ARTICLE IN BRIEF
✓ Efforts are under way to better use telemedicine and other technologies to improve neurologic care for injured soldiers in battle.
For battlefield brain injuries, having an expert neurologist or neurosurgeon available in the first hours after trauma can mean the difference between life and death or severe disability.
The US Army is developing “teleneurology” programs and devices that are likely to shape the emergency response to battlefield head injuries in the years to come. Some of these are already in place or are just getting under way, while others are on the drawing board or being studied as long-range projects.
Although real-time neurological evaluations are still limited to e-mail consultation, the military is pressing ahead to bring neurological experts into the field via Internet and wireless connections, even to far-forward operations, according to Kenneth C. Curley, MD, chief scientist at the Telemedicine and Advanced Technology Research Center (TATRC).
Neurological telemedicine research for the US Army is spearheaded by TATRC, part of the Army Medical Research and Materiel Command (USAMRMC), in Fort Detrick, MD, where more than 40 projects related to neurology and neuroscience are currently being developed, spanning basic science to clinical applications projects, he explained.
“TATRC is engaged in neuroscience-related research that covers the spectrum from functional imaging to neuropsychological tests to diagnose brain injury to the study of blood markers of brain injury,” Dr. Curley told Neurology Today in a telephone interview.
Before his position at TATRC, Dr. Curley served in the Department of Neuropharmacology and Molecular Neurobiology at Walter Reed Army Institute of Research in Washington, DC.
“Walter Reed already has had a teleneurosurgery program serving other military facilities in the US and abroad since about 2003. It is the only real-time neurosurgical telemedicine program,” Dr. Curley said. “The system was put in place three years ago in Afghanistan because at that point there were no Army neurosurgeons in the country, yet a need for their expertise developed. The challenge was that a full-time neurosurgeon wasn't necessary or practical, so the existing system was put in place.”
Today, Walter Reed has one full-time staff neurosurgeon devoted to this program. He is in contact with in-theatre (battleground) and stateside neurosurgeons and neurologists via videoconferencing.
“They use a video camera to send images of the injury in a special examining room — essentially a Webcam — and Dr. Sam Lyness, the neurosurgeon at Walter Reed, reviews the images and helps guide the distant providers through different procedures or makes clinical recommendations,” said Dr. Curley.
PORTABLE DIAGNOSTIC AND IMAGING EQUIPMENT
Portable diagnostic and imaging equipment designed to withstand the rigors of combat are also being developed for collecting and transmitting data so that it can be reviewed by other experts, far from the fighting.
“Our goal is to be able to transmit information from a medic attending the wounded warrior back to an expert neurologist in a combat support hospital in Iraq or Afghanistan, at Landstuhl in Germany, or even here in the US,” he explained. Ideally, he said, TATRC would like to have a system linking neurosurgeons and neurologist experts at Walter Reed and other facilities for real-time problem-solving in combat areas.
“They could basically mentor the trauma surgeons in real-time, even those who are situated far-forward,” Dr. Curley noted. “Real-time telementoring is coming. Right now we're working on individual components of a system, then we'll pull all the parts together.”
He added that some of these components should be available “sooner, not later.”
As an Army facility, TATRC is somewhat unusual in that it fosters a mix of partnerships between military, federal, academic, and commercial research groups working to develop promising technologies for military telemedical applications.
“We're sort of like the Army's medical skunkworks,” said Dr. Curley, where researchers from different fields brainstorm and collaborate on projects that might seem implausible to outsiders at first.
Several traumatic brain injury (TBI) initiatives are in various stages of development and testing. For example, researchers are working to design a non-invasive method for measuring intracranial pressure on the battlefield, a project currently in early development. Another project aims to identify clinically useful biomarkers of TBI that can be followed from the time of injury through recovery.
“We're using ophthalmodynanometry and other technologies to measure blood vessel pressure in the back of the eye as a signature of possible brain injury,” he said. “Combined with other technology, the system may eventually allow medics to make these measurements without having to insert a catheter through the skull.”
