Bay Glass Research Paper

Many healthcare leaders have their doubts about Google Glass. Does it violate patient privacy? Will it increase physician distractions? Most important for trauma professionals, does Google Glass have a role to play during a fast paced trauma activation?

Recently, members of the trauma team at Forbes Hospital, a Level II trauma center in Monroeville, Pennsylvania, began using Google Glass loaded with a software application designed specifically for trauma care. The application is called the Visual Information Zonal Reminder (VIZR) system, and it was created by trauma surgeon Alex Guerrero, MD.

Christoph Kaufmann, MD, is the trauma medical director at Forbes and an enthusiastic Glass explorer. He and other trauma team members began using the Glass system in December. So far, it has played a role in approximately 200 trauma activations. Dr. Kaufmann recently discussed his team’s experience with VIZR and why he thinks wearable technology is the future of trauma care.

1. It’s not about video
Glass includes a built-in camera for capturing images and video, which raises concerns about patient privacy. But VIZR does not use video. In fact, the system comes with a cap that fits over the Glass lens. “This system is not like what other people are doing with Glass — pictures, video, telemedicine,” Dr. Kaufman said. “We are using Glass as a reminder tool for some of the things that are often neglected.”

VIZR provides evidence-based checklists and prompts through Glass’s optical display. Clinicians use voice commands to initiate the system, navigate through the different phases of trauma care and access specific lists and protocols. The system is time-based. At specified intervals, VIZR presents a new list of clinical and logistical priorities. Users receive alerts via chime tones transduced through the skull.

According to Dr. Kaufmann, time-based reminders help trauma team leaders maintain situational awareness. “It is not distracting at all,” he said. “The user is perfectly capable of either looking at the Glass display or not, just like you can either look at or not look at a vital signs monitor.”

2. It helps you avoid missed opportunities
“We are all very good at the ABCs,” Dr. Kaufman said. “What Glass helps with are the ‘second level’ things that are so easy to overlook in the heat of battle.”

  • During resuscitation, for example, VIZR prompts the team leader to make sure TXA has been administered and the massive transfusion protocol has been activated as early as possible. If the case is a compound fracture, the system prompts the user to start antibiotics.
  • VIZR also provides a checklist of commonly overlooked questions for paramedics, such as how much fluid and pain medication the patient has received.
  • If the case is going to the OR, the system reminds the team leader to call for the cell saver and notify the backup surgeon.
  • Checklists also cover the most commonly forgotten aspects of emergency surgery.

“Many of these reminders are second-level issues that are often overlooked or delayed, but which are important for long-term outcomes,” Dr. Kaufmann said. “In the middle of an aggressive resuscitation, you might not get started on some of these things as early as you would otherwise. The application helps you avoid missed opportunities.”

3. You get instant reference for rare trauma protocols
“Glass can put information at your fingertips for things you may not have used in the last month,” Dr. Kaufmann said. “For example, you could say ‘Med List, ICU, Pressors, Starting Doses’ and the application will display the right units for ordering.”

VIZR also gives trauma teams instant refreshers on rarely used procedures. “Within the pregnant patient protocol, you can call up pictures on how to do a perimortem C-section,” he said. “It’s the thing we never want to do, but which you may need to do quickly.”

Nurses can also use VIZR to access step-by-step directions for less common processes, like using a Belmont Rapid Infuser. The application provides instructions and photos. “There are probably a dozen steps to getting the Belmont infuser started, and it’s not something we do every day,” Dr. Kaufmann said.

4. It helps you prepare for patient arrival
Dr. Kaufmann has found that VIZR is useful outside the trauma bay. “When an activation is called, you can use Glass to review protocols before patient arrival,” he said. “For example, say the patient is a pregnant woman with an ETA of 10 minutes. I can call up the pregnancy trauma protocol and review it as I walk to the Emergency Department.”

5. Teams can use it as a training tool
Heidi Felix, DHSc, MPAS, PA-C, is the chief physician’s assistant for the Forbes Hospital trauma department. She said the department plans to use VIZR to train new trauma team members.

“We are different from most trauma centers in that we have advanced practitioners involved in all aspects of patient care,” Felix said. “Glass will be a nice adjunct for training PAs on things like central lines, chest tube placement, medication doses and other processes. We see it as a tool for helping to teach a systematic approach.”

Forbes trauma bays are equipped with flat-panel screens that display the same information that appears in the team leader’s Glass. According to Dr. Kaufmann, shared checklists help keep everyone on the same page. “For example, the checklist includes making sure the patient is covered. When that item pops up, team members know to check even before I say it.”

6. It could be useful in mass casualty incidents
The VIZR system can track multiple patients simultaneously. The user toggles between patients with voice commands. The system maintains individual timers, reminders and checklists for each patient.

According to Dr. Guerrero, developer of the system, this capability could help trauma teams manage mass casualty incidents. “The system could be connected to the hospital intranet through an encrypted website,” he said. “That would allow the incident command center to monitor what’s going on in the trauma bay through the Glasses of the surgeons.”

7. Patients don’t object
When they began using Glass, the Forbes trauma team wanted to understand how patients react to the new technology. “When we introduced Glass, we also began a study examining patient perceptions,” Felix said. “We designed a survey to find out how patients think the technology affects their care, whether or not it interferes with their care, and whether they are even aware of it.”

