SPECIAL COMMENTARY
2010 Trauma Association of Canada Presidential Address: Why the
Trauma Association of Canada Should Care About Space Medicine
Andrew W. Kirkpatrick, MD, MHSc, FRCSC, FACS
Abstract: The Trauma Association of Canada is now 27 years old, having
been officially founded in 1983, at the meetings of the Royal College as a
maturation of the trauma committee of the Canadian Association of General
Surgeons. The first page of the official minutes also stressed the need to
welcome other disciplines into the fold. Personally, it has taken me years of
involvement, as well as the Presidency, to truly appreciate the depth of our
Founding Members commitment. These individuals set lofty mission goals
for the organization, namely: to strive to improve the quality of care provided
to the injured patient, including prehospital management and transport, acute
care hospitalization, and reintegration into society; to support, conduct, and
apply basic science and clinical and outcome research related to trauma; to
encourage effective and efficient use of healthcare resources in the delivery
of trauma care; and to foster professional and community education in the
field of injury prevention and in the care of the injured patient. As daunting
as these responsibilities are, I am suggesting one more: to overcome the great
penalty of geography that challenges our nation and penalizes many of our
citizens by aspiring to optimize these four goals, for all Canadians, irrespective of where they live— our potential fifth mission. Furthermore, I believe
that lessons from space medicine may offer some strategies to accomplish
this goal.
Submitted for publication June 8, 2010.
Accepted for publication June 9, 2010.
Copyright © 2010 by Lippincott Williams & Wilkins
From the Departments of Surgery, Critical Care Medicine, and Regional Trauma
Services and the University of Calgary, Foothills Medical Centre, Calgary,
Alberta, Canada.
Presented at the Annual Scientific Meeting of the Trauma Association of Canada,
May 6 –7, 2010, Halifax, Nova Scotia, Canada.
Address for reprints: Andrew W. Kirkpatrick, Regional Trauma Services, Foothills Medical Centre, 1403, 29 Street NW, Calgary, Alberta, Canada T2N
2T9; email: [email protected].
DOI: 10.1097/TA.0b013e3181ec2b11
Key Words: Surgical procedures, Weightlessness, Critical care, Ultrasound,
Telemedicine.
(J Trauma. 2010;69: 1313–1322)
T
he Trauma Association of Canada (TAC) is now 27 years
old, having been officially founded in 1983, at the meetings of the Royal College of Physicians and Surgeons of
Canada as a maturation of the trauma committee of the
Canadian Association of General Surgeons. The first page of
the official minutes also stressed the need to welcome other
disciplines into the fold. Personally, it has taken me years of
involvement, as well as the Presidency, to truly appreciate the
depth of our Founding Members commitment. These individuals set lofty mission goals for the organization, namely: to
strive to improve the quality of care provided to the injured
patient, including prehospital management and transport,
acute care hospitalization, and reintegration into society; to
support, conduct, and apply basic science and clinical and
outcome research related to trauma; to encourage effective
and efficient use of healthcare resources in the delivery of
trauma care; and to foster professional and community education in the field of injury prevention and in the care of the
injured patient.1 As daunting as these responsibilities are, I
am suggesting one more; to overcome the great penalty of
geography that challenges our nation and penalizes many of
our citizens by aspiring to optimize these four goals, for all
Canadians, irrespective of where they live— our potential
fifth mission. Furthermore, I believe that lessons from space
medicine may offer some strategies to accomplish this goal.
