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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5198_Библиотеки_им_академика_М_И_Перельмана.pdf
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- •Foreword
- •Preface: Trauma as a Team Sport
- •Contents
- •History
- •Documented Outcomes
- •Future Direction
- •References
- •Humble Beginnings
- •A New Paradigm Is Born
- •References
- •3: Evidence Supporting Crisis Resource Management Training
- •Introduction
- •References
- •Introduction
- •The Trauma Team
- •Trauma Team Leadership
- •Crisis Resource Management
- •Observe, Orient, Decide, Act OODA Loop
- •Observe
- •Orient
- •Conclusion
- •References
- •Introduction: Why Does Teamwork Matter?
- •Introduction
- •Team Culture: Not Just Leaders; Followers Too
- •Crisis Communication 101
- •Conclusion
- •References
- •Background
- •Leadership Styles
- •Self-Awareness
- •Self-Management
- •Social Awareness
- •Relationship Management
- •Validation
- •Putting It All Together
- •References
- •7: Followership
- •Intro
- •What Is Followership
- •Why Is Followership Important?
- •Summary
- •References
- •Introduction
- •Situational Awareness
- •Situational Awareness: Level One
- •Situational Awareness: Level Two
- •Situational Awareness: Level Three
- •Attention
- •Stress
- •Conclusion
- •References
- •Handover Foundations
- •Handover Challenges
- •Handover Structure
- •Written Handover
- •Conclusion
- •References
- •10: Engaging Team Members
- •Respect
- •Resources
- •Engaging Virtual Teams
- •Virtual Water Cooler
- •Conclusion
- •References
- •Implicit Coordination
- •The Zero-Point Survey
- •Adaptive Coordination
- •Making It Happen
- •References
- •Acute Versus Chronic Stress
- •Recognizing Chronic Versus Acute Stress
- •Education Helps
- •Hyper-realistic Simulation Training
- •Resilience Is Individualized
- •Training Is Key
- •References
- •13: Stress Exposure Training
- •Introduction
- •Stress Training
- •Information Provision
- •Cognitive Control
- •Physiological Control
- •Overlearning
- •Mental Practice
- •Decision-Making
- •Team/Communication Skills
- •References
- •Introduction
- •Conclusions, Implications, Next Steps
- •References
- •15: Trauma Video Review
- •Introduction/What Is Trauma Video Review?
- •Team Simulation/Education
- •Performance Improvement
- •Research
- •Potential Barriers
- •Consent Processes
- •Other Considerations
- •Future Directions
- •Conclusion
- •References
- •Pre-arrival
- •Patient Arrival
- •Resuscitation
- •Pre-departure
- •Communication Skills
- •Structured Handovers
- •Conclusions
- •References
- •Origination
- •United States Prehospital System Legal Structure
- •Science Behind Prehospital Injury Patterns
- •Team Synergy vs Rock Star Player
- •Medical Errors
- •Controversy What Should Our System Implement
- •Training Quality
- •Active Killer
- •Realistic Training
- •Lessons Learned
- •Response
- •Nonmedical Personnel
- •Conclusion
- •References
- •Introduction
- •Future Direction
- •Conclusions
- •References
- •19: Prehospital Trauma
- •Introduction
- •Safety
- •Scene Assessment
