First Young Neurosurgeons Forum quarterly online symposium29th January , 2011

Muhammad Raji Mahmud, MD, FWACSChair, Young Neurosurgeons Forum of the World Federation of Neurosurgical Societies (WFNS)

Neurosurgical Service for Disasters: Telemedicine/Telesurgery & the Mobile

Emergency/Neurosurgical Unit (MEU/MNU) Concept

Neurosurgical Service for Disasters: Telemedicine/Telesurgery & the Mobile

Emergency/Neurosurgical Unit (MEU/MNU) Concept

• Prof. Dr. Leónidas Quintana, WFNS 2nd Vice President

• Prof. Dr. Russell Andrews, WFNS Education & Training Committee

• Prof. Dr. Yoko Kato, WFNS Education & Training Committee Chair

World Federation of Neurosurgical Societies

Mission Statement• To facilitate the personal association of neurological surgeons

throughout the world.

• To aid in the exchange and dissemination of knowledge and ideas in the field of neurological surgery.

• To encourage research in neurological surgery and allied sciences.

• To address issues of neurosurgical demography.

• To address issues of Public Health.

• To implement, improve and promote the standards of neurosurgical care and training worldwide.

World Federation of Neurosurgical Societies

Main Priorities• Training of neurosurgeons from developing areas, both with Educational Courses in

different countries and with grants to enable them to train at selected neurosurgical centers in different parts of the world.

• Donation of instruments and equipment and the necessary technical advice to implement them in the neurosurgical units in economically challenged regions.

• Priority to public health issues: prevention & treatment of head injuries & spinal trauma, vascular pathology with special attention to the elderly, treatment of degenerative diseases, prevention of developmental & neonatal malformations.

• Research in neurosurgical subspecialties, such as brain tumours, vascular pathologies and degenerative diseases.

• The assessment and introduction of new technologies.

• A forum for young neurosurgeons.

• Maintenance of a Website which addresses neurosurgical interests of physicians, corporations, and the general public.

SOME BACKGROUND OF THIS CONFERENCE…..

Personal report against AC WFNS – Nyon, Switzerland, February 27th , 2010 - Humanitarian Assistance to Undeveloped Countries

A serious matter is Haiti , this country isn´t federated to FLANC, this society is affiliated to the Caribbean Society of Neurosurgery,but in this country, the social- economical situation is extremely bad.

My proposal is we could form a team, of humanitarian assistance , included our specialty of course,and the sequence to act , could be:

1- First to contact some representative of this country ( administrative,Health Ministry,or Government), to offer and give our assistance as a team. 2-In the near future, when we could have more information of the real health situation related with our specialty,3- Contact the authorities, and we could propose to travel with instruments promoted by the WFNS,and give our assistance. 4-If it´s needed, the team could stay some time, eg: 1 or 2 months, operate some urgent cases, and give, as a donation, the instruments to some public hospital,and designate some colleague(s) that be our representative, and be responsible of the instruments. Consider the Mobile Neurosurgical Unit (MNU). 5-Later, we could monitor the neurosurgical actions and activities at this country.

Chile EQ 8.8 Richter

The same day of my report, this was happening in my country……

Source: http://neic.cr.usgs.gov/neis/eqlists/eqstats.html

What´s happening in some parts of our planet ???

2010 -Two big earthquakes happened in AmericaHaiti- A country with a very weak social economical situation, and health system not well organized. EQ Magnitude 7.0 - HAITI REGION 2010 January 12 21:53:10 UTC - 04:53:10 PM at epicenter

According to official estimates, 222,570 people killed, 300,000 injured, 1.3 million displaced, 97,294 houses destroyed and 188,383 damaged in the Port-au-Prince area and in much of southern Haiti.

This includes at least 4 people killed by a local tsunami in the Petit Paradis area near Leogane.

2010 -Two big earthquakes in America happenedChile- A country with a middle high social economical situation(WDB), and health system well organized. EQ Magnitude 8.8 - OFFSHORE MAULE, CHILE 2010 February 27 06:34:14 UTC- 03:34:14 AM at epicenter.

