Mortality and morbidity from traumatic injury are twofold higher in rural compared to urban areas. Furthermore, the greater the distance a patient resides from an organized trauma system, the greater the likelihood of an adverse outcome. Delay in timely diagnosis and treatment contributes to this penalty, regardless of whether the inherent barriers are geographic, cultural, or socioeconomic. Since ultrasound is noninvasive, cost-effective, and portable, it is becoming increasingly useful for remote/underresourced (R/UR) settings to avoid lengthy patient travel to relatively inaccessible medical centers. Ultrasonography is a user-dependent, technical skill, and many, if not most, front-line care providers will not have this advanced training. This is particularly true if care is being provided by out-of-hospital, “nontraditional” providers. The human exploration of space has forced the utilization of information technology (IT) to allow remote experts to guide distant untrained care providers in point-of-care ultrasound to diagnose and manage both acute and chronic illness or injuries. This paradigm potentially brings advanced diagnostic imaging to any medical interaction in a setting with internet connectivity. This paper summarizes the current literature surrounding the development of teleultrasound as a transformational technology and its application to underresourced settings. 1. Introduction Despite revolutions and quantum leaps in the development of technology and health care systems, disadvantaged populations, separated from the mainstreams of modern technology by either geography, duty, choice, or fate, bear an increased burden of mortality and morbidity [1]. Such populations in remote/underresourced (R/UR) settings have limited access to the advanced medical health care that is the norm in the developed world. For instance, rural trauma such as the one after motor vehicle accidents may have mortality rates up to three times the national average [2, 3]. Preventable deaths in some rural areas are twice that of urban communities. While this may be explained by delays in transfer to definitive care from remote areas [3], other factors seem to come into play over and above distance alone. Often the homeless, dying within the direct line-of-sight of a major medical center, are as practically separated from potential life-saving care as a climber on Mount Everest, a soldier immobilized by enemy action, or a village dweller in the developing world. In a vacuum of primary and tertiary care, it may be difficult to prioritize what aspects of modern
References
[1]
J. D. O'Neil, “The politics of health in the Fourth World: a northern Canadian example,” Human Organization, vol. 45, no. 2, pp. 119–128, 1986.
[2]
B. A. Mueller, F. P. Rivara, and A. B. Bergman, “Urban-rural location and the risk of dying in a pedestrian-vehicle collision,” Journal of Trauma, vol. 28, no. 1, pp. 91–94, 1988.
[3]
D. C. Grossman, A. Kim, S. C. Macdonald, P. Klein, M. K. Copass, and R. V. Maier, “Urban-rural differences in prehospital care of major trauma,” Journal of Trauma, vol. 42, no. 4, pp. 723–729, 1997.
[4]
The Partnership for Maternal N, and Child Health, From pledges to action, New Delhi, India 13-14 November 2010 World Health Organization, http://www.who.int/pmnch/events/2010/2010_pf_innovation_ultrasound/en/.
[5]
W. H. Organization, Effective Choices for Diagnostic Imaging in Clinical Practice. Report of a WHO Scientific Group, World Health Organization, Geneva, Switzerland, 1990.
[6]
L. M. Gillman and A. W. Kirkpatrick, “Portable bedside ultrasound: the visual stethoscope of the 21st century,” Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, vol. 20, article 18, 2012.
[7]
A. W. Kirkpatrick, “Clinician-performed focused sonography for the resuscitation of trauma,” Critical Care Medicine, vol. 35, no. 5, pp. S162–S172, 2007.
[8]
J. Bowra, S. Forrest-Horder, E. Caldwell, M. Cox, and S. K. D'Amours, “Validation of nurse-performed FAST ultrasound,” Injury, vol. 41, no. 5, pp. 484–487, 2010.
[9]
K. S. Boniface, H. Shokoohi, E. R. Smith, and K. Scantlebury, “Tele-ultrasound and paramedics: real-time remote physician guidance of the Focused Assessment with Sonography for Trauma examination,” American Journal of Emergency Medicine, vol. 29, no. 5, pp. 477–481, 2011.
[10]
J. Roberts, J. McManus, and B. Harrison, “Use of ultrasonography to avoid an unnecessary procedure in the prehospital combat environment: a case report,” Prehospital Emergency Care, vol. 10, no. 4, pp. 502–506, 2006.
[11]
P. J. Fagenholz, J. A. Gutman, A. F. Murray, and N. S. Harris, “Treatment of high altitude pulmonary edema at 4240？m in Nepal,” High Altitude Medicine and Biology, vol. 8, no. 2, pp. 139–146, 2007.