Other researchers are working to develop a compact, portable ultrasound device that can be carried into combat areas to assess brain trauma. “Any device that can provide information on the cerebral status of injured troops non-invasively is being considered,” Dr. Curley said.
One major hurdle with portable imaging devices is that they require careful calibration, which can be difficult when they are moved about, he noted.
Another project is a direct result of concerns over milder brain injuries caused by repeated lower-level exposure to blast pressure waves, injuries that may be overlooked on the field.
TATRC and other Department of Defense scientists are exploring commercially available sensors that might be incorporated or attached to a helmet. A prototype helmet is currently being evaluated to measure and record exposure to concussion. The data might one day facilitate development of a brain injury assessment algorithm linking repeated lower-level exposure to cognitive deficits over time, said Dr. Curley.
“The Army is also in the process of exploring private-sector devices that measure exposure to blast pressure, units that can be attached or incorporated into helmets and body armor. Several sensors are available commercially and are being reviewed as possible candidates,” he noted.
Data on long-term mild brain damage are limited, Dr. Curley pointed out. Most medical literature about the cumulative neurological effects of repeated low-level head trauma comes from studies on professional boxers and football players. In that vein, another project to develop a comprehensive military neurotrauma database is in early development.
The first application of telemedicine in Iraq and Afghanistan was dermatology, which has been in place since 2004 and remains the most widely used in-theatre, followed by teleradiology.
More than 15 digital imaging and communications servers in medicine around the world can convert files from any image-capturing device — computer radiography (CR), CT, MR, or film X-rays — and transmit them for review by experts.
In Iraq, teleradiology is primarily used to send CR and CT scans from more than 200 units located throughout the region. The Army's main hospitals in Baghdad or Balad can send data to the Landstuhl Regional Medical Center in Germany for review so that when wounded GIs are evacuated, their CR and CT scans precede them. This not only enables better continuity of care but also provides early images and data of a wound to compare to new scans once a patient arrives, said Col. Ron Poropatich, MD, deputy director of TATRC.
The system can also distribute images within individual hospitals and over local area networks at field support hospitals, emergency rooms, and operating rooms, according to Dr. Poropatich.
He told Neurology Today in a telephone interview that the military has made considerable progress in three years to bring modern telemedicine to the field. “We've got 13 specialties now involved in telemedicine in Iraq and Afghanistan, but about two-thirds of all telemed consults are for dermatological problem, but there is some neurology. The doctors send e-mails with jpeg attachments. Basically there are two different flavors of teleradiology, a robust program in the US and a far more limited program in-theatre.”
He noted however that Navy and Air Force physicians have begun working with the Army on teleradiology, as are some civilian contractors.
“It's getting better every year. During the maneuver phase, when troops had to move around a lot, it was very difficult. But now we're all hunkered down.”
He noted that CT scans are available at three or four sites in-theatre, as well as MRIs and ultrasound capability to a lesser degree, depending on the combat support hospital. “A lot of times telemedicine allows us to avoid having to evacuate the wounded for evaluation — we can do it right there.”
At this time, however, the only far-forward tools being used are laptop computers and digital cameras, he noted.
By far, the single biggest limitation to battleground telemedicine today is the lack of available bandwidth for transmitting data and images, said Drs. Curley and Poropatich.
The military has only so much bandwidth to allocate for medical usage, and because telemedicine usually involves both images and video, the amount needed can be substantial. In addition, medical support services must share available bandwidth with all of the other information needs of the military in Iraq, including supply and command requirements.
“It's all about bandwidth — that's one of the biggest issues we're facing right now,” Dr. Curley said. “We're working to find ways to both increase bandwidth and to use existing bandwidth more intelligently.”
Dr. Poropatich agreed that the lack of dedicated bandwidth is the biggest limitation to in-theatre telemedicine today. ”The higher the resolution of the image, the more bandwidth it needs,” he explained. “It should take about 15 minutes to send a CT image, but for neurosurgeons in Balad, for example, it sometimes takes as long as four hours.”
Dr. Poropatich is optimistic, however, that a change is forthcoming. “It's taking time, but we're working to get dedicated bandwidth and I think it's going to happen really soon.”