Diagnostic Remote Guidance on Mars (Abstract)

Despite rigorous health screening in astronaut crews, there are a number of conditions that may occur during long duration, exploration class spaceflight.  The risk of abdominal conditions requiring surgical intervention is not clear, yet submarine and polar base experiences suggest contingency planning is warranted.  While radio communication time delay is only 2 seconds to the international space station (ISS), a potential Mars mission would necessitate time delays of about 15 minutes.  We sought to demonstrate the feasibility of remote expert guidance of diagnostic ultrasound followed by laparoscopic appendectomy in a simulated Mars environment.

Research was deemed exempt by the institutional review board.  A simulated Mars research environment was utilized on Devon Island in the Canadian Arctic.  Electronic communications including audio and video were established between the Arctic base and Henry Ford Hospital serving as Mission Control and incorporated the 15-minute communications lag into all communication.  Ultrasound and laparoscopic capabilities were integrated into communications for remote guidance.  Remote guidance methods and technology utilized has been previously published in communication with the international space station.

A simulated scenario involving a young female astronaut developing right lower quadrant pain was developed and utilized for this demonstration.  An anatomical appendectomy model was utilized for the ultrasound and laparoscopic portions.  Reference aids describing background technical aspects were developed.  A set of confirmation milestones was used to generate a hard stop and mandated remote review.

We report a successful remote guidance demonstration from a simulated mars environment with clinical control from a terrestrial base utilizing appropriate delay and consistent bandwidth and technology.  Reference aids were appropriate for non-surgical personnel and hard stops for milestones with remote approval and go ahead were shown to be feasible.  The appendicitis was appropriately diagnosed utilizing remote guidance of ultrasonography and the appendix removed laparoscopically using stapled technique with remote guidance as well.

Clinical Training Upgraded to iUltrasound 2.0

FAST ultrasound video log transmission via iPhone for overreading

 

Dan Nguyen

 

Introduction and Justification

Since the early 1980s, bedside ultrasound by emergency physicians has become increasingly popular [1]. The use of FAST ultrasoungraphy has now become an extension of the physical examination of the trauma patient [2]. It provides effective and timely diagnosis of potentially life-threatening hemorrhages and is a decision making tool to help determine the need for transfer to the operating room, CT scanner or angiography suite. In addition, it is cost effective solution with lower cost in manufacturing, telecommunication, and maintenance. Currently, ultrasound is performed in the trauma room by properly trained and credential staff. However, the protocols for education and varieties of teaching media vary from not only among specialties but within them as well.

As the economic healthcare paradigm continues to shift, we must be cognizant of how healthcare payments are now becoming linked with not only cost-effective but also high quality healthcare. This put the increasing responsibility on physicians, hospital staff, and healthcare facilities to closely monitor quality of care. This is why it is important to monitor and improve the quality of ultrasound training. By creating real-time ultrasound transmissions and an electronic procedure log of video and image recorded ultrasound, residents will be able to further assess their clinical skills individually and with resident training staff. It is the hope of this pilot study to develop future training protocols that will improve FAST ultrasound assessment and review complications. This will in turn, enhance the quality of patient care by improving critical diagnosis and improving the quality of clinical skill by student, residents, and attending physicians.

According to studies by Costantino et al. success in ultrasound education does improve with increased didactic training [3]. However, beyond 15 hours of didactic training there is no improvement in resident performance [3]. This is significantly lower than the 40 hours of recommended didactic training by the SAEM [4]. It is the goal of this study to implement a device that will develop a computer database of digitally procedure log of digitally recorded ultrasound images and video captures. This will improve clinical training by increasing the time and efficiency of ultrasound training to the clinical setting instead of increasing didactic lecture. Durning et al. showed that the number of ultrasound scans under supervision is the most critical predictor of successful ultrasound training [5]. Additionally, electronically recorded ultrasound will include benefits such as eliminating bias in recorded complications and allowing the resident to develop a better critical assessment of clinical skill and deficiencies and plan for a modified individual plan of improving quality of diagnosis. Additionally the use of an electronic database will allow hospital administration, healthcare payers, residency directors, etc. to monitor the quality of ultrasound imaging on an administrative level.

