DIU de pédagogie médicale

Année 2015-2016

Apport des nouveaux outils numériques en santé.

Expérience du projet ECHOES pour la formation

médicale.

Dr JM Davaine, Chirurgie vasculaire, CHU Pitié-Salpêtrière

Sommaire

I- Introduction

II- Article

a. Introduction

b. Matériel et méthodes

c. Résultats

III- Références

IV- Discussion

V- Figures et tables

Introduction

La santé est désormais connectée. Internet apporte son lot quotidien d’innovations et a

littéralement bouleversé le monde tel que nous le connaissions il y a une vingtaine d’année.

Le domaine de la santé, malgré toutes ses spécificités, n’a pas fait exception à la règle. Notre

façon de travailler au quotidien a été transformée par les nouvelles technologies et les outils

numériques de même que notre façon de nous maintenir informés et de consommer le savoir

médical. La vague numérique continue de déferler sur notre profession. Les "GAFA"

(Google, Amazon, Facebook, Apple) vont-ils supplanter les acteurs traditionnels de la santé

comme dans d'autres secteurs ? Il paraît fondamental que nous soyons acteurs de cette

transformation.

Concernant l’enseignement, la génération d’étudiants en médecine actuelle ne consomme pas

et ne conçoit pas les outils numériques de la même façon que les générations précédentes qui

ne sont pas nées avec internet. L’enjeu pour les enseignants-chercheurs est double : tirer le

maximum du potentiel de ces nouvelles technologies dans le domaine de la santé et d’autre

part tenir compte du public à qui il est destiné.

Ce projet trouve son origine dans le monde du jeu vidéo et des « gamers . Nous nous sommes

particulièrement intéressés aux jeux vidéos en ligne et à leur système de diffusion qui a la

particularité d’être bon marché. Par ailleurs, ce projet associe la Chaîne de l’Espoir (CDE) et

le service de chirurgie vasculaire de La Pitié Salpêtrière. La CDE est une association

humanitaire dont l’objectif est d’assurer la prise en charge chirurgicale d’enfants vivants dans

des pays où ils ne peuvent pas accéder aux soins qui leurs sont nécessaires. Une partie

importante de l’activité de la CDE concerne la chirurgie cardiaque infantile. Des missions

sont réalisées dans les pays en difficulté ou bien des enfants sont accueillis en France pour

bénéficier de soins adaptés. D’autre part la CDE s’est fixée une mission d’enseignement des

personnels de soins locaux afin de tendre vers l’autonomisation de ces derniers. Le constat

récent de la CDE est sans appel. Les pays où se font les missions, au Moyen Orient ou en

Afrique sont de moins en moins accessibles pour des raisons d’actualités tristement connues

de tous. Pour ces mêmes raisons, il devient de plus en plus difficile de faire venir des enfants

et du personnel étranger pour, respectivement, les soigner et les former. Parallèlement, la

planète en général et ces pays en particulier sont de plus en plus connectés (figure 1). Fort de

ce double constat, la CDE a créé la Chaîne du savoir (CDS) qui vise à utiliser les nouvelles

technologies pour améliorer les soins prodigués à ces enfants et promouvoir l’enseignement et

l’autonomisation des personnels soignants locaux. Cette expérience a impliquée le Professeur

Daniel Sidi, cardiologue pédiatre à Necker, M Rémi Rousseau, ingénieur polytechnicien,

Mme Agathe Metel, coordinatrice du projet, le Dr Eric Cheysson, président de la CDE et chef

de service de chirurgie vasculaire à l’Hôpital de Pontoise et moi-même.

Nous rapportons ici comment nous essayons d’utiliser les nouvelles technologies numériques

pour les mettre au service de la santé à travers une expérience baptisée projet ECHOES.

L’introduction, les méthodes et les résultats sont rapportés en anglais et correspondent au

travail en cours de rédaction et que nous souhaitons soumettre très prochainement. La

discussion est en français et est orientée vers les perspectives pédagogiques de ce travail. En

effet, les applications pédagogiques plus locales nous paraissent prometteuses et nous

transposons actuellement cette expérience au sein du service de La Pitié-Salpêtrière pour y

développer un outil d’enseignement pratique en médecine vasculaire. De plus, nous y

introduisons le deuxième volet de ce projet qui est actuellement en cours. Il s’agit d’utiliser la

vidéo peropératoire comme outil pédagogique pour le chirurgien vasculaire en formation et

pour les étudiants en médecine.