- •Trauma Dynamics
- •Prehospital Ultrasound
- •Trauma Management: Tranexamic Acid (TXA) Administration
- •Conclusion
- •References
- •20: Transport Medicine
- •Introduction
- •The Trauma Clinical Network (TCN)
- •Direct Transport
- •Inter-hospital Transport
- •Emergency or Non-emergency Transportation
- •Monitoring During Transport
- •Conclusion
- •References
- •Introduction
- •Trauma Team Leader (TTL)
- •Airway
- •Respiratory Therapy
- •Emergency Medicine Physician
- •General Surgery
- •Orthopedic Surgery
- •Neurosurgery
- •Recording Nurse
- •Trauma Team Activation
- •The Trauma Bay
- •Trauma Team Function
- •Summary
- •References
- •22: Interprofessional Team Roles
- •References
- •23: The Trauma Bay Environment
- •Introduction
- •Surge Capacity
- •Decontamination
- •Communication
- •Control Center
- •Security Considerations
- •The Trauma Bay
- •Trauma Observation Unit Setup
- •Special Situations
- •Hybrid Operating Rooms
- •Conclusion
- •References
- •Introduction
- •Design
- •Formalizing Clinician-Designer-Builder Partnerships
- •A Human-Centered Approach
- •The Missing Link
- •Evidence-Based Design
- •Build
- •Train
- •Excel
- •Putting It Together
- •Summary
- •References
- •Introduction
- •Human Factor Analysis
- •Hybrid Operating Environment Lexicon
- •Summary
- •References
- •Introduction
- •Project Implementation
- •Results
- •Conclusion
- •Appendix A: Dam Tools Usability Testing Questionaire
- •References
- •Introduction
- •References
- •Introduction
- •Team-Based Principles
- •Continuous Improvement Processes
- •Conclusion
- •References
- •29: Trauma Resuscitation
- •Mechanisms
- •Neurologic Injury
- •Musculoskeletal Trauma Including Spine
- •Conclusions
- •References
- •30: Damage Control Resuscitation
- •Introduction
- •Massive Transfusion
- •Permissive Hypotension
- •Vascular Damage Control Techniques
- •Non-vascular Damage Control Techniques
- •Abdominal Compartment Syndrome
- •Open Abdominal Management
- •Damage Control Environments
- •References
- •Damage Control Part 1: Operative Intervention
- •Damage Control Part 2: Resuscitation
- •Damage Control Strategy Under Special Circumstances
- •Blast Injuries
- •Burns
- •Head Injury
- •Crush Injury
- •Conclusions
- •References
- •32: Trauma Team Decision-Making
- •Predictive Scores
- •Clinical Practice Guidelines (CPGs)
- •Trauma Team Leadership: Translating Decisions into Action
- •Future Directions: Toward High Reliability Organizing
- •Conclusions
- •References
- •33: Emergency Critical Care Procedures
- •Introduction
- •Airway Management
- •Tube Thoracostomy
- •Controversies
- •Antibiotics
- •Tube Selection
- •Occult Pneumothorax
- •Vascular Access
- •Peripheral Intravenous Access
- •Central Intravenous Access
- •Intraosseous Access
- •Ultrasound
- •Resuscitative Thoracotomy
- •Outcomes
- •Contraindications
- •Volume Expansion
- •Management
- •Diagnostic Peritoneal Lavage
- •Summary
- •References
- •Introduction
- •REBOA Programs
- •Partial REBOA
- •Intermittent REBOA
- •Vena Cava Occlusion
- •Tourniquets
- •Junctional Tourniquets
- •Abdominal Aortic Compression.