 

Review of Literature

Optimal training required for proficiency in bedside ultrasound is unknown. Optimal media for ultrasound training is still being reviewed. In 1994 SAEM released formalized guidelines for ultrasound training [4]. This was followed by the American College of Emergency Physician publishing formalized guidelines in 2001 [1]. However there is no translation of protocols to credentialing criteria and quality assurance programs. Some hospitals have started to develop rigorous credentialing policies and ultrasound review committee systems like at the University of California, San Francisco [6]. However these protocols remain to be studied and embraced by the ACEP or SAEM. Other specialties have also started to develop their own ultrasound training protocols. The American College of Surgeons have published their own guidelines for formalized training including specified levels of training and focused modules for various ultrasound techniques [7]. Ultrasound use has also started to spread in newer realms of medicine, such as EMT’s in rapid assessment of left ventricular systolic function in a pacemaker function [8].

Ultrasound training has even started to be incorporated earlier in undergraduate medical education with high success rates [9]. Barloon et al. reported that 30 minutes of ultrasound training helped Year 2 medical students more accurately estimate liver size compared with students who did not receive ultrasound training [10]. Current literature has showed numerous studies on different techniques and media for clinical training specific to ultrasound scanning. Proctored examinations have shown significant value to retention of ultrasound knowledge after the introduction of an emergency ultrasound curriculum [11].

Many European countries have already high integrated ultrasound programs [12]. Sweden’s resident physicians are required to submit a portfolio of cases on a DVD format for educational review. Additionally in Germany, there is a national program for ultrasound procedures, especially those performed by obstetricians. In fact there are government guidelines linking reimbursement for obstetrical ultrasound payment [12]. This places pressure on hospitals and physicians to increase the quality of care due to financial incentives, compared to monetary caps on procedures which breed a culture of minimal quality care.

In a study by Dolmans et al. ultrasound procedures logs helped clerkship coordinators by providing a useful overview of the content and nature of the students’ learning experiences in the hospitals. However the logs were not utilized by students, supervisors, and faculty to help improve the structure of student learning [13]. With a video procedure log there would be increased oversight over medical education, where residents and supervisors can readjust the learning experience by catering to individual needs and goals [14, 15]. By embedding the procedure logs into supervision of training, there will be increased importance placed on procedure logs by resident physicians. However the reliability of current logbook data has its pitfall. In a study by Raghoebar-Krieger et al. there were numerous inconsistencies when comparing student procedure logs and feedback data from attending doctors [16]. Diseases were under reported, which lead to a breakdown in clear supervision and feedback, which is important for procedure logs to work

Fung et al. created a similar internet-based learning portfolio in resident education call the KOALA. They created an advanced portfolio of ultrasound images that were link to self-directed hyperlinks [17]. The hope of the study was to reduce the future need for textbooks and CME in favor of creating self-directed study of ultrasound techniques. In addition the internet portfolio provided a media to directly observe ultrasound scans and compare quality of ultrasound scans throughout the hospital [17].

A study by Blaivas et al. published in 2005, compared ultrasound images between commercial cell phone and traditional high-resolution thermal printout in image quality, detail and resolution. There was no statistically significant difference. There was however, a problem with reading measurement and a lower confidence in diagnosis with p-values of .003 and .02 [18]. With the fast developing market of portable cell phone with larger screens and higher resolution, our study reexamines current cell phone technology with real-time ultrasound transmission.

 

 

Research Objectives

1. Reduce the cost of current ultrasound technology by developing an “off-the-shelf” solution to an image/video capture system from commercially available technologies
   1. Prove that consumer available technology (iPhone) can be used for ultrasound transmission and oversight with diagnostic quality images.
2. Development of a video/image recorded ultrasound database for the storage of resident procedure logs.
   1. Better utilize procedure logs and clinical supervision to provide more efficient ultrasound education that will improve diagnostic accuracy and increase user confidence of FAST ultrasound scans.
   2. Enhance current credentialing and quality assessment protocol for FAST (Focused Assessment with Sonography for Trauma) ultrasound training in residency training by utilizing real-time ultrasound transmission and video procedure log of FAST ultrasound scans.

 

 

Research Methodology

 

This study is a comparison of ultrasound images and video outputted directly to an Apple iPhone with ultrasound images ultrasound video directly displayed on the portable ultrasound monitor. This study will take place at a level 1 trauma center ED (Henry Ford Health Systems, Detroit) with an accredited emergency medicine residency program and an active emergency ultrasound program. Currently all residents are trained to use ultrasound under the SAEM (Society of Academic Emergency Medicine) guidelines.