Article

Title:

The ECHOES project: the use of live streaming echocardiography to share medical

knowledge and to improve screening of children for cardiac surgery: proof of concept

and preliminary experience from the french humanitarian organization La Chaîne de

l’Espoir

Introduction

The use of telemedicine has considerably developed over the last decade and fulfills the need

of rapid medical advice in various fields such as general medicine, dermatology, diabetes

mellitus (1-3). Telemedicine has also a critical potential in terms of educational purposes.

Progress of new technologies have proven useful in situation where medical advice is required

in difficult to access areas whether because they are remote (4,5) or politically dangerous.

Several attempts with encouraging results have been made in the field of echocardiography

(6) and emergency echography (7).

La Chaîne de l’Espoir (CDE) is a humanitarian organization which goal is to fight against the

injustice of birth and allow optimal treatment for children with untreatable diseases in their

country. To do so, CDE has organized either the transfer of children in France to be treated

properly and sent back to their country and family or even better, as often as possible, to

ensure that the local abilities are able to treat those children through their own medical

institutions.

In the field of cardiology, CDE has helped in the construction, equipment, and training of

medical, paramedical and administrative local people. This experience was accomplished in

several institutions like in Vietnam in the early 90th, Cambodia in the late 90th, Mozambique

and Afghanistan in the early 2000th. The CDE fosters the development of these institutions

towards self sufficiency through medico surgical missions. Currently, the CDE is present in

around 30 countries. Beside the 4 institutions aforementioned, CDE has a local desk with

either representant having knowledge in pediatric cardiology (13 countries) or a doctor

without echography (11 countries). Every year, around 800 children with heart disease are

operated on either in France (about 200) or locally, especially from congenital heart diseases.

Before 2015, we had to multiply missions to expertise patients and train cardiologists that

used to spend 1 or 2 years in France. Over the last years, the missions have become

increasingly dangerous in these countries. Access for NGO members is frequently forbidden

by the french government. As a result, the number and length of the missions are decreasing.

Moreover and for similar reasons, it is becoming much more difficult to train foreign doctors

or nurses in France. A critical issue remains the inaccuracy of preoperative assessment.

Currently, 1 out of 10 children who were initially suggested by local physicians for a surgical

treatment are finally deemed not fit to undergo surgery. The reason lies in the lack of fully-

formed personnel to thoroughly and accurately evaluate these children in the preoperative

period. As a consequence, missions cannot be prepared as effectively as necessary. Medical

device and staff cast for the missions cannot be sufficiently anticipated because of the lack of

accurate information, resulting in impossibility to perform surgeries and preventing some

children to be treated properly.

Since February 2015, we have introduced telemedicine in our practice. New technologies

represent an opportunity to improve our access to these children in need of medical care and

to share medical knowledge with local physicians. What was initially seen as an opportunity

has clearly evolved into a necessity. CDE has thus created La Chaîne du Savoir (Chain of

Knowledge, CDE) (figure 2) to tackle these issues by using the latest available technologies.

We decided to use live streaming technology applied to echocardiography to screen children

that are good candidates for heart surgery. In this project, called the ECHOES project, a very

accomplished tool has been set up to allow CDE experts, having a deep knowledge of these

countries, to supervise pediatric cardiology consultation in collaboration with local

physicians. The aim of this project is twofold: provide real time specialized advice for

patients presenting in remote hospitals and train the local medical team to reach self-

sufficiency (North- South collaboration). Also, this project aims at setting up the missions, in

terms of medical devices and staff, as sharply as possible. Further, this project aims at helping

foster the development of a local network (south- south collaboration). We report our

experience with the first center in Cambodia, while two other centers have joined the program

since.

Methods

Population

All children were treated in «Le pavillon des enfants cardiaques », a center specialized in

pediatric cardiology, in Phnom Penh, Cambodia. Children presenting with cardiac

insufficiency symptoms were examined in this center. After a first local screening, children

were scheduled for a live echocardiographic session.

