IOS Devices in ETU

Using IOS devices in a Resource Poor Ebola Contaminated Environment to Facilitate Patient Care

Ebola Treatment Units (ETU) and Community Care Centers (CCC) frequently have limited electricity and internet connectivity. Objects taken into an Ebola Virus contaminated environment cannot be removed, thus making record taking complicated. Since doing my training with the CDC in Anniston, Alabama, I have been experimenting with some possible solutions to the problem of communication in the ETU and CCC environment.

Briefly, this page will outline components of a system that I hope will be able to be implemented by non-tech savvy clinicians (such as myself) in resource poor settings. Components include portable solar panels, IOS devices such as iphones, ipads and ipod touches, Seal Shield bleach proof covers, and inexpensive IOS apps and a wifi router. The general idea is for a clinician to enter the ETU in PPE, pick up a charged IOS device that has a preloaded PDF form for each patient on his/her task list. The clinician performs rounds and records, using drop down lists, clinical information such as I/Os, response to treatments, etc. The clinician can also record verbal notes. A clinician outside the the ETU/CCC can see a live video stream from the IOS device. This may facilitate patient care by direct communication with a patient and the ability to do remote physical exam. 

Components include:

1. Solar chargers. The unit I am testing in the dim light of a Michigan December is a 14 W 2A Foldable dual-port Solar Charger. You need 2 amps to be able to charge ipads from the solar panel. It costs $60 on Amazon.

2. USB batteries. I think charging an inexpensive battery from the charger is safer than directly charging an IOS device. These can be found at Costco, on Amazon and other sites. If ipads will be used, make sure it delivers 2 A. These vary in price depending on size and features. From $15 to $99. 

3. Cable to connect the battery and the IOS device. These come with the IOS device. I imagine the ideal situation would be for the cable to go through the ETU/CCC tent wall. This cable would have to be anchored to the wall so it couldn't slip in and out. This way the clean battery could remain outside the ETU/CCC and be moved to a free solar panel as needed. If the ETU/CCC has walls and no way for cables to get in or out, then the battery would have to go to a charger that is in the high risk zone. 

4. IOS devices. I've been testing this system with an old Ipod Touch version 4.2, IPhone 4s with version 8.1, Iphone 4s with 7.1 and a new Ipad air running 8.1. The old ipod touch doesn't have a camera, and has to run old versions of the apps. You would need a minimum of two devices, one that lives in the ETU/CCC and one that stays in the low risk zone. I think both units should be in a Seal Shield since they both should be bleached before and after each touch. A computer could be used in the low risk zone instead of an IOS device, but charging a computer would require more solar panels or a generator. Iphones are expensive, but if my family is any indication, a lot of people have old units sitting around. The ipod touch came to me via my nephew, the iphone 4s from my daughter and I'm hoping to get another 4s from my niece when she upgrades to android. 

5. Seal Shield covers. I bought one for my iphone 4s. It fit perfectly. It has a little door that covers the charging port. If carefully closed, the entire phone can be sprayed or dunked in bleach. They sell units without the door, but I don't think those would be useful since removing the covers is difficult. The screen is slightly foggy looking, but they have a port for the lens so pictures and videos are pretty good. I took the images of the box with the same iphone. The one they sent me for my ipad (which doesn't fit the air very well) was defective in that the plastic had dimples. They are sending me a replacement free, no hassle. The The devices for the iphone cost $20. I was able to use the screen with two pairs of nitrile gloves on.
 Sealable door.
Defective cover, note the dimples. 
The clearer image is without the cover.
I typed this wearing two pairs of snug nitrile gloves. I had to press a little harder than usual, but it was pretty easy.

6. Router preferably USB powered. I'm currently using an old router that plugs in a wall, I plan on ordering a USB charged one soon. This router would stay in the low risk zone. The range required would depend on the distance between the high and low risk zones. Essentially, this router would create a way for the IOS device inside high risk to communicate via wifi with a device in the low risk zone. These can be password protected for patient confidentiality. 

7. Apps. The trick with apps is to find ones that can run without a connection to the internet. If you have solid internet, then FaceTime would be great. The apps that I think would be useful that do not require an internet connection include:

AirBeam, $4 via Itunes. This basically turns your camera-equipped IOS device into a surveillance camera. It could be used to monitor the unit 24/7, although it would go through battery pretty quickly. It can use the microphone to pick up sounds. The video frame rate can be adjusted. I imagine this could be a way for patients to communicate with families, or as a way for non-clinical staff inside the high risk zone to transmit visual and auditory information to clinicians in the low risk zone. This app does not provide two way communication like FaceTime. A walkie talkie would be required so the low risk zone people could speak to high risk. If you had two IOS devices in the high risk zone, one could be a camera and the other a monitor so two way communication could occur. You can switch each device from camera to monitor, but that would be cumbersome. I've been testing this app and it works pretty well, but it eats battery. One nice feature is that you can remotely turn on the camera's light so you could even do a remote intra oral exam.

Irecorder Pro, $2.99 via Itunes. This app lets you record your voice and then transmit the recording to another device via wifi. I think this could be useful in that while doing rounds you can basically talk into your phone in the high risk zone. When finished you simply send the recording via wifi to a device in the low risk zone. You could then transcribe your notes in the comfort of the low risk zone. This would be more efficient than trying to write down information. Unfortunately, an internet connection is required for transcription services like Siri and Dragon.

PDF expert, $9.99 via Itunes. This app is pretty expensive, but what I like about it is it lets you fill in information on PDF forms. It doesn't let you run Java scripts, which is sad, but it does let you do pull down lists, type in fields, place time stamps and draw on forms. The completed PDF document can then be shipped to the low risk zone via wifi. This app didn't work on the ipod touch running 4.2. I imagine this app being useful in that each patient's task list can be uploaded ahead of time to the ios device for use while in the high risk zone. As tasks are completed they can be time stamped and check boxes or drop down lists can be filled in. While in PPE it is difficult to see information on tiny screens, and double gloves makes typing clumsy. Data input while in the high risk zone would have to be very minimal.

Technically easier and cheaper alternate....

Walkie talkies would be a cheaper approach, but would require a companion to be taking notes in the low risk zone. I tested a pair in plastic bags and they worked fine, so they could be disinfected before and after each use. A surveillance camera could be mounted in the high risk zone. I did find a camera, Foscam, that is suppose to transmit via wifi without internet. The Foscam is powered via AC cord. I found a usb cable and a chat on the internet that reported being successful. I've ordered these and will test them and report my findings when they get here. The support staff at Foscam told me images can be transmitted via wifi without an internet connection to android and ios products. It looks like you can record the video too.

A computer with Linux could be set up as a server, which would allow emailing and other nifty features, but would require some technical abilities.  

Thank you for reading this. Direct comments and questions to