Imaging imperatives

Telemedicine is an increasing aspect of the day-to-day operations of the National Health Service. Dr Dave Sloggett explores where it is currently delivering benefits to patients

Imaging imperatives

Coded Orthogonal Frequency Division Multiplex (COFDM) is hardly a term that trips off the tongue. But it is a piece of wireless technology that helps Hazardous Area Response Teams (HART) in the National Health Service quite literally save lives. 

In the event of a major man-made or natural disaster HART teams across the United Kingdom would be at the forefront of delivering care to patients in what is called the ‘Hot Zone’. This is the place where patients are in immediate danger. 

If a major shooting event, such as the recent attack on the Westgate shopping mall in Nairobi, were to take place somewhere in the United Kingdom it would be HART teams that would be deployed into harm’s way to try and stabilise and evacuate patients to hospitals for further treatment. 

These same teams would also be deployed if terrorists were to mount a major Chemical, Biological, Radiological or Nuclear (CBRN) attack. The horrific scenes broadcast from suburbs of Damascus show the indiscriminate nature of such attacks. Bringing relief to those involved quickly is essential if many are to survive.

Remote diagnosis

One of the problems that emerged with the pictures coming from Damascus was that they were taken by amateur cameramen, using their mobile phones in what were chaotic scenes. Trying to work out exactly what symptoms affected people were displaying, in what is now generally agreed to have been a Sarin gas attack, is really hard. This has led to claims and counter-claims as to who actually conducted the attack.

To aid situational awareness if any of these kinds of incidents were to occur in the United Kingdom, the HART personnel wear cameras. This is quite unusual and shows the level of thinking that has gone into developing the HART capability. At present this remains a unique capability in the NHS. 

The images collected from these cameras are sent back via a mobile GSM network that is based on a command vehicle deployed to the scene. In the command vehicle they can be accessed by Bronze commanders at the scene and transmitted on, via satellite, to Silver and Gold command teams managing the situation as well as medical professionals who would be charged with treating the patients once they are evacuated from the scene. 

Other specialists, such as experts in chemical weapons, can also be brought in to look at the imagery that is being collected first hand by the paramedics attending the scene. This will all help speed up the process of diagnosis of the source of any symptoms and help medical teams prepare correctly to receive patients. 

This is a great advance on the kind of response that was possible when terrorists struck five stations on the Tokyo Underground in 1995, killing twelve people and exposing more than 1,500 others to the chemical agent Sarin.

NHS HART units

This capability which is available to address a major event such as a CBRN attack can be deployed by the HART teams autonomously. In addition to the ability to capture imagery, the GSM network can also support a 10-line telephone exchange, which also uses a satellite link to pass voice encrypted conversations. 

Each team carries six Secure Internet Protocol (SIP) phones for use over the GSM network and a Wi-Fi link is also provided as back-up for another four phones should they be required. 

The important point is that the HART teams arrive at a scene and are immediately able, irrespective of the situation with any commercial networks that might have been affected by the attack, to send images and voice into their response networks.

This capability can be described as a tactical application of telemedicine. Images of patient’s wounds and symptoms and their immediate treatment by paramedics operating in the Hot Zone can be discussed with clinical professionals and any scientific support teams and advisors who have been mobilised.  

There are, however, other ways in which telemedicine is used in the NHS. At one level individual images can be emailed between specialists using the secure email facilities available in NHS Net. 

These, however, lack immediacy and emails are always open to interpretation. Being able to talk directly to a fellow professional nearly always has an advantage. 

Four key areas

Initiatives to introduce this kind of on-line consultation either between a specialist and patient or between medical professionals using telemedicine technologies are gradually being introduced into the NHS. These currently focus upon four specific areas.

The first is helping general practitioners located in remote rural areas to send images and conduct consultations with specialists saving patients travelling to hospital. This has been found to be especially useful in diagnosing dermatological problems.

Next is assisting the work of multidisciplinary teams, especially for cancer units where the pathologist and the radiotherapist may be located in different hospitals. This enables them to hold a weekly meeting discussing patients and share the scans and pathology slides on the screen. 

Similarly, really complex medical conditions could be discussed with experts in overseas countries such as America and Australia. This enables clinicians to open up a wealth of expertise that has traditionally not been available in areas of medicine where new treatments and procedures are being pioneered. 

The third area is providing remote access to the reporting of specialist X-rays and neurological scans, or, for example, the neurosurgeons could look at a scan from a hospital such as Boston in Lincolnshire and decide the patient needs to be transferred to a specialised neurosurgical unit at Nottingham for surgery, or else the problem could be managed in the Intensive Care Unit at Boston saving the long journey and keeping the patient close to home.

Finally, sharing computerised electronic patient records with hospitals designated to receive patients. Trusts, such as the East Midlands Ambulance Service, use this to transmit the data for the consultation that can include an ECG, so the receiving hospital is aware of the patient’s recent medical history before they arrive. 

The hospital can then advise on treatment on the way to the hospital or could advise that the crew should take the patient to a different specialist centre based on the information provided. In time this might also include images of the incident or the wounds of the patient.

Optimising care

These specific ways of using telemedicine are all centred on the patient and trying to optimise the care they are provided. They can help unravel complex medical conditions where specific expertise is required to understand the symptoms that are being presented by the patient. 

These uses of telemedicine come at a time when the NHS is under huge political pressure to do more with its resources. Centres of clinical excellence are being established that are able to provide advice to other parts of the NHS where replication of those services would simply be impractical from a financial viewpoint. Telemedicine is also being used to provide remote expertise to medical staff on the ground in war zones such as Afghanistan (see box).

These various applications of telemedicine are still developing in time. As new technological capabilities are developed it is possible to envisage a capability to look inside a patient in three-dimensions, a kind of virtual body tour enabling clinicians to gain even deeper insights into what may be complex interactions between different medical conditions whose combined symptoms can be misleading. 

By being able to call on such expertise and fuse their views into a comprehensive patient plan, the NHS will be able to deliver an even better service. For minister’s, irrespective of their political viewpoint, that can only be a good thing. 

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