Live streaming sessions

Sessions took place on a weekly basis according to a predefined schedule with a number of

patients ranging from 5 to 10. Beforehand, a medical summary including local conclusions

was sent by email to a CDE expert. Before the session, children were locally examined and

an email with details of the session was sent to the CDE. The same expert supervized the

sessions in Paris along with a cardiac surgeon.The session consisted in a clinical and

echocardiographic examination ran by the referent cardiologist in Phnom Penh under the

supervision of our experts. Four physicians were available in Phnom Penh, one considered as

a senior and local expert, and the three others were in training. In Paris, our experts had on

one screen, in real time, the exact same image that was acquired by the echocardiographist in

Cambodia. On a second screen, a live image of the patient was also on display to provide

additional clinical information (figure 2). Cambodian surgeons, others physicians involved in

the care of the children, as well as fellows and trainees were also present to discuss each case

with the CDE staff. At the end of each session a decision was made as to whether the patient

should undergo surgery or should proceed with medical treatment or alternatively should

undergo further investigation.

Technical aspects

The equipment used is cheap and widely available. There are two technical aspects to be

solved to start a session: (i) getting a video feed for an echo machine to a computer and (ii)

being able to livestream the video feed to this computer.

- getting a video feed for an echo machine to a computer

Videogame Live broadcasting has become a very popular practice in the last years with the

emergence of platforms like Twitch (http://www.twitch.tv/) that allow anyone to broadcast

their videogame session. It has opened an interesting market for video capture devices used by

streamers to connect their TV screens to a computer. Those devices are inexpensive (<500$)

and performant. Ultrasound machines are almost always equipped with a video output, though

the nature of the connector varies between different machines: it can be DVI-D, S-video,

HDMI, VGA. We tested different video capture devices and had great success with two: the

Elgato Game Capture HD, because it supports retrogaming (recording videogame sessions on

old consoles), is equiped to handle a lot of different connectors but it doesn’t support all

resolutions. More recently, we also had great success with the Ephiphan AV.io capture device

which transforms the video feed from the echo machine into a virtual camera recognized by

the PC. One of our objectives in the future developments is to build a database of every

ultrasound machine available and detail the precise process and hardware to get a video feed

from them available for streaming, which will be available on the Echoes platform. Those

video capture devices have to be connected to a recent laptop or desktop computer that can

handle the live video decompression.

- being able to livestream the video feed to this computer

Being able to broadcast live is critical for the quality of the session. We benchmarked several

software solutions and ended up with the Vidyo solution, which delivers the best quality with

the lowest bandwith available. The bandwith available is indeed the critical technical issue in

the project and it has to be superior to 1Mbps to deliver a good enough quality for

interpretation. The Vidyo feed can then be embedded in a webpage with the Vidyo API or

visualized on a smartphone with the Vidyo app. An aditionnal camera connected to the

broadcasting PC allows to broadcast both the video feed for the ultrasound machine and the

videofeed from the patient. A mike and speaker are necessary. The overall aditionnal cost of

the installation was inferior to 500$: it’s the cost of the video capture device, cables and an

additional camera. The PC that serves for the broadcasting was already there.

A cost to take in consideration in some countries would be the bandwith cost, which vary a lot

from place to place.

Results

Since 2001 around 4500 procedures (catheterisms or surgical procedures) have been

organized by the CDE organization in Phnom Penh. The present echo-experience has begun

in February 2015. After 15 months (until May 2016), a total of 253 cases have been treated in

the setting of this project. A mean of 7 children were examined per session, which occurred

on a weekly basis. The mean length of a session was 41.8 min. The mean time spent with each

child was 6.5min. The mean age of the children was 4.3 years old at the time of examination.

