A Case Series
This case series describes the utility of a live feed body-camera system in an EMS system to guide medical direction and decision making.
Abstract
Body-worn camera systems, though common in law enforcement, have been slow to develop in EMS agencies to date. Video recording of prehospital calls offer some significant benefits such as standardized quality improvement and the ability to augment EMS education. Novel technologies have now allowed for live streaming of video, allowing for real time medical direction and telemedicine. The current paper describes a case series utilizing a new live streaming feature of the Axon (Scottsdale, AZ) body-worn camera. An EMS assistant medical director utilized live streaming in the Cypress Creek EMS system (Harris County, TX) to provide online medical direction to EMTs and paramedics on scene. This case series suggests that live feed telemedicine provides additional data for medical direction in order to inform and direct decisions to allow for the highest quality of medical care. Additional considerations for body-worn camera systems in the prehospital environment are discussed.
Introduction
Although there has been a tremendous growth of body-worn cameras among law enforcement agencies across the United States in the last decade, there has been relatively few EMS agencies that have adopted similar systems. One such early adopter of a body camera system has been Cypress Creek EMS (CCEMS) agency north of Houston, Texas. Having initially trialed body-worn cameras in 2013, they became the first agency in the United States to utilize the Axon 2 body-worn cameras in 2019.1 Worldwide, EMS systems such as London Ambulance Service and the Australian South Wales Ambulance have recently incorporated body camera devices.2,3 Of note, a recent German study demonstrated that there were no significant differences in patient outcomes between having an EMS physician on scene verses a telemedicine EMS physician.4
There are several reasons why an EMS agency would want to incorporate a body-worn camera system. First, recordings of encounters can be used in review programs in order to improve the quality of care for the patient. Accessing and reviewing recorded data from calls is not a new concept. For example, data analysis has been used over the years in cardiac monitor downloads during cardiac arrests to provide key metrics such as hands-on time, compression rates and depths, 12-lead ECG data, defibrillations, and return of spontaneous circulation time with subsequent vital sign trends. Video call review provides an abundant amount of information that can guide a variety of aspects of EMS education and patient care from proper use of equipment and procedures, common system problems and appropriate clinic decisions and interventions.
Some body-worn camera systems now allow for real time monitoring. This allows a supervisor or medical director to make real-time patient management and safety decisions. Any unprofessional or unethical conduct can also be addressed. Details in a patient care report can be difficult to recall in complex cases. Dedicating a recorder may or may not be possible with limited personnel. Video from patient encounters can be used by EMS personnel to augment charting, making it more accurate. Higher-quality patient documentation, which minimizes inaccuracies, has been demonstrated using video from body camera systems in a pilot study for an EMS agency in Hennepin County, Minnesota.5
Related
- Can You See Me Now? Body-Worn Cameras in EMS
- Body Cameras in EMS
- The EMS Handoff: Body-Worn Cameras in EMS with Bradley, Eric, and David
Body cameras in an EMS system also have the ability to change behavior. The effect of body cameras in law enforcement officers may create more self-awareness, resulting in positive impacts such as a reduction in force and decreased citizen complaints.6 Self-awareness and accountability of events being recorded of both EMS and patients has a similar potential to lead to de-escalation and improved communications and patient care.7 Video evidence of events additionally can provide legal backing for incidences that lead to allegations or refusals of care. For example, a short clip that a bystander may record of an incident may be very differently viewed when reviewing the entirety of the patient encounter in multiple perspectives. Though body-camera systems may initially seem intrusive to EMS personnel, a study from the British Paramedic Journal demonstrated the majority of paramedics saw body-worn cameras as a positive step for the service.8 Another recent survey study indicated that most paramedics agreed or were neutral with the concept that telemedicine improved the patient care experience especially in diagnosis and patient satisfaction.9
There are several concerns regarding body camera systems in EMS systems that warrant further discussion. First are those concerning the Health Insurance Portability and Accountability Act of 1996 (HIPAA). HIPAA provides legislation for how personal identifiable information is maintained. Common body camera systems incorporate many safeguards in the protection of protected health information (PHI). For example, the Axon system provides audit trails for those accessing data, secures encryption through dual authentication and restricted IP addresses, removes data from the device when uploaded, tracks all cameras, uses proprietary software and stores on secure servers consistent with state and federal laws.10 EMS video recordings are handled as patient care records. It is important that patient data security remains a priority when utilizing a body camera system. There are also concerns that arise due to state and local laws. Patient invasion of privacy concerns and public right to know laws are state legislation issues that need to be thoroughly investigated and policies established before the implementation of a body camera system in an EMS system.