10 FAST ultrasound examinations will be randomly selected from approximately 20 computer recorded FAST ultrasound examination. Examination will only be performed on patient medically require a FAST ultrasound examination based on emergency department protocol. The ultrasound scans will be performed in the emergency department during a 2 week period by the on call emergency medicine resident that is trained and credentialed in the use of FAST ultrasound examination in the emergency department. Computer recorded FAST ultrasound will comprised of 10 second video clips and 1 high resolution image capture of each of the 4 primary views: perihepatic, perisplenic, pelvis & pericardium. All images and video that is computer recorded is also saved to the internal hard drive of the portable ultrasound device. All ultrasound scans will be outputted through VGA signal to the VGA2USB LR Frame Grabber. The converted USB signal will then be sent to a computer laptop. We will use a commercial available laptop produced by HP. The laptop will receive data from the portable ultrasound device through a VGA-to-USB converter box. The computer will then record both images and video at the highest possible resolution onto the internal hard drive. Resolution of the computer recorded ultrasound images and video will only be limited by the output capabilities of the VGA-to-USB converter box. Additionally, the ultrasound video will be streamed real-time through a Skype account to an iPhone. Once the video transmission to the iPhone is confirmed by the operating technician, the ultrasound scan is complete.

The premise of this study is to duplicate a scenario where a residency director, ultrasound director, attending, or resident can review recently performed FAST ultrasound scans for the purposes of assessing accuracy of diagnosis, evaluate quality improvement, and improve clinical skills. The 10 computer recorded FAST ultrasound data and the ultrasound recorded data will be graded by a hospital credentialed sonologist with a minimum of 5 years of experience. Approximately 1 week after ultrasound images are randomly selected 2 credentialed emergency sonologists (radiologist stationed with the emergency medicine department) with extensive ultrasound experience including study performance, interpretation and ultrasound education will review ultrasound database. Ultrasound review will include video replayed back on the portable ultrasound device and video replayed back on the iPhone. For practical purpose, real-time transmission via the iPhone will not be reviewed real-time by the sinologist. However, replayed ultrasound transmission will simulate real-time transmission.

For each ultrasound image, the reviewers will be initially asked for an initial interpretation of the images and video captures. Afterward, each reviewer is given a short clinical vignette of the patient’s complaint in addition to a procedure log of complication from the emergency medicine resident that performed the FAST ultrasound examination. Reviewers are allowed to manipulate the images as needed including increasing image size, changing contrast, etc. Then each image will be graded on the following: (1) total image quality, (2) image resolution, defined as the sharpness and crispness of the image and lack of haziness/blurriness; (3) image detail, defined as the clarity of organ outlines and ease with which boundaries of structures are seen and defined; (4) optimal quality image that is required for optimal review for resident training purposes. Each reviewer will rank their impressions on a 10-point Likert scale with 1 being the worst and 10 the best. All data will be filled out on a standardized data form, which will then be entered into a computerized database. Statistical analysis will include descriptive statistics and a paired t test with 95% intervals. Data will be analyzed using standard statistically

For safety consideration, a separate dedicated portable ultrasound device will still be kept in all resuscitation room in the emergency department according to emergency department protocol. If there are technical problems while scanning a patient with the proposed ultrasound transmission apparatus, the physician will be able to use the standard ultrasound device at the attending or resident physician’s discretion.

 

Materials

-GE Portable Ultrasound

-iPhone 3G:

3.5 inch (diagonal) widescreen Multi-Touch display, 480-by-320-pixel resolution at 163 ppi, Dimension 4.5 inches (height) x 2.4 inches (width) x 0.48 inch (depth), 16 GB flash drive capacity, UMTS/HSDPA (850, 1900, 2100 MHz), GSM/EDGE (850, 900, 1800, 1900 MHz), Wi-Fi, (802.11b/g), Bluetooth 2.0 + EDR, Video formats supported: H.264 video, up to 1.5 Mbps, 640 by 480 pixels, 30 frames per second,; MPEG-4 video, up to 2.5 Mbps, 640 by 480 pixels, 30 frames per second, Simpler Profile with AAC-LC audio up to 160 Kbps, 48kHz, stereo audio in .m4v, .mp4, and .mov file formats, 2.0 megapixel camera.

-HP Pavilion Laptop dv2700t series

Windows Vista Home Premium, Pentium® Core™ 2 Duo Processor T5750 (2.0 GHz), 14.1” diagonal WXGA HP BrightView Widescreen Display (1280 x 800), 2GB DDR2 System Memory (2 Dimm), 128MB NVIDIA GeForce 8400m GS, Intel® PRO/Wireless 4965AGN Network, 120GM 5400RPM SATA Hard Drive,

-VGA2USB LR Frame Grabber (made by Epiphan Systems Inc.)

