Using Wearable Augmented Reality as a Clinical-Decision Support Tool

for First Responders

LTC Kenneth L. Wilson, MD Assistant Professor

Division of Trauma and Surgical Critical Care Department of Surgery

Atlanta, Georgia

OEF/OIF Mechanisms of Injury

Peake, James B., NEJM, Jan 2005

344th US Military Major Service Admission Break out

GSW IED Indirect Fire Fall Others

Represented as percentages 2010-2011

IEDs

Oil Can Tank Buster

IEDs

Preventable Forms of Combat Deaths

60% Hemorrhage from extremity wounds 33% Tension pneumothorax 6% Airway obstruction

Explosive Delivery

Vehicle-borne improvised explosive device (VBIED)

Improvised explosive device (IED)

Levels of Care Front line

Forward Surgical Team (FST)

L-1

L-2

L-3

L-4 L-5

Combat Support Hospital (CSH)

Field Hospital = Landstuhl

US Medical Center

BAS

Medics

“Oh Lord, if I am called to the battlefield, give me the courage to conserve our fighting forces by providing medical care to all who are in need…” Combat Medic Prayer

Tactical Combat Casualty Care

• Care under fire • Casualty care rendered while under effective

hostile fire • Attention to suppression of hostile fire • Stop any life threatening injuries with a

tourniquet • Tactical Field Care

• ABCs • Analgesia/Antibiotics • Prepare for Evac to higher level of care

Immediate

• Life-threatening wounds • Require quick intervention • “2 Minutes” • High likelihood of initial survival with

minimal resource use • Injuries

– Airway, tension PTX, hemorrhage – Limb ischemia, incomplete amputations,

circumferential burns

Simulation Training

Care under fire – Stop life-threatening

bleeding – Move out of direct

enemy fire

Tactical Field Care CASEVAC

– Package the patient for transport

Combat Medic Training

• Ability to sustain trauma skills is problematic

• 50% of a medics’ core skills can be lost within the first six months and continuing medical education does little to slow the process

• Army combat medic may not work everyday in their occupational specialty

Semi-Annual Combat Medic Skills-Validation Test (SACMS-VT)

• SACMS-VT is used by the Army to determine combat medic competency

• Consists of 4 different scenarios • To pass the combat medic must achieve

at least a score of 70% • Cannot miss any performance steps that

are seen as critical

91W Participants in the SACMS-VT

• Subjects were males (n = 53) in the rank of E4 (specialist) or below

• Average age was 22 years • 4 had an associates degree and only 1

with a master’s degree • 94% had never been deployed

Military Medicine, Vol. 172, August 2007

Evaluation of Combat Medic Skills Validation Test

SACMS-VT Test Score

Challenges

• Training highly variable • Practice opportunities are limited • Many medics are deployed who have

had little to no training in a far forward setting

• Critical skills are highly perishable

Augmented Reality

Augmented reality (AR) is a term for a live direct or indirect view of a physical real-world environment whose elements are augmented by virtual computer-generated imagery.

It superimposes graphics, audio and other sense enhancements from computer screens onto real time environments.

Wearable Augmented Reality

• Wearable computer • Voice-activated • Superimposed graphics not altered by

movement • Head mounted vision allowing the

warfighter to treat causalities and maintain situational awareness

Subjects

• 1st and 2nd year medical school students to perform a needle decompression ( 34 participants) – Highly motivated – Negligible clinical experience

• Needle decompression procedure using cadavers at Morehouse School of Medicine

• All participated in a PowerPoint presentation to learn about how to perform a needle decompression procedure and to have an overview of a tension pneumothorax.

• None of the students had experience with needle decompression procedures.

Pleural Cavity Anatomy 101

Image: created by M. Jones. Biology 2404 Digestive Systems. http://science.tjc.edu/Course/BIOLOGY/2404/2404%20Digestive.htm

Surface Anatomy

Needle Decompression

Image: www.medical-supplies-equipment-company.com/fi

Tension Pneumothorax

• Injury to visceral pleura • One way flap valve • Allows air into pleural space but prevents

exit

Image: www.healthcentral.com/.../1/19589_6077_5.jpg

Tension Pneumothorax: History, Diagnosis and Treatment

Vignette: A 19 year-old Army Ranger is violently thrown against a humvee after an IED attack. He has a distended abdomen with tenderness. His airway is intact, but he has severe right-sided chest pain and is unable to catch his breath. He is requiring emergent intervention for a tension pneumothorax.

Juxtopia® CAARS OS

Step 3: Insert needle at a 90

degree angle as illustrated.

Juxtopia® CAARS: Needle Decompression Procedure: Step #3

1

2

3

4

Mean Scores

Evacuation

35

Continuous En Route Care

BAS Level 1

Point of Injury to Definitive Care

Surgical Capability

CASEVAC 1 Hour

Intratheater EVAC 24 Hours

Intertheater EVAC 48-72 Hours Forward Surgical

Teams Level 2

CSH, EMF, Theater Hospital Level 3

CONUS/OCONUS MTF Level 4/5

Wearable Augmented Reality for First Response

• Voice –request to visualize or hear status information from a variety of sources

• View dynamically changing course of action logistics

• Voice request assistance on complex clinical procedures

• Voice request video conferences

Summary

• Advanced situational interface • Facilitate better decision making

maneuvers • Communicate with experts • Appropriate triage to higher and

appropriate medical facilities