Bringing telemedicine into the ambulance

ED physicians get video, audio, and data relays

Patients in the critical minutes after an injury can now receive early physician intervention through a new cutting-edge information system that recently debuted in San Antonio.

The patented LifeLink system uses a computer, monitor, camera, and microphone to connect emergency department (ED) physicians to emergency medical technicians (EMTs) in ambulances through a combination of two-way visual, audio, and data relays. The trauma doctors can guide the EMTs in patient treatment, thereby reducing response times and improving patient care.

LifeLink is a project of TransGuide in San Antonio, a vast traffic management system jointly operated by the Texas Department of Transportation, the city, and VIA Metropolitan Transit. TransGuide is a 26-mile fiber optics-linked system of cameras and electronic variable message signs that primarily focus on traffic management but also work to support public safety operations, says Patrick L. Irwin, director of transportation operations for the Texas Department of Transportation and TransGuide, both located in San Antonio.

Implementing an idea

The idea for LifeLink was conceived when the Texas Department of Transportation began looking for ways to expand the TransGuide system over a year ago. The department contracted with Southwest Research Institute (SwRI) in San Antonio, an independent nonprofit applied engineering and physical sciences research and development organization, to develop technologies compatible with the TransGuide system.

The Texas Department of Transportation and the U.S. Department of Transportation have co-funded the project. Part of the funding comes from the U.S. Department of Transportation's Model Deployment Initiative program, which showcases current technologies in transportation. "We were selected as one of four sites around the United States to promote our program," Irwin says.

LifeLink is unique because trauma physicians no longer have to rely on condition reports from the EMTs in the emergency services (EMS) units. LifeLink technology allows them to scan the patient themselves with the video camera, look at pupil dilation, look at skin color, and zoom in on an injury. At the same time, the physicians can look at all of the bodily functions to see how that patient is reacting to treatment.

"They also can reassure the patient and have secure communications with the EMTs to direct and assist them as needed," adds Irwin. When the patient is being examined, the information is transmitted to the trauma center through a small antenna on top of the unit, he explains.

Mobile ethernet - a secure telecommunications technology developed by the Army for battlefield applications - and high-frequency spread-spectrum radio broadcast the signals from the ambulance to TransGuide's field equipment, which runs along the freeways. TransGuide then transmits the audio, video information, and data directly to the ED at University Hospital, also in San Antonio.

TransGuide does not monitor the transmission, Irwin says. "We have no need to monitor it. There are some confidentiality concerns, and we respect the patient's rights of privacy and the physician's rights and paramedic's rights, as well."

LifeLink began operations at the beginning of August. The Texas Department of Transportation hopes to add two other trauma hospitals in the city, Brooke Army Medical Center, an Army facility, and Wilford Hall Medical Center, an Air Force hospital, to the program in the near future.

"These are all Level one trauma centers," Irwin says. "We have good distribution of these hospitals so we can help cover all aspects of the city."

Could it work for you?

Some health care providers may think that such a system is not possible without an infrastructure such as TransGuide's in place. Not so, Irwin says.

"There are several ways you can get this type of information. You can do it with fiber optics. If fiber optics are not available, you can lease a very high-end communications telephone line called a T1. A T1 will provide roughly the same capability."

Hospitals would spend about $40,000 for the hardware and software. The software from Southwest Research Institute costs about $32,000. A high-end computer system with special specifications required by Southwest Research, such as video cards, costs about $8,000.

Ten ambulances were outfitted with the LifeLink technology, at a cost of about $22,000 each. Total cost of the program, which included 10 ambulances, was about $3.5 million. Included in that figure was the training of about 280 EMTs.

The future is bright

Hospital physicians and EMTs were skeptical of LifeLink at first, Irwin says. "Without the support of the physicians and EMTs, this program could not work at all." Their skepticism changed once they saw the capabilities of the system - and its possible cost and time savings. Some of the system's benefits include:

4 EMTs could get a physician's assistance if needed.

4 Physicians could start treating the patient before he or she arrived at the hospital.

4 Early intervention improves patient care and may shorten hospital stays.

4 The ED staff could see the condition of the patient and prepare for his or her arrival.

This helps staff prepare to care for the specific injury before the patient arrives. In addition, if physicians see that a patient's injuries are not serious, they could reroute the ambulance to a closer health center. That would put the EMS unit back in service more quickly and make it available for other emergency calls.

Donald Gordon, MD, PhD, medical director of the San Antonio Fire Department, says that he believes the time savings will amount from "$850,000 to $1,700,000 in increased resources in the first year."

Just as exciting as the possible savings with the LifeLink system is the potential of using it in rural areas with volunteer EMS units. "We want to explore ways to use satellite communications to get this capability to the volunteer EMS units out in the rural areas," Irwin says.

Rural volunteer EMTs often don't have the luxury of receiving the amount of training and skill updates as those in larger urban areas, he says. Physicians, therefore, believe LifeLink would have a dramatic impact on emergency medical care in those areas, Irwin says.

For Lifelink to work, each ambulance in the rural areas would need to be outfitted with the same technology as the ambulances in the metropolitan areas. Instead of transmitting directly to the hospital, though, the information would be transmitted to a receiver at Trans Guide, which would then put the information in a format that could be transmitted to the hospitals.

LifeLink also has the potential of being used at accident scenes, not just in ambulances. "The physicians tell us that if they can see the causes or factors of the injuries, such as the crash scene, it helps in their initial analysis of what could be wrong with the patient."

To be able to see outside the ambulance, Irwin hopes to use the Army's Medi-Cam system, in which a small camera is attached to the side of the medic's helmet. The Army has asked SwRI to evaluate the Medi-Cam, and the Texas Department of Transportation is working with SwRI to try to integrate the Medi-Cam system - which was developed for battlefield applications - into the LifeLink system.

"We believe, and Southwest Research Institute is fairly certain, that this video signal can be broadcast [from the helmet] to the ambulance and then broadcast back to the hospital. That would enable physicians to assist in situations that involve a severe incident where the firemen and policemen and EMTs need assistance in removing that patient from the crash site."