The Role of Advanced Medical Technology in Cardiology

NATO operations have expanded in recent years, and the old Cold War concept of “every nation provides its own medical support” is no longer tenable, nor is it NATO policy. In the future, NATO medical care will often be provided on a multinational basis, especially in case of emergencies such as NATO response to natural or man-made disasters or to terrorist actions. Even though deployed military personnel are usually young and relatively healthy, this is not the case for all those who may be provided care by NATO medical personnel. The pressures to “shorten the logistics tail”, coupled with the shortage of trained cardiologists in most of our nations, has and will continue to preclude the routine deployment of Cardiologists to all NATO operational missions. However, the need to provide services during these missions remains very real. Even following a natural disaster or exposure to toxic agents, the ability to distinguish a cardiac event from other causes of chest pain can be life-saving, and appropriate diagnosis will lead to improved survival, reduced inappropriate use of medical capabilities, and decreased inappropriate evacuation of patients.

Acute coronary syndromes (e.g. angina and myocardial infarction) and associated cardiac emergency conditions (e.g. arrthymias) remain the leading cause of death among industrialized nations, and deployed military personnel are certainly not immune from this threat. New diagnostic (e.g. portable ultrasound) and treatment modalities (e.g. fibrinolytic agents) have greatly improved the survival of the cardiac diseased patient, assuming the diagnosis can be made rapidly. Associated improvements in advanced medical technology and tele-communications, have enabled cardiac patients in remote or austere environments access to specialty consultation, even though the Cardiologist may be located elsewhere. This capability has resulted in decreased morbidity and mortality. Examples of this kind of second opinion consultation occur in the field of telehealth or telemedicine. In this case, cardiac patients in a remote site can undergo testing and evaluation with an electrocardiogram (ECG) or echocardiogram (ECHO) captured in a digital format, which can then be forwarded over commercial communication networks to a medical center for interpretation by a cardiac specialist. Supplementation of this capability with real time transmission of a patient examination with heart sounds (tele-stethoscopy) or videoteleconferencing (VTC), may augment the medical evaluation and provide the remote medical provider immediate referral recommendations that can be life-saving.

In the military setting, deployed NATO forces in remote locations (e.g. Kosovo) are comprised of young as well as middle-aged forces that are susceptible to suffering an acute cardiac event. These deployed sites typically do not have a cardiologist available at the remote medical treatment facility. Often, if two-way voice communication is established, cardiac specialists can be consulted with a limited view of the cardiac patient. Increased bandwidth availability is now becoming possible in remote deployed environments and permitting the use of tele-consultation in a variety of medical disciplines. Advanced medical technologies (digital cardiac ECG and ECHO machines) in the field of cardiology have been developed and are routine in the management of cardiac patients. Other enabling technologies include advances in compression of digital data allowing transmission of large data files over low bandwidth systems (e.g. Internet) as well as increased availability of large bandwidth systems using satellite technologies.

Many nations and agencies currently have ongoing research in this field, including the US, France, Spain, the Netherlands, Norway, Croatia, the European Commission, and the World Bank. There is a scientific need to bring many of these researchers together to discuss mechanisms for interoperability, and to begin the discussions about Telecardiology Standardization to allow regional and other multinational mutual support. In Croatia, the need for remote tele-cardiology consultation is necessary in order to meet the growing demand for expert medical advice for tourists vacationing in remote islands in the Adriatic Sea who take ill with a cardiac event. To address this concern in Croatia, a World Bank funded initiative in the field of tele-cardiology was approved and work is already underway to meet this need. The Croatian Ministry of Health is the stakeholder organization shepherding this initiative. Likewise, in the US military, transmission of digital ECG's and ECHO images is occurring in medical treatment facilities in the continental United States but infrequently in operational settings such as Iraq or Afghanistan.

In September 2005, a NATO sponsored Advanced Research Workshop (ARW) titled “Remote Cardiology Consultations Using Advanced Medical Technology – Applications for NATO Operations” was conducted in Zagreb, Croatia and provided a forum to discuss the advances in diagnostic medical technologies as they apply to the specialty of cardiology. Experiences gained from NATO forces in both garrison and deployed environments were shared. Lessons Learned from an international community in the field of tele-cardiology were identified with far-reaching impact as new systems are developed and deployed in future NATO missions.

The ARW consisted of several panel presentations over three days drawing from experts in health, clinical research, electrical engineering and law. The main focus of the meeting was to:

a. address the clinical need for tele-cardiology in a remote or austere environment;

b. to assess cost-effective technical solutions with “off the shelf” hardware and non-proprietary software;

c. to articulate the human factors challenges in developing regional cardiac consultation;

d. to identify the legal, regulatory, and security concerns for remote tele-consultation; and

e. to develop a business case analysis for tele-cardiology that will allow self-sustainment of services based on sound economic expectations.

The efforts of this meeting culminated in the development of this book which summarizes the current state of Telecardiology as presented by the member participants totalling nearly 60 individuals and representing over 16 NATO and Partner for Peace nations. We thank the meeting participants and the Organizing Committee for their tireless efforts in successfully conducting the meeting and preparing their manuscripts for inclusion in this book. We especially thank the NATO Advisory Panel on Security-Related Civil Science and Technology and the Assistant Secretary General for Public Diplomacy, for their financial award, without which this meeting could never have occurred.

NATO country co-director, COL Ronald Poropatich, MD, US Army Medical Research & Materiel Command, Telemedicine and Advanced Technology Research Center, Fort Detrick, MD, USA

Partner country co-director, Professor Ivica Klapan, MD, PhD, Croatian Telemedicine Society of the Croatian Medical Association (President), Telemedicine Committee-Ministry of Health and Social Welfare, Republic of Croatia (President), Department of ORL-H&N Surgery, Zagreb University School of Medicine & Clinical Hospital Center Zagreb, Šalata 4, HR-10000 Zagreb, Croatia