Typical proceedings of a session has been displayed on national television and can be seen on

the following link: http://www.francetvinfo.fr/sante/soigner/medecine-humanitaire-realiser-

une-echographie-a-distance_1442929.html These children suffered from ventricular septal

defects in 83 cases (32.8%), tetralogy of Fallot in 78 cases (30.8%), atrial septal defects in 35

cases (13.8%), persistent ductus arteriosus in 15 cases (5.9%) and other diagnosis in 42 cases

(16.7%) (Table 1). In all cases the children examined with the CDE expert during an echo-

session had been previously examined by the local team. Ultimately, the sessions were

characterized by two main scenarios. Whether the diagnosis was confirmed, or in contrast

straighten up by the CDE expert. At the end of a session, the children examined were

scheduled for a surgery/ catheterism by the local team or during a foreseeable mission of the

CDE in Cambodia. Alternatively, the children could be re-scheduled for another session if

further workup was required. A total of 171 (67.6%) procedures have been performed during

this period, including surgical procedures in 146 cases (85.4%) and therapeutic catheterisms

in 25 cases (14.6%). Nine postoperative death occurred due to multiple organ failure in

intensive care unit in 4 cases, pulmonary failure in 2 cases, cardiac insufficiency in 2 cases

and from unknown cause in one case (the patient died at home after discharge) (Table 1). The

other 162 patients are alive and are still followed up by the local team and by echo-session

when necessary. As for the other patients they are not yet operated on, considered as no

indication for surgery, lost to follow up, or refused surgery, or sometimes diagnoses too late

to undergo surgery.

The first main impact of this experience that we noted is the way CDE organizes its

missions. Previously, every three or four months, a team (surgeons, pediatricians,

cardiologists, anesthetists, nurses) was sent to Cambodia with medical equipment. Human and

technical means were chosen to be as accurate as possible. The first day of the mission a large

number of children were screened in order to determine the best candidates for surgery. A lot

of children could not be treated due to late diagnosis or due to the lack of appropriate medical

equipment. Since the beginning of this experience the way the missions are set up have

dramatically evolved. Several children (around 7) are examined every week. Diagnosis are

ascertained by our experts. As a result CDE team is able to schedule the missions almost as

sharply as it would be done in one of our local hospital in current practice. Medical material

and physicians are chosen according to a pre-defined schedule. Most importantly, the delay

between a first local consultation and diagnosis has considerably diminished for the children.

The second main impact that we have noted is the benefit in terms of transfer of

knowledge. The local team is made of 1 senior cardiologist and 5 cardiologists in formation.

Every child presented during a live session were previously evaluated by the local team. This

project offered the local cardiologists a comprehensive hands-on training with strong follow-

up with our experts. After 15 months of experience, both our experts and the local team had a

strong feeling that considerable progress had been made towards self-sufficiency. The mean

length of the sessions remained similar, but as we went on this project, more time was spent

on training and education as less time was necessary to straighten up incorrect diagnosis. It is

important to emphasize that both teams had a deep knowledge of each other through many

previous missions, which was, according to us, a key component to the success of this

experience.

Finally, this experience has proven very efficient in terms of technical success.

Provided that the two centers have a good internet connection, this protocol almost never

faced technical failure in our experience. Moreover, this good technical result was achieved at

a very affordable price (less than 500$). As a result, the CDE is currently spreading this

plateform to other countries (Mali, Afghanistan, Kenya, Senegal). A hub is being launched by

the CDE to allow access to other centers through a very straightforward process (figure 4).

Discussion

Cette experience de télé-échographie en direct est une opportunité qui s’est transformée en

une nécessité. Ce qui au départ était une tentative visant à pallier à un problème d’accès à ces

pays a finalement transformé la pratique de la CDE dans la façon de monter ses missions et de

transmettre le savoir medical aux équipes locales. Le délai d’accès des enfants à un examen

complet est raccourci. Il en découle que le délai d’accès au bon traitement est également

écourté. La qualité de l’examen est excellente: l’image du patient, le son et la capture

échographique sont d’excellente qualité. Des expériences similaires sont mise en place par la

NASA ou l’agence spatial européenne ou à distance entre centres de pointe. L’originalité de

l’approche est son faible coût, ce qui n’est pas le cas des autres programmes et de plus son

bénéfice en terme de pédagogie. Un véritable contrôle continu et une véritable formation dans

la durée est rendue possible par cette approche.

Les limites scientifiques de ce travail sont évidentes. Nous n’avons pas pu montrer de

bénéfice en terme de mortalité, de délai de prise en charge, de complications, de manière

objective. La raison est que ce travail n’était pas prévu au départ pour cela. Actuellement, la

plateforme ECHOES s’ouvre à d’autres centres (Sénégal, Mali, Afghanistan) et en parallèle

un outil de database prospective est mis en place afin d’objectiver cette activité de la manière

la plus scientifique possible.

