Each of the above systems is a huge benefit to elderly patients and their geographically-separated families. Through these devices, children and other family members can stay apprised of a parent or other loved one’s health through these at-home monitoring systems—in a similar manner as some parents track a new teenaged driver through his or her cell phone!
Other Smart Devices
Connected devices are moving past pill bottles and smart glasses. In the same manner that many people employ fitness trackers to monitor the number of steps taken and calories burned, multiple glucometers are available that sync with a patient’s smart phone, allowing upload of the data to his or her healthcare provider. This field is also growing into commercially available HR monitors that allow easy monitoring for arrhythmias in low-risk patients.
While these devices are a boon for primary care physicians and can greatly assist in determining medication noncompliance, some potential systems issues may result in a false emergency notification akin to patients presenting to the ED for evaluation after receiving an inaccurate high BP reading on a grocery-store or home monitoring device. For instance, HR monitors with a faulty lead may cause an alert from the monitoring system noting atrial fibrillation and recommending the patient seek immediate evaluation. Similarly, a smart phone-connected glucometer may note hyperglycemia in a patient after he or she has consumed a high-sugar meal.
While there has been a reemergence in the use of traditional tourniquets, they are not effective in controlling hemorrhage at junctional sites such as the groin or axilla as there is inadequate space to accommodate the tourniquet. Two recent solutions are the Combat Ready Clamp (CRoC) and SAM Junctional Tourniquet, which are specially designed to control bleeding in an improvised explosive device or blast-type injury. As with intraosseous access devices, the use of tourniquets is also making a comeback. Both owe their new-found popularity—at least in some part—to the involvement of the United States in the recent wars in Iraq and Afghanistan. High casualty rates from improvised explosive devices countered by significant improvements in body armor have resulted in preservation of the torso at the expense of extremities. Life-threatening hemorrhage from a distal extremity can easily be controlled by a tourniquet—something this author never used as an infantryman during Desert Storm, but which is now carried on the person of every soldier in the field.
The Combat Ready Clamp (Combat Medical Systems, Harrisburg, North Carolina)22 compresses the aorta and vena cava though intra-abdominal pressure (Figure 7). While some may find this device a bit cumbersome for field use, it is definitely feasible and applicable for hospital use. A similar option, the SAM Junctional Tourniquet (SAM Medical Products, Wilsonville, Oregon),23 (Figure 8) functions in a similar manner as the CROC but uses pneumatic instead of mechanical pressure. The SAM device is definitely more “rucksack friendly,” but both products are good alternatives for controlling hemorrhages in the ED.
Hemostatic agents such as QuickClot (Z-Medica, Wallingford, Connecticut)24 have been in popular use for about a decade now, and the next generation of this family of treatment options has become available. The XStat-30 (RevMedx, Wilsonville, Oregon)25 (Figure 9) is one such product. Its large syringe applicator (like a large Toomey syringe) is filled with tablets of chitin. The injector is designed to be inserted into a penetrating injury and its contents injected into the wound. Upon contact with blood, the chitin tablets expand in a similar manner as children’s “hatch-and-grow” toy eggs and capsules when immersed in water. The XStat-30 provides not only hemostasis, but also some level of tamponade.
Resuscitative Endovascular Balloon Occlusion of the Aorta
The final addition to the hemostasis comeback tour is the Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) device (Pryor Medical, San Antonio, Texas).26 Like many of the products discussed in this article, REBOA has been around for some time, but its use had fallen out of practice. A recent reemergence has shown that REBOA benefits patients with lower abdominal, pelvic, and extremity injuries.
The principal of its use is simple: An occlusive balloon is inserted into the femoral artery and advanced to roughly the level of the midabdomen. Once inflated, the balloon stops blood flow distally. While more research needs to be done on indications and outcomes, REBOA has been successfully used in England in many hospitals and even in the field.27
Summary
Some of the most notable recent evolutionary and revolutionary technological advancements to have a significant and beneficial impact on patient care have been seen in new noninvasive tonographic devices to measure IOP; video laryngoscopic devices for airway management; wireless patient vital signs monitoring systems; alternatives to traditional vascular access such as intraosseous vascular systems, laser-assisted vein visualization technology, and Internet-connected smart glasses; advances in wound-care dressings; medication monitoring systems; clamps and tourniquets to control junctional hemorrhage; and wireless, smart-phone connected glucometer devices and HR monitors. Many of these devices and systems are applicable and appropriate for use in the ED, the implementation of which will further facilitate and improve the quality of patient care.