Case Series
This case series will focus on several patient encounters during the month of December 2020 in which CCEMS was field testing live streaming in the Axon Body 3 (AB3) cameras. CCEMS is a medium sized 911 EMS system operating fourteen full time ambulances and responding to approximately 45,000 emergency calls each year. Each ambulance is staffed with a paramedic and EMT. In this EMS system, there are several supervisor paramedics on each shift with response vehicles. They respond to higher acuity calls such as cardiac arrests, traumas and high-risk respiratory cases. Supervisor paramedics carry advanced procedural equipment and medications for interventions such as rapid sequence intubation and whole blood administration. Cypress Creek EMS had been using the Axon body cameras since 2013 for use in QA, education and as a performance evaluation tool. Personnel were therefore already accustomed to the system. During the field testing of the AB3, the EMT wore a chest mounted camera that provided a live feed. The live camera feed could be accessed on a computer or phone by certain administrative personnel over a secure connection. Video is stored on a HIPAA-compliant encrypted server that includes chain-of-custody tracking. An EMS fellow served as assistant medical director, utilizing the AB3 camera system to provide online medical direction to Cypress Creek personnel in patient management decisions. The EMS fellow had a response vehicle to respond to calls as needed. Patient information was obtained from EMS run sheets, video recordings, personal interviews with providers and personal experience.
Patient 1: EMS Physician Intercept for Airway Management
A medic unit responded to an 86-year-old female with a dispatch report of unconsciousness with ineffective breathing. Medical direction was not contacted however as the EMS fellow read the associated dispatch notes and accessed the live video feed. The patient was visibly snoring with an apparent GCS less than five. The crew provided oxygen and basic airway management. Oxygen saturation was within normal limits with a non-rebreather mask; however, the patient was not protecting her airway. A supervisor was on scene with a plan to ride in with the medic unit for a 25-minute transport to local emergency department with no advanced airway management. After continuing to watch the patient on live feed with no improvement in patient status, the EMS fellow contacted the medical unit with plans to intercept to control the patient’s airway. With the assistant medical director on scene, the patient was successfully intubated and transported on a ventilator with no further complications.
Patient 2: Hospital Destination Decision and Examination for Tamponade
Medical direction was contacted by the supervisor paramedic for a 22-year-old male with history of renal cancer, previous cardiac surgeries for congenital heart defects (with recent revision) complaining of increasing difficulty breathing. The medic unit was currently enroute with the patient to a downtown Houston hospital (where the patient’s specialist physicians were located) with an estimated time of arrival of approximately 45 minutes. Medical direction was contacted for either diversion to closest facility or to proceed enroute. The video feed demonstrated a patient with tachypnea in the low 20s with a narrow complex tachycardia in the 160s to 170s. The patient was on supplemental oxygen at two liters per minute with saturations in the upper 90s with blood pressure in the 110/70. He was speaking in full sentences with no observed accessory muscle use or tripod positioning. Considering the recent cardiac surgery, pericardial effusion leading to tamponade was within the differential. Review of the 12-lead confirmed a regular, narrow complex tachycardia with no signs of electrical alternans. The supervisor paramedic had a portable ultrasound and some ultrasound experience. Utilizing the video feed, the assistant medical director directed the paramedic to obtain sufficient cardiac views to decrease the likelihood of tamponade. Based upon this data, the decision was made to bolus the patient with 1000 mL of 0.9% sodium chloride and to continue to the original destination. Instructions were given to reassess after fluids and recontact medical direction if needed. The heart rate lowered to 140s with an improvement in blood pressure. Medical direction was recontacted at the destination facility, informing the assistant medical director that the patient’s heart rate continued to decrease to the 120s with no further complications.