Les applications pédagogiques locales sont certaines. Nous transposons actuellement cette

expérience au sein du service de chirurgie vasculaire de La Pitié-Salpêtrière. Tous nos

patients opérés bénéficient d’un examen écho-doppler avant leur sortie auprès des médecins

vasculaires du service. Cette équipe assure une formation en échographie vasculaire dans le

cadre d’un DIU (DU Ultrasonographie Vasculaire). Les enseignements pratiques sont

difficiles à organiser et les enseignants et enseignés se plaignent d’un manque de suivi dans le

temps. L’apprentissage de l’échographie vasculaire nécessite en effet une formation pratique

et sur le moyen voire le long terme. Nous mettons actuellement en place ce système afin de

pouvoir échanger, via la platerforme de la chaîne, avec tous les participants de ce DIU.

Beacoup d’entre eux sont praticiens (urgentistes, cardiologues, internites, médecins

vasculaires en formation, chirurgiens vasculaires) et exercent en dehors de Paris et pour bon

nombre d’entre eux dans les pays du maghreb. Ce système permettra aux volontaires de

soumettre des cas de patients en direct aux médecins réfèrents du service lors de sessions

programmées. Nous espérons un résultat similaire à celui présenté ici.

La suite de ce projet au sein de la CDS est de developer un versant chirurgical, ce qui est en

cours. Un système de capture de video a été mis au point en collaboration avec l’ingénieur

travaillant sur ce projet. Deux caméras GoPro synchronisées sont fixées sur un casque.

L’opérateur, équipé du casque, peut capter ses interventions. Des applications légères sur

smartphone permettent d’éditer facilement la vidéo. Celle-ci peut être utilisée comme une

video standard ou utilisée en réalité virtuelle en utilisant un casque type Occulus rift.

Là encore le coût est très modéré (moins de 1000 euros d’équipement). Les applications

envisagées sont: de créer une banque de vidéos chirurgicales; d’utiliser ces vidéos comme

outil de progression pour les chirurgiens en formation, comme un sportif de haut niveau

pourrait le faire. D’utiliser la réalité virtuelle pour améliorer l’expérience, en consultant le

contenu avec les yeux de l’opérateur. Ainsi, un étudiant en médecine pourrait “s’immérger”

dans une salle opératoire, un chirurgien pourrait “s’immerger” en direct et à distance dans la

vue opératoire d’un collèguee et le conseiller, le guider au cours d’une intervention. Là aussi

nous pensons que les applications Nord-Sud et locales, plus académiques, sont nombreuses.

Références

1- J Am Coll Cardiol Img 2014;7:799–803.

2- J Am Soc Echocardiogr 2013;26:221–33.

3- J Am Coll Cardiol Img 2014 ;7:810-811

4- MEDINFO 2015: eHealth-enabled Health ; 2015 : 1-61499-564-7-937

5- IEEE Communications Magazine 2006;44(4):41-8.

6- International Journal of Telemedicine and Applications 2015 ; Article ID 504015

7- Telemed J E Health. 2015 Sep 16

Figures

Figure 1 : Couverture internet prévue en Afrique sub-saharienne, projection 2019

Figure 2 : logo de la chaîne du savoir

Figure 3 : Déroulement typique d’une séance

Paris Phnom Penh

Figure 4 : plateforme échographique en cours d’installation

Tables

Table 1

Pathologies N (%) Opérés Cathétérisme Décès

CIV 83 (32,8%) 42 1 3

T4F 78 (30,8%) 70 5

CIA 35 (13,8%) 9 11 1

PCA 15 (5,9%) 10 4

CAV 9 (3,5%) 7

APSO 4 (1,6%) 0

RM 6 (2,3%) 3 3

IM 4 (1,6%) 2

RA 6 (2,3%) 3

SP 6 (2,3%) 0 6

VM bio 1 (0,4%)

Mal Ebstein 2 (0,8%)

CMD 1 (0,4%)

S. Mediov 1 (0,4%)

HTAP Ir 1 (0,4%)

Sd Klippel T. 1 (0,4%)

Total 253 (100%) 146 (57,3%) 25 (9,9%) 9 (3,6%)