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39 Telemedicine andFuture Innovation
335
trauma surgeons or critical care providers to bridge the expe­rience and access gap to trauma care that may exist in rural settings [3]. Telemedicine serves as an interface for inter­hospital trauma care between echelons of care, in the pre­hospital setting to guide the care of rst responders, or as a mobile system deployed to disaster settings [3].
In its simplest form, telemedicine began as a sort of public health service in the Middle Ages, where bonres in Europe were lit to signal the spread of bubonic plague. Outside of simple mail service, the technology slowly developed until telegraphy was utilized in the 1800s by American Civil War surgeons to create casualty lists and request supplies. The telephone allowed further advances in the early twentieth century, ranging from simple communication to the trans­mission of heart sounds from an amplied stethoscope. A telepsychiatry program at the Nebraska Psychiatric Institute was developed by Dr. Cecil Wittson in the 1950s and expanded in the 1960s to encompass real-time consultation via closed-circuit television [4].
Early modern telemedicine is associated with another technological boon of the twentieth century—the National Aeronautics and Space Administration. NASA expanded on the telelinks that relayed biometric data collected from ani­mals sent into space to develop the Integrated Medical and Behavioral Laboratories and Measurement Systems (IMBLMS) program in 1964. IMBLMS sought to move past simple monitoring to actual assistance of an astronaut in the delivery of self-aid or buddy-aid when a return from orbit was impractical [5]. This technology matured in a terrestrial form through a partnership between NASA, the Papago Indian Reservation, the Indian Health Service, and the Department of Health, Education, and Welfare with Arizona’s Space Technology Applied to Rural Papago Advanced Health Care (STARPAHC). The service was provided from 1972 to 1975 and delivered health care in the underserved Papago Reservation through a van staffed by paramedics who broad­cast data such as X-ray images over a two-way microwave transmission to physicians at the Public Health Service Hospital [6]. Given limitations in technology and timeliness of the care that could be provided, nearly all of these efforts focused on routine care.
In 1978, Dr. R Adams Cowley simulated a response to a crash of a DC-6 airplane wherein providers were able to transmit images of burn victims in real time via satellite to a burn unit in San Antonio and medical centers throughout the Washington DC area [7]. The use of satellites for medical support in disaster management was rst seen during the coordination of international rescue assets after the Mexico City earthquake of 1985 [8]. Satellite transmission has become the mainstay of large data transmission, but its cost and large platform size often limit its wide-scale application. The expanded use of devices with access to broadband global area networks (BGAN) now allows for a portable communi-
cation device to provide telemedicine in areas devoid of local networks. Cost can still be an issue, though BGAN systems have the upload and download speeds to perform video tele­conferencing in contrast to cheaper and very small aperture satellite systems. Used in multiple congurations, devices with BGAN connectivity have been used in remote settings such as rural Africa to provide real-time ultrasound interpre­tation [9]. The military has incorporated devices with BGAN connectivity to aid rst responders in the triage and treat­ment of casualties [10]. In areas where the infrastructure exists, wireless cellular-based broadband has enabled a wide array of potential therapeutic interventions through the use of smartphones and laptops with applications to acquire, interpret, and transmit data. Modern trauma telemedicine and telepresence centers often use a combination of such systems to interact in prehospital and inter-hospital settings [3].
Outcomes
The use of telemedicine has amassed impressive evidence supporting its use as a reliable, reproducible technology fea­sible across multiple platforms and venues of care. Central to its utility is the ability to improve access to health care, but a signicant cost advantage lies in its ability to improve the triage of trauma patients. Rogers etal. [11] in 2001 described a tele-trauma program in rural Vermont in an observational study evaluating the impact of a real-time telemedicine con­sult with a trauma surgeon and a community hospital emer­gency department. In 41 consultations consisting mostly of motor vehicle collisions (49%) and/or blunt trauma (95%), 31 were transferred to the tertiary care center, of which three cases were considered lifesaving. Patient disposition was the predominant query, and 15% of cases were kept at the refer­ring facility. A total of 80% of providers surveyed felt that telemedicine improved patient care.