The Journal of TRAUMA® Injury, Infection, and Critical Care • Volume 69, Number 6, December 2010
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Kirkpatrick
The Journal of TRAUMA® Injury, Infection, and Critical Care • Volume 69, Number 6, December 2010
Trauma Care in Arctic Canada
Aboriginal (First Nations) people in Canada suffer
disproportionate rates of traumatic injury and critical illness,
reported as 6.5 times higher when compared with the Canadian average (and being even worse in some jurisdictions).2– 4
The Inuit, typically inhabiting the most remote areas of
Canada, have the lowest life expectancy among Canada’s
three aboriginal groups and have a 12-year to 15-year shorter
lifespan than most Canadian, and the further North they live,
the shorter their life expectancy.5,6 The potential reasons for
this are complex, involving an interplay of social, economic,
geographic, and logistical factors. The Canadian Broadcasting Corporation recently reported that one in five First Nations adults do not see a doctor or a nurse over the course of
a year.7 Thus, some have labeled the medical care in the
North as being fourth world, a definition that captures the
state of subpopulations that are both culturally and geographically isolated.8 –10 This occurs despite the fact that on the
surface, Canadian primary healthcare services are well financed
and seem to be among the best in the world.6 However, despite
some laudable achievements in reducing infectious disease mortality, Inuit and Indian populations exhibit mortality in excess of
even many of the poorest third world countries.6
Although the determinants of the First Nations health
outcomes are extremely complex and multifactorial, geography and transportation are clearly major challenges. Independent of race or ethnicity, patients injured in rural settings are
greatly penalized, with a greater than 50% increased mortality after motor vehicle crashes,11,12 and have worse functional
outcomes.13 Deaths from all injuries for males and females
were four times higher per capita in the North West Territories and Nunavut, compared with Ontario (Fig. 1).14 Nearly
half a century of research has shown that consolidating expertise
at geographic sites known as trauma centers improves outcomes.15–18 However, Hameed et al.19 have shown that 20% of
Figure 1. Combined injury rates for both sexes all ages year
2000 in Canada.
1314
Canada lives beyond the “golden hour” from a trauma center
and that, realistically, the North, comprising 41% of our land
mass, lacks reliable access to definitive trauma care.
Corollaries Between Remote Trauma Care and
Space Medicine Trauma Challenges
Many of these challenges faced by inhabitants of the
isolated remote regions of Canada are comparable with those
faced by astronauts once they leave our planet’s surface.
There are environmental extremes, limited onsite care, restricted communications, periods of nonevacuation, and dangerous transport conditions just to name a few.20 –23 In
essence, space medicine and TAC are attempting to address
many of the same challenges. Unintentional injuries continue
to be the leading cause of death from ages 1 year to 34
years,24 the overall second leading cause of preventable lost
years of life,25 and the highest ranked condition of concern
for space medicine considering the probability of occurrence
versus the impact on the health of the crew and the mission
itself.26 Space is dangerous and involves construction. Massive objects are easily set into motion, and although they have
no weight, they still have injuring force as described by
classic physics (force equals mass multiplied by the acceleration of an object).20,22
International Space Agencies and the Global
Exploration Strategy
Space agencies around the world, especially the Canadian Space Agency (CSA), have well noted these similarities,
and a major goal of the CSA mandate is to advance medical
care for remote Canadians.27 In May 2007, 14 international
space agencies adopted a Global Exploration Strategy, signifying a new era in cooperation for exploration beyond low
earth’s orbit.27,28 In December 2008, the CSA defined specific
Canadian contributions, in which Operational Space Medicine
was identified as a particular Canadian strength,27 with five
overall objectives, of which two are particularly pertinent to both
TAC and the University of Calgary (UofC). These are diagnostic
and treatment technologies and telemedical support.
