Bringing robots to life: a conversation with David Lindstrom



Bringing robots to life: a conversation with David Lindstrom



David Lindstrom talks about the RED STAMP project: a study that looks at how paramedics are trained and furthers their education in airway management.

David Lindstrom, director of emergency preparedness in the College of Medicine at Penn State is co-investigator of the Remote Expert Direction and Simulation Training in Airway Management with Paramedics (RED STAMP) project. Lindstrom and Dr. Thomas Terndrup (Principal Investigator) have been directing the RED STAMP research team in analyzing paramedic training procedures to help healthcare organizations improve their emergency response techniques. A staff member of 37 years at Penn State, Lindstrom first began working at the University after setting national standards for paramedics as a member of a committee of the National Academy of Sciences/National Research Council. He later served as Penn State’s chief privacy officer, before moving into his current role in 2009.

We recently sat down with David to talk about RED STAMP’s achievements and how IT is helping to make emergency training possible.

What do you see as the future role of IT in both EMS and emergency medicine?

When we look at the use of information technology assets in healthcare, the growth and interdependency amazes me when I slow down and reflect on the changes in both systems since I took my first ambulance call in March 1968.

We will continue to discover new ways to use IT to share, track, control, secure, and analyze information that we used to do on paper or in person. Nationally, we have started to use geographic information system (GIS) technology in the management of EMS operations. Obviously, our critical care transport helicopters use GIS-based instrumentation in the cockpit and many large ambulance services use GIS tracking and management tools to monitor the location and activities of their vehicle fleet.

Mobile device use has been piloted in EMS and emergency medicine since the first PDAs hit the market. The availability and decreasing price of tablet devices makes them a very attractive documentation and communication tool through Wi-Fi and the cellular network. Satellite technology is recognized as a critical platform in many emergency management environments, but its wide-scale use has been slow to develop in everyday operations. One only needs to work in an emergency medicine capacity at Beaver Stadium to understand why satellite communications, data collection, unit tracking, and other functionality must become part of our EMS and emergency medicine toolkit.

The public safety sector is rapidly embracing the use of all kinds of applications for use in emergency preparedness and response. A recent website called AppComm acts as an online forum where public safety professionals, the general public, and app developers can rate and comment on apps, submit ideas for new apps to serve public safety needs, and suggest additional apps for inclusion on the site. This site has an initial listing of 60 apps selected by the Association of Public-Safety Communication Officials (APCO) and they are just scratching the surface.

The challenge for those of us in healthcare is to develop core IT knowledge in all providers and administrators of healthcare systems. The younger employees have been exposed to IT resources and solutions for decades, but not all healthcare employees have the knowledge or comfort with IT issues that they should. It’s almost like all healthcare employees need an “IT 101” course so they can better understand how to identify and use the resources available now and in the future.

Could you describe your current research efforts and any other projects in which you are involved?

I am currently a co-investigator on a project funded by the Agency for Healthcare Research and Quality (AHRQ) an agency of Health and Human Services. AHRQ’s mission is to improve the quality, safety, efficiency and effectiveness of healthcare, and our project is designed to improve patient safety through the use of simulation. In an effort to make our project understandable to all people, we have titled it Remote Expert Direction and Simulation Training in Airway Management with Paramedics (RED STAMP). RED STAMP is a joint project between Penn State and Ohio State and I am the Penn State Consortium Principal Investigator.

The project has two major phases. In Phase I (which has just ended), we recruited 200 currently certified paramedics from all over Pennsylvania to participate as research subjects. Each paramedic volunteered to participate in an advanced airway management simulation that realistically mimicked situations they might encounter when responding to a 9-1-1 request for emergency medical service (EMS). In order to create a realistic simulation, we used the latest technology available in an advanced airway trainer (a type of manikin with an anatomically correct respiratory system). This trainer is more sophisticated than the typical manikin used in CPR training.

