Telementorable "just-in-time" lung ultrasound on an iPhone.

Sir,

Pleural and lung ultrasound (PLUS) is increasingly used in the bedside management of pulmonary pathology such as with the EFAST and BLUE protocols.[12] As ultrasound is operator-dependent, however, there are challenges to ensure that clinicians have adequate training. With a current explosion in the availability of ultrasound machines, we believe there is a need to optimize ultrasound availability to patients, yet ensure quality and avoidance of misinformation from erroneous exams. The National Aeronautics and Space Administration has addressed this challenge by examining the concept of remote telementored telesonography (RTMTS), wherein just-in-time users onboard the International Space Station are guided to capture meaningful images by remote terrestrial experts using elaborate informatics.[3] The World Health Organization also recognizes that communication technologies have the potential to address challenges in both developed and developing countries in providing accessible, cost-effective, and high-quality healthcare services, especially for rural and underserved communities in developing countries.[4] Thus, we endeavored to provide RTMTS using markedly simpler informatics.[5]

We investigated the provision of RTMS by allowing remote experts in Aberdeen to view real-time PLUS images displayed on a smartphone (iPhone-4, Apple, Cupertino, CA). A portable ultrasound (Sonosite 180, Sonosite, Bothell, WA) in Calgary was interfaced to a laptop computer (Aspire 5741, Acer, Kuala Lumpur, Malaysia) via an analogue-to-digital converter (VC-211V, ActionStar LinXcel, Taiwan) [Figure on-line supplement]. Xsplit Broadcaster (SplitMediaLabs ltd, Hong Kong) allowed video-streaming of both an inexpensive head-mounted webcam (LifeCam VX-2000, Microsoft, Washington) and ultrasound over Skype (Skype, Luxembourg), easily viewed on any smartphone. The remote experts were thereafter able to easily view both the Calgary examiners hands and probe and resultant ultrasound images and to audibly bidirectionally communicate during the conducting of PLUS, with the iphone images deemed of diagnostic quality demonstrating clear evidence of real-time lung sliding [Figure 1]. While best appreciated real-time, the color-power Doppler function also documented this movement as the “Power-slide,”[6] confirming and documenting respiration and pneumothorax absence.

Figure 1

iPhone image as viewed in Aberdeen demonstrating the “Power slide” confirming pleural sliding with imbedded image of remote examiner holding US probe in Calgary

While ultrasound images have been previously viewed over smartphones, we believe this is the first utilization of this ever more-prevalent technology to allow cost-minimal telementoring in lung telesonography. Therefore, despite the myriad of challenges for global health improvements, we believe that as the globe is shrunk by informatics, remote experts in developed nations could increasingly assist with education and clinical care delivery using affordable technologies that are likely to be already in our coat pockets.