At least 521 people killed, 56 missing, about 12,000 injured, 800,000 displaced and at least 370,000 houses, 4,013 schools, 79 hospitals and 4,200 boats damaged or destroyed by the earthquake and tsunami in the Valparaiso-Concepcion-Temuco area.

At least 1.8 million people affected in Araucania, Bio-Bio, Maule, O'Higgins, Region Metropolitana and Valparaiso.

The total economic loss in Chile was estimated at 30 billion US dollars.

Electricity, telecommunications and water supplies were disrupted and the airports at Concepcion and Santiago had minor damage.

The tsunami damaged or destroyed many buildings and roads at Concepcion, Constitucion, Dichato and Pichilemu

TELEMEDICINE

TELECOMMUNICATIONSARE VERY IMPORTANTIn emergency situations!!!!and for M.D. this means….

The World Health Organization defined Telemedicine (TM) as the use in the clinic of the medical knowledge, through communication networks when the distance is a determining factor.

This definition makes clear the need for the use of advanced technological support for the practice of medicine has no distance limitations for the patient.

The technology infrastructure allows to perform the exchange of information between various participants involved in an act of TM and its main objective is to provide multimedia network services (transfer of audio, video, images, data and text) that enable healthcare

Telemedicine can be broken into three main categories:

1- Store-and-forward

2-Remote monitoring

3-Interactive services

Store-and-forward Telemedicine

It involves acquiring medical data (like medical images, biosignals etc) and then transmitting this data to a doctor or medical specialist at a convenient time for assessment offline.It does not require the presence of both parties at the same time. Dermatology (cf: teledermatology),radiology, and pathology are common specialties that are conducive to asynchronous telemedicine. A properly structured Medical Record preferably in electronic form should be a component of this transfer.

Remote Monitoring

Also known as self-monitoring or testing, enables medical professionals to monitor a patient remotely using various technological devices. This method is primarily used for managing chronic diseases or specific conditions, such as heart disease, diabetes mellitus, or asthma. These services can provide comparable health outcomes to traditional in-person patient encounters, supply greater satisfaction to patients, and may be cost-effective.

Interactive Telemedicine Services

Provide real-time interactions between patient and provider, to include phone conversations, online communication and home visits. Many activities such as history review,physical examination, psychiatric evaluations and ophthalmology assessments can be conductedcomparably to those done in traditional face-to-face visits. In addition, “clinician-interactive” telemedicine services may be less costly than in-person clinical visits.

Emergencies in Disasters

What is the real situation in Disasters?

Isolation Communications failPrompt action in the devastated places difficultHealth cares difficult to performTraumatic cases increaseAlso , another pathologies

How we could improve the healthcares during a DISASTER ???

Mainly treating some urgent problems as:1- Quick communication with the area or region of theDisaster ( Diagnosis of the situation).(Satellital, IP telephony)(Physically by helicopters)2- Quick access with medical cares, essencialy, for urgentCases( Trauma). Mobile Emergency Unit (MEU)3- Treat and compensation of clinical cases in the areaaffected.(*)4- Maintain the communication with the general medicaldoctor ( surgeon), to give more informations and indications from the base hospital.(Telepresence)5- Triage of the affected cases to the base hospital.

(*)SAP <90mmHgHBO2sat <90%PaO2 < 60 mm Hg

My visit to…………………..

Cisco HealthPresence Sites

MEU

Mobile Emergency UnitMobile Surgical UnitMobile Neurosurgical Unit

Sensors devices

X Ray-CT Scan

Operating room

Laboratory

Robotic op. –Robotized Camera assistance

Telepresence

The countries of the world under developing social-economical status must continue to seek ways to meet the basic needs of their populations, through nutrition and sanitation programs, poverty reduction, universal quality education, and economic modernization. At the same time, they must do their part to address global challenges.In such a context, leveraging the opportunities presented bytechnological change in a globalized economy becomes anecessity for any emerging economy.