[12]
P. B. McBeth, I. Crawford, M. Blaivas, et al., “Simple, almost anywhere, with almost anyone: remote low-cost telementored resuscitative lung ultrasound,” The Journal of Trauma, vol. 71, no. 6, pp. 1528–1535, 2011.
[13]
E. M. Fincke, G. Padalka, D. Lee et al., “Evaluation of shoulder integrity in space: first report of musculoskeletal US on the International Space Station,” Radiology, vol. 234, no. 2, pp. 319–322, 2005.
[14]
L. Chiao, S. Sharipov, A. E. Sargsyan et al., “Ocular examination for trauma; clinical ultrasound aboard the International Space Station,” Journal of Trauma, vol. 58, no. 5, pp. 885–889, 2005.
[15]
A. E. Sargsyan, D. R. Hamilton, J. A. Jones et al., “FAST at MACH 20: clinical ultrasound aboard the International Space Station,” Journal of Trauma, vol. 58, no. 1, pp. 35–39, 2005.
[16]
J. A. Jones, A. E. Sargsyan, Y. R. Barr, S. Melton, D. R. Hamilton, S. A. Dulchavsky, et al., “Diagnostic ultrasound at MACH 20: retroperitoneal and pelvic imaging in space,” Ultrasound in Medicine and Biology, vol. 35, no. 7, pp. 1059–1067, 2009.
[17]
P. B. McBeth, T. Hamilton, and A. W. Kirkpatrick, “Cost-effective remote iphone-teathered telementored trauma telesonography,” Journal of Trauma, vol. 69, no. 6, pp. 1597–1599, 2010.
[18]
I. Crawford, P. B. McBeth, M. Mitchelson, C. Tiruta, J. Ferguson, and A. W. Kirkpatrick, “Telementorable, “just-in-time” lung ultrasound on an iPhone,” Journal of Emergencies, Trauma and Shock, vol. 4, no. 4, pp. 526–527, 2011.
[19]
I. Crawford, C. Tiruta, A. W. Kirkpatrick, M. Mitchelson, and J. Ferguson, “Big brother could actually help quite easily: telementored, “just-in-time” telesonography of the FAST over a smartphone,” Annals of Emergency Medicine, vol. 58, no. 3, pp. 312–314, 2011.
[20]
M. C. Gibbons and C. Rivera Casale, “Reducing disparities in health care quality: the role of health it in underresourced settings,” Medical Care Research and Review, vol. 67, no. 5, pp. 155S–162S, 2010.
[21]
America CoQoHCi, Crossing the Quality Chasm: A New Health System for the 21st Century, Washington, DC, USA, 2001.
[22]
L. M. Gillman, C. G. Ball, N. Panebianco, A. Al-Kadi, and A. W. Kirkpatrick, “Clinician performed resuscitative ultrasonography for the initial evaluation and resuscitation of trauma,” Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, vol. 17, article 34, 2009.
[23]
I. Crawford, P. B. McBeth, Mitchelson m, J. Fergusen, C. Tiruta, and A. W. Kirkpatrick, “How to set up a low-cost tele-ultrasound capable video-conferencing system with wide applicability,” Critical Ultrasound Journal, vol. 4, no. 13, 2012.
[24]
J. Gershon-Cohen and A. G. Cooley, “Telognosis,” Radiology, vol. 55, no. 4, pp. 582–587, 1950.
[25]
W. L. Sobczyk, R. E. Solinger, A. H. Rees, and F. Elbl, “Transtelephonic echocardiography: successful use in a tertiary pediatric referral center,” The Journal of Pediatrics, vol. 122, no. 6, pp. S84–S88, 1993.
[26]
N. J. Squibb, “Video transmission for telemedicine,” Journal of Telemedicine and Telecare, vol. 5, no. 1, pp. 1–10, 1999.
[27]
J. A. Brebner, H. Ruddick-Bracken, E. M. Brebner et al., “Low-bandwidth tele-ultrasound,” Journal of Telemedicine and Telecare, vol. 5, pp. S75–S76, 1999.
[28]
F. Y. Chan, J. Whitehall, L. Hayes et al., “Minimum requirements for remote realtime fetal tele-ultrasound consultation,” Journal of Telemedicine and Telecare, vol. 5, no. 3, pp. 171–176, 1999.
[29]
P. Smith and E. Brebner, “Tele-ultrasound for remote areas,” Journal of Telemedicine and Telecare, vol. 8, supplement 2, pp. 80–81, 2002.