“So far, patient perceptions are very positive,” she said. “Most patients feel the technology does have a place in their care. And most don’t find Glass obtrusive or even necessarily know that we’re using it.”

A natural evolution
The VIZR system is available through VIZR Tech, a healthcare technology consulting firm founded by Dr. Guerrero and partners. The firm customizes the application’s checklists and prompts to the needs of individual trauma teams.

Dr. Kaufmann sees the VIZR system as another opportunity for medicine to learn from aviation. “It’s fair to say that trauma surgeons are the fighter pilots of medicine,” he said. “We use some of the most advanced technology in a highly time-sensitive environment that demands rapid and correct response. Pilots have heads-up displays, and Glass lets surgeons use the same tool. It’s natural that trauma professionals be among the first to adopt this technology.”

One of the most instantly recognizable features of glass is the way it reflects light. But a new way of creating surface textures on glass, developed by researchers at MIT, virtually eliminates reflections, producing glass that is almost unrecognizable because of its absence of glare — and whose surface causes water droplets to bounce right off, like tiny rubber balls.

The new “multifunctional” glass, based on surface nanotextures that produce an array of conical features, is self-cleaning and resists fogging and glare, the researchers say. Ultimately, they hope it can be made using an inexpensive manufacturing process that could be applied to optical devices, the screens of smartphones and televisions, solar panels, car windshields and even windows in buildings.

The technology is described in a paper published in the journal ACS Nano, co-authored by mechanical engineering graduate students Kyoo-Chul Park and Hyungryul Choi, former postdoc Chih-Hao Chang SM ’04, PhD ’08 (now at North Carolina State University), chemical engineering professor Robert Cohen, and mechanical engineering professors Gareth McKinley and George Barbastathis.

Photovoltaic panels, Park explains, can lose as much as 40 percent of their efficiency within six months as dust and dirt accumulate on their surfaces. But a solar panel protected by the new self-cleaning glass, he says, would have much less of a problem. In addition, the panel would be more efficient because more light would be transmitted through its surface, instead of being reflected away — especially when the sun’s rays are inclined at a sharp angle to the panel. At such times, such as early mornings and late afternoons, conventional glass might reflect away more than 50 percent of the light, whereas an anti-reflection surface would reduce the reflection to a negligible level.

While some earlier work has treated solar panels with hydrophobic coatings, the new multifunctional surfaces created by the MIT team are even more effective at repelling water, keeping the panels clean longer, the researchers say. In addition, existing hydrophobic coatings do not prevent reflective losses, giving the new system yet another advantage.

Other applications could include optical devices such as microscopes and cameras to be used in humid environments, where both the antireflective and anti-fogging capabilities could be useful. In touch-screen devices, the glass would not only eliminate reflections, but would also resist contamination by sweat.

Ultimately, if the cost of such glass can be lowered sufficiently, even car windows could benefit, Choi says, cleaning themselves of dirt and grit on the exterior surface of the windows, eliminating glare and reflections that can impair visibility, and preventing fogging on the interior surface.

The surface pattern — consisting of an array of nanoscale cones that are five times as tall as their base width of 200 nanometers — is based on a new fabrication approach the MIT team developed using coating and etching techniques adapted from the semiconductor industry. Fabrication begins by coating a glass surface with several thin layers, including a photoresist layer, which is then illuminated with a grid pattern and etched away; successive etchings produce the conical shapes. The team has already applied for a patent on the process.

Since it is the shape of the nanotextured surface — rather than any particular method of achieving that shape — that provides the unique characteristics, Park and Choi say that in the future glass or transparent polymer films might be manufactured with such surface features simply by passing them through a pair of textured rollers while still partially molten; such a process would add minimally to the cost of manufacture.

The researchers say they drew their inspiration from nature, where textured surfaces ranging from lotus leaves to desert-beetle carapaces and moth eyes have developed in ways that often fulfill multiple purposes at once. Although the arrays of pointed nanocones on the surface appear fragile when viewed microscopically, the researchers say their calculations show they should be resistant to a wide range of forces, ranging from impact by raindrops in a strong downpour or wind-driven pollen and grit to direct poking with a finger. Further testing will be needed to demonstrate how well the nanotextured surfaces hold up over time in practical applications.

Andrew Parker, a senior visiting research fellow at Oxford University’s Green Templeton College in the U.K. who was not involved in this work, says, “Multifunctional surfaces in animals and plants are common. For the first time, as far as I am aware, this paper learns a lesson in manufacturing efficiency from nature by making an optimized antireflective and anti-fogging device. … This is the way that nature works, and may well be the future of a greener engineering where two structures, and two manufacturing processes, are replaced by one.”

The research was funded by the Army Research Office through MIT’s Institute for Soldier Nanotechnology; the Air Force Office of Scientific Research; Singapore’s National Research Foundation through the Singapore-MIT Alliance for Research and Technology (SMART) Centre, and the Xerox Foundation. Park and Choi are recipients of fellowships from Samsung and the Kwanjeong Educational Foundation/STX Scholarship Foundation, respectively.

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