Patient 3: Medical Direction Guiding More Aggressive Resuscitation
A CCEMS ambulance was on scene with a 70-year-old female with a past medical history of liver cancer and ascites. The crew was dispatched for unresponsiveness. Medical direction was not contacted and the EMS fellow activated the video feed. The patient had snoring respirations with a GCS less than five not protecting her airway. Basic airway maneuvers and respiratory support was initiated. The paramedic on scene attempted to get IV access and was unsuccessful after several attempts. Fingerstick glucose revealed a reading of 30, and Glucagon was given. The patient was then loaded in the back of the ambulance with no change in patient status. Considering patients’ hypoglycemia, no change in mental status after Glucagon, the EMS fellow instructed the paramedic to immediately obtain IO access to prevent hypoglycemic brain injury and hopefully improve airway status. The paramedic successfully placed an IO cannula and administered 10% Dextrose. The patient subsequently improved in mentation and began to protect her airway.
Patient 4: To Intubate Or Not to Intubate
Medical direction was contacted for a 70-year-old male with history of atrial fibrillation on Apixaban with left sided hemiparesis in his face, arm and leg with an onset of approximately two hours ago. No prior history of stroke existed. Medical direction was contacted for assistance with the decision to intubate. The video feed demonstrated a patient who was conscious, alert and fully oriented to person, place and events. There was no aphasia and only mild dysarthria were observed. The patient appeared to be protecting his secretions. Vital signs did not require intervention. The paramedic was instructed to withhold intubation at this time and to transport to a comprehensive stroke center as the patient was protecting his airway. Instructions were given to recontact medical control for any change in patient status and possible interception for airway control. The patient was successfully transported to the comprehensive stroke center with no further complications enroute.
Patient 5: Hospital Destination Decision with Informed Decision Making
Medical direction was contacted for a hospital destination decision regarding a 63-year-old male with difficulty breathing. The patient had a relevant history of recent intestinal surgery approximately three weeks prior, but no known lung disease. The patient was requesting he go back to the hospital where he received surgery. This would be an approximately 30–40-minute transport. Video feed was activated demonstrating a patient who is able to speak in full sentences on four liters nasal cannula with an oxygen saturation of about 90% and tachycardic to a heart rate of 110. The patient reports symptoms of generalized weakness and dyspnea that had progressively worsened over the course of a week. Lung sounds were reported to be clear. The 12-lead EKG was unremarkable. It was determined that the patient had the capacity to make informed medical decisions. The EMS fellow discussed the risks of transport if patient decompensates – up to and including death. The EMS fellow instructed the paramedic the patient currently appeared stable for transport and to divert to the closest facility and to recontact medical direction should his condition deteriorate. The patient was administered a small fluid bolus enroute with no change in status enroute to the patient’s hospital destination.
Patient 6: Patient Initiated Refusal
Medical direction was contacted for a patient-initiated refusal. This patient was a 70-year-old wheelchair-bound male with history of muscular dystrophy and recent diagnosis of COVID-19 two days prior. His wife was concerned because his oxygen saturations have been in the low 90s. He had no previous history of lung disease. The video feed was activated which demonstrated the patient in no acute distress and was speaking in full sentences with no observed accessory muscle use. Vitals were remarkable for an oxygen saturation of approximately 93% at the lowest with good waveform. The patient was afebrile with no history of fever. It was determined the patient had capacity and the EMS fellow discussed risks of refusal. A plan was made to recontact EMS should the patient’s condition worsen, and the patient was to contact the primary care physician the following morning. No known patient complications resulted from this refusal.
