By Michael J. Carr, MD FACEP FAEMS; and Nathan Stanaway, MS NRP
If you鈥檝e worked as part of a team providing EMS in rural areas, you know it is especially challenging, in part because of the longer distances between patients and emergency departments that are best equipped to treat time-sensitive critical conditions like stroke, STEMI, burns, smoke inhalation, poisoning and serious injuries from vehicle accidents. The longer distances result in increased response times, delaying patients鈥� access to the critical treatment they need.
Adding to the challenge, paramedics often work with minimal support and equipment, making it difficult to provide comprehensive care during the long journey to the emergency department (ED).
Improving rural emergency care with PAVES
We created Prehospital and Ambulatory Virtual Emergency Services () with the vision to expand and improve the quality of emergency care for residents in rural areas, to bring it on par with emergency care in urban cities; and to help address the access disparity in rural areas of Georgia. Specifically, we provide EMS-focused telemedicine services to EMTs and paramedic staff treating patients across rural Georgia.
PAVES is funded by a grant from the U.S. Health Resources and Services Administration (HRSA) and enables rural ambulance staff to remotely diagnose, triage, treat and route patients to the closest local care facility able to treat the patient. Most frequently, patients and EMS staff are able to leverage this support to safely keep patients in their home community.
Emergency care in a rural setting
One of our partners, (WCRMC), provides telemedicine services supported by the PAVES network. WCRMC is a rural hospital located within the nearly 900 miles of rural, sometimes dirt roads in Washington County, Georgia. Nestled between Augusta and Macon, this small, innovative medical center has an eight-bed ED and a 25-bed in-patient space. In the evenings, the hospital鈥檚 ED is often staffed by a single physician and two nurses.
The next closest ED is roughly 25 miles away and has similar, or even more staffing constraints. Patients often travel 45 miles or more to reach a hospital that can match or exceed WCRMC鈥檚 capabilities. However, it鈥檚 important to note that this situation is not unique to Georgia; many rural areas in the U.S. face similar emergency care challenges.
Our mobile decentralized paramedicine system
To enhance the emergency care capabilities within Washington County, we worked closely with WCRMC to deploy a mobile system that connects EMS staff with medical professionals in the WCRMC ED and, if necessary, specialized medical experts in the region. The use of video communication technology enables remote consultations and support from medical professionals in a way that dramatically improves the depth of information sharing without adding to the EMS staff workload.
The technology system we use includes that are purpose-built for EMS and public safety environments. The tablets are military-grade rugged with responsive, yet robust sunlight-readable touchscreen displays for detailed imaging. In addition to the front and back cameras on the tablets, we attach an pan-tilt-optical zoom camera to the tablets in the ambulances to provide an EMS hands-free visual feed to remote medical personnel.
The tablets run Microsoft Windows IoT Enterprise, streamlining integration with our ED systems and software , which has strong encryption and high-quality audio/video capabilities, so we can provide mobile point-of-care wherever the patient is located.
We configured the system so that the tablet in the WCRMC hospital ED connects to the tablets mounted in the back of the ambulances. This approach provides the ability for the EMS team, physicians and other healthcare practitioners in the ED, as well as medical subject matter experts in separate locations to view, interact with, diagnose and help treat patients as though they were in the same room.
Remote stroke assessment
Tetra Jenkins, a registered nurse and Stroke and Trauma Program coordinator at WCRMC, explains how this technology system accelerates crucial medical intervention for stroke victims. 鈥淭o save a stroke victim鈥檚 life or preserve their quality of life, it鈥檚 critical to provide essential treatment within a 3-4-hour window,鈥� said Jenkins. 鈥淲ith this technology, we can kickstart the treatment process in the ambulance. The ED physician can remotely initiate a comprehensive stroke scale to assess the severity of the stroke and, for instance, help guide EMS staff in managing the patient鈥檚 blood pressure before arriving at the hospital. Starting this process while enroute helps stabilize the patient sooner so when they reach the ED, our medical team can immediately begin other critical life-saving treatments.鈥�
Hub and spoke clinical network
Michael Padgett, WCRMC鈥檚 director of EMS, uses the system to help overcome staffing shortages in the EMS field. 鈥淲e are often required to interpret a 12-lead EKG when treating a cardiology patient on advanced life support,鈥� said Padgett. 鈥淏ut staffing shortages leave some EMS teams without the practitioners to interpret this test, and then administer the proper medication. With this technology, the physician in the ED can interpret the 12-lead and direct the EMS staff to give certain medications.鈥�
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In other instances, the mobile system can resolve difficulties encountered while transferring patients between WCRMC and neighboring facilities. 鈥淚f we encounter a problem with a patient during transport and the closest facility is 60 miles away with no alternatives enroute, we can connect to our ED or the receiving ED and have our clinician guide us,鈥� said Padgett. 鈥淭he mobile audio/video communication capability helps us provide safer transports, improved patient care and better patient outcomes.鈥�
Starting the pre-registration process while enroute to the ED saves precious time and improves patient care. 鈥淏y pre-registering patients for X-rays or CT scans, the registration is completed before they even arrive at the hospital,鈥� said Jenkins. 鈥淭his ensures that the patients鈥� charts are ready when the radiologist reads the report, improving workflow and speeding up the process.鈥�
Disaster medical assistance
Delivering emergency care at disaster scenes typically requires a challenging mix of rugged mobile devices and connectivity. But our system enables EMS personnel to go into any environment and easily set up a field exam room with a connection to doctors at a nearby city or major medical center. This seamless approach gives teams a greater ability to treat and release some patients without the need to go to an ED.
鈥淭here are times when mass casualties or motor vehicle accidents overwhelm our system quickly,鈥� said Padgett. 鈥淏y positioning tablets at the scene, at other hospitals and connecting with larger health center networks, we can expand the amount of care we can provide to patients during these critical moments when all of our onsite resources may be tapped.鈥�
In the future, we envision a similar model for disaster response in the event of train derailments, chemical spills and other mass emergency situations. This type of distributed telemedicine technology enables first responders to consult with a variety of subject matter experts, toxicologists and specialists 鈥� sometimes from around the world 鈥� providing the specific expertise needed for rapid, effective responses to novel incidents.
Saving time saves lives
A decentralized mobile telemedicine system can rectify many of the disparities in medical care experienced in rural environments and during patient surge events. The WCRMC example demonstrates how effective telemedicine, using purpose-built rugged medical tablets and telehealth software, can significantly reduce time-to-care, expand the number of practitioners treating patients, and improve patient care overall. It is a true force-multiplier!
ABOUT THE AUTHORS
Michael J. Carr, MD FACEP FAEMS, is associate professor, Department of Emergency Medicine, Emory University School of Medicine; executive director, Prehospital & Ambulatory Virtual Emergency Services (PAVES); chief quality and innovation officer, Cardiac Arrest Registry to Enhance Survival (CARES); medical director, DeKalb County Fire Rescue; and medical director, Air Methods/Air-Life Georgia.
Nathan Stanaway, MS, NRP, is project manager for PAVES & SRDRS MOCC, Emory University School of Medicine, Department of Emergency Medicine, Prehospital and Disaster Medicine Section.