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Strode et al. The utility of telesonography was demonstrated in several studies when applied within a clinical context [ 15 , 17 , 22 , 24 , 27 ]. In addition to benefits that resulted directly from access to ultrasound imaging some authors also described incidental benefits from a telemedicine link to specialists, such as advice on patient management [ 22 ].

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Several articles also considered the qualitative reactions of medical staff to telesonography [ 17 , 22 , 30 , 36 , 39 ]. These were mostly positive, with the majority of users remarking on benefits to patients [ 17 , 22 ], positive learning experience [ 17 , 22 , 30 ], ease of use and applicability [ 36 ].

However, the study by Sibert et al. Telesonography was considered as a teaching tool in several studies [ 17 , 18 , 20 , 22 , 27 , 29 , 30 , 38 ]. There is evidence that it is feasible to tele-mentor or remotely support novices with medical and non-medical backgrounds [ 15 , 17 , 18 , 20 , 22 , 27 , 28 , 29 , 30 , 31 , 35 , 36 , 37 ]. Evaluative work comparing tele-mentoring to onsite mentoring suggests that there is no significant difference between time taken and success rate of image acquisition between onsite and remote mentoring [ 29 ]. Two papers found that telesonography with remote mentors had almost equivalent sensitivity and specificity to conventional ultrasonography in a range of scenarios [ 25 , 42 ].

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The use of tele-mentored telesonography was described as beneficial in clinical practice in several instances [ 15 , 17 , 22 ]. Furthermore, the use of tele-mentoring was viewed in a positive light by both physicians performing and observing telesonography [ 17 , 22 ] and improved the skills of participants [ 17 , 22 , 27 , 30 , 36 , 39 ]. The use of minimally trained operators and asynchronous transmission resulted in a low proportion of usable images: In all articles in which didactic teaching or telementoring was provided there was minimal description of the protocols and supportive materials used and there was concern over the methodological quality of a subset of articles assessing telementoring.

Most papers in this review have included a proportion of patients found outwith the emergency setting. As a consequence studies may contain findings that cannot be replicated when the additional challenges of pure emergency medicine are imposed. Nonetheless, there was evidence from these articles that telesonography could be used to identify variety of abnormalities relevant to emergency medicine such as the presence of peritoneal fluid or pneumothorax [ 15 , 18 , 21 , 24 , 27 , 29 , 30 , 31 , 34 , 38 ].

Only one telesonography system was used in the setting of resuscitation and in this case it was reported that telesonography was a beneficial addition to the emergency department [ 17 , 22 ]. Paediatric cases were considered in two articles [ 25 , 26 , 42 ] which found strong evidence to support the feasibility of tele-mentored ultrasound, although this was somewhat less sensitive A range of scan views were considered and the evidence within each of these is discussed in Table 3. There were also a number of simulation studies which considered less conventional field hospital and prehospital applications of telesonography [ 16 , 23 , 28 , 34 , 35 , 36 , 38 , 39 , 40 , 41 ].

Of these several included studies of telesonography during patient transport in ambulances [ 39 , 40 , 41 ] and in flight [ 35 ]. Outcomes including image quality and transmission reliability suggest it may be problematic to transmit real time images from an ambulance [ 39 , 40 , 41 ].

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In general, these studies were of poor methodological quality and were limited by small sample size and the use of simulated patients. Studies using satellite transmission had mixed results [ 21 , 34 , 41 ]. These papers predominantly used asynchronous transmission and incurred significant transmission delays [ 34 , 41 ] although this varied according to the satellite system used [ 34 ]. There is limited evidence of reliability as variable levels of image degradation were reported and this resulted in reduced sensitivity and specificity [ 4 ]. There were a number of articles in which cellular transmission was utilised for all or part of the data transmission route [ 16 , 19 , 21 , 25 , 26 , 29 , 32 , 33 , 35 , 36 , 39 , 40 ].

