At Times Like This: Telemedicine Comes to the Country

     There are long transports, then there are long transports. At Fletcher Allen Health Care, a level 1 trauma center and teaching hospital in Burlington, VT, long can mean prehospital times of six hours or more.

     "In this region," says trauma surgeon Bill Charash, MD, "the helicopter often can't fly because of weather, so we have long ground transport times. From my data, the time from injury to arrival at our medical center can average 300-400 minutes."

     Times like that are when a doc could really use telemedicine.

     "When you think about it," says Charash, "these are some of the most critically ill humans the medical establishment is ever going to care for. And they disappear into a black box for hours. And as evolved as patient-care protocols can be, there's only so much EMS can do for them."

     Which explains why, as the quest for telemedicine continues, much of the focus is coming to lie outside major metropolitan areas.

     Take, as an example, the DREAMS consortium's Texas project profiled on page 64. It's brought telemetry and telemed capabilities to places like Liberty County (population: 74,000) and Bryan (around 68,000)--not the big urban areas you'd typically associate with cutting-edge advances.

     DREAMS researchers solved the problem of infrastructure by developing a system that can automatically identify and aggregate small bits of available bandwidth as it finds them-even from disparate media like cell phones, satellite phones and data radios-in building a "pipeline" big enough to stream video. What's more, if part of that bandwidth is lost (in a cell phone dead spot, for example), their system intelligently manages itself by adjusting the frame rate and resolution of its video feed in response to how much pipeline is available.

     Fletcher Allen got in the game using that same technology, and while docs and EMS there haven't tried it with actual patients yet, tests suggest it could be beneficial. Charash programmed human patient simulators with various trauma scenarios and had two groups of EMS providers-one assisted by telemed docs, one working under standard protocols-treat them in ambulances. Preliminary data indicated better outcomes for those "patients" with whom the physicians assisted.

     Now the organization is working to deploy a "to-go" version.

     "It's what's called a grab-and-go box," says James Wall, PhD, director of the Texas Center for Applied Technology's Computing and Information Technology Division and part of the team behind the DREAMS project. "We created a minimal configuration-i.e., some antennas and a few mounts-so if an ambulance is going on a run that looks like it could be a particularly difficult case, they just grab this box and plug it in."

Cells and Satellites
     Bandwidth remains a key impediment here, and while some EMS providers may have wireless broadband capabilities through their cell carriers, that isn't an answer for everyone. Even with such capabilities, there's a difference between download and upload speeds that's critical for applications like telemedicine. "Your data is coming from the ambulance to the trauma center, not the other way around," Charash notes, "so it's the upload speeds you need."

     That's if you're covered at all.

     "In Loretto, PA, where we are, there's not much available for wireless connectivity," says David Wolfe, a wireless communications specialist with the Center of Excellence for Remote and Medically Underserved Areas (CERMUSA) at St. Francis University. "You're lucky if your cell phones work. So here, satellite is basically the only option from a mobile platform if you're going any great distance."

     Such reasons are why satellite is the medium of choice for many telemed projects. CERMUSA's First Responder Emergency Communications-Mobile (FREC-M) is one. Developed with military funding, the FREC-M relied on satellite for its video capabilities (this enabled two-way video, whereas the Texas project only achieved one-way), with EKG data sent via digital radio or a Verizon cellular card plugged into a laptop.

     The FREC-M was first deployed in the field by nearby Cresson Area Ambulance Services. Cresson providers had some success with the system, but also encountered some kinks. They've since started using Medtronic's Lifenet Blue wireless data transfer application, which provides everything except video, while CERMUSA pursues improvements to its video technology.

     "I'm in the process of exploring newer Internet-capable satellites to send this video more cheaply and efficiently," says Wolfe. "We learned a lot from this, and we're going to focus now mainly on the videoconference aspect. It has to be simple-the medic hits one button, and it's connected. We can't have them fiddling with remote controls and things."

     More remote even than central Pennsylvania is the Amazon River basin in Peru. Satellite also formed the basis of a streaming video/data system set up there to support marathon swimmer Martin Strel's effort to swim the entire 3,300-mile length of South America's mightiest river.

     This project utilized General Devices' Rosetta-Go, a portable variation of the E-Bridge system being installed on ambulances for a telemedicine project in Tucson, connected to a ZOLL CCT monitor to provide streaming data. That data-physiologic data, voice, and still and moving images-traveled, via satellite, all the way to an EMS telemedicine facility back in Tucson.

Best bets
     Projects like these suggest that with sufficient funding (always a thorn, of course), telemetry and even telemedicine are potentially within the reach of rural EMS.

     Where cell coverage is spotty, satellite will likely be the best immediate bet. The con is that it isn't cheap. "We're talking several dollars a minute for connectivity," says Wolfe. "And you know, for a local EMS service that doesn't have a lot of money, that comes into play."

     It's also occasionally unreliable, meaning those pursuing broadband applications may be wise to look at a combination of media.

     "In our state," says Montana EMS boss Jim DeTienne, chair of the National Association of State EMS Officials' Rural EMS Committee, "we're looking at technologies that use combinations of the P25 digital radios, the 700 MHz, the cell phone and the sat phone. Because in areas of our state, one or none of those may be available at any given time."

     "The future may involve a mix of satellite options and 700 MHz options," says Kevin McGinnis, a program advisor with NASEMSO. "There's that 24 MHz of spectrum in the 700 range coming to public safety, and the FCC has reconfigured that for broadband use and the ability to do things like telemetry and video."

     Meanwhile, if you have cell, its improving capabilities are worth keeping an eye on.

     "Cell phones are only going to get better," says Charash. "The world is going to demand more bandwidth in more locations, and there's pressure on carriers to continuously improve that. Vermont's the proof. We have, I'm told, the second-worst cell phone coverage in the nation, and yet we're able to make it work. So if we can make a telemedicine system work with our terrible cell phone coverage, then it'll work only better everywhere else." -JE