[30]
J. Pyke, M. Hart, V. Popov, R. D. Harris, and S. McGrath, “A tele-ultrasound system for real-time medical imaging in resource-limited settings,” in Proceedings of the 29th Annual International Conference of IEEE-EMBS, Engineering in Medicine and Biology Society (EMBC '07), pp. 3094–3097, Lyon, France, August 2007.
[31]
F. B. Rogers, M. Ricci, M. Caputo 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,” Journal of Trauma, vol. 51, no. 6, pp. 1037–1041, 2001.
[32]
J. C. Duchesne, A. Kyle, J. Simmons, S. Islam, R. E. Schmieg Jr., J. Olivier, et al., “Impact of telemedicine upon rural trauma care,” The Journal of Trauma, vol. 64, no. 1, pp. 92–98, 2008.
[33]
Y. M. Paulus and N. P. Thompson, “Inexpensive, realtime tele-ultrasound using a commercial, web-based video streaming device,” Journal of Telemedicine and Telecare, vol. 18, no. 4, pp. 185–188, 2012.
[34]
K. O'Connell, A. J. Bouffard, A. Vollman, R. Mercado-Young, A. E. Sargsyan, I. Rubinfeld, et al., “Extreme musculo-skeletal ultrasound: training of non-physicians in the Arctic Circle,” Critical Ultrasound Journal, vol. 3, pp. 19–24, 2011.
[35]
C. Otto, J. M. Comtois, A. Sargsyan, A. Dulchavsky, I. Rubinfeld, and S. Dulchavsky, “The Martian chronicles: remotely guided diagnosis and treatment in the arctic circle,” Surgical Endoscopy and Other Interventional Techniques, vol. 24, no. 9, pp. 2170–2177, 2010.
[36]
N. Biegler, P. B. McBeth, M. Tevez-Molina, J. R. McMillan, I. Crawford, D. R. Hamilton, et al., “Just-in-time cost-effective off-the-shelf remote telementoring of paramedical personnel in bed-side lung sonography—a Technical Case Study,” Telemedicine Journal and E-health, vol. 18, no. 10, pp. 807–809, 2012.
[37]
A. W. Kirkpatrick, “2010 Trauma Association of Canada presidential address: why the Trauma Association of Canada should care about space medicine,” Journal of Trauma, vol. 69, no. 6, pp. 1313–1322, 2010.
[38]
M. Millery and R. Kukafka, “Health information technology and quality of health care: strategies for reducing disparities in underresourced settings,” Medical Care Research and Review, vol. 67, no. 5, 2010.
[39]
P. W. Groeneveld, S. B. Laufer, and A. M. Garber, “Technology diffusion, hospital variation, and racial disparities among elderly medicare beneficiaries 1989–2000,” Medical Care, vol. 43, no. 4, pp. 320–329, 2005.
[40]
A. W. Kirkpatrick, J. A. Jones, A. Sargsyan et al., “Trauma sonography for use in microgravity,” Aviation Space and Environmental Medicine, vol. 78, no. 4, pp. A38–A42, 2007.
[41]
A. W. Kirkpatrick, D. R. Hamilton, S. Nicolaou et al., “Focused assessment with sonography for trauma in weightlessness: a feasibility study,” Journal of the American College of Surgeons, vol. 196, no. 6, pp. 833–844, 2003.
[42]
D. R. Hamilton, A. E. Sargsyan, A. W. Kirkpatrick et al., “Sonographic detection of pneumothorax and hemothorax in microgravity,” Aviation Space and Environmental Medicine, vol. 75, no. 3, pp. 272–277, 2004.
[43]
S. A. Dulchavsky, A. E. Sargsyan, K. M. Garcia, S. L. Melton, D. Ebert, and D. R. Hamilton, “Intuitive ultrasonography for autonomous medical care in limited-resource environments,” Acta Astronautica, vol. 68, no. 9-10, pp. 1595–1607, 2011.
[44]
C. M. Foale, A. Y. Kaleri, A. E. Sargsyan et al., “Diagnostic instrumentation aboard ISS: just-in-time training for non-physician crewmembers,” Aviation Space and Environmental Medicine, vol. 76, no. 6, pp. 594–598, 2005.
[45]
D. Kwon, J. A. Bouffard, M. van Holsbeeck et al., “Battling fire and ice: remote guidance ultrasound to diagnose injury on the International Space Station and the ice rink,” American Journal of Surgery, vol. 193, no. 3, pp. 417–420, 2007.
