Craniotomies on five year-old kids and repairing ruptured bladders were not run-of-the-mill procedures for Lt. Col. T. Sloane Guy IV, M.D. A highly-skilled cardiothoracic surgeon, Lt. Col.Guy specializes in cracking open chests to conduct bypass surgeries, replacing cardiac valves and completing lung resections.
Although out of his comfort zone, Lt. Col. Guy successfully completed all of his procedures while deployed to Salerno, Afghanistan, as the chief of clinical services with the 249th General Hospital from 2005 to 2006.
At the time, Lt. Col. Guy would have been comforted with another specialist or two by his side. "I envisioned that when a case came in, I could place a call to an operating room [in the U.S.] with details of the case," Lt. Col. Guy said. "Then a specialist, such as a neurosurgeon or urologist, would get on the line and assist with the procedure from afar."
In August, Lt. Col. Guy's vision advanced a step further with the successful test of a new telesurgery mentor initiative led by the Telemedicine Advanced Technical Research Center (TATRC) U.S. Army Medical Research & Materiel Command (USAMRMC), headquartered at Fort Detrick, Md.
While deployed as the chief of surgery with the 47th Combat Support Hospital (CSH), Lt. Col. Guy performed a complex and rare surgical procedure. At the same time, Lt. Col. (P) William "Chance" Conner, a specialist at Brooke Army Medical Center (BAMC) in Fort Sam Houston, Tex., peered over his shoulder to view live video footage of the procedure and offered real-time guidance when requested.
The Army's medical recording system-Medical Communications for Combat Casualty Care (MC4)-enabled the live consult to take place through rugged laptops armed with new technology.
The Nuts & Bolts of the Operation
Lt. Col. Guy's original concept included a camera system configured in the operating room (OR)-one camera worn on the head of the deployed surgeon and another mounted in the overhead light fixture. This configuration would offer different views of the operative field, all connected in real-time over the Internet.
In 2007, Lt. Col. Guy, now the principal investigator and clinical champion for the project, met with Col. Ronald Poropatich, medical informatics consultant to the Army Surgeon General, and the leadership at TATRC USAMRMC for assistance. In 2008, the project received funds, setting the wheels in motion. The next step was to develop the heart of the concept-the software. The project leaned on SRI International to provide the solution, based on their expertise in telesurgical projects.
"My idea was to reach back to stateside doctors and provide the sights and sounds from the OR to receive the greatest assistance possible for difficult procedures or those outside of my specialty," Lt. Col. Guy said. While he formulated and refined his concept, all the necessary pieces did not exist.
"One component added by SRI is the ability to perform telestration on images," Col. Poropatich said. "Stateside doctors have the ability to freeze-frame live footage. They can write instructions or details on an image and send it to the deployed OR at the other end of the line. It is something similar to what John Madden made famous during football games."
The next step meant navigating theater processes and procedures before attacking the technical set-up. Information management officers helped the project gain local buy-in from leadership, securing an interim authority to test and to operate in Iraq.
MC4 support personnel shouldered the configuration and technical support for Lt. Col. Guy. After resolving firewall issues and inserting the technology into the OR in theater, MC4 provided the hardware to BAMC to link Lt. Col. Guy with providers stateside.
Way Ahead
Lt. Col. Guy's telesurgery mentor system vision took years to germinate from an idea formed in a treatment facility in Afghanistan to a working prototype tested on the battlefield in Iraq. While it originated from the need for specialized assistance, the system has the potential to help providers in various trauma settings and may prove to be a valuable educational tool.
"I believe this system could be used in any deployed setting-Iraq, Afghanistan, Kosovo or Honduras," Col. Poropatich said. "Surgeons could take advantage of the 'awake clock' and reach back to facilities that are awake and open. Calls for assistance could go into a central consult routing system and go to Tripler Army Medical Center in Hawaii, Landstuhl Regional Medical Center in Germany or the 121st CSH in Korea."
During the hurricane season in the U.S., the telesurgery mentor system could reveal its benefits should a disaster decimate an area laden with small hospitals.
"If a hurricane comes on land in a rural area, smaller civilian hospitals most likely would not have the surgical expertise to handle some of the case that would come in," Col. Poropatich said. "The local providers could still handle the workload by utilizing this system and working with specialists at other locations."
The new system could also better prepare new surgeons for the realities of theater trauma care. Surgeons graduating from military programs and preparing to deploy for the first time could watch live procedures from the battlefield.
"Stateside medical personnel just do not see the same type of cases that are handled in theater," Col. Poropatich said. "This can only make them more insightful and prepared to treat the polytraumatic cases that come in every day."
For more information about the U.S. military's tactical electronic medical recording efforts, visit <a href="http://www.mc4.army.mil">www.mc4.army.mil</a>.
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