Frank J Staub, MD
OR consultation by telemedicine Bidirectional television communication in the practice of medicinetelemedicine-extends health care services normally available only in large medical centers to smaller, isolated hospitals. Telemedicine is being used to distribute anesthesia consultations t o areas where such services are in short supply. Use of television for such consultations may help to reduce operative deaths related to anesthesia. Estimates vary widely on the number of anesthetics given annually in the United States, but it appears to be about 18 million.' Recent data indicate that about 4% of operative deaths are related to anesthesia of which twothirds are judged preventable.2 These preventable deaths are attributed to such causes as pulmonary aspiration, hypotension, cardiac arrest, tension
Frank J Staub, MD, is assistant professor of anesthesiology at Lakeside University Hospital, Cleveland. A graduate of Syracuse University College of Medicine, Syracuse, N Y , Dr Stau b is also associate anesthesiologist at University Hospitals of Cleveland. This project was supported by Grant Number R18 HS 01390 from the Bureau of Health Services Research, Health Resources Administration.
pneumothorax, inadequate fluid replacement, and drug overdose. Using the results of a large university hospital survey of 34,145surgical patients, a death rate of 1 5 3 cases, or 2% could be established for the surgical and immediate postoperative per i o d ~ Applying .~ this rate to our 18 million procedures yields 360,000 deaths of which 14,400 are attributable to anesthesia. Of the 14,400 deaths, nearly 10,000 are believed preventable. With federal funding in 1972, eight telemedicine projects have been undertaken.4 The largest is the threehospital network based a t Case Western Reserve University (CWRU), Cleveland. The institutions involved are the Lakeside University Hospital of CWRU, the Cleveland Veterans Administration Hospital, and the Forest City Hospital, a small innercity community facility. These institutions lie from one-half to 2% miles apart and are connected by a system of laser beams, microwaves, and underground cables. A viewer at Lakeside University Hospital can observe both Veterans Administration Hospital and Forest City Hospital simultaneously and can orally communicate with either. An operating room a t each of the remote hospitals is equipped with a
AORN Journal, May 1977, V o l 2 5 , No 6
1169
\
I
Clark Tower
I
I
Lakeside Hospital monitoring room
Y
/ /
A
I
MacDonald House
= booster amplifier
I
U This diagram, which is not to scale, shows how Lakeside Hospital is connected by laser beams, microwaves, and underground cables to Veterans Administration Hospital and Forest City Hospital. MacDonald House is
an obstetrical hospital, which is not currently part of the system. Clark Tower is a tall dormitory building on the campus of Case Western Reserve University.
television camera and screen. Both cameras have pan, tilt, zoom, and focus controls as well as movable irises, which can be manipulated by the operating room personnel as well as remotely from the Lakeside University Hospital control room. As part of our comparison studies in evaluating
telemedicine systems, we have used a color camera a t Veterans Administration Hospital and a black-and-white unit at Forest City Hospital. The anesthetists at both remote hospitals are able to view the Lakeside University Hospital consultant as well as the pictures of themselves being
AORN Journal, May 1977, Val 25,No 6
1171
Control box used by consultant.
This console in the main control room has a large 17-inchcdor screen in the center. Directly above it is a small black and while television camera and small screen monitor to display the consuttant’s image. The two small screens in the left section show the operating rooms at the Veterans Administration Hospital and the Forest City Hospital. Either of these can be selected to be displayed on the large color monitor screen. Beneath the cdor screen is the electrocardiogram oscilloscope displaying continuous signals simultaneously from both remote hospitals.
transmitted. Vocal communication is via microphone and earpiece using specially installed telephone lines. An electrocardiographic (EKG) signal is also sent over these same lines and displayed on an oscilloscope at Lakeside University Hospital just beneath the television screen. We have recently placed in service a newly designed electronic stethoscope that allows the Lakeside University Hospital consultant to hear heart sounds, Korotkov
sounds, or breath sounds with minimal distortion. We have devised a paging system whereby an anesthetist at either Veterans Administration Hospital or Forest City Hospital who wants to reach a consultant anesthesiologist at Lakeside University Hospital has merely to push a button in the operating room, which transmits a signal via phone lines to an automatic tape-dialer at Lakeside University
AORN Journal, May 1977,Vol25, No 6
1173
Right: This mobile unit with a color camera on top is used at Forest City Hospital in the newborn nursery, the intensive care unit, and eventually in the recovery room in the future. It can be wheeled about and plugged in appropriately wired terminals. Below: The OR unit at both Forest City Hospital and Veterans Administration Hospital shows the OR scene as transmitted to Lakeside University Hospital and the picture of the consultant.