An important message ……

Neurosurgical Service for Disasters: Telemedicine/Telesurgery & the Mobile

Emergency/Neurosurgical Unit (MEU/MNU) Concept

(Second Part)

Strategies for developing the Action of the MEU/MNU

Mobile Emergency Unit (MEU)

• Mobilization to disaster site w/in 24 hours• Transport by a few transport helicopters

– Chinook Helicopter payload ~ 12,000 kg

• Located w/in ~ 1,000 km of disaster site– Chinook Helicopter range ~ 1,100 km

• Continuously operating MEU will be ready for deployment at any time

• Ideally 4 sites: Latin America, Africa, Central Asia, Southeast Asia

Mobile Emergency/Neurosurgical Unit (MEU/MNU)

• Portable basic neurosurgical operating room

• Portable CT, microscope, OR table, lighting

• Generators, water supply, sterilization

• Staff (neurosurgeons/trauma surgeons/ortho-pedic surgeons, anesthesiologists, nursing, maintenance/support)

WFNS MEU/MNUSite Selection

• Competitive application - similar to site selection for educational courses & meetings

• In conjunction with local neurosurgical unit• Located where the ongoing service need is great

(underserved region)• Located where tertiary backup available (e.g. by air

transport)• Two years in a given location/country

WFNS MEU/MNUSite Staffing

• Combination of host country and ‘developed country’ senior neurosurgeons

• Combination of host country and ‘developed country’ in-training neurosurgeons

• Combination of host country and ‘developed country’ support staff (e.g. nursing)

• One month to one year term for all staff• Maintenance and accommodation provided by host country

WFNS MEU/MNUSite Educational Benefits

• Curriculum to be developed and certified by WFNS – standardized training

• Residency training credit for both host country and ‘developed country’ residents

• Benefit to host country residents: training w/ resident & faculty from ‘developed country’

• Benefit to visiting residents: intense clinical experience; appreciation of neurosurgery in ‘under-developed country’

WFNS MEU/MNUAdditional Site Benefits

• A relatively ‘apolitical’ means by which the WFNS can foster universal neurosurgical standards for training and certification

• The honor of selection as an MEU/MNU site should boost the host country neurosurgical community’s stature with its government, etc

• Junior host country neurosurgeons will gain appreciation & respect for the WFNS mission

• Neurosurgical research platform

WFNS MEU/MNUAdditional Organizations

• Medical/Surgical Societies:

• Trauma Surgeons, Orthopedic Surgeons

• Anesthesiologists

• Surgical Nurses

• Rehabilitation• International Education Societies:

• FIENS – Found. Intl. Education in Neurol. Surg.• Medical Disaster Organizations:

• Doctors without Borders

• Civilian & Military Emergency Response • Junior host country neurosurgeons will gain appreciation & respect for the WFNS mission

THE HIGHEST TECHNOLOGY

USNS Comfort (off of Port-au-Prince 1994);Ship Operating Room;

Mobile CT Scanner

Haiti, 1/2010 – US Military Medical Transport Helicopter & Truck

WFNS MEU/MNUThe US Military Combat Support Hospital

• A Combat Support Hospital (CSH ) is a mobile hospital delivered in standard military-owned Demountable Containers (MILVAN) cargo containers and assembled by the staff into a tent hospital to treat wounded soldiers. The hospital is typically between 16 and 256 operational hospital beds.

• The great operational advantage of the DEPMEDS facility is the use of single or double expanding milvans to create hard sided, air conditioned, sterile operating rooms and intensive care facilities, which can produce surgical outcomes similar to that seen in fixed facility hospitals, and do so in an austere environment. Wikipedia

World Federation of Neurosurgical SocietiesNeurosurgical Service for Disasters

MNU Concept Benefits

• Extended day-to-day association between neurosurgeons from developed and developing countries - camaraderie

• Improvement and standardization of neurosurgical education and training worldwide

• Research platform for neurotrauma as well as clinical interventions utilizing basic neurosurgical techniques

• Improve surgical care for disasters in particular and neurotrauma in general (major Public Health issues)

• Improve neurosurgical demography worldwide