In articles which used 3G networks there were mixed outcomes and several authors had difficulties successfully transmitting useable images [ 32 , 33 , 39 ]. However, other studies did manage to transmit high quality images [ 26 , 35 , 36 ] and were most successful when high bandwidth MBps cellular connections were used [ 25 , 29 ]. It was noted that transmission reliability may be improved by the use of a communications management system to withstand bandwidth fluctuation [ 40 ].

A number of articles used Wi-Fi connections [ 15 , 18 , 30 , 31 , 32 , 33 , 42 ]. Where this was compared with 3G cellular connections, Wi-Fi produced reduced image degradation and transmission loss [ 32 , 33 ]. However, several articles purely investigated transmission using a local, hospital Wi-Fi connection, which was likely to be more stable than over a larger area [ 18 , 30 , 31 , 42 ].

Robotic ultrasound remains a theoretical possibility but has not yet been proven to be effective [ 21 , 23 ]. Courreges et al. Furthermore, Ito et al.

Several studies investigated the use of images recorded by a secondary device, such as a mobile phone or video camera pointed at the screen of the ultrasound machine [ 16 , 19 , 30 , 31 ]. In these articles a surprisingly high subjective image quality was seen, ranging from 7. The remainder of the articles used systems in which the original image data from the ultrasound machine was transmitted either through ultrasound machines with inbuilt communication technologies or through intermediate devices [ 15 , 18 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 32 , 33 , 34 , 35 , 36 , 38 , 39 , 40 , 41 , 42 ].

The hardware used for receiving and viewing scans remotely included mobile phones [ 16 , 19 , 26 , 32 ], and portable laptops [ 15 , 18 , 30 , 31 , 33 , 35 , 36 , 41 , There was a range of ultrasound models used and the majority of studies employed portable devices [ 16 , 18 , 20 , 27 , 28 , 30 , 31 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 ]. There was no obvious disadvantage to the use of these portable devices, although some models lacked spectral Doppler or M-mode capabilities [ 34 , 35 , 36 ].

It was demonstrated that free Voice over Internet Protocol VOIP software can be used [ 15 , 18 , 27 , 32 , 33 , 35 , 36 ] although a custom videoconferencing VC system may provide a more stable connection and stronger security options [ 15 , 17 , 21 , 22 , 23 , 24 , 37 , 39 , 42 ]. Despite heterogeneous literature with substantial risk of bias, telesonography is feasible in a wide range of settings and for a wide range of indications. Furthermore, the diagnostic accuracy of telesonography has been shown to be comparable to conventional in-person ultrasound in emergency situations where there are overt ultrasound signs.

Additionally, novice operators may, in some situations, be successfully tele-mentored to produce clinically usable ultrasound images in the acute setting.

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Both real time and delayed asynchronous ultrasound diagnosis can be useful in the clinical setting, however the impact of telesonography on patient outcomes has not been assessed. There was no single telesonography system that conveyed superior benefit in all circumstances, and no particular disadvantage seen when smaller screens or portable ultrasound machines were used.

In remote locations telesonography may be a useful addition to a portable clinical toolkit and may provide benefit in emergency and elective cases. However, there is insufficient research on the applications in resuscitation situations and in prehospital care. Included studies were limited in size and scope and future research on this topic should consider a more rigorous approach to the design of feasibility studies, as well as the reporting of technical aspects and study limitations in order to build a more cohesive and applicable body of literature.

The principal finding of this review was that telesonography is feasible in a range of circumstances. How widely this conclusion might be applied is more contentious. Nonetheless, even in the least developed countries the majority of internet connections are capable of between kbps and 2 Mbps therefore telesonography is theoretically possible [ 44 , 45 ]. Of the telesonography systems available, asynchronous transmission may be the most widely accessible form.


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This way images of diagnostic quality can be sent over less reliable communication channels with a lower bandwidth, as transmission delays and interruptions are less relevant. This mode might also pose fewer financial and logistic difficulties especially in terms of scheduling time with remote experts.

Furthermore, Johnson et al. If these results are replicated and synchronous transmission is shown to provide limited additional benefit asynchronous transmission may often become the preferred mode of telesonography, particularly if there is capacity for the occasional use of synchronous transmissions in cases of uncertainty. However, some investigators remain sceptical of the asynchronous approach and in a review in , Meuwly concluded that asynchronous transmission was unsuitable for emergency situations or for cases where local operators lack experience.

