could be administered by a properly-trained paramedic.
I used to be an EMS director... and I have reservations about putting certain things too far out in the resuscitation chain.
That said, I agree with you; Early treatment is arguably better for many things... assuming that early treatment saves more lives than it costs.
For instance, Thrombolytics for stroke. I find very few patients actually qualify for that particular intervention, either because they ignore their symptoms and miss the 3-hour window, or because they have contraindications. Despite the NINDS trial, I still have reservations. Maybe in the aggregate we do more good than harm, but in my personal sample size, I've seen a awfully high percentage of intracranial bleeds. This isn't something you could even consider moving out to the EMS world, if only because we don't have mobile CT yet.
RSI is another example. Rapid Sequence Intubation with paralytics is practiced in very few EMS systems, if only because it's so very difficult to keep people trained to a sufficient standard where they can use it safely. Truth be told, even some physicians can't use it safely.
The other issue becomes protocols and medical control (which is what this system appears to augment). Do your paramedics have sharp enough skills to be your remote H&P? I know more than a few physicians who'd have serious reservations about ordering a high-risk intervention based on somebody else's history and exam, particularly in this high-liability era. Remember... liability falls on the medical control or medical director physician. Even if the paramedic is just following protocols... who writes those protocols? It's usually the EMS director.
Telemedicine is definitely here to stay; teleradiology has proven that. It just remains to be seen how far we feasibly take it.
BTW, do you know Davak?
Even if a man chops off your hand with a sword, you still have two nice, sharp bones to stick in his eyes.