Duchesne etal. conducted a comparative analysis of out­comes before and after the introduction of telemedicine in the management of trauma patients treated at seven rural emergency departments in Mississippi, [12] demonstrating both improved rural evaluation and management. The hospi­tals utilized remote-controlled video cameras to evaluate the management of traumatically injured patients over 5years, comparing 351 historical controls directly transferred to the trauma center with 463 virtual consults. Of the virtual con­sults, only 51 patients were triaged to the trauma center despite telemedicine patients having a higher injury severity score (18 vs. 10, p<0.001), with no differences in patient age, sex, method of transportation, or mortality. An impres­sive difference in hospital cost was found between the groups (USD 1,126,683 versus 7,632,624, p < 0.001) suggesting that telemedicine signicantly improved evaluation and
336
C. J. Kucik et al.
management of rural trauma patients at reduced costs with­out signicant changes in mortality.
In a retrospective analysis of one of the more robust tele­medicine centers in the United States, Lati etal. described their early experience of a telemedicine system involving ve rural hospitals and a Level I trauma center in southern Arizona [13]. In a retrospective analysis of 59 tele-consults involving a mix of general surgery (41%) and trauma patients (59%), 29% of patients were held at their referring hospital for ongoing care while six tele-consults led to potentially lifesaving therapy. Reducing transfers saved an average of USD 19,698 per air transport or USD 2055 per ground trans­port, again suggesting that a telepresence can effectively improve trauma outcomes while reducing costs.
In a study of telemedicine for 70 burn patients, Safe etal. described a 55.7% reduction in emergent transfers to a burn center compared with a historical cohort [14]. Ten patients were effectively discharged from their referral cen­ter’s emergency department. In addition to the decreased transfers, this strategy allowed for more effective utilization of the increasingly limited resource of the modern burn cen­ter. Interestingly, estimates of burn sizes by burn center phy­sicians correlated between telemedicine and direct inspection estimates, though both differed signicantly from the esti­mates of the referring physician, suggesting not only a reduc­tion in the over- or under-triage inherent in initial burn assessment but also the diagnostic integrity of the telemedi­cine system on a clinical variable likely to have signicant impacts on care and patient outcome. Notably, the telemedi­cine interaction was also viewed favorably by both providers and patients.
In a Canadian evaluation using videoconferencing and the transfer of a real-time ultrasound information, Dyer et al. were able to observe and direct 20 acute, focused assess­ments with sonography for trauma (FAST) exams, identify­ing ve cases of hemoperitoneum and two pneumothoraces, while also being able to provide feedback for the sonogra­pher [15]. The ability of telepresence to ll the experience gap present in trauma care was again demonstrated when, using a video laryngoscope modied with a Wi-Fi module broadcasting over a telemedicine network, a physician spe­cializing in airway management was able to assist a health­care provider performing tracheal intubation in a remote hospital [16].
Developing aTelemedicine System
Multiple factors will inevitably surface to impede the easy implementation of a telemedicine program. Though an indi­vidual location’s factors will vary widely, at a minimum, an institution considering adopting such an innovation should:
1. Develop a comprehensive business plan, to include information technology and administrative support at all hours if necessary.
2. Assess the need for administrative or structural changes required for its incorporation in the delivery of care.
3. Build infrastructure when necessary.
4. Encourage and provide funding for telemedicine devel­opment and research, often through the designation of promising and respected local champions.
5. Develop a plan for implementation (once clinical effec­tiveness and cost-effectiveness have been demonstrated).
6. Gain “buy-in” from all staff (physicians, nursing, infor­mation technology, administration, patient advocacy).
7. Create training, practice guidelines, credentialing, and continuing quality improvement mechanisms.
8. Address overarching and local ethical and medico-legal concerns.
9. Ensure the security of patient data under existing privacy regulations.
10. Integrate clinical staff (user) concerns into any engineer­ing or technical changes.
11. Account for linguistic and literacy differences.
12. Be sensitive to particular technical and organizational factors, allowing for continuous reporting, disclosure, and full transparency.