- •Hemostatic Agents
- •Topical Hemostatic Agents
- •Chemical Hemostatics
- •Physiologic Hemostatics
- •Hemostatic Dressings
- •Intra-abdominal Foam
- •Summary
- •References
- •What Is Interventional Radiology
- •Diagnostic Imaging Workup
- •Embolic Therapies
- •Gelfoam
- •Mural Repair
- •References
- •Non-verbal
- •Verbal
- •Wider Structural Perspective
- •Transferrable Solutions
- •Conclusion
- •References
- •Introduction
- •Pharmacotherapy
- •Paravertebral Block
- •Serratus Plane Block
- •References
- •Clinical Decision Support
- •Quality Improvement
- •Research
- •Trauma Systems
- •Conclusion
- •References
- •Outcomes
- •The Future
- •References
- •Introduction
- •Challenges
- •Provider Stress
- •Non-verbal Communication
- •Standardized Communication
- •Strategy 1: Scripted Procedures
- •Strategy 2: Structure Triage Tool
- •Conclusions
- •References
- •Introduction
- •Fetal Monitoring
- •Radiology
- •Conclusions
- •References
- •Introduction
- •Elderly Population
- •Psychiatric Comorbidities
- •Anticoagulated Patients
- •Conclusion
- •References
- •Introduction
- •Advanced Trauma Life Support (ATLS)—The Basics
- •Advanced TBI Guideline-Based Care
- •Noninvasive ICP/CPP Determination Methods
- •Brain Tissue Oxygen Monitoring (PbtO2)
- •Extracellular Brain Chemistry—Cerebral Microdialysis
- •Transcranial Doppler
- •Near-Infrared Spectroscopy
- •Continuous Electroencephalography (cEEG)
- •Cerebrovascular Reactivity Monitoring
- •Cerebral Compensatory Reserve
- •Individualized ICP Thresholds (iICP)
- •Integrating “Omics” into Acute Phase TBI Care—The Future
- •Conclusions
- •References
- •44: Basic Trauma Ultrasound
- •Introduction
- •The FAST Examination
- •Technique
- •Uses
- •Blunt Abdominal Trauma
- •Penetrating Trauma
- •Limitations
- •Summary
- •References
- •Introduction
- •Trauma Ultrasound Development
- •Pneumothorax
- •Musculoskeletal Ultrasound
- •Head Trauma
- •Contrast-Enhanced Ultrasound
- •Conclusions
- •References
- •Introduction
- •Imaging Modalities
- •Plain X-ray
- •Computed Tomography (CT) Scan
- •Other Modalities
- •Critical Thinking
- •References
- •Introduction
- •Initial Trauma CT Protocol
- •Iodinated Contrast Administration
- •Emergency Trauma MRI
- •References
- •48: Disaster Medicine
- •Natural or Man-made Disaster
- •The Disaster’s Cycle
- •Incident Command System
- •Triage
- •“Second Hit” Phenomenon
- •Conclusions
- •References
- •49: The Multi-casualty Trauma
- •Introduction
- •Historical Perspective
- •Prehospital Management
- •Triage
- •Pediatric Considerations
- •Intrahospital Management
- •Transfer Corridors
- •Blood Bank
- •Conclusions
- •References
- •Introduction
- •Crew Resource Management (CRM)
- •Resources
- •Review Process Including Logistics
- •Transactive Memory
- •Team Building (Before)
- •Team Performance (During)
- •Team Debrief (After)
- •Health
- •Fitness
- •Interagency Collaboration
- •Bystanders
- •Emergency Medical Services/Tactical EMS
- •Conclusions
- •References
- •Introduction
- •Improvised Explosive Device
- •Anti-police Violence
- •Improved Community Preparedness
- •Conclusions
- •References
- •Introduction
- •Procedures
- •Conclusions
- •References
- •Introduction
- •The MARCHE Algorithm Approach
- •Massive Hemorrhage Management (“M”)
- •Tourniquets
- •Wound Packing
- •Hemostatic Dressings
- •Junctional Tourniquets
- •Airway Management (“A”)
- •Respiration (“R”)
- •Circulation (“C”)
- •Vascular Access
- •Crystalloid
- •Hemostatic Resuscitation
- •Tourniquet Re-assessment
- •Hypothermia Prevention/Head Injury (“H”)
- •Hypothermia Management
- •Traumatic Brain Injury
- •Eye Injuries
- •Analgesia
- •Secondary Survey
- •Antibiotic Administration
- •Prolonged Field Care
- •Summary
- •References
- •Introduction
- •Hypothermia
- •Etiology
- •Pathophysiology
- •Lethal Triad (Diamond) Component
- •Treatment
- •Afterdrop
- •Resuscitation Progression
- •Prognosis
- •Team Dynamics
- •Conclusion
- •References
- •55: Burns
- •Incidence
- •Etiology
- •Prognosis
- •Initial Management: “ABCDE” Approach
- •Admission
- •Dressings
- •Nutrition
- •Multidisciplinary Recovery
- •Summary
- •References
- •War Zones
- •Casualty Care Team Preparation
- •Biological Weapons
- •Biological Warfare Historical Considerations
- •Personal Protective Equipment
- •Anthrax
- •Botulism Toxin
- •Conclusion
- •References
- •57: Nuclear Injuries
- •Introduction
- •Historical Background
- •Transportation
- •Hospital Care
- •Conclusions
- •References
- •Further Reading
- •Introduction
- •Historical Perspective
- •Parabolic Testing
- •Surgical Field Testing
- •Diagnostics
- •Immediate Damage Control Procedures
- •Conclusions
- •References
- •Introduction
- •Pandemic Impact
- •Financial Support
- •Conclusion
- •References
- •Introduction
- •Staff
- •Retraining/Reassignment
- •Consultants
- •Space/Structure
- •Trauma Bay
- •Operating Room
- •ICU or Floor
- •Clinic
- •Systems
- •Country Level
- •Regional Level
- •Hospital Level
- •Division or Trauma Team Level
- •Conclusion
- •References