Hospital. This tape-dialer in turn automatically dials the code number of a small electronic page unit carried by the consultant directing him to proceed a t once to the central console. At 7:15 am each day, our consultant activates the system at Lakeside University Hospital while the anesthetists at Veterans Administration Hospital and Forest City Hospital do the same at their respective locations. After preliminary adjusting of picture quality, color, and volume intensities, the day’s cases are discussed. The charts are reviewed for completeness, permits are checked, and the availability of blood is ascertained. Questions are answered and appropriate advice is given when 1174
requested. The first patients at each hospital are then brought into the respective operating rooms and the usual anesthesia preliminaries are accomplished. If the patient’s condition permits, a brief greeting is made to the patient over a loudspeaker installed in the operating room for that purpose, and the patient is able to see the consultant on the nearby television screen. The induction of anesthesia a t both hospitals is observed and the EKG followed on the oscilloscope. After the patient’s condition is stable, the consultant then attends to other duties in the Lakeside University Hospital operating room suite returning to the
AORN Journal, May 1977, V o l 2 5 , No 6
console every 30 to 40 minutes or earlier if paged. Accurate records are kept of all cases. As soon as possible after the case has finished, a postanesthetic review is accomplished where alternative methods are weighed and specific problems addressed. The Lakeside University Hospital consultants try to keep conversation at a minimum during the actual administration of the anesthetic, intervening only when asked or if an untoward event occurs that appears to jeopardize the patient’s welfare. Other operating room personnel, eg, circulating nurses, scrub nurses, and aides, have been cooperative in displaying bloody sponges and tapes in strategic locations for television viewing as well as positioning themselves so as not to block the camera lens. A physician anesthesiologist is always onsite at Veterans Administration Hospital and Forest City Hospital in case actual physical intervention becomes necessary, but he can carry out other activities during the television monitoring. From June through October 1976, we consulted on a total of 122 anesthetic procedures via television and were available if needed on an additional 20 cases. During these consultations, several interesting events occurred that emphasize the value of the television consultant even though he was not physically present in the room. In a number of instances, premature ventricular contractions were noted on the EKG that were successfully treated by increasing the patient’s ventilation. On several occasions, anesthetists were “talked through” difficult endotracheal intubations. In one particular case, a n anesthetist successfully managed a cesarean section on a 29-inch midget delivering a five-pound infant despite
1176
the fact that the anesthetist’s experience in obstetrical anesthesia was quite limited. We have just completed a series of comparative studies wherein two trained anesthesiologists observed the same events, one via color television, the other onsite in the operating room.5 We found the colors were unreliable in tone due to the type and intensity of the lighting used during surgery. Of particular concern was the distortion of blue shades making the detection of cyanosis imprecise. Another problem area was the inability to detect accurately very small movements (eg, chest excursions with tidal volumes less than 200 cc) unless the zoom feature of the camera was .used. While this feature enabled the television observer to see details too small to be detected by the onsite observer, i t was achieved only by severely limiting the field of view for the several seconds required to zoom the camera in and back out again. Despite these shortcomings, we have found increasing acceptance of the system in the operating rooms at Forest City Hospital and Veterans Administration Hospital. At present, our consulting capabilities do not extend to the recovery room. However, in view of our demonstrated capabilities of rendering useful service to anesthetized patients in the operating room, it is a logical step to make these services available on a continuing basis to those same patients during their recovery phase. A precedent for continuing care has been established at Forest City Hospital in the intensive care unit and newborn nursery. Here, a mobile television camera is used for daily rounds in each of these areas by consultants specializing in these fields. A number of innovations in patient evaluation and care
AORN Journal, May 1977,Vol25, No 6
have been introduced a t Forest City Hospital by these consultants. The initial experiences have been so satisfactory t h a t plans are now being made t o
Notes 1. J S Gravenstein, J E Steinhaus, P P Volpitto, “Analysis of manpower in anesthesiology,” Aneshesiology (September ,970)350-357. 2. G F Mam, Cynthia V Mateo, L R Orkin,
incorporate the emergency loom and “Computer analysis of postanesthetic deaths,” delivery suite i n t o the system. Anesthesiology 39 (July 1973) 54-58. Our telemedicine system in Cleve3. Ibid. l a n d i s but the “tip of the iceberg” in the incorporation of modern electronic 4. Benefits and Problems of Seven Exploratofy Telemedicine Projects, Washington, Mitre Corp, communications into the practice of 1975, (MTS-6787). medicine and m a y help answer t h e question, H o w can advanced medical 5. F J Staub, D W Eastwood, P K Jones, care be made more the public?
to
0
“Capabilities and limitations of television in the operating room: Anesthesia surveillance,” manuscript in preparation.