Signicant learning curves for the use of technology must be anticipated. Partnering with an existing telemedicine pro­gram may help to gain acceptance of new ideas through the careful application of lessons learned. Naturally, as with any new technology applied to a eld with proud traditions (such as trauma care), reluctance to adopt new practices will need to be expected, appreciated, and managed through the care­ful accumulation of data and the politic presentation of new ideas.
The Future
“Moore’s Law,” the observation that computer processing speeds have doubled roughly every two years and will likely continue to do so for the foreseeable future, will further enable innovation in telemedicine to bridge the austerity­trauma divide. As internet and broadband communications improvements accumulate, the delity and reproducibility of telemedicine systems will lead to faster collaborations between clinicians, more efcient use of resources (includ­ing improved diversion amongst hospitals based on the avail­ability of assets), cost savings throughout the spectrum of care, improved access to the electronic health record, and better patient outcomes, engagement, and even follow-up
39 Telemedicine andFuture Innovation
337
after discharge. Though there are several emerging technolo­gies and ideas worth exploring, nearly all of their potential in contributing to augmented trauma care can be traced to improvements in computing power, speed, and integration.
While in some aspects it still may be considered the stuff of science ction, telemedicine in its most developed state will compress or even negate the impositions and limitations of distance, rendering the recognized ow of “Point of Injury—Enroute Care—Emergency Department—Operating Room—Intensive Care Unit” distinctions obsolete. Integrated wearable or even implantable sensors [17] will instantly detect trauma in a particular patient, inform the echelons of care to initiate response and evacuation, and even, as in the case of certain designs of exoskeletons, either prevent certain traumas (as in the sense of a body armor function [18] or a haptic vibrating “early warning” system [19]) or initiate some form of self-aid (as in an exoskeleton with incorporated extremity tourniquets). Effective inte­grated sensors of this type are already being investigated by various militaries, and in the case of a mass casualty involv­ing multiple injured soldiers, will even assist in triage, informing rst responders even before their arrival on the scene of patient criticality and triage priority.
Once medical professionals arrive, several mobile diag­nostic devices, miniaturized ultrasounds, and various other “apps” will augment their capabilities to diagnose and treat eld trauma, including “Tricorder” devices solicited through such calls as the Nokia Sensing XCHALLENGE competi­tion. Wearable integrated sensing and communications tech­nologies such as the ULTRA-Vis [20] or the Google Glass and others will allow rst responders and remote advanced practitioners to have instant decision support from trauma experts located anywhere in the world (or beyond), while at the hospital, such devices will contribute to more seamless integration of data or checklists in a real-time, hands-free “heads-up display” that a clinician will be able to utilize simultaneously, even while scrubbed into a procedure [21].
Remote diagnostics and therapeutics will be made even more accessible through the improvement in existing haptics technologies that transmit palpatory stimuli from the patient to a remote practitioner. While exoskeleton devices that pro­vide tactile or auditory “early warning” are already in vari­ous stages of use in the military and can aid further in the prevention of trauma, further advances in such feedback modalities will continue to improve tactile sensation in remote robotic surgery. Though some skeptics may argue robotic surgery yields no better outcome than traditional sur­gery, [22] it is difcult to argue that remote robotic surgery is
in any way inferior to receiving no treatment in those cases that no competent surgeon is on site to deliver care personally.
Although beyond the scope of this chapter, innovations in transportation and robotics deserve brief mention. Tremendous strides in communication and interconnectivity have drastically improved ground and aerial medical evacua­tion through better patient tracking, medical information sharing, and the integration of medical devices in various “ying ICU” congurations. Advanced device integration, already revolutionizing intensive care and patient safety, [23] can even allow remote monitoring of patients and adjustment of ventilators and medication pumps when medical atten­dants cannot be at the patient’s bedside, as in xed-wing takeoff and landing [24]. Nanotechnology applied to robotic surgery and embolic therapy is gaining acceptance, [25] while the self-driven car of today [26] will become the self­driven ambulance and self-ying helicopter of tomorrow. Robotic extraction systems [27] will expand the reach (and safety) of rst responders, even obviating the need to put a person at risk to rescue a patient, just as unmanned underwa­ter vehicles and robotic explosive ordnance devices have done, respectively, for human divers and bomb technicians.
