Category Archives: Technology

New Tech: Augmented Reality In The OR?

Virtual reality headsets have been all the rage for some time. They immerse the wearer in a complete virtual world, and are typically used for gaming. Augmented reality, on the other hand, overlays virtual items on the real world so both are visible at the same time. Think the notorious Pokemon Go app:

What if this technology could be used for medical purposes? You could overlay diagnostic or anatomic information on your patient to help guide therapy, surgery, etc.

A group at the University of Alberta in Canada have been playing with this technology. ProjectDR takes any kind of image-related information and projects it directly on a patient.The patient is first scanned using surface markers like they do when making movies:

Obviously, no fancy suit or huge number of markers is needed. Once this is accomplished, the diagnostic information can be projected onto the patient. The patient can move, and the projector will compensate and keep the projection anatomically correct.

Here is a short video that demonstrates the system:

So is this useful? Unfortunately, not yet. It may eventually be good for office-based trauma professionals, but it needs further refinement. This version uses an actual digital projector, which means it will be subject to shadows which will interfere with viewing, especially if a surgeon gets his or her big head in the way.

Here’s how it will really have to work: The system could function quite well in surgical procedures. Imagine the surgeon being able to don a VR headset (lightweight, please!) and see the surgical field with key information overlaid on the display. Or even easier, incorporate it in the DaVinci robotic system display. Add vital signs in the upper corner and details of anatomic structures that have not been surgically exposed yet. It could help show anatomic anomalies in great detail, such as vascular variants. And heck, why not throw in some on-demand magnification as well?

As with most new and exciting tech that hits the general media, a version that is actually usable by clinicians is several years away. But it should be fun when it finally gets here!

Reference: University of Alberta ProjectDR system

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The Next Generation 3D Bioprinter For Skin

3D printing for medical purposes (bioprinting) continues to evolve, and I’ve written a number of posts on this topic over the past 7 years. Skin bioprinting has been around for some time, but it keeps getting more and more sophisticated. Now, appropriate cell lines for the “ink” tanks can be grown in just a few days, and laid down in layers that are getting closer to real skin.

Take a look at this video to see the state of the art:

The next step: adding hair, being able to print large sheets, and ultimately printing directly onto the body!

Related posts:

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The Electronic Trauma Flow Sheet – Final Answer

After more than 8 years of experience, moving to an electronic trauma flow sheet is still not ready for prime time. I’ve seen many, many hospitals struggling to make it work. And all but a very few have failed.

There are two major problems. First, existing computer input technology is underdeveloped. Trying to rapidly put information into small windows on a computer, and having to switch between mouse and keyboard and back is just too slow. And second, output reports are terrible. Humans cannot scan 26 pages of chronological data and reconstruct a trauma activation in their head. There is so much extra data in the typical computer-generated reports, the signal (potential PI issues) gets lost in the noise.

The technology exists to remedy both of the problems. However, the EHR vendors keep tight control over data exchange in and out of their products. Sure, there is CareAnywhere and it’s ilk, but the user is still forced to use the vendor’s flawed input and output systems.

Bottom line: You can’t make a complex system (trauma care) easier or safer by adding complexity (the EHR). Yet.

The electronic trauma flow sheet will never work as well as it could until all the vendors settle on a strong data interchange standard to put data into and get reports out of the EHR. Once that happens, scores of startup companies will start to design easy input systems and report outputs or displays that are actually meaningful. There’s not enough interest in this niche market to make it worthwhile for a company the size of Epic or McKesson, but there is definitely enough for a lot of young companies just chomping at the bit in Silicon Valley.

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The Electronic Trauma Flow Sheet – Part 1

I started voicing my concerns about trying to use an electronic trauma flow sheet (eTFS) way back in 2008. There are very few reports in the literature that specifically detail using the EHR as a trauma flow sheet. The first (see reference 1 below) described an early experience with the conversion process. It outlines lessons learned during one center’s experience, and I’ve not seen any published followup from that center.

Now, on to a report of a “positive” experience. A Level I pediatric trauma center made the same change to the eTFS. They designed a custom menu-driven electronic documentation system, once again using Epic. Specific nurses were trained to act as the

electronic scribe, and had to be present at every trauma resuscitation. The goal of the study was to compare completion rates between paper and electronic documentation. One year of experience with each was collected.

Here are the factoids:

  • There were about 200 trauma activations each year that were admitted, and only 50 or so were highest level activations (in a year!)
  • 11 data elements were compared, including treatments prior to arrival, vitals, fluids, primary survey, level and time of activation, patient and surgeon arrival, and disposition
  • The eTFS was better at capturing time of activation, primary survey components, attending arrival time, and fluid administration

Yes. That’s it. They looked at 11 data points. It says nothing about the wealth of other information that has to be recorded and needs to be abstracted or analyzed. And nothing about the reports generated and their utility. Or how much additional time must be spent by the trauma PI program to figure out what really happened. Or how good their paper documentation was in the first place (not so good, apparently). Or the bias of knowing that your documentation under Epic is being scrutinized for the study.

And to get to that level, this hospital had to maintain a complement of highly trained nurses who were facile with their customized Epic trauma narrator. And they had to maintain their skills despite seeing only one highest level trauma activation patient per week, or one activation at any level only every other day.

I’ve had a number of discussions with the trauma program manager from this hospital, and I am convinced that they have managed to make it work well at their center. However, I’m not certain that their system can be generalized to hospitals with higher volumes and and degree of staffing restraints.

In my final post of this series, I’ll tell you what I really think about using the electronic trauma flow sheet in your trauma resuscitations, and why.

References:

  1. Using the electronic medical record for trauma resuscitations: is it possible? J Emerg Nursing 36(4):381-384, 2010.
  2. A comparison of paper documentation to electronic documentation for trauma resuscitations at a Level I pediatric trauma center. J Emerg Nursing 41(1):52-56, 2015.
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Trauma Patient Stay In The ED After Implementing an Electronic Health Record

So as we discovered, we may spend less time and see fewer patients if we use an EHR. One would think that ED length of stay (LOS) would then increase. But does it?

A 2 year observational study from Greece looked at ED throughput before and after implementation of an electronic trauma documentation system. A total of 101 trauma patients were processed under the paper charting system, and 99 were handled after implementation of the electronic system.

Here are the factoids:

  • Injury severity was high overall, with half going for emergent surgery and an overall mortality rate of about 12%
  • Total ED LOS decreased from 206 to 127 minutes with the EHR
  • This was accomplished by decreasing time between arrival and completion of care from 149 to 100 minutes, and from completion of care to leaving the ED from 47 to 26 minutes

Bottom line: Looks great! Badly hurt patients, moving through the ED at breakneck speed after implementation of an EHR. The problem is that it was not really an EHR, but an “electronic documentation system.” Upon close inspection, this is a homegrown system with very specific functionality for monitoring care, providing checklists, and offering case-specific guidance. This is not the type of complex documentation system one usually thinks of when visualizing an EHR. But it does go to show that well-designed and focused software can be beneficial.

Tomorrow, I’ll start to focus specifically on the electronic trauma flow sheet (eTFS).

Reference: The effect of an electronic documentation system on the trauma patient’s length of stay in an emergency department. J Emerg Nursing 40(5)469-475, 2014.

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