Prompt resuscitation can save heart victim
Obesity is killer disease
Many heart attack victims have been saved through prompt resuscitation by a nonmedical person at the time of the attack, an editorial in Journal of the American Medical Association reports. Samuel Vaisrub, MD, senior editor, cites one study of 631 patients admitted to the hospital after cardiac arrest. Of those who received resuscitation at the scene, 36% survived. Only 8% of those who were left to wait for an ambulance crew survived the attack. The longer the delay in initiating resuscitation, the greater the death toll. For bystanders fearing involvement in litigation, Dr Vaisrub states that research of legal, medical, and lay literature has not shown a single case of a layman held liable for attempting to help. The physician believes that those who feel they aren’t sufficiently skilled or trained in resuscitation techniques should make an attempt. Dr Vaisrub writes that “the timing of resuscitation (beginning immediately) rather than the credentials of those who perform it is crucial to its success. The lay bystander need have no hesitation in rescuing a victim of cardiopulmonary collapse. Nor need the physician hesitate to train and instruct as many lay persons as possible in resuscitative measures.”
Obesity, the number one malnutrition problem in the United States, is increasing, the Senate Select Committee on Nutrition and Human Needs reports. The committee adjourned its month-long hearings on the relationship between obesity and health in mid-February. Although people in the US spend $10 billion annually on weight-loss products and programs, the problem still exists. Due to improper diet, obesity is more likely among the poor. Witnesses told the committee that obesity is not only a cause of poor health but has been called a killer disease. Proper diet and weight can help prevent cardiovascular diseases, hypertension, diabetes, and arthritis. As of Dec 31, 1977, the committee will become a part of the Senate Committee on Agriculture, Nutrition, and Forestry. Areas presently under jurisdiction of the committee include nutrition and preventive health; nutrition and the consumer; food stamp and child nutrition programs in relation to poverty, unemployment, and infant mortality; and the status of nutrition education curriculum in medical schools. The committee should complete reports on all these areas before December.
1178
AORN Journal, May 1977,Vol25, No 6
OR consultation by telemedicine Bidirectional television communication in the practice of medicinetelemedicine-extends health care services normally available only in large medical centers to smaller, isolated hospitals. Telemedicine is being used to distribute anesthesia consultations t o areas where such services are in short supply. Use of television for such consultations may help to reduce operative deaths related to anesthesia. Estimates vary widely on the number of anesthetics given annually in the United States, but it appears to be about 18 million.' Recent data indicate that about 4% of operative deaths are related to anesthesia of which twothirds are judged preventable.2 These preventable deaths are attributed to such causes as pulmonary aspiration, hypotension, cardiac arrest, tension
Frank J Staub, MD, is assistant professor of anesthesiology at Lakeside University Hospital, Cleveland. A graduate of Syracuse University College of Medicine, Syracuse, N Y , Dr Stau b is also associate anesthesiologist at University Hospitals of Cleveland. This project was supported by Grant Number R18 HS 01390 from the Bureau of Health Services Research, Health Resources Administration.
pneumothorax, inadequate fluid replacement, and drug overdose. Using the results of a large university hospital survey of 34,145surgical patients, a death rate of 1 5 3 cases, or 2% could be established for the surgical and immediate postoperative per i o d ~ Applying .~ this rate to our 18 million procedures yields 360,000 deaths of which 14,400 are attributable to anesthesia. Of the 14,400 deaths, nearly 10,000 are believed preventable. With federal funding in 1972, eight telemedicine projects have been undertaken.4 The largest is the threehospital network based a t Case Western Reserve University (CWRU), Cleveland. The institutions involved are the Lakeside University Hospital of CWRU, the Cleveland Veterans Administration Hospital, and the Forest City Hospital, a small innercity community facility. These institutions lie from one-half to 2% miles apart and are connected by a system of laser beams, microwaves, and underground cables. A viewer at Lakeside University Hospital can observe both Veterans Administration Hospital and Forest City Hospital simultaneously and can orally communicate with either. An operating room a t each of the remote hospitals is equipped with a
AORN Journal, May 1977, V o l 2 5 , No 6
1169
\
I
Clark Tower
I
I
Lakeside Hospital monitoring room
Y
/ /
A
I
MacDonald House
= booster amplifier
I
U This diagram, which is not to scale, shows how Lakeside Hospital is connected by laser beams, microwaves, and underground cables to Veterans Administration Hospital and Forest City Hospital. MacDonald House is
an obstetrical hospital, which is not currently part of the system. Clark Tower is a tall dormitory building on the campus of Case Western Reserve University.