Undergirding all these advances will be a powerful and ubiquitous network of data storage, decision support, addi­tive manufacturing (“3D Printing”), and Articial Intelligence aids that will be able to assist the clinician in determining courses of treatment based on best available evidence [28]. The additive manufacturing of today, which fashions surgi­cal tools that more perfectly ts the surgeon’s hand or which construct an implantable cranioplasty in alignment with the patient’s native skull shape, will become the bioprinters [29] of tomorrow capable of “growing” tissues, and eventually, organs, from host cells. Remote computing will likewise allow for the completion of many tasks virtually, from inter­preting a radiologic study remotely on a mobile device before patient arrival to ordering a study or writing that note one forgot to complete through a secure telework system at home.
But such network advances will not only help the clini­cian in addressing trauma, perhaps the greatest inuence of technology will be in the realms of social media, crowd­sourcing, the inuencing of opinion, and the empowerment of the consumer toward healthy behaviors. Indeed, the trau­matologist of the future may not only be able to care for vic­tims of trauma more efciently and effectively but will also play a role in steering them from harm, thereby preventing some from ever becoming patients in the rst place.
338
Key Points
• Quality control is the process by which an organiza­tion reviews all the factors contributing to perform­ing and production outcomes.
• Health care quality is dened as safe, effective, patient-centered, timely, efcient, and equitable cri­teria for health care and provider evaluation.
• Crew resource management is a methodology to effectively adapt team strategies, tools, and patient safety measures to ensure engagement of the trauma team and improve quality patient outcomes.
• Leadership is earned and adapted from historical shared experiences within the organization and team allowing for constructive open communica­tions and corrections without reprisal.
• Team performance should be constantly evaluated and discussed to improve communication, effec­tiveness, and motivation of all members of the trauma team.

References

1. Reid J.A telemedicine primer: understanding the issues. Topeka KS: Innovative Medical Communications; 1996.
2. Craig J, Patterson V.Introduction to the practice of telemedicine. J Telemed Telecare. 2005;11(1):3–9.
3. Lati R, Weinstein RS, Porter JM. Telemedicine and telepres­ence for trauma and emergency care management. Scand J Surg. 2007;96(4):281–9.
4. Benschoter RA, Wittson CL, Ingham CG.Teaching and consulta­tion by television: I.Closed-circuit collaboration. J Hosp Commun Psychiatry. 1965;16:99–100.
5. National Aeronautics and Space Administration. NASA satellite aids in Mexico City rescue. NASA News; 1985. p.85–133.
6. Bashshur R.Technology serves the people: technology serves the people: the story of a cooperative telemedicine project by NASA, the Indian Health Service, and the Papago people superintendent of documents. Washington, D.C.: US Government Printing Ofce;
1980. p.110.
7. Maull K. The friendship airport disaster exercise: pioneer­ing effort in trauma telemedicine. Eur Jour Med Research. 2002;7(supplement):48.
8. Houtchens BA.Telemedicine and international disaster response. Prehospital Disater Med. 1993;8:57–66.
phy tele-operated in several medical centres sites, from an expert center, using a robotic arm and telephone or satellite link. J Gravit Physiology. 2007;14(1):139–40.
C. J. Kucik et al.
10. Strode CA, Rubal BJ, Gerhardt RT, etal. Wireless and satellite transmission of prehospital focused abdominal sonography for trauma. Prehosp Emerg Care. 2003;7(3):375–9.
11. Rogers F, Ricci M, Shackford S, 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. J Trauma. 2001;51(6):1037–1041A.
12. Duchesne JC, Kyle A, Simmons J, et al. Impact of telemedicine upon rural trauma care. J Trauma. 2008;64(1):92–7.
13. Lati R, Hadeed GJ, Rhee PA, etal. Initial experiences and out­comes of telepresence in the management of trauma and emergency surgical patients. Am J Surg. 2009;198(6):905–10.