In order to create an authentic performance environment, we had to pick a location that accurately represented the kind of scenario a paramedic might encounter when treating a patient in need of the full spectrum of advanced airway management skills. Many patients are found on the floor or the ground, where they need to be given oxygen and have a breathing tube placed in their trachea so paramedics can "breathe for the patient" (a technique called positive pressure ventilation). This technique is similar to mouth-to-mouth, but uses a direct connection to the patient’s trachea. The other location where EMS advanced airway skills are frequently applied is in the back of an ambulance — and we chose that environment as the location for our research project.

You may be wondering how it's possible to simulate an ambulance environment? Hershey has a 53' tractor trailer mobile training and evaluation unit (called Lion Reach) that we could have used as a platform for this research project; however, we chose to modify an ambulance that was recently removed from active service. By using an ambulance, we were able to create a life-like clinical environment and supplement the regular ambulance equipment and supplies with video capture and recording equipment. This Mobile Sim Lab (MSL) is really just a specially equipped Life Lion EMS ambulance that is now dedicated to simulation exercises and other training research.

What are your plans for Phase II of RED STAMP?

In Phase II, the RED STAMP research team will use the “validated instrument” from Phase I to assess two new groups of paramedics, with 250 in each group. In Phase II, subjects will be randomly divided into a control and study group, respectively. Both groups will have access to an online copy of their personal performance (as recorded in the mobile simulation lab) as well as a number of annotated, anonymous video images of patient airways recorded in the Penn State Milton S. Hershey Medical Center operating rooms.

In order to provide remote expert direction, we will review the performance of each paramedic as recorded in a new simulation, and identify areas of performance where patient safety may be at risk or where airway management proficiency needs improvement. In these cases, targeted educational interventions will be selected from a set of prepared recorded short lectures, demonstrations, and skill review sessions. These interventions will be prepared by the research team and airway experts from the Hershey Medical Center Department of Anesthesiology and Department of Emergency Medicine. Paramedics in the study group will have web-based access to these recorded sessions through “Mediasite,” an enterprise video platform currently in use at the Medical Center. This platform enables us to capture, manage, and deliver interactive on-demand video content to those Phase II research subjects.

Through Mediasite, we will be able to track user access, control videos seen by each research subject, and develop accurate reports regarding the frequency with which subjects view specific videos.

How has your Penn State history helped you as a co-investigator in this project?

My clinical experience as an EMS provider, curriculum designer, instructor, and researcher has been key in my ability to help our research team, which has been led by Principal Investigator, Thomas Terndrup (who also serves as the department chair, associate dean for research, and distinguished professor of emergency medicine at Hershey). Just as important as my EMS experience are my connections in the IT world of Penn State Hershey and University Park. Since my job duties involve work throughout Pennsylvania, I have maintained a research office here at University Park and have a workstation at Penn State Hershey, as well.

As a result of my spending time at both campuses in my weekly life, I can draw from both worlds. The IT leadership and staff members of the Vice President for Research have been exceptionally helpful in finding solutions to various challenges faced as we develop a web presence for use by research subjects. Penn State Hershey’s academic computing leadership and staff members have excellent experience with the Mediasite platform and have been instrumental in designing our video capture, import, management, and delivery of research content. Without our access to existing IT systems and the expertise of the IT staff, we would have been stuck.

I see the initials CIPP/G as part of your credentials. What is the significance of that credential and what is it?

Shortly after our Health Insurance Portability and Accountability Act (HIPAA) compliance work at University Health Services (UHS), I was asked to assume a new position at Penn State. Former Vice Provost for Information Technology Gary Augustson had been chairing a small work group charged with evaluating the impact of HIPAA on the Penn State enterprise. That group was the first group at the University beyond UHS to realize that the impact of HIPAA was going to require an institution-wide approach that was beyond the capability of a volunteer committee.

