TELERADIOLOGY IN HAITI

A prototype for remotely assisting distressed areas

January 12, 2010

• A 7.0 magnitude earthquake hit Haiti with an epicenter 10 miles west of Port-au-Prince and its 2 million inhabitants.

• The major quake sent 33 aftershocks ranging in magnitude from 4.2 to 5.9.

• Haiti has no real construction standards, which magnified the resulting damage and casualties.

• 3 million people were in need of emergency aid after the earthquake.

January 12, 2010

Haiti following the earthquake: massive devastation

Devastation after the January 12, 2010 earthquake. Father Rick and Bishop Pierre Dumas perform blessings over mass graves in Titanyen. The state left the bodies piled up and the priest brought in bulldozers to give them a proper burial. Photo by Alison Wright. Used by permission.

Over a million displaced people have been made homeless and forced to live outside under tarps and tents.

Photo by Alison Wright. Used by permission.

Children in Haiti

Nearly 10% of children die before their 5th birthday, largely of  treatable illnesses.

Half of all the deaths in Haiti every day, are children under the age of 5.

1 out of 4 children are moderately to severely malnourished

138,000 children die of preventable diseases each year.

Photo by Alison Wright. Used by permission.

St. Damien Hospital for Children

Near the epicenter of the quake. 

Treats more than 37,000 children per year.

Performs about 4800 x-rays annually.

90% of all x-rays were chest x-rays were performed to exclude respiratory tract infection. After the quake, most x-rays performed were trauma-related.

St. Damien Hospital for Children

The x-ray suite at St. Damien

St. Damien’s x-ray technologists

St. Damien’s x-ray suitefollowing the earthquake

Why the digital X-ray suite at St. Damien survived the earthquake

The suite was designed on a limited budget. Paradoxically, this is the reason it survived the quake. The expensive lead sheets commonly utilized in the USA to shield the walls of x-ray suites were bypassed by the suite’s designer in favor of a much more inexpensive alternative:

“The walls…were being constructed with rebar and cinder blocks. I suggested filling the cinder blocks with concrete, making them solid concrete blocks. I tested my idea with x-rays and sure enough, no radiation penetrated the one foot wall of concrete”

-Barbara Tomasini, RTR, CV, RCIS

Complete Radiology Reading Service’s (CRRS’s) role

CRRS: a teleradiology practice specializing in radiology interpretations for private imaging centers.

After the Haiti earthquake, CRRS sought a way to help, volunteering our interpretations.

Doctors Without Borders and the US State Department were not receptive to our offer.

We found an article in Aunt Minnie(AM) regarding the St. Damien Hospital for Children.

Complete Radiology Reading Services’ role ( continued)

AM article: St. Damien’s Hospital x-ray suite had survived the quake and was operational.

We contacted the AM reporter who forwarded our email to Ms. Barbara Tomasini, who had designed St. Damien’s digital x-ray suite.

Through Ms. Tomasini we made contact with the hospital, and explained our offer to their IT specialist.

Complete Radiology Reading Services’ Role ( continued)

CRRS was immediately able to access the St. Damien PACS system. We were relieved to find their system was one familiar to us: Viztek’s OpalRAD system.

In conjunction with Viztek engineers, we configured the hospital system to automatically send a copy of all x-ray’s performed to our servers in New York for interpretation by our radiologists.

CRRS received the first St. Damien’s examination 4 hours following our initial contact with Ms. Tomasini.

Challenges

One small PC was being utilized for: Hospital employee email and surfing Local viewing of x-ray examinations Housing their PACS

Satellite internet issues Relatively slow and unreliable internet

connection Reports not accessible easily Problems with DICOM transmission No fax machine Unreliable email No way to communicate urgent findings

Challenges and solutions:One small PC doing triple duty

One small PC at St. Damien utilized for multiple tasks: Hospital employee email and surfing Local viewing of x-ray examinations Housing their PACS

CRRS with Viztek’s help, donated a large, powerful, high capacity OPALRAD server to St. Damiens in order to provide them with a dedicated PACS server. The server arrived pre-configured at the hospital several weeks following the earthquake, It was installed by Patrick with remote assistance from Viztek engineers.

Challenges and solutions:Internet Speed

Satellite internet provider at St. Damien- a relatively slow and unreliable internet connection.

This remains an issue. Their internet line speed ranges between 4-10 kBps. Under a load it drops to 1-2 kBps. For reference: an old style dial-up modem runs at 24-56 kBps.

 

Challenges and solutions: Report access

The CRRS PACS distributes our reports via our web server. Because of the intermittent and slow internet connection at St. Damiens this was not an option, nor was email. The hospital did not have a fax machine either.

CRRS designed a system to convert all St. Damien reports to PDF files which are automatically uploaded to our FTP server and then automatically downloaded to a folder on the desktop of the St. Damien viewing computer whenever a connection is available.

Challenges and solutions: DICOM transmission

Their satellite provider sends a packet received response to the St. Damien PACS server before the data has been received by the CRRS server. If data packets are dropped after this spurious response, the sending server will not resend the dropped packets, producing missing studies and images on the CRRS server.

Viztek engineers designed a workaround to add additional packet checking and to force synchronous transfer through the satellite connection.

Challenges and solutions: Communication of urgent findings

The limitations of the internet connection and the resulting lack of dependable email and the lack of a fax machine was problematic.

CRRS developed an email to SMS gateway that allows our radiologist volunteers to instantly communicate urgent findings to the St. Damien doctors cell phones directly by sending an email to the SMS gateway.

Initially, the x-ray examinations CRRS received from St. Damien

were mostly trauma related, such as crush injuries, multiple

fractures and amputations

6 fx’s pelvis/crush

Saint Damien Hospital, Haiti. Photos by Alison Wright. Used by permission.

Photos by Alison Wright. Used by permission.

Saint Damien Hospital, Haiti.

Photo by Alison Wright. Used by permission.

Saint Damien Hospital, Haiti. Photo by ALISON WRIGHT. Used by permission.

After a few months the x-ray examinations CRRS received from St. Damien reflected entities related to poor hygiene and malnutrition, prematurity, and congenital heart disease

RDS/PTX

Free Air/NEC

CHD

Rickets vs OI vs short-limbed dwarfism

Photos by Alison Wright. Used by permission.

To date, CRRS radiologists have interpreted

approximately 3200 examinations from St.

Damiens Children’s Hospital in Haiti. We plan on

continuing our efforts indefinitely.