14. Safe JR, Edelman L, Theurer L, et al. Telemedicine evalu­ation of acute burns is accurate and cost-effective. J Trauma. 2009;67(2):358–65.
15. Dyer D, Cusden J, Turner C, etal. The clinical and technical evalu­ation of a remote telementored telesonography system during the acute resuscitation and transfer of the injured patient. J Trauma. 2008;65(6):1209–16.
16. Sakles J, Mosier J, Hadeed G, et al. Telemedicine and telepres­ence for prehospital and remote hospital tracheal intubation using a GlideScope™ videolaryngoscope: a model for tele-intubation. Telemed J E Health. 2011;17(3):185–8.
17. Hodgetts TJ.The future character of military medicine. J R Army Med Corps. 2012 Sep;158(3):271–8.
18. Lewis EA, et al. The development and introduction of ballistic protection of the external genitalia and perineum. J R Army Med Corps. 2013 Mar;159(Suppl 1):i15–7.
19. Elliot LR, etal. Development of Tactile and Haptic Systems for U.S.Infantry Navigation and Communication, vol. 6771. Human Interface and the Management of Information, Interacting with Information Lecture Notes in Computer Science; 2011. p.399–407.
20. Dent S.DARPA aunts wearable display with Oculus-like head­tracking. May 22nd 2014, http://www.engadget.com/2014/05/22/
darpa- ultra- vis- head- tracking/. Accessed 15 Sep 2014.
21. Viswanathan V.Is there a place for GoogleGlass in hospitals? The Atlantic, July 21, 2014.
22. Bochner BH, et al. A randomized trial of robot-assisted laparo­scopic radical cystectomy. N Engl J Med. 2014;371:389–90.
23. Pronovost P.Re-engineering health care for safety and cost savings.
http://armstronginstitute.blogs.hopkinsmedicine.org/2013/12/11/ re- engineering- health- care- for- safety- and- cost- savings/. Accessed
20 Sep 2014.
24. Palmer RW. Integrated diagnostic and treatment devices for Enroute critical Care of Patients within theater. Combat Casualty Care Research Program, U.S.Army Medical Research and Materiel Command, Fort Detrick, Maryland; April 2010.
25. Hartgerink JD. Nanomedicine: new material stops bleeding in a hurry. Nat Nanotechnol. 2006;1:166–7.
26. Thrun S.Google’s driverless car. Ted Talk, Ed (2011).
27. Tomoaki Y, etal. Improvements to the rescue robot quince toward future indoor surveillance missions in the Fukushima Daiichi nuclear power plant, vol. 92. Springer Tracts in Advanced Robotics;
2014. p.19–32.
28. Watson D.From games shows. ITNOW, Summer. 2012;54(2):16–7.
29. Murphy S, Atala A. 3D bioprinting of tissues and organs. Nat Biotechnol. 2014;32:773–85.
Human Factors ofTeleresuscitation andTelementoring
LaurenHampton andLawrenceMarshall Gillman
40

Introduction

Telementoring in medicine refers to the remote guidance of a novice medical provider by an expert over distance [1]. The use of telementoring in medicine has become more com­monplace as technology continues to provide new and improved ways of communicating all the way to the most remote corners of the globe [2, 3]. Telementoring from basic smartphone technology to augmented reality videoconfer­encing has been used to augment ultrasound assessment, trauma resuscitation, and advanced surgical procedures, despite thousands of miles of separation between experts and providers [412]. This chapter will focus on the ways tele­mentoring can be applied to improve acute care wherever signicant injuries, illness, or conict occurs and regardless of whether the responder has any medical training. Despite its potential for far-forward lifesaving interventions, tele­mentoring comes with additional interpersonal and commu­nication challenges. Here we outline these challenges and identify strategies to overcome them. Overall, we believe that telementoring’s potential will only be fully realized when technology is matched by teamwork, and procedural dexterity is matched by “verbal dexterity” [13].
