June 17, 2019

After her 3-year-old son Timothy fell headfirst off his bed onto the hardwood floor, “he cried inconsolably,” says his mom, Lindsey Peifer. Unable to calm him down, she took him to their pediatrician, who found a large knot on the side of his head and recommended imaging at the nearest emergency department. There at the outside hospital, a CT scan showed an epidural hematoma (EDH), which prompted emergency transport to Johns Hopkins Children’s Center and pediatric neurosurgeon Eric Jackson, who had already reviewed the image via email showing a skull fracture and a large EDH. Now, under the gun, he was preparing his team for surgery to relieve the dramatically building pressure in Timothy’s brain. They were successful.

“As soon as we arrived they got him to an exam room to take his vitals,” says Peifer. “We were there for 10 minutes at most before he went into the operating room.”

“Everything went very quickly—we got the call and were pretty much ready for him when he arrived,” says Jackson. “By getting patients to the OR faster, there’s less injury to the brain, which improves their outcomes.”

That, explains Jackson, is what he and pediatric critical care specialist Corina Noje were aiming for in developing a telemed protocol for children with suspected intracranial hematomas (ICH) transported from outside hospitals. They live by the mantra “time is brain” and the knowledge that evaluation of adult patients with suspected ICH within 4 hours improves their outcomes. Although there are no such data in children, from experience they believe early intervention will improve pediatric outcomes, as well.

“If you don’t treat intracranial hematoma in a timely fashion, the patient can die, or suffer significant neurologic damage requiring multiple days in intensive care and rehab, and some patients do not recover their neurologic status,” says Noje. “In our mind, if these children come to Johns Hopkins directly and are operated on immediately, they would have better outcomes.”

To test the point, they conducted a retrospective review of outcomes before and after implementation of their telemedicine program by the pediatric transport service. If telemedicine was used, a consult with the medical control physician (MCP) at the Johns Hopkins Children’s Center was triggered by a neuroimaging interpretation, either by the referring hospital or by the transport team. The MCP would then review the case and images with the on-call pediatric neurosurgeon, who would then decide on the need for time-sensitive surgery. If early neurosurgery was needed, the transport would be expedited, the emergency medicine physicians would have a more focused evaluation, and the surgical and anesthesia staff would be mobilized more quickly.

“Before the child even gets to the Children’s Center, the neurosurgeon is able to see the images and decide if this is someone who requires emergency surgery or not,” says Jackson. “We could then expedite transport, minimize time these patients would spend in the trauma bay, and do a more focused trauma bay evaluation in less than 5 minutes, and have the surgeon and anesthesiologist in the OR ready for the patient.”

The results? Patients in the telemedicine group had decreased repeat neuroimaging, decreased time from trauma bay to operating room, decreased pediatric ICU and hospital lengths of stay, and a higher number of patients discharged home rather than inpatient rehabilitation compared to the non-telemedicine group (Ped Crit Care Med. 2018;19:1033-1038).

“All of the children in our telemedicine group spent a day or two at most in the hospital, went home and were completely neurologically okay,” says Noje.

Because of the study’s small size, it looked at only 8 patients in the telemedicine group and 7 in the non-telemedicine group, Jackson and Noje note that larger and more definitive studies are needed. But clearly, they add, as Timothy Peifer’s experience shows, implementing a shared imaging telemed protocol for these patients does make a difference.

“This was someone who potentially had a life threatening injury and is now a normal 3 year old,” says Jackson.

“He’s fine, he’s active, adventurous and curious,” adds Lindsey Peifer. “It’s like it never happened.”