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.

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