Undoubtedly, given the dearth of available professionals in remote and under-resourced areas, recruitment of skilled operators may be the chief barrier to asynchronous telesonography [ 46 ]. Existing WHO training recommendations involve substantial time and resource commitments for ultrasound trainees 3—6 months and — ultrasound examinations for physicians [ 47 ]. Training standards in emergency medicine are less clear, and may be less intensive if the need for interpretation was entirely removed.

Telemedicine for Trauma, Emergencies and Disaster Management

Given the evidence in this review and the wider literature that suggests that a wide range of individuals can execute simple scan protocols further research on the efficacy of the use of minimally trained operators is warranted. It has been proposed that the use of 3D scans, which do not require the operator to understand the interaction between the 2D ultrasound beam and the 3D anatomy, will reduce the risk of novice operators acquiring inadequate ultrasound images [ 48 ]. A review in of 3D ultrasound for novices found that 3D ultrasound may be superior to 2D imaging techniques in improving the reliability of measurements of irregular organs, reducing both the time required for scanning and the need for rescanning of patients [ 48 ].

However, only two papers used this technique within this review and there was no critical evaluation of the relative effectiveness of this method within emergency medicine [ 15 , 34 ]. Therefore, it is conceivable that it may be useful within emergency medicine, and also merits further investigation. Another key barrier to successful application of asynchronous transmission is the potential for loss of important information regarding the clinical context.

This may decrease the applicability of advice provided and has the potential to increase diagnostic errors, as has been demonstrated in a study of emergency teleradiology services in the UK [ 49 ]. This issue may partly be ameliorated by the use of synchronous transmission that allows for personal interaction between remote experts and local staff.


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  6. This may simultaneously facilitate additional broader interactions regarding patient management and allow for clinical teaching [ 22 , 27 , 50 ]. In areas where communications are insufficient to support real time transmission of full quality images, an alternative option is Remote Task Scale. This technique involves the real time image transmission of low quality images followed by asynchronous transmission of full quality images [ 2 ] but was not found in any papers in this review. The choice of telecommunications method must be made based on the requirements of the locality and the system.

    Despite 20 years of telesonography research the image standards essential for diagnostic utility have not yet been defined. Some researchers have suggested bandwidths ranging from kbps to 0.

    However, emergency medicine scans may not require the same resolution as specialised scans looking for subtle anatomical defects. Therefore, it is necessary to determine threshold values for acceptable image quality across a number of scan types specifically for use in emergency medicine.

    Fixed line broadband connections are likely to offer the most stability and the highest bandwidth, particularly if advanced technology such as fibreoptic cables are used. An alternative is satellite broadband and this may be the only viable solution in extremely rural areas. It is likely that as the affordability, coverage, reliability and bandwidth provided by satellites continues to improve they may become an increasingly attractive option for telemedicine [ 53 ]. This may be particularly important for emergency medical transmissions in the case of damage to terrestrial antennas, wired connections and ground-stations, as may occur during a natural disaster or humanitarian crisis [ 54 ].

    Despite their scarcity and small size the results from the included pilot studies of telesonography between hospitals were promising, but there is a need for more robust studies to be conducted before this is routinely used in clinical practice. These findings are in line with the conclusions of a series of narrative reviews on general telesonography published between and , which found no substantial evidence of benefit to patients.

    All found marked heterogeneity in the design of the included studies and all recognised the need for further more definitive research [ 2 , 47 , 52 , 55 , 56 , 57 ]. This review found that in studies where telesonography was used in hospital emergency departments some clinical benefits were seen and a positive response from involved staff was reported. This echoes the conclusions of a systematic review of general telemedicine use in the emergency room, which found considerable benefits for small hospitals with a low frequency of emergency cases.

    These included improvements in staff satisfaction, clinical processes and outcomes [ 57 ]. Therefore, in future studies of telesonography qualitative process analysis should be encouraged [ 55 ].