television camera and screen. Both cameras have pan, tilt, zoom, and focus controls as well as movable irises, which can be manipulated by the operating room personnel as well as remotely from the Lakeside University Hospital control room. As part of our comparison studies in evaluating
telemedicine systems, we have used a color camera a t Veterans Administration Hospital and a black-and-white unit at Forest City Hospital. The anesthetists at both remote hospitals are able to view the Lakeside University Hospital consultant as well as the pictures of themselves being
AORN Journal, May 1977, Val 25,No 6
1171
Control box used by consultant.
This console in the main control room has a large 17-inchcdor screen in the center. Directly above it is a small black and while television camera and small screen monitor to display the consuttant’s image. The two small screens in the left section show the operating rooms at the Veterans Administration Hospital and the Forest City Hospital. Either of these can be selected to be displayed on the large color monitor screen. Beneath the cdor screen is the electrocardiogram oscilloscope displaying continuous signals simultaneously from both remote hospitals.
transmitted. Vocal communication is via microphone and earpiece using specially installed telephone lines. An electrocardiographic (EKG) signal is also sent over these same lines and displayed on an oscilloscope at Lakeside University Hospital just beneath the television screen. We have recently placed in service a newly designed electronic stethoscope that allows the Lakeside University Hospital consultant to hear heart sounds, Korotkov
sounds, or breath sounds with minimal distortion. We have devised a paging system whereby an anesthetist at either Veterans Administration Hospital or Forest City Hospital who wants to reach a consultant anesthesiologist at Lakeside University Hospital has merely to push a button in the operating room, which transmits a signal via phone lines to an automatic tape-dialer at Lakeside University
AORN Journal, May 1977,Vol25, No 6
1173
Right: This mobile unit with a color camera on top is used at Forest City Hospital in the newborn nursery, the intensive care unit, and eventually in the recovery room in the future. It can be wheeled about and plugged in appropriately wired terminals. Below: The OR unit at both Forest City Hospital and Veterans Administration Hospital shows the OR scene as transmitted to Lakeside University Hospital and the picture of the consultant.
Hospital. This tape-dialer in turn automatically dials the code number of a small electronic page unit carried by the consultant directing him to proceed a t once to the central console. At 7:15 am each day, our consultant activates the system at Lakeside University Hospital while the anesthetists at Veterans Administration Hospital and Forest City Hospital do the same at their respective locations. After preliminary adjusting of picture quality, color, and volume intensities, the day’s cases are discussed. The charts are reviewed for completeness, permits are checked, and the availability of blood is ascertained. Questions are answered and appropriate advice is given when 1174
requested. The first patients at each hospital are then brought into the respective operating rooms and the usual anesthesia preliminaries are accomplished. If the patient’s condition permits, a brief greeting is made to the patient over a loudspeaker installed in the operating room for that purpose, and the patient is able to see the consultant on the nearby television screen. The induction of anesthesia a t both hospitals is observed and the EKG followed on the oscilloscope. After the patient’s condition is stable, the consultant then attends to other duties in the Lakeside University Hospital operating room suite returning to the
AORN Journal, May 1977, V o l 2 5 , No 6
console every 30 to 40 minutes or earlier if paged. Accurate records are kept of all cases. As soon as possible after the case has finished, a postanesthetic review is accomplished where alternative methods are weighed and specific problems addressed. The Lakeside University Hospital consultants try to keep conversation at a minimum during the actual administration of the anesthetic, intervening only when asked or if an untoward event occurs that appears to jeopardize the patient’s welfare. Other operating room personnel, eg, circulating nurses, scrub nurses, and aides, have been cooperative in displaying bloody sponges and tapes in strategic locations for television viewing as well as positioning themselves so as not to block the camera lens. A physician anesthesiologist is always onsite at Veterans Administration Hospital and Forest City Hospital in case actual physical intervention becomes necessary, but he can carry out other activities during the television monitoring. From June through October 1976, we consulted on a total of 122 anesthetic procedures via television and were available if needed on an additional 20 cases. During these consultations, several interesting events occurred that emphasize the value of the television consultant even though he was not physically present in the room. In a number of instances, premature ventricular contractions were noted on the EKG that were successfully treated by increasing the patient’s ventilation. On several occasions, anesthetists were “talked through” difficult endotracheal intubations. In one particular case, a n anesthetist successfully managed a cesarean section on a 29-inch midget delivering a five-pound infant despite
