camera phones for the follow-up of soft-“>Correspondence

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Camera phones for the follow-up of soft-tissue injuries in adult and pediatric ED patients: a feasibility study

To the Editor,

A previous study has demonstrated that many patients with sutured lacerations fail to recognize early signs of infection despite explicit in- struction [1]. The ease of use of a familiar device such as mobile phone with a built-in digital camera has particular appeal in wound monitoring and follow-up, enabling color image transfer directly to a treating physi- cian. The purpose of our study was to examine the feasibility and accuracy of using camera phones for the follow-up of soft tissue injuries in adult and pediatric patients discharged from the emergency department (ED). This was a prospective, observational study that was conducted at a level I adult ED and level I pediatric ED (PED) using a convenience sample of patients with soft tissue injuries (eg, bite wounds, lacerations, or Crush injuries). Patients unable to speak English or with wounds that involved genitalia or buttocks, or that were considered difficult to photograph were excluded. Consenting patients and/or parents owned a mobile phone capable of sending pictures to another mobile device or an e- mail recipient. During the initial instructions, a photo was taken of the wound. Patients were then asked to e-mail a photo of the wound at 3 and 5 days after ED discharge. Submitted photos were reviewed indepen- dently as computer images by 2 ED or 3 PED physicians, respectively. Photo sharpness, color accuracy, distortion, and presence of artifacts were measured using a standardized classification system. Indications of wound complications such as infection, poor healing, and dehiscence

were noted. Intraobserver agreement was determined using ?.

A total of 50 adult (mean age, 29.3 years) and 50 pediatric (mean age, 10.4 years) patients were enrolled. Forty-seven adult patients (94%) re- ported using picture messaging “frequently,” and 44 (88%) used the cam- era on their mobile phone to take pictures regularly. In adults, wounds were mostly located on the upper (64%) or lower (30%) extremity; 3 pa- tients (6%) had wounds located on the face. In pediatric patients, wounds were mostly located on the head (54%) and upper extremity (26%). In both the adult and pediatric groups, 47 (94%) of 50 patients successfully trans- mitted photographic images of their wounds at 3 and 5 days postdischarge from the ED. Examples of submitted photographs can be seen in the Figure. Image sharpness and quality were rated “good” to “excellent” 88% and 94% of the time, respectively, by the adult ED physicians. Similarly, PED phy- sicians rated sharpness and quality of photographs of the wounds of pedi- atric patients “good” to “excellent” 89% and 95% of the time, respectively. No artifacts or distortions were noted in any submissions for either group. Physician raters reported that 89% (42/47) of adult patients and 91% (43/ 47) of pediatric patients submitted images of significant enough quality as to be able to rule out infection. Intraobserver agreement between repeat- ed photographic assessments and observers for image quality was excellent

for both the adult (? = 0.86) and pediatric (? = 0.88) groups.

Two adult patients had apparent Wound infections during the review of their images and were contacted by study personnel. One patient was

contacted at home and told to follow-up in the ED for wound examina- tion. The other patient was contacted and had already returned to the ED, and required extensive debridement of her finger.

The utilization of widely available and familiar technology such as

smartphone or camera phone for follow-up of ED patients with soft tissue wounds can be considered feasible and reliable. Few studies have looked at the utilization of smartphones in medicine. Studies which have exam- ined this equipment have recommended incorporating it into medicine [2-4]. This study serves to bolster those suggestions.

Allowing patients to send photos of healing wounds after discharge may serve to reduce return visits for patients who may have limited ac- cess to transportation or medical care, as well as to lighten the burden on practitioners if wounds appear to be healing without complications. Smartphone imaging may have other uses such as feedback to learners after wound closure, as well as quality improvement. Within a short peri- od, a teaching program could accumulate a variety of soft tissue images for education purposes.

In this study, 94% of patients were able to successfully transmit images to physicians for review. Education of patients before discharge regarding how to take a clear, detailed image of the wound is paramount. Practice photographs should be taken, and a written list of directions should be sent home with the patient. Younger generations and people with frenetic schedules may be especially inclined to submit photographs. Because pa- tients may have difficulty recognizing a wound complication, the ease of sending a photograph to a dedicated phone number or e-mail address for review by a physician may be appealing to many patients and practitioners.

Erica Michiels, MD ²

Department of Emergency Medicine, Spectrum Health, Grand

Rapids, MI Department of Emergency Medicine, Michigan State University

College of Human Medicine Corresponding author at: 15 Michigan St NE, Suite 701, MC 038 Grand Rapids, MI 49503. Tel.: +1 616 267 0122

E-mail address: [email protected]

Lindsey Ouellette, MPH ¹ Collen Bush, MD 2 Eric VanDePol, MD 2 Tiffany Fleeger, BS 2 Jeffrey S. Jones, MD 2

Department of Emergency Medicine, Spectrum Health, Grand Rapids, MI Department of Emergency Medicine, Michigan State University

College of Human Medicine

¹ 15 Michigan St NE 420-B, Grand Rapids, MI 49503.