Currently, the next leaders in space exploration are yet
to be determined; will it be National Aeronautics and Space
Administration (NASA) with a redefined goal to visit Mars
by now collaborating with private industry rather than competing? President Obama just stated his belief that humans
will venture to Mars in his lifetime.29 Or will it be China, who
are ever progressing or private industry noting, for instance,
that a private company, Bigelow Aerospace, actually has two
inflatable spacecraft in orbit right now in a serious effort to
create a space hotel industry.30 However, no matter who
leads, ultimately, the human species has a destiny to explore
and colonize beyond our planet. Unfortunately, it is the
human crews that will likely be the weak link of the operation
and will require medical care.20 –22 Throughout the history of
exploration, human failures rather than transportation system
failures have been more common.21,31
© 2010 Lippincott Williams & Wilkins
The Journal of TRAUMA® Injury, Infection, and Critical Care • Volume 69, Number 6, December 2010
The Calgary Space Medicine/Surgery Research
Initiative
The trauma service in Calgary has had the privilege of
pursuing space medicine research and, more importantly,
terrestrial spin-offs for many years. As a brief overview, the
scientific study started modestly in the late twentieth century
by comprehensively reviewing the trauma in space literature
and identifying questions regarding the potential use of ultrasound in weightlessness.22,32 We thereafter partnered with
NASA in the weightless research environment of parabolic
flight to explore these questions.33–39 These studies were
productive both for space and terrestrial medicine and were
subsequently followed up in a number of directions. These
included the terrestrial spin-off and study of ultrasound techniques originally envisioned for space diagnosis,40 – 46 further
space-analog evaluations of the basic physiology and technical
requirements for space interventions,47,48 and, most importantly, terrestrial evaluation of the concepts of remote-guided
telesonography, both on the International Space Station
(ISS),49 –51 and here on the earth.52–54 In fairness to the great
vision of Scott Dulchavsky, the UofC group has had little
involvement with ultrasound onboard the ISS, hence, the
most correct dashed line reflecting the overall programmatic
structure of the UofC Trauma Services Program (Fig. 2).
Ultrasound in Weightlessness
The original studies in 2000 looked at the possibility of
using ultrasound in weightlessness because it was and is still
the only imaging modality in space; there is no X-ray,
computed tomography, or magnetic resonance imaging.35,36
Although the ground laboratory test was conducted in Vancouver, the most interesting research was done onboard the
KC-135, an aircraft capable of generating up to 30 seconds of
weightlessness by flying a ballistic or parabolic profile.38 This
project reconfirmed that almost any procedure, including
ultrasound can be performed in weightlessness as long as the
investigator is prepared and the operator, patient, and equipment are restrained.35,36,46 Most importantly, however, it dem-
Figure 2. Schematic overview of the Calgary Space Medicine Research Program.
© 2010 Lippincott Williams & Wilkins
TAC in Space Medicine
onstrated the power of ultrasound as a tool for answering clinical
questions in real time, no matter what the environment.
Terrestrial Applications
It, thus, seemed natural to assess novel and nontraditional indications for point-of-care ultrasound back in the
terrestrial setting where many more patients might potentially
benefit. Thus, many of the same investigators from the
parabolic flight studies directed their own clinical teams to
examine the “outside the box” ultrasound applications from
weightless in their terrestrial practices.42,43,55–59
The Canadian Gasless Laparoscopy in
Weightlessness Studies
In addition to ultrasound, the group also examined weightless surgical procedures back in 2000.39 Realistically, surgery in
space should be avoided if possible by preventing or prophylaxing, evacuating to earth early, or treating surgical conditions
either nonoperatively or percutaneously.60,61 Unfortunately, if
humans venture many years from earth, there are many reasons
why they will be at greater risk for emergency surgical conditions or trauma than even on earth.20,21,62,63 Physiologic concerns
regarding long-duration space flight include but are not limited
to immune dysregulation and potentially inherently more virulent microbes.22,23,64 Although providing care involves a very
small number of patients, learning the basic science, technology,
and conduct of surgery in such challenging environments has
much to teach us regarding care back on earth. Further, I believe
that just embarking on such a project attracts our most talented
colleagues and stimulates our trainees. An example of such a
project is the Gasless laparoscopy in weightless project conducted in March 2007, reflecting the cooperation of academic,
government, industry, and military collaborators.