L. Hampton Departments of Surgery Section of General Surgery, University of Manitoba, Winnipeg, MB, Canada e-mail: hamptonl@myumanitoba.ca
L. Marshall Gillman (*) Departments of Surgery Section of General Surgery, University of Manitoba, Winnipeg, MB, Canada
Internal Medicine Section of Critical Care, University of Manitoba, Winnipeg, MB, Canada e-mail: Lawrence.Gillman@umanitoba.ca

Challenges

Communication in health care comes with many challenges, and even in-person interactions can be fraught with difculty if there is a lack of understanding between the members of a team. Resuscitation over distance with a remote mentor brings additional challenges. Emotional stress may be ampli­ed by isolation, lack of resources, and personal ties to the patient. Patient access in extreme environments may limit what can reasonably be achieved by the rescuer, who may even be injured themselves. Most importantly, we know that a lot of communication lies outside of what is said, and remote mentoring comes with a loss of non-verbal communi­cation such as facial expressions or guiding the hands. While technology will play a role in bridging these gaps with vid­eoconferencing, augmented reality, and telestration, there will be times when all you have is words, and optimizing communication is key.
Provider Stress
Imagine for a moment you are part of a six-person team deployed to the weather station in Resolute Bay, Nunavut, to conduct research on climate change. You and your colleagues all received advanced rst-aid training before departure and have been working together for months in a close-knit unit. Now imagine one of your colleagues, and friend, is griev­ously injured with no hope of evacuation for hours, or even days. Are you stressed out yet? The reality of providing advanced interventions in the eld is that they will be pro­vided by people who are often near and dear to the patient. Fortunately, we know from a review of out-of-hospital car­diac arrests that emotional distress is not frequently a barrier to performing CPR, despite the victim being known to the provider. The most important limiting factors were physical barriers and the tness of the rescuer to provide CPR [14]. Similarly, in a study of simulated remote damage-control surgery by non-physicians, participants had lower stress,
© Springer Nature Switzerland AG 2025 L. Marshall Gillman, S. Widder (eds.), Trauma Team Dynamics, https://doi.org/10.1007/978-3-031-86312-7_40
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L. Hampton and L. Marshall Gillman
measured by a post-test survey and heart rate variability, than when they performed the same procedure without guidance [6, 15]. All of this means that you may be in a position to provide the right advice to the wrong situation if you do not know what it is like out there for the rescuer. Taking the time at the beginning of the interaction to establish the environ­ment the rescuer is up against, whether they can safely access the patient and whether they are injured themselves, is imperative before delving into triage and resuscitation efforts.
Non-verbal Communication
Continuing the scenario above, imagine you need to insert a chest tube for a pneumothorax for the rst time with no train­ing. You’ve accepted the fact that you must plunge a knife into your friend and you are on speakerphone with a physi­cian who is telling you to mark the fourth or fth intercostal space between the mid and anterior axillary line. You have no idea what that means, and they can’t point to the landmarks on the chest to show you. The loss of non-verbal communica­tion is a challenging problem to overcome, and communica­tion must be sufciently robust to compensate [16]. Technological advancements such as video conferencing with telestration, augmented reality, and even remote- controlled robotics have all been used to virtually bring the remote men­tor into the room to bridge this gap [2, 5, 7, 17]. While these are exciting options for remote-mentored surgery in con­trolled environments, it is imprudent to think that a robotic consultant will be available to each rural emergency room, army medic, or arctic expedition. The more likely scenario is a voice or video call from a commercially available smart­phone, and the remote mentor must be ready to work within the connes of words and limited gestures. Standardized communication is one strategy a remote mentor can use to ensure they are conveying ideas in a way that is most likely to result in an effective action by the rescuer [14].

Standardized Communication

Communication is a vital medical skill and should be delib­erate, in terms of both what is said and how it is understood and carried out [13, 18]. Telementoring is not equivalent to interacting face-to-face or conducting a typical telephone call. During telementoring, the mentor needs to convey indi­rectly not only data but also information and meaning. This then needs to translate rapidly into direct physical action, even though the provider is a relative novice, potentially scared, or both. Strategies that focus on standardized com­munication with concise language and short instructions appear to benet both mentors and providers.