-Skype Account (commercial video streaming website)

-Remote Computer Access

-Public Wi-Fi access at the Henry Ford Health Systems Downtown Detroit Main Campus

 

 

Limitations/Potential Future Amendments

-Small sampling size may provide a biased analysis for the efficacy of video ultrasound logs

-Development of an all-in-one device for ultrasound recording and transmission will allow for easier mobile setup of ultrasound scans.

-After the release of the iPhone 3G, third party developers will be able to develop higher quality online conferencing clients for use on the iPhone or Apple may develop proprietary video conferencing software.

-Future tests can include computer laptops with an integrated video camera

-Future research should expand on the development of an online database (FTP) for remote access from any Wi-Fi capable device.

-Future research should experiment with using other device that are portable and Wi-Fi capable (PSP®, computer laptops, palm, blackberry, etc).

 

Literature Cited

 

1. American College of Emergency Physicians. ACEP emergency ultrasound guidelines. 2001. Annals of Emergency Medicine. 38: 470-481.
2. Marik, P. E. & Mayo, P. 2008. Certification and training in critical care ultrasound. Intensive Care Medicine. 34:215-217.
3. Costantino, T. G., Satz, W. A., Stahmer, S. A., & Dean, A. J. 2003. Predictors of success in emergency medicine ultrasound education. Academic Emergency Medicine. 10(2):180-183.
4. Witting, M. D., Euerle, B. D., & Butler, K. H. 1999. A comparison of emergency medicine ultrasound guidelines of the Society for Academic Emergency Medicine. Annal of Emergency Medicine. 34(5):604-609.
5. Durning, S. J., Cation, L. J., & Jackson, J. L. 2007. Are commonly used resident measurement associated with procedural skills in internal medicine residency training? Society of General Internal Medicine. 22:357-361.
6. Stein, J. C., & Nobay, F. 2008. Emergency department ultrasound credentialing: A sample policy and procedure. The Journal of Emergency Medicine, ?, ?-?.
7. Staren, E. D., Knudson, M. M., Rozycki, G. S., Harness, J. K., Wherry, & Shackford, S. R. 2006. An evaluation of the American College of Surgeons’ ultrasound education program. The American Journal of Surgery. 191:489-496.
8. Ghani, S. N., Kirkpatrick, J. N., Spencer, K. T., Smith, G. L., Burke, M. C., Kim, S. S., Desai, A. D., & Knight, B. P. 2006. Rapid assessment of left ventricular systolic function in a pacemaker clinic using a hand-carried ultrasound device. Journal of Interventional Cardiology Electrophysiology. 16:39-43.
9. Butter, J., Grant, T. H., Egan, M., Kaye, M., Wayne, D. B., Carrion-Carrie, V., & McGaghie, W. C. 2007. Does ultrasound training boost Year 1 medical student competence and confidence when learning abdominal examination? Medical Education. 41:843-848.
10. Barloon, T. J., Brown, B. P., Abu-Yousef, M. M. 1998. Teaching physical examination of the adult liver with the use of real-time sonography. Academic Radiology. 5:101-103.
11. Noble, V. E., Nelson, B. P., Sutingco, A. N., Marill, K. A., & Cranmer, H. 2007. Assessment of knowledge retention and the value of proctored ultrasound exams after the introduction of an emergency ultrasound curriculum. BioMed Central Medical Education. 7(40):1-5.
12. Brezinka, C. 2006. Training, certification and CME in obstetric ultrasound scan in Europe. European Clinic Obstetrics Gynecology. 1:223-226.
13. Dolmans, D., Schmidt, A., van der Beck, J., Beintema, M., & Gerver, W. J. 1999. Does a student log provide a means to a better structure clinical education? Medical Education. 33:89-94.
14. Vanek, E. P., Barrigua-Unal, R. M., Hekelman, F. P., Hull, A. L., Lindley, B. D., Barely, B. E., Krackov, S. K., & Packman, C. H. 1999. Use of patient encounter documentation (log) systems at three medical school. Teaching Learning Medicine. 5: 164-168.
15. Ferrel, B. G. 1991. Demonstrating the efficacy of the patient log-book as a program evaluation tool. Academic Medicine. 66(9): s49-s51.
16. Raghoebar-Krieger, H. M. J., Sleiffer, D. Bender, W. Steward, R. E., & Popping, R. 2001. The reliability of logbook data of medical students: an estimation of interobserver agreement, sensitivity and specificity. Medical Education. 35:624-631.
17. Fung, M. F. k., Walker, M., Fung, K. F. K., Temple, L., Lajoie, F., Bellemare, G., & Bryson, S. C. 2000. An internet-based learning portfolio in resident education: the KOALA™ multicentre proramme. Medical Education. 34:474-479.
18. Blaivas M., Lyon, M., & Duggal, S. 2005. Ultrasound image transmission via camera phones for overreading. American Journal of Emergency Medicine. 23:433-438.

