Patient-Specific Computer-Assisted Monitoring Devices
Trauma scenes, especially those involving multiple or mass casualties such as vehicular crash sites, disaster zones or military combat operations are chaotic and complex. First responders may not have sufficient experience to deal with the needs of many trauma victims simultaneously. In mass casualty situations there may be delayed evacuation times and limited resources.
The problem of transferring medical information from first-responders to evacuation personnel to emergency department triage personnel to attending physician adds to the confusion. And there is great potential for critical patient-specific information to be missed, misplaced or wrongly assigned.
Some of these issues could be mitigated through the use of patient-specific computer-assisted monitoring devices that are strapped to patients at the trauma scene. These devices monitor, store and display vital sign information throughout a patient’s progression from the trauma scene to the post-emergency department. They monitor patients, freeing medical staff to attend to other patients, and can alert medical staff if intervention is required. As technology improves, these devices will become more sophisticated and may become routinely used in trauma practice.
Computerized Clinical Decision Support Systems
Medical computerized clinical decision support systems (CCDSS) can provide guidance and recommendations for medical care based on patient monitoring and standard care procedures in many medical fields. One example of CCDSS, used at the US Army Institute of Surgical Research, is a system that guides the fluid resuscitation of ICU burn patients. CCDSS have also been used for mechanical ventilation of patients with acute respiratory distress syndrome1 and shock resuscitation.2 Furthermore, CCDSS are valuable tools in the fight against hospital-acquired infection, providing clinicians and caregivers with a real-time microbiology browser for more directed antibiotic prescription and standardized order sets that result in measurable improvements in antibiotic use.3 CCDSS for antibiotic use showed a significant advantage in eight of ten hospitals where they were tested.4
Given chronic staff/nursing shortages, especially in very complex and heavily monitored environments such as intensive care units, CCDSS can aid in the monitoring of patients, decreasing the necessary nurse:patient ratio. CCDSS also provide an opportunity for streamlining the patient care process so that less experienced staff members can benefit from computer assistance in decision-making.
As decision support systems become more advanced, they can automate some of the manual procedures now performed by care providers through the use of open and closed loop technology. Open loop systems directly interface with the patient: A user accepts, rejects or adjusts the recommendations, and the system executes the final procedure automatically. Closed loop systems completely automate a procedure: The computer system reads, interprets and executes the necessary steps to manipulate devices attached to the patient. Areas in which this technology could be useful are burn and trauma resuscitation, nutrition, ventilation management,5 blood transfusion systems and glucose control. Research is required in this area to build computer models and develop more precise algorithms, and to prove the safety and efficacy of these devices for human use.
Topical Negative Wound Therapy
Topical negative wound therapy (TNP) is a technology currently used for wound healing. TNP describes the application of suction to a wound and is also known as wound vacuum or “wound vac” for short. TNP has been shown to stimulate healing, decrease bacterial load and control wound exudate, leading to improved wound healing. Although there are many wound vacs currently on the market, improved devices would control fluid loss and diminish bleeding.
It is difficult to train trauma surgeons and medical care staff in trauma care because it is nearly impossible to simulate the stress and environmental challenges presented in real-life emergency situations. Organ simulation is a valuable tool in training and education that can provide a low-risk, directed learning environment without the distractions inherent to an emergency situation. Simulation is now used for teaching aspects of airway management, chest trauma, abdominal ultrasound, torso surgery and lower extremity orthopedics. However, the simulators are expensive, and there are few specifically designed for trauma. Current challenges in organ simulation technology include realism, authenticity and acceptance by teaching faculty.6
Sensors for medical applications have been in development since the 1970s. Biosensors can be placed inside the patient, for instance in a vein, to provide continuous monitoring of variables such as chemical changes in the blood indicating a patient is in shock. While there are some commonly used biosensors, such as the pulse oximeter, further development is needed. Advanced biosensors could provide more accurate and stable measurements of physiologic or subphysiologic status, be smaller and weigh less, have easily interpreted outputs and/or displays, and be minimally invasive. Technology and programming support for translation and interpretation of information from biosensors is also required. The medical potential of these devices is to help early diagnosis and treatment strategies, and to identify patients at risk for deterioration or secondary problems.
The development of imaging technology and software is important for accurate diagnosis of trauma and assessment of both treatment strategies and healing. Trauma facilities routinely use ultrasound and x-ray imaging, and increasingly use computed tomography (CT) scanning (generation of a 3-dimensional image from a series of 2-dimensional x-rays), full body scanning technology and magnetic resonance imaging (MRI) as these technologies become more portable and cost effective. Advances in this area should include development of appropriately sized, cost-effective, advanced systems that can provide 3- and 4-dimensional images, in real time in the ER.
Development of these technologies will provide reliable continuity of care, support clinical decision making, improve early diagnosis of unrecognized injuries and prevent currently unavoidable treatment delays and movement of critically-ill patients, ultimately saving lives.
1McKinley, B.A., Moore, F.A., Sailors, R.M., Cocanour, C.S., Marquez, A., Wright, R.K., Tonnesen, A.S., Wallace, C.J., Morris, A.H., and East, T.D. (2001) Computerized decision support for mechanical ventilation of trauma induced ARDS: results of a randomized clinical trial. J Trauma 50, 415-424; discussion 425
2Santora, R.J., McKinley, B.A., and Moore, F.A. (2008) Computerized clinical decision support for traumatic shock resuscitation. Curr Opin Crit Care 14, 679-684
3Thursky, K.A., Buising, K.L., Bak, N., Macgregor, L., Street, A.C., Macintyre, C.R., Presneill, J.J., Cade, J.F., and Brown, G.V. (2006) Reduction of broad-spectrum antibiotic use with computerized decision support in an intensive care unit. Int J Qual Health Care 18, 224-231
4Shebl, N.A., Franklin, B.D., and Barber, N. (2007) Clinical decision support systems and antibiotic use. Pharm World Sci 29, 342-349
5Wysocki, M., and Brunner, J.X. (2007) Closed-loop ventilation: an emerging standard of care? Crit Care Clin 23, 223-240, ix
6Cherry, R.A., and Ali, J. (2008) Current concepts in simulation-based trauma education. J Trauma 65, 1186-1193