A Recorded Refusal: EMS Telemedicine System Previewed

The patient needed to be transported but wouldn't go. Frustrated, the EMS crew turned to medical control to help make their case. There in the back of the ambulance, the patient saw and spoke with the physician about his prospects, with their conversation—and the patient's unstinting refusal of care-captured on a digital logging recorder. Whatever happened later, this crew and doc were now legally protected.

Once farfetched, scenarios like this become more possible every day. Advances in technology are allowing ever-greater interactivity between prehospital crews and distant resources like medical control, specialists and more.

The above scenario was part of a demonstration of a telemedicine system being developed by General Devices in Ridgefield, NJ. Bringing together an array of private vendors and equipment, the system-previewed at a February Gathering of Eagles meeting in the Dallas area-proved able to send real-time video images, digital voice communications and physiological data from a specially equipped ambulance to a mock ED.

"We were trying to determine if it's possible to do telemetry on a regional basis," explains Raymond Fowler, MD, FACEP, deputy medical director for BioTel, which provides central medical direction for EMS in the Dallas area. "Is it possible, for example, that for five, six, seven, 10 places in a state or region, there might be a single online medical control to whom very complex, complicated patients might be telemetered in real time?"

The results of the February trial were positive. Participants played out three scenarios in which the transmission of vital signs and other data (e.g., EKG, pulse oximetry, capnography, pulse rate, NIBP) allowed Fowler to assess a volunteer patient and bolster the work of the field crews.

Several components were involved. The ambulance featured a prototype of General Devices' Rosetta-VC. As the “core” of the EMS telemedicine system, this element—planned for commercial release in early 2006—automatically links elements in the ambulance (monitors, cameras, etc.) to a variety of communications devices and relieves the crew of tasks that would interfere with patient care. Also tied in were a pair of remote-control cameras and an MRx Field Monitor modified by its maker, Philips, to accommodate a range of streaming physiological information. The mock ED had a CAREpoint EMS Workstation, also from General Devices, that provided system controls, a display screen and the built-in recorder.

Wireless communications came via MESH Networks, a division of Motorola, which is developing a system that will provide high-speed wireless connectivity upwards of two megabits/second throughout the Dallas suburb of Garland via 900 wireless "access points" mounted to lampposts around the area. Because that network is not yet complete, Fowler said, at present there are many dead spots in the coverage area. Once these "holes" are patched and the system is fully up and running, more extensive testing of the EMS telemedicine system will be done. As far as the Eagles demonstration went, however, the main goal-showing the basic feasibility of EMS telemedicine-was met.

However systems like this ultimately take shape, they promise many benefits, including:

• Providing distant physicians with a far better understanding of what is happening on scene, so they can perform faster diagnoses and make expertise more-readily available to the field personnel;
• Helping to ensure that hospitals, particularly trauma teams, are better prepared to receive critically ill patients;
• Giving crews a level of security handwritten run reports never could. That intractable patient can't come back a year from now and claim he wasn't warned about what might happen to him.

"I explained to the guy what the problem was and what we needed to do, and he still refused all care," says Fowler. "I told him, 'Speak into the camera and say, 'I refuse all care.' He said, 'I refuse all care,' and we recorded it. It’s a nice legal record, and everybody's covered."

While this latter feature is important, it's not the primary goal of the system, according to General Devices. From the company's perspective, the main benefit comes in patient assessment.

The EMS telemedicine demonstration at the Gathering of Eagles meeting provided its viewers-who included U.S. Surgeon General Dr. Richard Carmona-with a brief glimpse of what may be the emergence of a valuable new tool for EMS.