39 Telemedicine andFuture 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 bonres 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 amplied 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 congurations, 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
signicant cost advantage lies in its ability to improve the
triage of trauma patients. Rogers etal. [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 etal. 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 5years,
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 signicantly improved evaluation and

336
C. J. Kucik et al.
management of rural trauma patients at reduced costs without signicant changes in mortality.
In a retrospective analysis of one of the more robust telemedicine centers in the United States, Lati etal. 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, Safe
etal. 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 signicantly 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 signicant
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 modied 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 aTelemedicine 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.
Signicant 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 efcient 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 andFuture 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 difcult 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” congurations. 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 Articial 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 inuence of
technology will be in the realms of social media, crowdsourcing, the inuencing 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 efciently 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 dened as safe, effective,
patient-centered, timely, efcient, 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 Ofce;
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, etal. 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, etal. 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, etal. Initial experiences and outcomes of telepresence in the management of trauma and emergency
surgical patients. Am J Surg. 2009;198(6):905–10.
14. Safe 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, etal. 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, etal. 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, etal. 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 ofTeleresuscitation
andTelementoring
LaurenHampton andLawrenceMarshall 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 [4–12]. This chapter will focus on the ways telementoring can be applied to improve acute care wherever
signicant injuries, illness, or conict 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 difculty
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 amplied 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,
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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 sufciently 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 connes 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 benet 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 5cm” [19].
Similarly, children have performed well with remotely mentored ultrasonography using simple “up,” “down,” “right,” and
“left” commands. In contrast, they were bafed 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
modied 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 modications. 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 Table40.1 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 ofTeleresuscitation andTelementoring
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 identication of available resources and barriers
to success have the potential to improve the safety, efcacy,
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 identication of
available resources and barriers to success have the
potential to improve the safety, efcacy, 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.
2. Kirkpatrick AW, LaPorta A, Brien S, etal. Technical innovations
that may facilitate real-time telementoring of damage control
surgery in austere environments: a proof of concept comparative
evaluation of the importance of surgical experience, telepresence,
gravity and mentoring in the conduct of damage control laparotomies. Can JSurg. 2015;58(3 Suppl 3):S88.
3. Kirkpatrick AW. 2010 Trauma Association of Canada Presidential
Address: Why the Trauma Association of Canada should care about
space medicine. J Trauma. 2010;69:1313–22.
4. Ajami S, Lamoochi P.Use of telemedicine in disaster and remote
places. J Educ Health Promot. 2014;3:26.
5. Cubano M, Poulose B, Talamini MA, etal. Long distance telementoring— a novel tool for laparoscopy aboard the USS Abraham
Lincoln. Surg Endosc. 1999;13:673–8.
6. Kirkpatrick AW, McKee LJ, McBeth BP, etal. The Damage Control
Surgery in Austere Environments Research Group (DCSAERG): a
dynamic program to facilitate real-time telementoring/telediagnosis to address exsanguination in extreme and austere environments.
