Emergent Telemedicine Components Deliver Expertise to Front-Line Forces

July 1999
By Maryann Lawlor
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Advanced medical devices empower medics to maximize “golden hour” of emergency treatment.

Internal Defense Department research and development coupled with commercial off-the-shelf technologies is speeding medical care to wounded soldiers on the battlefield. In ongoing programs, scientists are investigating remote health maintenance and trauma care tools ranging from dog tags that hold an entire medical history to diagnostic equipment that helps evaluate the severity of an injury.

Although the primary setting for initial equipment deployment may be a hostile area of operations, military telemedicine experts believe the benefits of current research will be far-reaching. The goal is to offer the highest level of care “from the womb to the tomb” for all military personnel and their families through their retirement years.

Spearheading and coordinating the Defense Department’s telemedicine effort is the U.S. Army Medical Research and Materiel Command’s Telemedicine and Advanced Technology Research Center (TATRC), Fort Detrick, Maryland. TATRC comprises military personnel from all services as well as staff from industry and academia. This joint approach provides open and continuous dialog, a factor the center’s coordinators believe is critical to ensuring that the command, control, communications and computers sector of the military forces will support these specialized communications technologies for medical personnel.

The Medical Research and Materiel Command is the umbrella organization for several efforts in military health care and maintenance. It encompasses work related to infectious diseases, combat casualty care, operational medicine, and chemical and biological defense research. The group provides technology that promotes force protection as well as health awareness in the battlespace. It also develops methods to reduce the time between injury and critical intervention, improve the skills and efficiency of medical personnel, and enhance the quality of emergency care on the battlefield.

TATRC is tasked with prototyping and demonstrating new technologies. The center is organized in five divisions: logistics; clinical applications; programs, integration and planning; information sciences; and operations.

Because time is a critical element in emergency care, many of the technologies now being developed aim at tapping into information and expertise in the fastest way possible. This is all predicated on the concept of a “golden hour.” According to Lt. Col. John Albano, MC, SFS, USA, deputy chief, clinical applications division, TATRC, a recent study of trauma cases shows that “if you get to patients in that first hour, the chances of them dying or having permanent injuries go way down.” Since medical specialists may not be able to attend to injured soldiers during that first hour, military medics, who are usually the first on the scene, or evacuation center personnel can supply a higher level of care through telemedicine, he explains.

One current teleophthalmology project involves the design of a high-resolution, digitized telerobotic stereo video slit lamp. The device permits users to examine the anterior structure of the eye in fine detail to determine the extent of an injury, Dr. Gene Channing, contract and project manager, TATRC, says. Because the images are digitized, they can be sent via telecommunications technologies from the patient’s location on the battlefield to ophthalmologists in distant locations where they can be assessed by specialists. This eliminates the need to take soldiers out of the unit to send them for evaluation examinations.

Eye injuries, which account for 10 percent of all battle casualties, could have a significant detrimental effect in a combat situation because eyesight is relied upon for travel, situation awareness and targeting. An eye injury is considered a two-for-one kill because another person must now assist the injured soldier.

Determining the extent of an eye injury is difficult without access to sophisticated equipment. A wound that appears superficial could actually be serious, and this evaluation can only be made with equipment that would not normally be part of front-line medical supplies, Col. Albano explains.

Benefits of teleophthalmology extend beyond the battlefield. As military personnel retire and relocate to remote areas, this specialty will be used to offer skilled care to retirees by allowing them to visit local clinics while continuing to draw on the expertise of military doctors, the colonel adds.

Channing predicts that within five years these capabilities will be available to the general public through large medical centers and in academic environments where a large research base exists. “However, within 10 years, the production of devices and capabilities will be so economical that the prices will go down and more will be used,” he offers.

Telemedicine played a part in assisting the victims of the August 1998 bombing at the U.S. embassy in Nairobi, Kenya. Injured Americans and Kenyan nationals were evacuated and treated at Walter Reed Army Medical Center, Washington, D.C., and Landstuhl Regional Medical Center, Landstuhl, Germany.

“After treatment, there was an ethical and moral obligation to provide follow-up care or monitoring. So how can we do this? We couldn’t send them back to the U.S. or Germany every time they needed to be seen. Through telemedicine, we now can, in real time or through store-and-forward capabilities, provide continuity of care. They can see the same doctors that provided their care in the hospitals,” Col. Albano says.

To supply this telemedicine to a region with a limited information technology infrastructure, TATRC provided the Nairobi health clinic with a very small aperture terminal (VSAT) C-band satellite earth station consisting of a 2.4-meter dish, radio frequency transceiver, satellite modem, multiplexer/demultiplexer and uninterruptable power supply. In this continuing effort, the multiplexer is configured to offer integrated services digital network (ISDN), transmission control protocol/Internet protocol networking and telephone service. The ISDN line is connected to a portable computer running videoconferencing and data sharing software. At the other end of the setup is a Ku-band 4.2-meter earth station in Landstuhl with similarly configured equipment. Signals received in Germany from the satellite can be transmitted worldwide.