² 15 Michigan St NE, Suite 701, MC 038, Grand Rapids, MI 49503.

http://dx.doi.org/10.1016/j.ajem.2016.10.033

0735-6757/(C) 2016

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Figure. Exemplar photographs submitted by an adult (top) and pediatric (bottom) patient.

References

1. Seamon M, Lammers R. Inability of patients to self-diagnose wound infections. J Emerg Med 1991;9:215-9.
2. Tsai HH, Pong YP, Liang CC, Lin PY, Hsieh CH. Teleconsultation by using the mobile

   camera phone for remote management of the extremity wound: a pilot study. Ann Plast Surg 2004;53(6):584-7.

   Halstead LS, Dang T, Elrod M, Convit RJ, Rosen MJ, Woods S. Teleassessment compared with live assessment of pressure ulcers in a wound clinic: a pilot study. Adv Skin Care 2003;16:91-6.

3. Ottawa (ON): Canadian Agency for Drugs and Technologies in Health. Personal wireless device use for wound care consultation: a review of safety, clinical benefits, and guide- lines. http://wwwncbinlmnihgov/pubmedhealth/PMH0071147/pdf/PubMedHealth_ PMH0071147pdf; 2014. [Accessed March 2016].

   comparative analysis of five methods of emergency zipper release by experienced versus novice clinicians

   

   The entrapment of penile tissue (foreskin, shaft, or glans) within the actuator or teeth of a zipper accounts for one of the most common genital injuries in young boys [1]. Literature suggests that zipper injuries are relatively uncommon, and that localized edema and pain are the most common outcomes, with significant injury such as skin loss and necrosis occurring rarely [1,2]. The purpose of our study was to compare five common techniques for releasing zipper-entrapped skin using an animal model.

   This was a prospective, randomized trial using an animal model consisting of chicken skin firmly entrapped by a metal zipper on a pair

   of denim jeans. Volunteers consisted of 12 Emergency Medicine (EM)	Technique	Success rate	procedure times
   physician faculty and 18 medical students (novice clinicians). During the simulation lab, participants were taught the five common tech-		Novice (N = 18)	Experienced (N = 12)	Sec +- SD (N = 30)
   niques for releasing zipper-entrapped skin: 1) cutting the median bar, 2) using a screwdriver to separate faceplates, 3) manipulation of the	Cutting median bar Rotating screwdriver	53% 35%	57% 29%	126.0 +- 110.0 131.6 +- 90.5
   zipper using mineral oil lubricant, 4) lateral compression of the zip fas-	Mineral oil	94%	100%	53.9 +- 25.6
   tener using pliers, and 5) removal of teeth of the zip mechanism using trauma scissors [2-6]. The order in which the techniques were	Lateral compression Cutting zipper, pulling teeth apart	24% 77%	14% 86%	137.1 +- 96.9 136.7 +- 71.2

   performed by each volunteer was chosen by a random number genera- tor. Subjects were timed by evaluators using a digital stopwatch from the time they began until the successful release of the entrapped skin, or for five minutes, whichever came first. Success was defined as the re- lease of the entrapped skin while minimizing trauma to the skin. Failure to successfully release the skin within five minutes, or causing full thick- ness laceration to the skin, were logged as failures.

   Overall, procedure times were 16.2 s faster for EM faculty compared to students (P b 0.05), however success rates did not vary significantly (Table 1). Manipulation of the zipper using mineral oil lubricant was the most successful technique in novice (94%) and experienced (100%) clinicians. Because of the small number of successful procedures, the indi- vidual times in student and EM physician groups were pooled. Gentle ma- nipulation of the zipper using mineral oil lubricant was the quickest technique among novice or experienced clinicians (53.9 +- 25.6 s), follow- ed by cutting the median bar (126.0 +- 110 s) and use of a screwdriver to widen the faceplates (131.6 +- 90.5 s). The procedure that was least trau- matic to skin involved cutting the closed teeth of the zipper using trauma scissors, permitting the unzipping the zipper from the distal end. Gentle manipulation was the preferred technique overall, followed by cutting the closed teeth of the zipper using trauma scissors (Table 2).

   This is the first randomized trial to compare the five types of methods for releasing zipper-entrapped skin. Based on our animal model, the preferred technique is simply gentle manipulation of the zip-

   Table 1

   Success rates and procedure times for novice and experienced clinicians.