KankaneKumar_ApplyOfWhats
306 | Kankane et al - Apply of WhatsApp in Neurosurgery
Apply of WhatsApp: A quick, simple, smarty and cost
competent method of communication in neurosurgery
Vivek Kumar Kankane, Gaurav Jaiswal, Tarun Kumar Gupta
Department of Neurosurgery, R.N.T. Medical College & M.B. Hospital, Udaipur, Rajasthan, India
Abstract: Objective: Neurosurgeons habitually have to hinge on judgments of
subordinate staffs to build an assessment on patients whom they cannot be present at
immediately. WhatsApp is a no charge to use application for image transfer on Internet.
We evaluated the use of WhatsApp in neurosurgical milieu, to show it is economical,
quick, available, reliable and practicable. Materials and methods: We coordinate a
prospective observational study from December 2014 to June 2015. Residents were
skilled to take sharp pictures and upload them immediately using WhatsApp on Internet.
Primary conclusion was difference between opinion of residents and consultants on
WhatsApp images and time delay in decision-making. Conflict was evaluated significant
if it changed management decision. Results: In the study period, 1356 (mean age: 35.53
years, 71.28% males) patients were included in study those admitted in after hospital
hours. Internet packs of smart phone available in market in very economical cost.
Judgment could be made on images received on WhatsApp at an average of 4.06 min.
There was Conflict in 7.22% cases between residents’ reports and images on WhatsApp.
All Radiological imaging modalities, were associated with statistically Insignificant
difference (P >0.05). Conclusion: This study suggests that apply of WhatsApp in
neurosurgery can be a simple quick reliable and almost free mode of communicating
images enabling a quick decision. Though this cost-effective method should be used with
concern particularly with Radiological imaging modalities, which require dispensation
and appraisal on console.
Key words: Multimedia messaging service, Communication, neurosurgery, WhatsApp,
Smart phone
Introduction
Radiological imaging (RI) Conflict has
been often reported when junior doctors or
residents report on imaging done during off
hours. [1‑5] This RI Conflict has been found
to have significant clinical impact. [1‑5] To be
capable to make an assessment on a
neurosurgical patient as soon as his primary
management is complete, will not only
accelerate the definitive care but also improve
Romanian Neurosurgery (2016) XXX 2: 306-312 | 307
the final outcome. Such an approach will have
an impact on the residency training program.
Smart phones are broadly available.
WhatsApp is a free of charge to use
application, which can be used over an
extensive number of mobile and enable one to
talk as well as send pictures over Wi-Fi or 3G
or 2G network. 3G or 2G Internet packs
available in market in very economical rate.
This study was coordinate to look at the option
of using this free app in communicating
information related to neurosurgical
emergencies. The objective of this study was to
observe if use of WhatsApp is economical,
quick, easy to get to, reliable and realistic in
neurosurgery mainly in reporting emergency
cases in off hours of hospital.
Materials and Methods
A Prospective observational study was
coordinate in the Department of
Neurosurgery, R.N.T. Medical College & M.B.
Hospital, Udaipur, and Rajasthan, India from
December 2014 to June 2015. All patients
observing emergency department in off hours
of hospital and assessment by neurosurgical
residents were included in the study. Personal
smart phones with facility of camera
(resolution at least 5 Megapixel) and
WhatsApp installed were used in the study.
Residents were trained to take clear pictures
and upload them immediately using
WhatsApp over Internet [Figure 1]. Images
were taken in close and distant mode. There
was no restriction on number of images
however uploading big number of images took
more time. Radiological Images transferred
include those of X-rays, Computed
tomography (CT) scans, magnetic resonance
imaging (MRI) scans; CT angiography scans
[Figure 2]. These images were studied by
consultant neurosurgeon and afterward
compared with the reporting done by resident.
RI reported by residents was considered as
Group 1, by the consultant neurosurgeon on
WhatsApp as Group 2, by residents’
radiologist as Group 3, by the consultant
neurosurgeon on actual images as Group 4 and
by consultant radiologist as Group 5.
Outcome variables
Primary endpoints were Conflict of
opinion between Group 1 and 2, and
compared to Group 2& 4 and Group 3 & 5 and
time delay in decision-making on WhatsApp.
Conflict was considered significant if it
changed management decision. Afterward
analysis involved which RI modality was
difficult to study on WhatsApp using Chi-
square test. Statistical software for Social
sciences (SPSS) version 17 was used for
analysis of data.
Figure 1 - Resident captivating snapshot on Smart
headset
308 | Kankane et al - Apply of WhatsApp in Neurosurgery
Figure 2 - dissimilar category of smart phones used
in the study with WhatsApp on display
Ethical issues
As this study instructed collecting data and
did not entail direct intervention on patients,
there were no ethical issues involved. Patients
enrolled were not provided with economic
incentives, as this study did not require any
extra investigation.