Patient 7: Confirmation of Death on Scene
The medic unit contacted medical direction for a shooting of a 44-year-old male with multiple gunshot wounds to torso occurring less than 15 minutes prior to arrival of EMS. The video feed was activated, revealing no signs of life. Asystole was confirmed on the monitor. The EMS fellow instructed the crew to confirm no pulse, no respirations and no further signs of life. Pronunciation of death was made of the patient based on the totality of on-scene video evidence.
Discussion
Technology has progressed such that live video feed can provide valuable information to the on call medical director in the prehospital arena. Live video feed provides an EMS physician with much more data than the traditional radio or phone. Information that can be easily conveyed with live video can be lost in voice only communications. Decisions can be rapidly made which can alter the course of care for patients using live body cameras. There are several circumstances that may yield the highest benefit in live feed systems that were highlighted in this case series.
One area for use could be in the assessment of a patient’s airway and breathing status. Airway and respiratory status may be difficult for a paramedic to convey to medical direction depending on level of experience and communication ability. Decisions either to take control of a patient’s airway through an advanced airway or to withhold definitive airway control may not always be in the best interest of the patient. EMS physicians have been trained to recognize these signs through years of residency and numerous patient encounters. They are therefore much more comfortable with making these decisions. Live video feed can convey true respiratory distress and signs of impending loss of airway instantly, leading to direction of immediate actions. Conversely it can prevent unnecessary interventions.
Live video feed allows for improved communications during refusals and hospital transport decisions. Patient refusals can be high-risk scenarios. Being able to see the living conditions of patients, observing how patients interact and respond to questioning, and picking up on other nuances on scene are all data that aid in making the best decisions for patients. Clearer communications between all parties allows for better informed decision making for clinicians and patients alike.
Having the ability for the EMS physician to log on to the live video stream to provide assistance during a complex call can be of tremendous benefit to the team. A systematic review in Europe showed that real time telemetry between the tele-emergency physicians and EMS were associated with higher treatment quality and shorter time to treatment in invasive procedures in the setting of trauma.11 Directing the team to be more aggressive with the airway or peripheral access, recommending certain medications, or helping with the diagnosis can greatly affect the outcome of a critically ill patient. Aid with diagnosis decisions could decrease the time from symptom onset to treatment especially in critical patients. Stroke is one example. A recent meta-analysis evaluating 6,605 patients treated with tissue plasminogen activator (tPA) demonstrated that ambulance telemedicine was significantly associated with decreased time from symptom onset to hospital arrival with no increase in adverse events.12
Crucial information can also be obtained while enroute to a call. Though safety measures should clearly take precedence when driving and accessing the live feed, vital information such as airway and breathing status, pertinent history, and needed supplies can be obtained prior to arrival on scene by watching the live feed. Interruption to the team on scene may not be necessary in the majority of circumstances. There are benefits to simply observing calls in real time. Observing patient care and only intervening if necessary does not cause interruption and can help a medical director gain a sense of common system errors and ways to improve patient care.
Termination of resuscitation and dead-on scene are additional scenarios in which live video feedback may be beneficial. In cardiac arrests, video feed can confirm EKG rhythms, ensure appropriate interventions were made, aid with examination for signs of life, and help to make any final recommendations and discussion with family before ceasing efforts and pronouncement of death. Live feed for medical direction on a presumed death on scene can be used to confirm signs incompatible with life, rigor mortis and livor mortis or to instead initiate resuscitative efforts. Visual feedback may provide additional details that were not conveyed over the phone or radio and could change management.
EMS body cameras which utilize live feed is a novel modality which offers future potential in the prehospital environment. As video streaming technology improves, these camera systems may be more frequently incorporated into EMS systems. If patient information remains secure, live body cameras can be a useful tool for medical directors and medical supervisors in assuring the best care possible for each patient.