In additional to the usual perceived benefits of minimally
invasive surgery, in space, there are additional potential benefits
in terms of keeping the cabin environment cleaner and returning
the crewmember to duty sooner.32,39,62 Contrary to original
predictions, the ability to perform laparoscopy in weightlessness
is no more difficult than in 1g.39,62 Further, the abdominal cavity
had anecdotally been reported to change from a flattened oval to
a more round shape creating, more surgical domain to operate
within. However, before simply accepting that laparoscopy is
appropriate for space, the issue of intra-abdominal hypertension
(IAH) and its attendant physiologic penalties need consideration.
There are many questions as to whether an injured astronaut
could tolerate the stresses caused by insufflating gas under
pressure required to perform standard laparoscopy.21 Clinicians in general and especially the World Society of the
Abdominal Compartment Syndrome recognize that increased
intra-abdominal pressure has adverse affects on nearly every
organ65 and go to great lengths to avoid this.66,67
We, thus, speculated that “abdominal wall lift devices”
might allow us to perform minimally invasive surgery without gas insufflation. These devices were introduced on earth
over a decade ago68,69 but never achieved widespread acceptance.70 It was hypothesized that this technique might work
better coupled with the spontaneous abdominal wall changes
that occur in weightlessness.
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weightless flights, the FRL and CSA provided familiarization
for the novice team members, involving formal lectures and
brief introductory parabolic flights, so that each individual’s
tolerance to varying gravity could be understood.72
The Modular Critical Care Resuscitative
Surgical Suite
Figure 3. The National Research Council of Canada’s FRL
Falcon 20 Aircraft.
To proceed, a weightless laboratory, meaning parabolic
flight, was required. Although NASA’s Vomit-Comet is famous,
most Canadians do not know that the National Research Council
of Canada also runs a parabolic flight program based at the
Flight Research Laboratory (FRL) at Uplands Airport in Ottawa,
using the Falcon 20 Aircraft (Fig. 3).71 In addition to the actual
Another great challenge was that there are no compact
surgical platforms in existence that fit within the confines of
the Falcon 20, which is limited by a physical space of 1.5 by
1.5 m.71 Thus, the FRL engineering and design team disassembled the standard hardware and equipment from veterinary critical care and surgical suites and then reconfigured it
to fit on the Falcon. The platform was designated as the
Modular Critical Care Resuscitative Surgical Suite (MCCRSS),
which we perceive as unique. The MCCRSS satisfied many
structural, informatic, anesthetic, and surgical challenges presented by doing surgery in a small aircraft, all packaged
within a small footprint of a 36 by 36 by 19.5-inch frame. The
resuscitation and anesthetic systems included oxygen, a transport ventilator, three separate IV pumps, and a state-of-the-art
multichannel intensive care unit/anesthesia vital signs monitor. The laparoscopic surgery required a video monitor, light
source, gas insufflator, and camera. There was a doubly
redundant DVD recording capability and compressed medical
gasses including oxygen for the pig and carbon dioxide for
the surgery (Fig. 4). Finally, the fully anesthetized pig was
Figure 4. Schematic overview of the configuration of the MCCRSS.
