Incremental Improvement

We’ve been looking at new cardiac monitors for a couple of years now, but management hasn’t made a decision on what to buy. We have a lot of choices and apparently no one is married to our current provider despite the fact that we’ve used that company for close to thirty years. Competition is good and at least two other companies have shown interest in the pre hospital market. This gives us choices and we’ve been reviewing current offerings from three manufacturers.

For all intents and purposes they all do the same thing, it’s the packaging, displays, controls that differ between the three.

For the record, here is what each one does,

Cardiac monitoring
Defibrillation/cardioversion
Pacing
Pulse Oximetry
Blood Pressure
ETCO2
Esophageal (or rectal in one case) temperature monitoring.

They also have options for sensors, such as arterial blood pressure (invasive) monitoring, but for us that’s not needed.

If nothing else, I think we need a new name. Cardiac monitor only begins to describe what these devices do.

Depending on the model, they weight anywhere from about 12 pounds up to 20 pounds. The 20 pound number is about what our current equipment weighs and it’s a pain in the ass to lug that thing up and down stairs all shift long. Especially down stairs, with all of the leads attached to the patient. In some, no many, cases, we’ll disconnect all of the cables from the monitor for the carry down the stairs.

By way of explanation, in this part of the country much of the urban housing stock was built before, during, and even after World War I. Not II, I. Building codes are much different now, but the older buildings still have narrow stair ways, sharp turns, tread width and heights that wouldn’t meet code, doors that open in awkward directions. Not to mention what some people leave in their halls and on their stairs. Bikes, skates, child car seats, plants, table saws, hockey equipment, tool boxes, construction equipment, I’ve seen them all. Some times it’s like an obstacle course as much as stairs or hallways. Hence, it’s a major pain to move often not skinny patients, oxygen, IV lines, CPAP, and the monitor with it’s connections to the patient. so, if we judge that the patient’s condition is stable enough, we’ll take the calculated risk of disconnecting the monitoring.

Which lead me to a thought last night as I was trying to fall asleep. Which was odd since I’ve not been at work for several days and wasn’t thinking about work related issues.

Here’s my thought. The basic design premise is faulty. Why should the monitoring be connected to the patient by wires? We know that remote medical sensing technology exists. Hell, it was used during the space program back in the 1960s and ’70s. The technology has advanced exponentially since then, especially when it comes to size, ability, and battery power.

Why doesn’t someone make a “two piece” for lack of a better term cardiac monitor? One part attaches to the patient and contains the sensors and therapy cable. It’s sort of a black box, with a minimum number of controls. The ECG leads, pulse oximeter, ETCO2, defib pads, and thermometer all attach to the patient as they do now, but terminate in the “sensor module”. The controls, display, and even printer are part of the “control module”. The two modules are connected wirelessly, with a wired back up in case the wireless fails. The wired back up is easy using either an Ethernet or USB cable.

The sensor module stays on the stretcher, scoop frame, stair chair, or Reeves stretcher and the person doing the monitor can be several feet away monitoring cardiac rhythms and other vital signs.

I know that technology exists I’ve seen it used in cardiac and other specialty, and yet no pre hospital manufacturer seems to have even contemplated this.

About ten years ago a friend of mine showed me this neat gizmo that attached to his Palm Pilot and allowed him to monitor a patient. It was simple, it didn’t do 12 leads, it didn’t defibrillate, it just showed rhythm strips. I wouldn’t be surprised if someone developed hardware and an app for the iPhone or Android OS to do 12 leads. 12 Lead acquisition is simple and computer bases interpretation is, well computer based. All of the other sensors used in what we still persist in calling cardiac monitors are computer based. Signal data from the various sensors is interpreted and displayed using computer algorithms.

So, how hard would it be to take a Windows based (or Android based for that matter) laptop or tablet computer and use that as the monitor/control part of a cardiac monitoring system with a sensor module connected to the patient? All that would need to be added would be a printer and there are ways around that using fax technology and cell data cards.

It wouldn’t have to be a proprietary computer, although the manufacturers would love to have have that. It could even be the same hardware that is used for writing ePCRs. Zoll has monitors and an entire data division, one of whose products is an ePCR system. Wouldn’t it be cool to use one piece of hardware to acquire the ECG and document the patient care. Why I bet that the ECG could be seamlessly integrated.

I think that there is a great opportunity for at least one of the major cardiac monitor manufacturers to make a device which costs about the same as the current offerings, but is much more user friendly package.

Not one thing that I’ve described here is ground breaking technology. In fact the military talked about it in 2002 in Combat Medical Informatics, Present and Future. I know that the military has done a lot of development in this field, most of which has not yet migrated out to civilian medicine. If nothing else good happens in war, medical technology generally advances dramatically.

The challenge to the self anointed leaders in pre hospital medical technology is to change the paradigm of a 20 pound piece of equipment that has to be kept within 5 or 6 feet of the patient to something that can monitor the patient but not get in the way.