Results
A total of 1356 (mean age: 35.53 years,
range 3 month days to 91 years, 71.28% males)
patients were included in the study. All
patients with accidents, 997 (73.52%) patients
had road traffic accidents, 171 (12.61%) had
fall and 188 (13.86%) had physical assault. 610
(44.98%) patients presented with headache,
132 (9.73%) with weakness, 680 (50.14%) with
altered sensorium and 162 (11.94%) with
seizure. Of the 1356 different types of RI
transferred on WhatsApp included: 828
(61.06%) cranial CT scans, 155 (11.43%) X-
rays, 13 (0.95%) CT angiography images, 360
(26.54%) MRI images and respectively.
Decision could be made on images sent on
WhatsApp after a mean delay of 4.06 ± 1.482
min (range 3‑12 min) from availability of
images for upload. This delay involved taking
pictures, uploading and communicating to
consultant. Using WhatsApp, conflict between
RI reporting by residents (Group 1) and
consultant neurosurgeon (Group 2) was 7.22%
(98 cases). In 58 cases (4.27%), residents could
not comment due to confusion in diagnosis, in
14 cases (1.03%) they could not identify
surgical indications, in 17 cases (1.25%) they
missed critical findings and in the last 9 cases
(0.66%) they missed surgical requirement as
well as critical findings. Resident usually
missed location as well as differentials in
Romanian Neurosurgery (2016) XXX 2: 306-312 | 309
hypodense lesions on CT scans. They
frequently missed critical findings that had
bearing on deciding time of surgery as well as
approach. This Conflict was clinically
significant in 80 cases out of 98 cases (81.63%)
where management of patients changed. This
change in management plan from medical to
surgical intervention or adding osmotic
diuretics Of all imaging modalities, Conflict
between Group 1 and Group 2 was highest for
CT angiography head (30.76%) followed by X-
ray of cervical spine (21.93%) followed by MRI
(8.33%) and CT head (3.623%). There was
100% Accord between Group 3 and 4 however
there was 5.16% conflict between images seen
on WhatsApp (Group 2) and actual image
interpretation (Group 4) and there was 7.81%
conflict between image seen on consultant
radiologist (Group 3) and image seen by
resident radiologist (Group 5). It was found
that of all the RI modalities, had statistically
Insignificant difference between group 1 and
group 2 Compare to group 2 and group 4 (P
value > 0.05) and also all RI modalities, had
statistically Insignificant difference between
group 1 and group 2 Compare to group 3 and
group 5 (P value > 0.05) [Table -1]. Of 1356
patients, 351 patients (25.88%) underwent
surgery and rest 74.12% were managed
conservatively. As this app is freely available
on Internet and can be used on any mobile or
pc platform, using this app and service was free
of cost. Moreover due to very cost effective 3G
or 2G internet packs available in market. Effect
of time of day when images were sent for
consultation was studied to know whether
exhaustion induced during duty hours and
consequent slowness during off hours has
effect on delay in reporting or increase in
difference between RI reporting.
TABLE I
Comparison of conflict between group 1, 2 and group 2 & 4 and comparison of conflict between
group 1 & 2 and group 2 & 4 according to different images sent on WhatsApp
Comparison of
Groups
X ray ( Skull
&Cervical Spine)
NCCT Head CT Angiogram MRI (Brain &
Spine)
Yes No Yes No Yes No Yes No
Conflict between
group 1 & 2
34 121 30 798 4 9 30 330
Conflict between
group 2 & 4
25 130 20 808 3 10 22 338
P Value 0.193 0.07 0.658 0.249
Conflict between
group 1 & 2
34 121 30 798 4 9 30 330
Conflict between
group 3 & 5
25 132 40 788 2 11 39 321
P Value 0.107 0.222 0.352 0.225
310 | Kankane et al - Apply of WhatsApp in Neurosurgery
TABLE II
Drawback and dealings to settle
Drawback dealings to settle
deprived resolution When taking images with a smart phone camera, try to go as close as
possible to the subject rather than zooming in when you take a shot.
You will get better-resolution photos cropped, than zoomed in.
Images of flash/
neighboring luminosity
Camera flash you have on your phone is almost always too harsh and
rarely helpful. Instead try increasing your camera’s exposure and ISO
levels. Alternatively you could use an external flash like iBlazer or Light
strap so close flash light keep away from any direct luminosity over image
while taking snap
Missing fractures learn on bone windows of real images
Under reporting
angiography
learn on console/3D
Difficulty in Beginners to taking
snaps
Residents were skilled to take clear pictures & gave basic knowledge
about focus, exposure, white balance and ISO.
Discussion
Neurosurgical care is limited in many parts
of the world to one or two hospitals serving a
large geographic area. The quality of
neurosurgical response to emergencies depends
on the reliability and completeness of the
information received from referral hospitals.