[46]
D. R. Hamilton, A. E. Sargsyan, D. S. Martin et al., “On-orbit prospective echocardiography on international space station crew,” Echocardiography, vol. 28, no. 5, pp. 491–501, 2011.
[47]
D. Dyer, J. Cusden, C. Turner et al., “The clinical and technical evaluation of a remote telementored telesonography system during the acute resuscitation and transfer of the injured patient,” Journal of Trauma, vol. 65, no. 6, pp. 1209–1216, 2008.
[48]
A. Al-Kadi, D. Dyer, C. G. Ball et al., “User's perceptions of remote trauma telesonography,” Journal of Telemedicine and Telecare, vol. 15, no. 5, pp. 251–254, 2009.
[49]
C. A. Strode, B. J. Rubal, R. T. Gerhardt, J. R. Bulgrin, and S. Y. N. Boyd, “Wireless and satellite transmission of prehospital focused abdominal sonography for trauma,” Prehospital Emergency Care, vol. 7, no. 3, pp. 375–379, 2003.
[50]
O. J. Ma, J. G. Norvell, and S. Subramanian, “Ultrasound applications in mass casualties and extreme environments,” Critical Care Medicine, vol. 35, no. 5, pp. S275–S279, 2007.
[51]
N. Nikoli？, V. Mozeti？, B. Modrcin, and S. Jaksi？, “Might telesonography be a new useful diagnostic tool aboard merchant ships? A pilot study,” International Maritime Health, vol. 57, no. 1–4, pp. 198–212, 2006.
[52]
C. Otto, D. R. Hamilton, B. D. Levine et al., “Into thin air: extreme ultrasound on Mt Everest,” Wilderness and Environmental Medicine, vol. 20, no. 3, pp. 283–289, 2009.
[53]
B. Soong, F. Y. Chan, S. Bloomfield, M. Smith, and D. Watson, “The fetal tele-ultrasound project in Queensland,” Australian Health Review, vol. 25, no. 3, pp. 67–73, 2002.
[54]
F. Vi？als, L. Mandujano, G. Vargas, and A. Giuliano, “Prenatal diagnosis of congenital heart disease using four-dimensional spatio-temporal image correlation (STIC) telemedicine via an Internet link: a pilot study,” Ultrasound in Obstetrics and Gynecology, vol. 25, no. 1, pp. 25–31, 2005.
[55]
B. A. McCrossan, A. J. Sands, T. Kileen, C. R. Cardwell, and F. A. Casey, “Fetal diagnosis of congenital heart disease by telemedicine,” Archives of Disease in Childhood Fetal and Neonatal Edition, vol. 96, no. 6, pp. F394–F397, 2011.
[56]
B. G. Choi, M. Mukherjee, P. Dala, H. A. Young, C. M. Tracy, R. J. Katz, et al., “Interpretation of remotely downloaded pocket-size cardiac ultrasound images on a web-enabled smartphone: validation against workstation evaluation,” Journal of the American Society of Echocardiography, vol. 24, no. 12, pp. 1325–1330, 2011.
[57]
A. S. Liteplo, A. F. Murray, H. H. Kimberly, and V. E. Noble, “Real-time resolution of sonographic B-lines in a patient with pulmonary edema on continuous positive airway pressure,” American Journal of Emergency Medicine, vol. 28, no. 4, pp. 541.e5–541.e8, 2010.
[58]
J. B. Landwehr Jr., I. E. Zador, H. M. Wolfe, M. P. Dombrowski, and M. C. Treadwell, “Telemedicine and fetal ultrasonography: assessment of technical performance and clinical feasibility,” American Journal of Obstetrics and Gynecology, vol. 177, no. 4, pp. 846–848, 1997.
[59]
“Ambulance crash-related injuries among Emergency Medical Services workers—United States, 1991–2002,” Morbidity and Mortality Weekly Report, vol. 52, no. 8, pp. 154–156, 2003.
[60]
D. Lutman, M. Montgomery, P. Ramnarayan, and A. Petros, “Ambulance and aeromedical accident rates during emergency retrieval in Great Britain,” Emergency Medicine Journal, vol. 25, no. 5, pp. 301–302, 2008.
[61]
F. Y. Chan, “Fetal tele-ultrasound and tele-therapy,” Journal of Telemedicine and Telecare, vol. 13, no. 4, pp. 167–171, 2007.