 

 

Doc at a Distance

Authors: Alton Parker, MD; David Kwon, MD; Ilan Rubinfield, MD, MBA. Henry Ford Health System - Detroit, MI.

Abstract

BACKGROUND: Ultrasound is rapidly becoming a more versatile diagnostic tool for use with medical and non-medical personnel. The advent of the Mediphan device has made it possible to transmit ultrasound data in real-time to a remote location via Internet. We proposed that non-medical personnel with minimal training could be remotely guided to obtain diagnostic quality ultrasound images for use on the field by professional athletic teams.

METHODS: A Detroit Lions athletic trainer was given a brief tutorial on the Logic-e portable ultrasound machine and several musculoskeletal exams from an expert ultrasonographer. The trainer then examined Detroit Lions professional football players. The examination data was via internet to the remote expert ultrasonographer. The trainer was then remotely guided by the ultrasonographer via telecommunications.

RESULTS: All examinations were of diagnostic quality.

CONCLUSION: Non-medical personnel can accurately obtain diagnostic quality ultrasound images for musculoskeletal examinations using the Mediphan and remote guidance.

INTRODUCTION

Ultrasound (US) is rapidly becoming a more versatile diagnostic tool in medical applications. It has been found to be both a rapid and accurate method of diagnosis in a wide variety of clinical conditions that were previously reserved for X-Ray or CAT Scan. In recent years, investigations have shown that non-physician operators can reliably perform focused clinical US examinations to facilitate on-site diagnosis of medical conditions such as intra-ocular foreign body, abdominal blunt trauma, as well as muscle, tendon, and bone injuries. In addition, technological advances have improved the portability and quality of the images. In the not too distant past, the ultrasounds were completely immobile. Improved portability, combined with the addition of an ultrasound Ethernet port, has made it possible to send the ultrasound data over a secured network from remote locations. However, no hardware or software had been specifically developed for the ultrasound device, until recently.

Researchers at the National Aeronautical and Space and Administration (NASA) and the National Space Biomedical Research Institute

(NSBRI) have optimized rapid ultrasound training methods that allow minimally trained, non-physician operators to obtain diagnostic quality ultrasound images, which can be used to diagnose a wide variety of clinical conditions.

We have successfully used portable ultrasound in conjunction with the Epiphan real-time remote guidance hardware and software to rule-out or diagnose injuries in professional athletes on the field. We proposed that non-medical personnel could undergo minimal training and, combined with remote guidance, obtain diagnostic quality ultrasound images.

METHODS

The Procedures described herein were reviewed and approved by the Henry Ford Health (HFH) System Human Investigation Committee. The ultrasound trial was also approved by the Detroit Lions Administration. Team athletic trainers and physicians were interviewed to determine common football player injury patterns, with special emphasis on musculoskeletal injuries. Injury patterns were classified as muscular, ligamentous, or bone.

The Detroit Lions’ athletic trainers were given a brief tutorial on the Logic e portable ultrasound machine from an expert ultrasonographer. In addition, they were provided with the Onboard Proficiency Enhancement (OPE) tutorial interactive CD that is currently used to train NASA astronauts for International Space Station (ISS) ultrasonography. Topographic reference cue cards to facilitate US examinations were developed based on cue cards used aboard the ISS. The cue cards provide locations of ultrasound controls, keyboard shortcuts, as well as examples of transducer placement for various examinations. Trainers had access to this OPE program for review at any time.

Trainers participated in mock sessions performing musculoskeletal US examinations on non-injured subjects. During these tutorials, trainers received hands-on experience including device positioning, remote guidance terminology, and trouble-shooting complex scenarios. In addition, they became familiar with the characteristics of US images that should be obtained during each specific examination.