J Trauma Acute Care Surg. 2017;83(Suppl 1):S156–63.
7. Nguyen N, Okrainec A, Anvari M, etal. Sleeve gastrectomy telementoring: a SAGES multi-institutional quality improvement initiative. Surg Endosc. 2018;32:682–7.
8. McBeth P, Crawford I, Tiruta C, etal. Help is in your pocket: the
potential accuracy of smartphone- and laptop-based remotely guided
resuscitative telesonography. Telemed J E Health. 2013;19:924–30.
9. Moore RG, Adams JB, Partin AW, etal. Telementoring of laparoscopic procedures: initial clinical experience. Surg Endosc.
1996;10:107.
10. Kirkpatrick AW, McKee I, McKee JL, etal. Remote just-in-time
telementored trauma ultrasound: a double-factorial randomized
controlled trial examining uid detection and remote knobology
control through an ultrasound graphic user interface display. Am J
Surg. 2016;211:894–902.e1.
11. Lee Y, Kim C, Choi HJ, etal. A feasibility study of telementoring
for identifying the appendix using smartphone-based telesonography. J Digit Imaging. 2017;30:148–55.
12. Dyer D, Cusden J, Turner C, etal. The clinical and technical evaluation of a remote telementored telesonography system during the
acute resuscitation and transfer of the injured patient. J Trauma.
2008;65:1209.
13. Brindley PG, Reynolds SF. Improving verbal communication in
critical care medicine. J Crit Care. 2011;26:155–9.
14. Hampton L, Brindley P, Kirkpatrick A, etal. Strategies to improve
communication in telementoring in acute care coordination: a scoping review. Can J Surg. 2020;63(6):E569–77. Published 2020 Nov
30. https://doi.org/10.1503/cjs.015519.
15. Kirkpatrick AW, Tien TH, LaPorta EA, etal. The marriage of surgical simulation and telementoring for damage-control surgical training of operational rst responders: a pilot study. J Trauma Acute
Care Surg. 2015;79:741–7.
16. Wachs JP, Gomez G. Telementoring systems in the operating
room: a new approach in medical training. Medicina (B Aires).
2013;73:539–42.
17. Budrionis A, Augestad K, Patel H, Bellika J.An evaluation framework for dening the contributions of telestration in surgical telementoring. Int J Med Res. 2013;2:e14. https://doi.org/10.2196/
ijmr.2611.
18. Brindley PG, Cardinal P.Optimizing crisis resource management
to improve patient safety and team performance: a handbook
for all acute care health professionals. Ottawa: Royal College of
Physicians and Surgeons; 2017. Available: https://www.royal-
college.ca/rcsite/documents/practice - performance- innovation/

342
L. Hampton and L. Marshall Gillman
optimizing- crisis- resource- management- improve- patient- safetyteam- performance- e.pdf. Accessed 2020 Jan 15.
19. Mirza M, Brown TB, Saini D, etal. Instructions to “push as hard
as you can” improve average chest compression depth in dis-
patcher assisted cardiopulmonary resuscitation. Resuscitation.
2008;79:97–102.
20. McBeth PB, Crawford I, Blaivas M, etal. Simple, almost anywhere, with almost anyone: remote low-cost telementored resuscitative lung ultrasound. J Trauma. 2011;71:1528–35.

Part IV
Specialized Trauma Populations

Trauma inPregnancy
AlexandraMarseu, MichelleL.Morais, LuaR.Eiriksson,
andPaulT.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 signicant
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%) [9–11], 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 ofPregnancy
Multiple organ systems undergo adaptation during pregnancy. The uterus remains intrapelvic until 12weeks’ gestation and subsequently rises out of the protection of the bony
pelvis as it expands with the growing fetus. By 20weeks, 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
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L. Marshall Gillman, S. Widder (eds.), Trauma Team Dynamics, https://doi.org/10.1007/978-3-031-86312-7_41
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