Limitations
The primary limitation of this study is that it is a retrospective case series involving a small number of patients. While the results suggest increased scene awareness and data for decision making by an online medical director, further studies are needed to determine utility and feasibility across systems. The medical decisions made by the online assistant medical director are representative of one EMS system and one physician. At the time of this study, the AB3 cameras only allowed for video and audio streaming at the physician end and did not utilize the built-in speaker for two-way communication. The physician therefore had to utilize a mobile phone in order to be heard at the other end. As technology improves, two-way communications which allow for the visual and audio feedback of the physician can provide for better communications on scene with EMS personnel and patients.
Conclusion
This case series describes the utility of a live feed body-camera system in an EMS system to guide medical direction and decision making.
References
1. Partridge C. First EMS Provider Joins Axon Network with Full Body Camera Deployment for Paramedics. Axon. (https://www.prnewswire.com/news-releases/first-ems-provider-joins-axon-network-with-full-body-camera-deployment-for-paramedics-300774453.html).
2. Donnelly L. Paramedics to be given body cameras to protect them from violent patients. The Telegraph 2018 (https://www.telegraph.co.uk/news/2018/06/30/paramedics-given-body-cameras-protect-violent-patients/).
3. Lackey B. REVEALED: The extreme lengths paramedics are taking to stop them being used as ‘punching bags’ by aggressive patients. DailyMailcom. Daily Mail Australia. (https://www.dailymail.co.uk/news/article-7704965/Paramedics-trial-wearing-body-cameras-stop-punching-bags.html).
4. Quadflieg LTM, Beckers SK, Bergrath S, et al. Comparing the diagnostic concordance of tele-EMS and on-site-EMS physicians in emergency medical services: a retrospective cohort study. Sci Rep 2020;10(1):17982. (In eng). DOI: 10.1038/s41598-020-75149-8.
5. Ho JD, Dawes DM, McKay EM, et al. Effect of Body-Worn Cameras on EMS Documentation Accuracy: A Pilot Study. Prehosp Emerg Care 2017;21(2):263-271. (In eng). DOI: 10.1080/10903127.2016.1218984.
6. Ariel B, Farrar WA, Sutherland A. The Effect of Police Body-Worn Cameras on Use of Force and Citizens’ Complaints Against the Police: A Randomized Controlled Trial. Journal of Quantitative Criminology 2015;31(3):509-535. DOI: 10.1007/s10940-014-9236-3.
7. Ho J, Hick J, Nystrom P, Simpson N, Jones G, Miner J. 6 Effect of an EMS body-worn camera. BMJ Open 2019;9(Suppl 2):A3-A3. DOI: 10.1136/bmjopen-2019-EMS.6.
8. Dewar A, Lowe D, McPhail D, Clegg G. The use of body-worn cameras in pre-hospital resuscitation. Br Paramed J 2019;4(2):4-9. (In eng). DOI: 10.29045/14784726.2019.09.4.2.4.
9. Simon LE, Shan J, Rauchwerger A, et al. Paramedics’ perspectives on telemedicine in the ambulance: a survey study. JEMS 2020;4(30):20.
10. Ems CC. First EMS provider in the United States to roll out Axon’s Flex 2 cameras. (https://www.ccems.com/about-ccems/axon-cameras/).
11. Eder PA, Reime B, Wurmb T, Kippnich U, Shammas L, Rashid A. Prehospital Telemedical Emergency Management of Severely Injured Trauma Patients. Methods Inf Med 2018;57(5-06):e1. (In eng). DOI: 10.3414/me18-05-0001.
12. Baratloo A, Rahimpour L, Abushouk AI, Safari S, Lee CW, Abdalvand A. Effects of Telestroke on Thrombolysis Times and Outcomes: A Meta-analysis. Prehosp Emerg Care 2018;22(4):472-484. (In eng). DOI: 10.1080/10903127.2017.1408728.