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The Journal of TRAUMA® Injury, Infection, and Critical Care • Volume 69, Number 6, December 2010
secured aboard the platform for flight. The MCCRSS easily
fit within the physical confines of the Falcon, so we surmise
that, if needed, it could also fit within larger transport helicopters or even our smaller tactical support helicopters. We
believe that collocating and bringing together different resuscitative and interventional technologies is the way of the
future. Delivering the most critically injured to a hybrid
surgical or trauma capable operating room is an example of a
new way of performing resuscitation, and correspondingly,
Alberta Health Services, in conjunction with the Calgary
Health Trust, is building the world’s first dedicated purposedesigned trauma hybrid operative/resuscitative theater in Calgary.73 Currently, although a mobile robotic hybrid operating
room for space flight is just a dream, it is perceived to be a
future requirement for a safe mission to Mars.21,60
Variable Gravity Onboard the Falcon 20
Aircraft
Assessing the potential of gasless laparoscopy in weightlessness involved three different abdominal manipulations onboard the Falcon 20. The baseline comparator condition was
gasless conditions during which no formal abdominal wall
manipulations were conducted. The second distinct state that
did involve marked manipulation of the abdominal wall was
abdominal wall retraction during which the anterior abdominal wall was physically retracted away from the spine in an
attempt to increase the peritoneal laparoscopic domain. The
third abdominal condition was standard laparoscopic insufflation at 15 mm Hg, by definition, a state of IAH.66,74
Abdominal Morphology and Surgical
Endoscopy in Weightlessness
In-flight measurements confirmed the spontaneous conformational change from a compressed oval to a more circular shape, regardless of whether the abdomen was insufflated
or not.48 Despite these spontaneous changes in the abdominal
wall dimensions, gasless laparoscopy without retraction was
completely inadequate to perform any laparoscopic manipulations or even to visualize the pelvis. This was also dangerous, contributing to bowel injuries with resultant septic
shock.75 As an addendum, these complications, in addition to
the prolonged anesthetic provided in multiple transport vehicles and various gravitational fields, offered an excellent
rationale for reviewing both the veterinary and anesthetic
management for space medicine research in general.75
Abdominal wall retraction was variably effective in normal terrestrial gravity. Unfortunately, in weightlessness, despite
the increased potential X dimension, the viscera (especially the
small bowel) simply floated up to fill the increased space,
actually reducing the surgical domain.48,72 As a result, and
contrary to the original hypothesis, laparoscopic visualization of
the pelvis requires gas insufflation. Even with good viewpoints
in 1g or 2g, the pelvic visualization generally improved in 0g.48
Thus, it was concluded that both spontaneous or abdominal wall
retracted gasless laparoscopy in weightlessness are not feasible
and, therefore, gas insufflation, should remain the standard of
care, as it provides good if not better visualization in 0g compared with 1g. Future studies will address the relative levels of
© 2010 Lippincott Williams & Wilkins
TAC in Space Medicine
positive pressure insufflation that balance the physiologic costs
and logistical realities.
Physiologic Penalties of Long-Term Exposure
to Weightlessness
The long-duration astronaut suffers many physiologic
changes that are akin to the debilitated critically ill bedridden
patient.22,76,77 Thus, research to overcome the decompensated
physiology of an injured astronaut may offer insights into the
care of many-fold more terrestrial patients. Physiologic concerns accompanying long exposures to weightlessness include
reduced circulating blood volume, red cell mass, and cardiac
function; immunologic detriments; and bone and muscle atrophy.22,78 – 81 Thus, the Falcon 20 studies also considered the
thoracoabdominal interactions involved with weightlessness and
abdominal manipulation. Correlating each tidal volume with the
abdominal condition, first confirmed that IAH of as modest
degree as 15 mm Hg markedly affects tidal volume in normal
gravity. More importantly, however, was that simply being in
weightlessness nearly offsets this impairment as the abdominal
cavity is physically “unloaded” from the thoracic cavity.47
Regardless of the abdominal condition, overall, weightlessness was associated with increased tidal volumes. Hypergravity however, resulted in reduced tidal volumes.47 Further,
regardless of the gravitational field, standard gas insufflation
was associated with reduced tidal volume, an effect that was
much reduced but not obviated with abdominal wall retraction. The most unique points of this initiative, however, were