First time Servadei F et.al conducted a study
from January 1998 to December 2000, the aim
of this study is to show how application of
guidelines for head injury management in an
entire area can be usefully combined with
transmission of images from the peripheral to
the central hospital. In conclusion of this study
is unnecessary transfers can be avoided and the
neurosurgeons can evaluate the images of a
number of patients who have always been
treated outside our Units. This results in more
work for the neurosurgeons on duty, but also in
a better quality service for the whole area [9].
During the last decade, there is an
increasing demand to discuss diagnostic
images and reports of difficult cases with
experienced staff. A possible solution besides
physically transporting patients and material
is to use high-speed communication networks
to transfer images and reports electronically.
With the web application PACS flow we have
developed a solution to transfer images,
reports, and messages as a single package in a
one-step procedure. The PACS flow is an
interoperable and standard compliant web-
based application, which gives clinicians a
user-friendly interface for their work on a daily
basis, so clinicians have tried sending images
using KIS, RIS and PACS after office hours in
specialties such as radiology [6, 3], Medicine
and cardiology[2,11,12,]. Patients archiving
and communication system (PACS) which is
time consuming and requires expensive
hardware’s or definite system. The advance of
communicating images using WhatsApp only
requires taking appropriate pictures and
Romanian Neurosurgery (2016) XXX 2: 306-312 | 311
uploading on Internet. This process is speedy
as it takes only fractions of minutes to upload
as well download on the recipient
workstations. In this study it took a mean of
4.06 min. to decide on images. This was much
faster than reported delay in actual image
interpretation by radiologist in literature (8.6
h). [5]. Using other modes of communications
like sending images by using Multimedia
Messaging Service (MMS) is used by
neurosurgical residents to transmit scan
images to the attending neurosurgeon in
conjunction with telephone consultation. This
service has been well received by the attending
neurosurgeons, who felt that after viewing
scan images on their phones, they felt
increased confidence in clinical decision
making and that it reduced the need for recall
to the hospital.
Bullard TB et al. Investigated whether
head CT images captured using a mobile
phone would be of sufficient quality for
neurosurgeons at a level 1 trauma center to
make decisions about whether to transfer
patients from referring hospitals. Mobile-
phone images of CT scans appear to provide
adequate images for triaging patients and
helping with transfer decisions of
neurosurgical cases [4]. Pick j.et al introduce
Image transfer by mobile phones into clinical
practice to improve communication between
neurosurgeons. Most images were transferred
from the resident on call to the senior
neurosurgeon backing him up. Overall, the
system was extremely reliable, quick, and
enabled immediate decisions in all emergency
situations [8].
Thapa A et al [10] used Viber in
neurosurgical scenario, to show it is cheap,
fast, accessible, reliable and feasible. This study
suggests that the use of Viber App in
neurosurgery can be an easy fast reliable and
almost free mode of communicating images
enabling a quick decision. Our study is similar
to this study, except number of patient and
number of groups is more in our study and we
used Different apps of smart phone. Conflict
between resident and consultant (consultant
neurosurgeon) was comparable to other
studies, published particularly by emergency
physicians [5, 1] and radiologist.[7,13] In our
study, we found that in 81.63% cases where
there was between resident report and image
interpretation on WhatsApp, treatment was
significantly altered. Medical imaging sent
over mobile phones has been found to be
constantly interpretable as in our study. In
only 4.08% cases images reported on
WhatsApp required further modification on
actual image interpretation, which was found
to be in cases of CT angiography and MRI
spine. Our study shows that WhatsApp not
only helped in early and proper decision
making but also take required interventions. It
was found that those Medical Imaging
modalities, which required maneuvering on
console especially CT angiography head,
required careful analysis on WhatsApp and we
recommend that it should not exclusively be
reported on WhatsApp. Hence this study
shows that use of WhatsApp in
communicating neurosurgical emergencies is
economical, speedy, handy, reliable and
realistic; however there is drawback as noted in
Table 2.
312 | Kankane et al - Apply of WhatsApp in Neurosurgery
Conclusion
This study, a first of its way recommends
use of WhatsApp in neurosurgery; an easy fast
reliable and almost free mode of
communicating radiological images enabling a
quick decision. However this cost effective
method should be used with concern
particularly with radiological imaging
modalities, which necessitate dealing out, and
evaluation on console. The mobile phone
system is adequately useful for early diagnosis
and start of treatment in emergent cases. This
is attributable to its low cost and eases of
handling for sending images to remote areas
and between hospitals, despite the small
dimensions of the monitor.
Correspondence
Vivek Kumar Kankane
M.Ch.Neurosurgery Resident, R.N.T. Medical College
& M.B. Hospital, Udaipur, Rajasthan, India.
Email address: vivekkankane9@gmail.com
Address: C/O Dr. Khamesara 59 Sardarpura,
Udaipur, Rajasthan, India, Pincode 313001
Mobile no. 8955337812
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