[62]
F. Y. Chan, B. Soong, D. Watson, and J. Whitehall, “Realtime fetal ultrasound by telemedicine in Queensland. A successful venture?” Journal of Telemedicine and Telecare, vol. 7, supplement 2, pp. 7–11, 2001.
[63]
C. Lewis, “A tele-ultrasound needs analysis in Queensland,” Journal of Telemedicine and Telecare, vol. 11, supplement 2, pp. 61–64, 2005.
[64]
C. R. Macedonia, R. J. Littlefield, J. Coleman et al., “Three-dimensional ultrasonographic telepresence,” Journal of Telemedicine and Telecare, vol. 4, no. 4, pp. 224–230, 1998.
[65]
F. Y. Chan, B. Soong, D. Watson, S. Bloomfield, R. Cincotta, and J. Whitehall, “200 fetal tele-ultrasound consultations: clinical value and cost-effectiveness,” Ultrasound in Obstetrics & Gynecology, vol. 26, article 469, 2005.
[66]
J. Norum, T. S. Bergmo, B. Hold？ et al., “A tele-obstetric broadband service including ultrasound, videoconferencing and cardiotocogram. A high cost and a low volume of patients,” Journal of Telemedicine and Telecare, vol. 13, no. 4, pp. 180–184, 2007.
[67]
F. Y. Chan, A. Taylor, B. Soong et al., “Randomized comparison of the quality of realtime fetal ultrasound images transmitted by ISDN and by IP videoconferencing,” Journal of Telemedicine and Telecare, vol. 8, no. 2, pp. 91–96, 2002.
[68]
J. A. Brebner, H. Ruddick-Bracken, E. M. Brebner et al., “The diagnostic acceptability of low-bandwidth transmission for tele-ultrasound,” Journal of Telemedicine and Telecare, vol. 6, no. 6, pp. 335–338, 2000.
[69]
R. M. Ferlin, D. M. Vaz-Oliani, A. C. Ferreira, E. G. Tristao, and A. H. Oliani, “Tele-obstetric ultrasound: analysis of first-trimester ultrasound images transmitted in realtime,” Journal of Telemedicine and Telecare, vol. 18, no. 1, pp. 54–58, 2012.
[70]
I. Edler and K. Lindstr？m, “The history of echocardiography,” Ultrasound in Medicine and Biology, vol. 30, no. 12, pp. 1565–1644, 2004.
[71]
S. Awadallah, I. Halaweish, and F. Kutayli, “Tele-echocardiography in neonates: utility and benefits in South Dakota primary care hospitals,” South Dakota Medicine, vol. 59, no. 3, pp. 97–100, 2006.
[72]
B. M. Adriaanse, C. H. Tromp, J. M. Simpson, T. Van Mieghem, W. J. Kist, D. J. Kuik, et al., “Interobserver agreement in detailed prenatal diagnosis of congenital heart disease by telemedicine using four-dimensional ultrasound with spatiotemporal image correlation,” Ultrasound in Obstetrics & Gynecology, vol. 39, no. 2, pp. 203–209, 2012.
[73]
J. Espinoza, W. Lee, C. Comstock et al., “Collaborative study on 4-dimensional echocardiography for the diagnosis of fetal heart defects: the COFEHD study,” Journal of Ultrasound in Medicine, vol. 29, no. 11, pp. 1573–1580, 2010.
[74]
T. H. Lim, H. J. Choi, and B. S. Kang, “Feasibility of dynamic cardiac ultrasound transmission via mobile phone for basic emergency teleconsultation,” Journal of Telemedicine and Telecare, vol. 16, no. 5, pp. 281–285, 2010.
[75]
S. A. Dulchavsky, S. E. Henry, B. R. Moed et al., “Advanced ultrasonic diagnosis of extremity trauma: the FASTER examination,” Journal of Trauma, vol. 53, no. 1, pp. 28–32, 2002.
[76]
M. R. Nowak, A. W. Kirkpatrick, J. A. Bouffard, D. Amponsah, and S. A. Dulchavsky, “Snowboarding injuries: a review of the literature and an analysis of the potential use of portable ultrasound for mountainside diagnostics,” Current Reviews in Musculoskeletal Medicine, vol. 2, no. 1, pp. 25–29, 2009.
[77]
K. Ito, S. Sugano, and H. Iwata, “Portable and attachable tele-echography robot system: FASTele,” in Proceedings of the 32nd Annual International Conference of the IEEE Engineering in Medicine and Biology Society (EMBC '10), pp. 487–490, Buenos Aires, Argentina, September 2010.
