Complete and Resilient Documentation for Operational Medical Environments Leveraging Mobile Hands-free Technology in a Systems Approach: Experimental Study.

BACKGROUND: Prehospitalization documentation is a challenging task and prone to loss of information, as paramedics operate under disruptive environments requiring their constant attention to the patients. OBJECTIVE: The aim of this study is to develop a mobile platform for hands-free prehospitalization documentation to assist first responders in operational medical environments by aggregating all existing solutions for noise resiliency and domain adaptation. METHODS: The platform was built to extract meaningful medical information from the real-time audio streaming at the point of injury and transmit complete documentation to a field hospital prior to patient arrival. To this end, the state-of-the-art automatic speech recognition (ASR) solutions with the following modular improvements were thoroughly explored: noise-resilient ASR, multi-style training, customized lexicon, and speech enhancement. The development of the platform was strictly guided by qualitative research and simulation-based evaluation to address the relevant challenges through progressive improvements at every process step of the end-to-end solution. The primary performance metrics included medical word error rate (WER) in machine-transcribed text output and an F1 score calculated by comparing the autogenerated documentation to manual documentation by physicians. RESULTS: The total number of 15,139 individual words necessary for completing the documentation were identified from all conversations that occurred during the physician-supervised simulation drills. The baseline model presented a suboptimal performance with a WER of 69.85% and an F1 score of 0.611. The noise-resilient ASR, multi-style training, and customized lexicon improved the overall performance; the finalized platform achieved a medical WER of 33.3% and an F1 score of 0.81 when compared to manual documentation. The speech enhancement degraded performance with medical WER increased from 33.3% to 46.33% and the corresponding F1 score decreased from 0.81 to 0.78. All changes in performance were statistically significant (P<.001). CONCLUSIONS: This study presented a fully functional mobile platform for hands-free prehospitalization documentation in operational medical environments and lessons learned from its implementation.

Effects of Percutaneous LVAD Support on Right Ventricular Load and Adaptation.

Both operative and hemodynamic mechanisms have been implicated in right heart failure (RHF) following surgical left ventricular assist device (LVAD) implantation. We investigated the effects of percutaneous LVAD (pLVAD; Impella®, Abiomed) support on right ventricular (RV) load and adaptation. We reviewed all patients receiving a pLVAD for cardiogenic shock at our institution between July 2014 and April 2017, including only those with pre- and post-pLVAD invasive hemodynamic measurements. Hemodynamic data was recorded immediately prior to pLVAD implantation and up to 96 h post-implantation. Twenty-five patients were included. Cardiac output increased progressively during pLVAD support. PAWP improved early post-pLVAD but did not further improve during continued support. Markers of RV adaptation (right ventricular stroke work index, right atrial pressure (RAP), and RAP to pulmonary artery wedge pressure ratio (RAP:PAWP)) were unchanged acutely implant but progressively improved during continued pLVAD support. Total RV load (pulmonary effective arterial elastance; EA) and resistive RV load (pulmonary vascular resistance; PVR) both declined progressively. The relationship between RV load and RV adaptation (EA/RAP and EA/RAP:PAWP) was constant throughout. Median vasoactive-inotrope score declined after pLVAD placement and continued to decline throughout support. Percutaneous LVAD support in patients with cardiogenic shock did not acutely worsen RV adaptation, in contrast to previously described hemodynamic effects of surgically implanted durable LVADs. Further, RV load progressively declined during support, and the noted RV adaptation improvement was load-dependent as depicted by constant EA/RA and EA/RAP:PAWP relationships. These findings further implicate the operative changes associated with surgical LVAD implantation in early RHF following durable LVAD.

Hybrid options for treating cardiac disease.

The options for treating heart disease have greatly expanded during the course of the last 2 1/2 decades with the advent of hybrid technology. The hybrid option for treating cardiac disease implies using the technology of both interventional cardiology and cardiac surgery to treat cardiac disease. This rapidly developing technology has given rise to new and creative techniques to treat cardiac disease involving coronary artery disease, coronary artery disease and cardiac valve disease, and atrial fibrillation. It has also led to the establishment of new procedural suites called hybrid operating rooms that facilitate the integration of technologies of interventional cardiology catheterization laboratories with those of cardiac surgery operating rooms. The development of hybrid options for treating cardiac disease has also greatly augmented teamwork and collaboration between interventional cardiologists and cardiac surgeons.

Delayed primary closure of the burn wounds.

'Early closure' of burn wounds by excising the burned tissues and promptly covering it with skin-grafts or its substitutes within first 'five' post-burns day is a standard technique of burn-wound-management in the burn-units of the "developed" world. But lack of education in general, and health-education in particular amongst the common people in the "developing" countries could hinder acceptance of this procedure. Lack of well-trained and motivated burns-surgeons could worsen the situation. The Sultanate of Oman is one of the developing gulf-countries in the middle-east, where at Khoula hospital, the National Burns-Center in the capital city of Muscat, 'early' surgery was introduced in November 1997 to soon become a routine protocol for burn-wound-management. But delay in getting consent for surgery from unwilling patients or in transferring them from the peripheral hospitals were often the reasons for delaying the burn-wound excision and closure 'beyond 6 days to 11th or 12th' day post-burn. Hence, instead of the term "early", the authors prefer to call it "delayed primary" burn-wound closure because, it still offers "primary intention healing" of the burn-wounds. The aim of this article is to analyze retrospectively the results of the "delayed primary" closure of the burn-wounds done in the Khoula Hospital Burns-Unit of the Sultanate of Oman. During a period of 50 months from November 1997 to December 2001, carefully selected 143 patients out of a total of 592 admissions in burns-unit were subjected to burn-wound excision and auto-skin-grafting (STSG), of whom about 87% patients had "delayed primary" and 13% had "early" surgery. There was no mortality or post-operative morbidity in these operated patients. However, due to the non-availability of skin substitutes the excision and auto-grafting could not be done in extensive burns with inadequate skin-donor-area. The maximum percentage of burns treated by delayed primary surgery (DPS) was 50% in children and 55% in adults. Follow-up results were good functionally as well as cosmetically. The authors conclude that "delayed primary" is the second best alternative to the "early" burn-wound excision and closure with similar advantages of reducing risk of septicemia, mortality, and morbidity, hospital stay and cost of treatment. It should be preferred over "secondary" skin-grafting of granulating wounds. Thus, in the developing countries, the indications of delayed primary burn surgery could be (1) patients unstable or unfit for surgery during the first post-burn week; (2) delay in transferring in the patients; (3) delay in getting patient's consent for surgery; (4) very major burns without availability of skin substitutes; and (5) lack of operating time in a busy burns-unit. The contraindications for delayed primary surgery are any sign of invasive sepsis or organ failure.