to compare the relative consequences of using these different
techniques in different gravitational fields. As expected, introduction of IAH from a CO2 pneumoperitoneum in normal
gravity induces a marked (27%) tidal volume reduction in
normal 1g, and this effect was further accentuated in 2g. Weightlessness itself was beneficial in this regard, as tidal volumes in
gasless or baseline conditions spontaneously increased just with
entering 0g. It was unexpected, however, that compared with
gasless in 1g, entering weightlessness itself appeared to protect
the lungs from reduced tidal volumes and thoracic compliance,
such that there was a nonsignificant change from baseline with
insufflation in 0g, even though the peritoneum was now insufflated and subjected to IAH.47
Integration and Conceptualization of Space
Surgery/Critical Care Findings With Normal
Physiology
We believe these changes are congruous with previous
studies of pulmonary volumes performed onboard the Spacelab,
as long as the supine orientation of the pig is understood. Not
surprising, surgeons and physiologists tend not to communicate
well with each other. When standing upright on earth, gravity
normally unloads the lower lung fields. In general, space physiologists, thus, speak of reduced lung volumes after entering
weightlessness. When standing, the functional residual capacity
(FRC) decreases on entering weightlessness as the diaphragms
are no longer pulled caudad by gravity, and the FRC decreases
by ⬃500 mL.82– 86 Compared with this healthy standing adult on
earth, weightlessness reduces the FRC, expiratory reserve volume, total lung capacity, residual volume, and inspiratory vital
capacity. Induction plethysmography confirms a decrease in the
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abdominal circumference related to an inward displacement of
the abdominal wall of the erect (1 Gz) human on entering
weightlessness.83,87
However, for critical care medicine in space our comparator should be the supine subject, such as a debilitated
intensive care unit patient in normal gravity, whose lung
bases will, therefore, be less compressed by the abdominal
contents in weightlessness than they will be in gravity,
causing comparatively increased lung volumes in space.
Thus, in onboard the Space Life Sciences-1 Spacelab studies,
the average FRC and expiratory reserve volume were 650 mL
and 850 mL, respectively, increased over those measured in
the 1g supine posture.84 To summarize, IAH induced by gas
insufflation markedly embarrassed thoracic compliance as
measured by tidal volume changes in 1g, an effect that was
accentuated in hypergravity (2g), thus providing construct
validity. Conversely, abdominal wall retraction largely preserved tidal ventilation in both normal and hypergravity.
Most notably, performing laparoscopy with the normal IAH
that accompanies standard gas insufflation impaired the tidal
volumes markedly less in weightlessness than occurs on
earth. We believe these findings have important implications
for the development of surgery in space. It may be that
reduced pressure laparoscopy or even standard laparoscopy
may be better tolerated than expected. Further, the findings of
improved ventilatory parameters may have implications for
serious respiratory conditions in space, such as adult respiratory distress syndrome, which are typically worsened by
recumbency and IAH on earth.22
The immediate deliverable is potentially better care for
a Mars mission because ultimately humans will go to Mars,
and we will have to identify the best possible modality of
care. Of greater relevance to many more patients, however, is
a better understanding of the interactions between thoracic
and abdominal pressure and the effects of gravity here on
earth. For instance, prone ventilation is often dramatically
effective in catastrophic situations,88,89 but despite at least 10
randomized-controlled trials and 5 meta-analyses to reanalyze them, proving efficacy is problematic.90 –93 Although the
physiology of prone positioning is complex and still debated,
it is integrally related to the mechanism of relieving gravity
from the lung bases, both to allow increased lung volumes
and to remove gravitational flow gradients.91,94 –96 We believe
that weightlessness has the same benefits, making it an ideal
environment to study the interactions between intrathoracic
and intra-abdominal pressures without being confounded by
positioning and weight, which become irrelevant. In terms of
our next initiatives, we hope to study whether there is a
hybrid solution wherein partial pressure laparoscopy might
offer adequate laparoscopic domain without gravity while
still using lower insufflating pressures. We also wish to
further explore the true interactions between the chest and
abdomen in weightlessness with a hope to learning how to
better care for people on earth.