Strategy 1: Scripted Procedures
Most of what is known about telementoring comes from the world of dispatcher-directed CPR.While CPR is considerably simpler than a complex trauma resuscitation, the lessons learned from this more basic interaction provide principles that can be applied to more intricate scenarios. An excellent example is a study that found improvement in average chest compression depth when participants were instructed to “push as hard as you can” instead of “compress the chest 5cm” [19]. Similarly, children have performed well with remotely men­tored ultrasonography using simple “up,” “down,” “right,” and “left” commands. In contrast, they were bafed by terms such as “parallel” and “rotate” [20]. Language choices are critical to a successful resuscitation and should not be left to chance in hopes that the mentor and provider understand one another. There may be value in preemptively scripting procedures, lim­iting the words said to critical steps in the correct order with avoidance of unnecessary jargon. Any script would require input from experts as well as from those who are going to carry out the instructions. Instructions might also need to be modied for language and educational levels. Those who work in dispatch already have experience giving instructions to a wide variety of recipients and would therefore be key con­tributors to modications. Scripts would be “t for task” only once validated by end-users and maintained through realistic ongoing simulations [14]. Work in this area is ongoing. Mentors who nd themselves in this situation should break down these resuscitative procedures into equipment needed, identify the fundamental steps, and relay them in plain lan­guage to create a shared mental model between the provider and mentor. See Table40.1 for an example script used to tele­mentor novices through a tourniquet application.
Strategy 2: Structure Triage Tool
How many times have you hung up the phone after receiving a consult and thought, “I forgot to ask about X.” Even expe­rienced CPR dispatchers still failed to identify out-of­hospital cardiac arrests due to the omission of critical questions [14]. Out-of-hospital arrests are easier to identify and CPR is simpler to initiate than a complex multisystem trauma. The successful diagnosis of cardiac arrest has been improved by implementing standardized questions as part of the dispatcher’s triage protocol. Patient handover is also a source of medical error due to poor communication between providers, and the SBAR (Situation-Background­Assessment- Recommendation) handover method has been shown to improve the transfer and retention of critical patient information to overcome communication errors. A structured approach to assessing a patient through telementored inter­actions is a logical extension of the ATLS algorithm and has
40 Human Factors ofTeleresuscitation andTelementoring
341
Table 40.1 Sample script for telementoring novices through tourni­quet placement
I will walk you through putting on a tourniquet Remove any clothing if possible so the tourniquet sits directly on the skin Place the tourniquet around the limb four ngers above the wound Insert the strap through the opening in the buckle Grab the strap close to the buckle and tighten by pulling the strap against the buckle While keeping it tight, velcro the extra strap back on itself The tourniquet should now hold itself in place but it may still be bleeding Now we’re going to tighten the tourniquet Twist the rod clockwise until the bleeding stops Has it stopped? IF NOT—Try to keep twisting the rod IF YES—place the rod in the C-shaped hook beside it Feed any extra band over the rod Place the white velcro strap over top and write down the current time on the strap
the potential to ease the transfer of critical information, improve active listening, and simultaneously provide a means of documentation for a busy off-site trauma expert. While there is currently no standard triage tool available, those experienced in trauma management should transition to the deliberate use and documentation of these questions to improve communication and therefore patient outcomes.

Conclusions

Telementoring is becoming more common as medicine and technology improve worldwide. Optimization of the non­technical factors of telementoring must keep pace, and research and quality improvement efforts are essential. Communication strategies consisting of standard approaches, short, concise validated scripts using simple language, and systematic identication of available resources and barriers to success have the potential to improve the safety, efcacy, and overall experience for mentors and remote providers.
Key Points
• Telementoring in medicine refers to the remote guidance of a novice medical provider by an expert over a distance.
• Telementoring has proven to be a viable means of providing advanced medical care in remote or aus­tere environments.
• Communication strategies consisting of standard approaches, short, concise and validated scripts using simple language, and systematic identication of available resources and barriers to success have the potential to improve the safety, efcacy, and overall experience for mentors and remote providers.

References

1. Gambadauro P, Torrejon R.The “tele” factor in surgery today and tomorrow: implications for surgical training and education. Surg Today. 2013;43:115–22.