Twelve Detroit Lions professional football players were enrolled after suspected hamstring muscle and foot. The football players were informed of the NASA research, and potential benefits for injury diagnosis. Informed consent from the players were obtained before each examination.

A GE Logiq e US machine was placed in the locker room of Ford Field in Detroit, Michigan. The 12L (7-13MHz) transducer was used for all examinations.

Video stream from the VGA port of the portable ultrasound device was broadcasted onto the internet utilizing an Epiphan DVI-2USB device (Epiphan, Ottawa, Canada). The real-time video stream was routed to a secure, encrypted web site for viewing by remote guidance experts at Henry Ford Hospital in Detroit, Michigan. Audio communication over a secure phone line between a remote expert ultrasonographer and the trainers was used for all experiments.

The trainers began the examination autonomously using the provided cue cards. The expert ultrasonographer physicians, with remote guidance experience, viewed the transmitted US images. The physician then guided the trainers using previously specified directional language and cues. The trainers were given instructions to obtain, or enhance the images by the physician via real-time, secured telecommunications.

(Table 1).

Submission Type	Abstract Length	Page Length Maximum
Paper Stu	125-150 words	Five
Student Paper	125-150 words	Five
Poster	50-75 words	One
Panel	150-200 words	Three
Workshop	150-200 words	Three
Theater-style Demonstrations	150-200 words	One
Partnerships in Innovation	150-200 words	Three
ACMI Senior Presentations	150-200 words	Two

Table 1. Cue Card used to assist the athletic trainer in ultrasonography.

Figure 1. Diagnostic quality ultrasound image that was obtained by the minimally trained athletic trainer.

Figure 2. Picture of Epiphan DVI-2USB Device -GE Logic-e coupled

Figure 3. Diagram of coupling and information flow.

RESULTS

Equipment setup, operator, and subject positioning was accomplished in less than 5 minutes. Average bandwidth of transmission through the digital subscriber line from each facility to HFH was 300Kbps. There was a 0.5 to 1.0-second transmission delay for video, which did not impact the conduct or quality of ultrasound examinations. All experiments were archived on an offsite, remote server based in Ottawa, Canada, for future examination. Digital Imaging and Communications in Medicine (DICOM) images were saved at intervals during the examination and then downloaded after completion of the experiment. All downloaded DICOMs and video-streams were deemed adequate for professional interpretation by musculoskeletal ultrasound radiologists.

Complete ultrasound examinations of the hamstring were obtained on 12 athletes. One complete exam was obtained of the calcaneous. Examination completeness was evaluated by the remote experts while viewing the real-time ultrasound video stream. The remote-guided examinations were completed by the non-physician operators in less than 15 minutes each.

Musculoskeletal US examinations of the hamstring included (X) muscles and (X) views. Ultrasound examinations of the foot included views (X) bones and (X) ligaments.

Twelve professional athletes were examined using three trainers. Eleven hamstrings and one foot exam were obtained. These exams were labeled either “Diagnostic Quality” or “Non-Diagnostic Quality” by the expert ultrasonographer. All positive injuries were confirmed with the appropriate gold standard examination and compared to the conclusion drawn from the ultrasound exam and the expert interpretation. All exams were correctly diagnosed. All exams were considered “Diagnostic Quality”.

CONCLUSION

Ultrasound is currently readily available, in most urban and rural medical centers. It is also now portable, less expensive, and less cumbersome than X-Ray, CT or MRI technology. It has been shown to be sensitive and specific for musculoskeletal injury diagnosis in other studies, which have focused on minimally trained operators. The ability to provide timely and accurate diagnostic imaging to athletes by operators with limited medical training, although challenging, appears to be a viable option. There was no difference between the remote guidance diagnostic images and those obtained in standard conditions, when evaluated by a musculoskeletal US expert radiologist. Although our experiment has limited power, other investigations show similar results when training non-medical personnel in diagnostic ultrasound technology. With minimal training, non-medical personnel can accurately obtain diagnostic quality ultrasound images in the field for musculoskeletal examinations using the Epiphan remote guidance system. This, and other investigations warrant expansion of the study of remote guidance ultrasonography into other professional, amateur and high school teams as well as community first responder agencies such as paramedics, fire and police departments.

References

Pryor TA, Gardner RM, Clayton RD, Warner HR. The HELP system. J Med Sys. 1983;7:87-101.

Gardner RM, Golubjatnikov OK, Laub RM, Jacobson JT, Evans RS. Computer-critiqued blood ordering using the HELP system. Comput Biomed Res 1990;23:514-28.