Telemedicine and Remote Telementored
Sonography for Guiding Resuscitation
The other important CSA emphasis in space medicine
that is particularly relevant to the CSA, TAC, and the UofC
1318
is telemedicine, especially in the techniques of remote telementored telesonography.27 The UofC team has greatly leveraged off an ongoing collaboration with the NASA team
that have pioneered “just-in-time,” remote-guided telesonography using novice onsite care givers, guided by terrestrial
experts. The philosophy recognizes that there is a state-ofthe-art ultrasound machine on the ISS as the only potential
imaging modality,38 yet, there is typically no physician onboard formally trained to use it. The NASA group has defined
this as an emerging discipline of future medicine.49 –51,97,98
To evaluate the potential terrestrial applications of this
same technology, especially for remote and arctic Canada, the
CSA has funded an ongoing evaluation of this concept
between the emergency rooms of both Foothills Medical
Centre and the Banff Mineral Springs Hospital.52,53 It should
be stressed that Banff was chosen because of its geography
and referral patterns and because the Banff physicians are
already experienced in trauma ultrasound.99 Thus, the project
is a test with a view to refining these techniques for use in the
high North. Essentially, it links Foothills Medical Centre to
the trauma Bay in Banff, wherein a novice user, such as a
student who has never used ultrasound before, can be guided
by a remote expert, who cannot only see the patient but is also
viewing the ultrasound findings real time (Fig. 5).
This research is funded by the CSA, not just to aid
Albertans but, more specifically, as a testbed to aid develop
the technology and protocols required to use this technology
in the arctic. Concurrently, simulated trauma resuscitations
from Devon Island in the Northwest Territories to a medical
panel of in Calgary were conducted. Devon Island is used by
both NASA and the CSA as a Mars surrogate as it is the
closest available analog to the red planet on earth.61 The
onsite project medical officer located in Devon Island was
able to readily communicate real time over satellite with
consultants in Calgary, who in turn could follow and guide
every step if necessary. Only the future will prove whether
this truly helps patients. Sustainability remains a ubiquitous
Figure 5. Resuscitation room in the Banff Mineral Springs
Hospital illustrating ultrasound equipment and videoconferencing screen.
© 2010 Lippincott Williams & Wilkins
The Journal of TRAUMA® Injury, Infection, and Critical Care • Volume 69, Number 6, December 2010
challenge for telehealth. Whatever helps us communicate and
improves timely diagnosis is a good prognosis for the future
however. Although TAC is primarily concerned with trauma
care, we also have expanding international health interests
and recognize that maternal-fetal health is a massive global
problem that would be greatly impacted by readily accessible
and timely ultrasound diagnoses. The World International
Network Focused on Critical Ultrasound has, thus, identified
this as an immediate need with high priority for ultrasound
providers.100,101 This technology has tremendous potential,
and currently, tele-obstetrical links are being evaluated
among Iqualuit, Cambridge Bay, and Rankin Inlet.
Cost-Effective Remote Telementored
Sonography
A technology has the best hope for wide acceptance if
it is both efficacious but also cost-effective and easily acceptable.102 Thus, one of our newest initiatives is directed at both
investigating how simply and cheaply we can provide advanced ultrasound diagnoses to those requiring medical care
and exploring how to interact with nontraditional just-in-time
healthcare providers of either convenience or “last resort.”
Paul McBeth, a surgical resident with additional robotic
engineering experience, has shown that 7 year olds can be
guided remotely to use ultrasound to demonstrate lung sliding
and excellent vascular anatomy over the Internet as you guide
them using appropriate vocabulary. This simple system uses
a free online social networking system for the mentor and
mentee to communicate, with the mentee’s hands and the
patient displayed to the mentor by a head-mounted videocamera and a handsfree microphone (Fig. 6A). A telling
vignette from one of these sessions was that as the child had
no difficulty in manipulating the ultrasound probe to obtain
meaningful images (Fig. 6B), the remote mentor forgot who
he was mentoring and reverted to typical medical terminology, prompting the child to ask her mother; “Mommy—
TAC in Space Medicine
what’s parallel mean?” This vignette reemphasizes the
importance of using or speaking the appropriate language that
might be well below the mentors educational level or a
different language altogether. With deep extraterrestrial exploration, future considerations might concern guiding providers who might not even be human nor even have hands.