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Part IV
Specialized Trauma Populations
Trauma inPregnancy
AlexandraMarseu, MichelleL.Morais, LuaR.Eiriksson, andPaulT.Engels
41

Introduction

Trauma is the leading cause of non-obstetric maternal death in pregnancy worldwide [1]. Trauma complicates 6–8% of all pregnancies [2], with 0.4% requiring hospitalization for the treatment of traumatic injuries [3], and 0.1% experienc­ing major trauma (injury severity score > 15) [4]. Unintentional trauma accounts for a large proportion of trauma in pregnancy, with motor vehicle collisions (MVCs) being the most common mechanism [5, 6]. Intentional trauma, most commonly domestic violence (DV) or intimate partner violence (IPV), is also associated with signicant maternal and fetal morbidity [6] and is reported to occur in 4–8% of pregnancies [7], particularly clustering in the third trimester [8]. Blunt trauma (80%) predominates over pene­trating trauma (20%) [911], with the latter resulting in peri­natal mortality rates of up to 70% [12]. Compared to pregnancies unaffected by trauma, fetal demise at any gesta­tional age is more common among trauma victims, and trauma is associated with a higher occurrence of neonatal death at any gestational age [13]. Leading mechanisms of fetal death related to trauma are MVCs (82%), rearm inju­ries (6%), and falls (3%), with 11% of cases involving con­current maternal death [14]. Placental abruption is the leading cause of fetal death resulting from trauma, account­ing for 50–70% of fetal losses related to trauma [15]. The next most common cause of trauma-associated fetal death is
A. Marseu · P. T. Engels (*) Department of Obstetrics and Gynaecology, Division of Maternal Fetal Medicine, McMaster University, Hamilton, ON, Canada e-mail: alexandra.marseu@medportal.ca; engelsp@mcmaster.ca
M. L. Morais Departments of Surgery and Critical Care, McMaster University, Hamilton, ON, Canada e-mail: moraism@mcmaster.ca
L. R. Eiriksson Department of Obstetrics and Gynecology, McMaster University, Hamilton, ON, Canada e-mail: eiriksson@hhsc.ca
maternal death [15]. The leading causes of maternal death are head injury and hemorrhagic shock [16, 17]. Trauma patients also have an increased risk of obstetrical complica­tions, whether trauma is severe or non-severe [18]; these include spontaneous abortion, preterm premature rupture of membranes, preterm labor, placental abruption, fetal­maternal hemorrhage, uterine rupture, fetal distress, mater­nal death, and stillbirth [9, 18, 19].
The management of the pregnant trauma patient may be complicated by delayed diagnoses of shock or hemorrhage due to minimal changes in vital signs secondary to physio­logic changes of pregnancy, as well as challenges in the con­current assessment of both the fetus and the mother. The prevailing principle is that fetal well-being is dependent on maternal status, such that optimal resuscitation of the mother will typically result in optimal resuscitation of the fetus, with consideration given to obstetrical complications that can compromise both mother and fetus.
Physiologic Changes ofPregnancy
Multiple organ systems undergo adaptation during preg­nancy. The uterus remains intrapelvic until 12weeks’ gesta­tion and subsequently rises out of the protection of the bony pelvis as it expands with the growing fetus. By 20weeks, the uterus reaches the level of the umbilicus and is considered to be an abdominal organ; however, the fetus continues to be protected by a relatively large volume of amniotic uid. It is during the third trimester when the now thin-walled uterus is at the greatest risk of penetration, rupture, and premature rupture of membranes [20]. The inelasticity of the placenta in comparison to the elastic uterus increases the risk of abruption when shearing forces are applied [21], and even cases of apparent minor blunt abdominal trauma may result in compromise or death [19]. The uterus and placenta receive 20% of the cardiac output in the third trimester, highlighting the urgency for assessment of the uterus during the primary survey. Due to the size and weight of the uterus, placement in
© Springer Nature Switzerland AG 2025 L. Marshall Gillman, S. Widder (eds.), Trauma Team Dynamics, https://doi.org/10.1007/978-3-031-86312-7_41
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