1176
the fact that the anesthetist’s experience in obstetrical anesthesia was quite limited. We have just completed a series of comparative studies wherein two trained anesthesiologists observed the same events, one via color television, the other onsite in the operating room.5 We found the colors were unreliable in tone due to the type and intensity of the lighting used during surgery. Of particular concern was the distortion of blue shades making the detection of cyanosis imprecise. Another problem area was the inability to detect accurately very small movements (eg, chest excursions with tidal volumes less than 200 cc) unless the zoom feature of the camera was .used. While this feature enabled the television observer to see details too small to be detected by the onsite observer, i t was achieved only by severely limiting the field of view for the several seconds required to zoom the camera in and back out again. Despite these shortcomings, we have found increasing acceptance of the system in the operating rooms at Forest City Hospital and Veterans Administration Hospital. At present, our consulting capabilities do not extend to the recovery room. However, in view of our demonstrated capabilities of rendering useful service to anesthetized patients in the operating room, it is a logical step to make these services available on a continuing basis to those same patients during their recovery phase. A precedent for continuing care has been established at Forest City Hospital in the intensive care unit and newborn nursery. Here, a mobile television camera is used for daily rounds in each of these areas by consultants specializing in these fields. A number of innovations in patient evaluation and care
AORN Journal, May 1977,Vol25, No 6
have been introduced a t Forest City Hospital by these consultants. The initial experiences have been so satisfactory t h a t plans are now being made t o
Notes 1. J S Gravenstein, J E Steinhaus, P P Volpitto, “Analysis of manpower in anesthesiology,” Aneshesiology (September ,970)350-357. 2. G F Mam, Cynthia V Mateo, L R Orkin,
incorporate the emergency loom and “Computer analysis of postanesthetic deaths,” delivery suite i n t o the system. Anesthesiology 39 (July 1973) 54-58. Our telemedicine system in Cleve3. Ibid. l a n d i s but the “tip of the iceberg” in the incorporation of modern electronic 4. Benefits and Problems of Seven Exploratofy Telemedicine Projects, Washington, Mitre Corp, communications into the practice of 1975, (MTS-6787). medicine and m a y help answer t h e question, H o w can advanced medical 5. F J Staub, D W Eastwood, P K Jones, care be made more the public?
to
0
“Capabilities and limitations of television in the operating room: Anesthesia surveillance,” manuscript in preparation.
Prompt resuscitation can save heart victim
Obesity is killer disease
Many heart attack victims have been saved through prompt resuscitation by a nonmedical person at the time of the attack, an editorial in Journal of the American Medical Association reports. Samuel Vaisrub, MD, senior editor, cites one study of 631 patients admitted to the hospital after cardiac arrest. Of those who received resuscitation at the scene, 36% survived. Only 8% of those who were left to wait for an ambulance crew survived the attack. The longer the delay in initiating resuscitation, the greater the death toll. For bystanders fearing involvement in litigation, Dr Vaisrub states that research of legal, medical, and lay literature has not shown a single case of a layman held liable for attempting to help. The physician believes that those who feel they aren’t sufficiently skilled or trained in resuscitation techniques should make an attempt. Dr Vaisrub writes that “the timing of resuscitation (beginning immediately) rather than the credentials of those who perform it is crucial to its success. The lay bystander need have no hesitation in rescuing a victim of cardiopulmonary collapse. Nor need the physician hesitate to train and instruct as many lay persons as possible in resuscitative measures.”
Obesity, the number one malnutrition problem in the United States, is increasing, the Senate Select Committee on Nutrition and Human Needs reports. The committee adjourned its month-long hearings on the relationship between obesity and health in mid-February. Although people in the US spend $10 billion annually on weight-loss products and programs, the problem still exists. Due to improper diet, obesity is more likely among the poor. Witnesses told the committee that obesity is not only a cause of poor health but has been called a killer disease. Proper diet and weight can help prevent cardiovascular diseases, hypertension, diabetes, and arthritis. As of Dec 31, 1977, the committee will become a part of the Senate Committee on Agriculture, Nutrition, and Forestry. Areas presently under jurisdiction of the committee include nutrition and preventive health; nutrition and the consumer; food stamp and child nutrition programs in relation to poverty, unemployment, and infant mortality; and the status of nutrition education curriculum in medical schools. The committee should complete reports on all these areas before December.
1178
AORN Journal, May 1977,Vol25, No 6