A further initiative to allow just-in-time and point-ofcare users to concentrate solely on just following the instructions of the remote experts consists of having a remote
ultrasound keyboard that controls the distant machine, thus
freeing the user from having to worry about the “knobology”
of the machine (i.e., gain, depth, or focus). To this end, initial
evaluations have been conducted involving investigators in
Calgary and Hamilton controlling the control panel of a
remote Ultrasonix ultrasound on Mount Mauna Kea in
Hawaii. Collectively, these experiences with telementored
sonography continue to reinforce the point that the limiting
factors concerning sustainability are the availability of competent referral specialists. The onsite providers want to use
this service for their patients, but “experts” typically are not
available for them and likely will not be until we establish a
national or multinational, potentially virtual center of competent content experts capable of telementoring onsite providers to obtain the appropriate diagnostic information to
improve remote patient care. This concept has been championed by Douglas Hamilton, and it is an idea whose time will
eventually come. Simply put, this new discipline of telecare
specialists needs to have content knowledge, patience, communications skills, and triage experience.
CONCLUSIONS
The TAC is very much a growing and vibrant contemporary organization that is ever increasing its responsibilities
and scope in its aims of providing better care for those injured
in Canada. There are further ongoing initiatives to extend
Figure 6. (A) Example of novice just-in-time user being remotely mentored to obtain clinically meaningful images using inexpensive communications technology. (B) Telementored image of the cervical vascular anatomy obtained through remote
guidance of a novice just-in-time provider. (The macro video-feed and the ultrasound images are real-time. The physiologic
display is not actual data and was displayed only as an example of a conceptual work in progress.)
© 2010 Lippincott Williams & Wilkins
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Kirkpatrick
TACs concern to injured people outside of our borders by
taking a more international interest in the welfare of humanity
through initiatives such as partnering with other societies
such as the Australasian and Pan American trauma societies.
TAC has also created an International Issues/Disaster Committee led by Tarek Rezak and Dianne Dyer, and introduced
an annual international lecture at the annual meeting (Fernando Ferreira was the initial speaker). To continue this
trend, I personally look forward to a future requirement,
justified by both a need and progress in care, to initiate an
extraterrestrial trauma committee of TAC, as it will presumably symbolize the culmination of many medical breakthroughs in helping back on earth. Furthermore, I believe that
many of these space medicine breakthroughs will benefit our
most remote Canadians, a group who need the special consideration and the increased attention of the TAC now and
into the future.
ACKNOWLEDGMENTS
I thank Dr Rosaleen Chun and Dr Chad Ball for review
of the manuscript.
REFERENCES
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Available at: http://www.traumacanada.org/mission.htm. Accessed
April 22, 2010.
2. Karmali S, Laupland K, Harrop AR, et al. Epidemiology of severe
trauma among status Aboriginal Canadians: a population-based study.
CMAJ. 2005;172:1007–1011.
3. Laupland KB, Karmali S, Kirkpatrick AW, Crowshoe L, Hameed SM.
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G. WHITAKER INTERNATIONAL BURNS PRIZE-PALERMO (Italy)
Under the patronage of the Authorities of the Sicilian Region for 2011
By law n.57 of June 14th 1983 the Sicilian Regional Assembly authorized the President of the Region to grant the
“Giuseppe Whitaker Foundation”, a non profit-making organisation under the patronage of the Accademia dei Lincei with
seat in Palermo. The next G. Whitaker International Burns Prize aimed at recognising the activity of the most qualified
experts from all countries in the field of burns pathology and treatment will be awarded in 2011 in Palermo at the seat
of the G. Whitaker Foundation.
The amount of the prize is fixed at Euro 20.660,00. Anyone who considers himself to be qualified to compete for the
award may send by January 31st 2011 his detailed curriculum vitae to: Michele Masellis M.D., Secretary-Member of
the Scientific Committee G. Whitaker Foundation, Via Dante 167, 90141 Palermo, Italy.
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© 2010 Lippincott Williams & Wilkins