In addition to providing extended health care for bomb blast victims, the telemedicine capabilities also are supplying a wider range of medical services to embassy employees.

Although vidoeconferencing is the primary telemedicine service being performed in Nairobi and is a useful tool, the colonel believes the store-and-forward capability offers more flexibility. “Videoconferencing still requires people to set up a schedule and be in a certain place. Store-and-forward allows the experts to review the information as soon as they have the time, and then they can directly respond,” he says.

For situations where immediate access to medical history is needed for critical intervention to begin, TATRC has been examining and refining personal information carriers (PICs) for more than four years. The PIC project was initiated by the Army surgeon general in response to a presidential directive under which the military is to develop and deploy a PIC device by the end of this year.

As a result of a request for information, the center received seven possible technologies that would allow individual soldiers to carry their entire medical record on a device that could be as small as a dime but no larger than a military identification card. The item could be worn as a ring or on a necklace like a dog tag or, using smart-card technology, carried in a pocket, according to Maj. Catherine Beck, USA, chief, information science division, TATRC.

During an emergency, a medic could access the soldier’s medical history from the tag and then input information about the medical treatment administered at the site for full documentation. The PIC would then be transported with the patient to the next level of care, where medical personnel could access the record, determine what procedures had already been performed and continue treatment and data entry.

In its request for proposals earlier this year, TATRC outlined several mandatory requirements. Initially, the devices would be issued to deploying troops. Consequently, the information would have to be erasable so that the tag could be recycled. Because time can be a critical component in saving lives, the center required a data transfer rate of at least 300 kilobytes per second. In addition, the total size of the device could be no larger than a military identification card, and it would have to operate like a computer disk, appearing as a drive letter when inserted into a computer, Maj. Beck says.

The design and capabilities of the proposed devices surprised TATRC’s staff members. One item is the size of a postage stamp and offers 120 megabytes of information storage capacity. Another features a data transfer rate of 6 megabytes per second. During the down-select this spring, subsets of the proposed devices were chosen. These currently are undergoing tests for capabilities, ruggedness and comfort, and later will enter the proof of concept stage. Maj. Beck predicts initial field use of PICs will begin next year.

Another project currently under investigation would complement PIC utilization. The center is reviewing voice recognition technologies that would allow medics to dictate the procedures to the computer as they are performing them. The data would be recorded in two formats, audio and written, and could be accessed by the next station providing care.

Voice recognition technologies would also be used in place of traditional medical transcription. This would increase the speed at which details about procedures performed or medication administered is entered into a patient’s record, Maj. Beck explains.

TATRC plans to begin testing voice recognition items this summer, and the capability could be offered as an alternative to traditional transcription methods in January 2000.

Although the Defense Department is sponsoring many of the current research and development efforts, capabilities acquired will also benefit people outside the military, Col. Albano offers.

Through virtual reality training and other telementoring techniques, telemedicine will help train civilian health professionals to deal with injuries they could encounter if terrorist threats are carried out. “People are beginning to realize that, when it comes to biological or chemical terrorist threats, it may not happen in the military setting but in some urban area where the civilian medical personnel would not be familiar with or prepared for treatment. We can use simulations of this to train civilian medical personnel because they may be the ones who face it,” he says.

A trauma patient simulator is one item that could assist in this training. The computer program allows users to train on a three-dimensional screen-image of an interactive, animated virtual body. The “patient” injuries can occur in multiple scenarios as well as in different locales, such as a kitchen, aid station, highway or construction site. The visual components are complemented by an audio track that features physiological, event, environmental and location sounds.

Initially, three of the systems were installed for assessment at the Army Medical Department Center and School, Fort Sam Houston, Texas, and demonstrations have been conducted for both military and civilian medical and training personnel. Response has been positive with many expressing an interest in incorporating this into their initial or ongoing training programs, TATRC officials say.

Computer training and user-friendly designs are critical to the acceptance of telecommunications technologies in the medical arena, Col. Albano says. Although health professionals have accepted technology in the diagnostic realm, the integration of telemedicine technologies into standard and trauma practices still faces some cultural barriers.

“The key to overcoming this is training,” Col. Albano offers. “People have to be taught to use the technology and use the keyboard instead of a pen in hand. As the new generations are coming into the field, they are much more comfortable with the computer. It is part of the Clinical Applications Division’s job to make people comfortable with the technology and to design things so they are easy to use. The old commercial about it not being Hanes until the inspector says it’s Hanes—we have the same thing here. Even though there are a lot of departments that are providing technology, it doesn’t say it’s part of telemedicine until the Clinical Applications Division says it’s telemedicine. If a computer person creates technology and the field doesn’t use it because it’s not user friendly, then it’s nothing more than an expensive doorstop.”

In general, telemedicine is one way to address force reduction. As each service faces a decrease in new recruits and the government continues to downsize, technology helps extend the capabilities of a limited number of personnel, he says.