I was asked to assume a temporary appointment as special assistant to the Provost for HIPAA Compliance. As part of my early work with HIPAA, I realized that Penn State had many other privacy and security obligations under Pennsylvania and Federal Law. The International Association of Privacy Professionals (IAPP) was a new association focused on issues of privacy and I began attending conferences and meetings sponsored by the IAPP.

In 2003, I had become Penn State’s full-time chief privacy officer and realized I needed to participate in a certification process. I became a “Certified International Privacy Professional” by taking a certification exam through IAPP. Later, I successfully passed a second exam about government privacy issues. That’s the significance of the “G” at the end of the title.

Even though I am no longer a full-time privacy professional, I continue to use much of the knowledge I gained in my former role. All researchers have significant privacy and security requirements, so my background serves me well.

How did you happen to make the switch from chief privacy officer to your current position?

In 2008, the former deputy for operations of the Pennsylvania Emergency Management Agency asked me to direct a $2.3 million emergency preparedness project. From 2008 – 2012, I was the principal investigator of the Pennsylvania Radiological Emergency Preparedness and Response Effort (PREPARE). Eventually, I wanted to get back to a full-time faculty role in my original professional area and Project PREPARE provided me with an opportunity to bring a funded research project to Penn State. A logical home for the project was in the Department of Emergency Medicine since the department head, Dr. Tom Terndrup, had a strong emergency preparedness background and interest. I accepted a faculty position and assumed a research role in the College of Medicine.

Can you describe a typical day in your work life and the role information technology plays in your role as a member of the Department of Emergency Medicine?

I start my day quite early checking email and getting ready for work in the University Park office, a trip to a research subject recruiting site, or a drive to Hershey. I work with many people who are around-the-clock in their clinical work life in the emergency department or as part of our Life Lion EMS and Critical Care Transport Service. As a result, my colleagues are sending email around the clock and the quality of Penn State’s email systems are critically important to me since I work remotely from many members of the research team.

Video conferencing, phone bridges, Skype, webinars, and other technologies have become essential communication tools for our work needs. The ready access to Wi-Fi in University facilities and throughout Penn State Hershey has become a key asset to people who are members of an increasingly mobile work force.

The role of mobile devices, like smartphones and tablets, are becoming so prevalent in the EMS community that we need to be ready to meet our research subjects’ needs for 24/7 interaction on a mobile platform. Any interaction with our current pool of research subjects needs to be supported on mobile devices.

One project, currently in the planning stage, will use mobile devices to collect out-of-hospital patient data as part of a post-discharge, follow-up home visit process. If we are able to implement this service as planned, we hope to be able to use mobile devices to access forms and templates to be used in the collection of clinical data while visiting patients at their residence. Through the use of encrypted communication, we’d like to be able to use that data to populate a portion of the electronic medical records that will be instantly accessible to the physicians and care coordination staff members on the patient’s treatment team.

I’m currently consulting with a physician group in the state of Indiana that is considering the use of telemetry and other telemedicine tools to collect diagnostic information in patient’s homes through the use of specially trained community health assistants (CHAs).  The CHA may be a certified paramedic or other healthcare worker and while in the home, they are planning to broadcast real time, voice, data, and images for review by a physician member of the care delivery team located many miles away.  Through the analysis of the patient’s diagnostic information, the team can determine the best way and the best location to provide the care the patient needs.  The goal is to reduce unnecessary visits to the emergency department and avoidable healthcare expenses while providing high quality in-home care. 

Obviously, our physicians work with some of the most sophisticated medical technology in the business. It is part of today’s standard healthcare environment. I remember the early 1980’s when the city of Toronto had just one CT scanner and patients were loaded on a bus circulating among various facilities to pick up patients needing a CT scan. Today, we have a CT scan across the hall from our trauma bays, right in the emergency medicine department, along with the many others throughout the Penn State Hershey Medical Center. Technology has come a long way and our dependence on those technologies grows by the minute.

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