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The Sci-Fi Life

     First thing each day, they sign into the system. This links them to the central EMS database and ties them into a scalable network of entities and agencies that can include not only other emergency responders, but hospitals, public health, transportation authorities and anyone else with a need to participate. It also triggers the self-testing of medical equipment aboard their ambulance and the automatic download of the latest news from sources like their EMS agency and county public health.

     Biometric identity checks authenticate both users--the paramedic and the EMT who will be staffing the ambulance that day--and the levels of data available to each. Automatic inventory-control and vehicle-status programs respectively track the rig's medical supplies and operating systems. When all is confirmed well, the shift begins.

     Today the database tells the crew of two scheduled events. The first is a request by a surgeon at a local hospital to check on a post-op patient's infected wound. Video streamed from the patient's home to the surgeon allows him to observe her wound remotely and give the medic special instructions for dealing with it.

     The second involves a bedridden older male whose cardiac recording monitor has stopped sending signals to his cardiologist. At his house, the medic examines the man, relaying his findings verbally into a portable communications device that translates them into text and transfers them into the database. Vitals are transmitted as well, and the cardiologist is automatically notified when the data becomes available.

     Soon after, dispatch learns of a single-car accident. An automatic crash notification system has evaluated vehicle data and generated a "high urgency" alert that activates the local trauma center and air resources. The central database tells dispatch what units are in the crash area and how long it will take them to get to the scene. Road and traffic information from local transit authorities is pulled into the system to guide them efficiently.

     At the trauma center, the database tells staff of another crash, an overdose and a workplace accident--all patients headed their way. A second trauma team is activated to deal with the coming influx. Meanwhile, responders to the initial crash report icy roads en route. This information is reflected in both the EMS database and a similar transportation database, warning subsequent responders of the hazard. A road crew is dispatched to sand the road.

     Upon arrival, the crew notes scene hazards, which are fed into the database to alert other responders. The vehicle's male driver is complaining of chest pain. His vital and EKG readings are taken and transmitted wirelessly; the medic relates other findings, such as a lack of chest tenderness, verbally, and voice-recognition software converts them to text in the database.

     The female passenger will go to the trauma center with another crew. When this is decided, her network status is updated and shows a color change, alerting the trauma team she's coming. The driver, on the other hand, has suffered a heart attack. A temporary network is established between EMS, an ED physician at the local hospital, a doc at the nearest trauma center and a cardiologist at the regional cardiac care center. The trauma doc orders ultrasound. Results of the scan, transmitted to him, rule out major trauma. The patient is then sent directly to the cardiac center for fast treatment. There, a cath team is activated in advance and plugged into the network.

     During the heart patient's transport, EMS continues sending EKG data ahead for monitoring by the cardiac team. Meanwhile, a chopper arrives for the trauma patient at a landing zone a mile away. As the second crew takes her to it, another network is created so they can receive further instructions. The trauma doc is tied in and orders a body scan for her too--it shows a pelvic fracture and swelling of the brain.

     The trauma patient is then flown to the trauma center, where a team is at the ready that includes a trauma surgeon, an orthopedic surgeon to deal with her pelvic fracture and a neurosurgeon to address the brain swelling. The heart patient goes to the cardiac center and straight into the cath lab.

The Future World
     If you're not yet giddy about the promise advancing technology holds for EMS, just consider the above scenario. Then listen to the guy who put it together.

     "All of the technology described in that scenario," says Kevin McGinnis, a program adviser with the National Association of State EMS Officials, "is available today."

     An expanded version of the scenario will appear in both a forthcoming report from the Intelligent Transportation Society of America and the next version of the Statement of Requirements for Public Safety Wireless Communications & Interoperability from the Department of Homeland Security's Safecom program. It is intended, says McGinnis, to describe what an EMS response of the future might look like, so that EMS leaders and policy-makers might understand what's within their grasp and start preparing for it now.

     "We want to communicate that future world to the movers and shakers," he says, "so they can start looking for that technology, budgeting for that technology, and making sure their systems are prepared to integrate that technology."

     There's a lot entailed in that. But then, there's a lot at stake.

Snapshots & Beyond
     EMS has always been about communication, but those needs have not been static. As the years have passed, more data and more information has become available throughout the EMS process, and exchanging it quickly and accurately has become increasingly important.

     "Our needs have evolved over time," says Ray Fowler, MD, deputy medical director for the BioTel system in Dallas and a technophile who's been a key player in a number of recent telemedicine projects. "Things have evolved as far as how we dispatch, how we communicate with medics in the field, what techniques we use to do online medical control. We've seen a growing need to be able to communicate things like hospital diversions and 12-lead information. And we are very close now to being able to communicate patient criticality, in real time, by means other than just voice communications."

     Voice and video are ways to paint part of a picture, but what this is really about is data. Reams of data collected noninvasively, transmitted wirelessly and aggregated automatically. Data to inform field providers, doctors at hospitals, researchers at universities. Data leading to better care of single patients and entire populations.

     "We're now expected to be able to receive, store and analyze all the information we get," says Cai Glushak, MD, medical director for the Chicago South EMS system and chair of the National Association of EMS Physicians' Communications Committee. "It's no longer good enough just to have the experience and then go back and review, trying to capture the simple paper-based and voice-recording-based material we have. There's much more valuable data that's available, and we're obligated to be on top of it. We should be able to pull in things like pulse oximetry, capnography, the 12-lead EKG, the patient-care record itself.

     "Traditionally we capture a snapshot of that data: one point in time, the most relevant part the prehospital provider chooses to document. And we get a brief static description of something that's evolving over a period of time. Why shouldn't we have the same record and access to what's going on as we would if the patient were in our own ED?"

Achtung, Baby
     Why Not Indeed.

     Expense? Expense is relative. A telemedicine system linking trauma docs in Tucson to small hospitals a hundred or more miles away paid for itself with the first few unnecessary air transports it prevented. (The city is now bringing a similar system to its ambulances.) Many components also get cheaper every day.

     Fear of Big Brother, of medics losing their authority and independence? Get over it. "I don't think videotaping [prehospital providers] is going to be necessary or even helpful a lot of the time," says Glushak. Adds Fowler: "Real-time telemetry is not something that would benefit most patients. Maybe one in 20 is so sick that a medic would actually benefit by having a physician helping make clinical decisions."

     Awareness and understanding? Now you're getting somewhere.

     "There are so many things in that scenario that would make people drool and say ‘Yeah! I could see that!'" says McGinnis. "We're trying to raise awareness and get people excited about this--especially the EMS leaders, who are supposed to have the vision about the future."

     But "getting people's attention is a difficult thing," says Michael Smith, president of New Jersey-based General Devices, a top producer of voice and data communications equipment and telemedicine systems for EMS. "Most people in EMS aren't even aware of these new technologies coming online now. When I mention mesh to EMS directors, most don't have any idea what it is or what it can mean to EMS."

     And that brings us to matters of technology and infrastructure.

A Happy Medium
     For the potential discussed above to be realized, EMS needs robust communications media that can move great amounts of data quickly and reliably. It has not traditionally had that, but that's changing.

     One way is through mesh networks. These are local-area networks that connect large numbers of "nodes" (i.e., work stations or radio receivers) directly to each other, and use them to pass data back and forth. Data basically "jumps" from node to node, with each one acting as a repeater. Little additional infrastructure is required, and compared to other avenues available to EMS, a lot of data can be moved quickly this way.

     "A UHF system transmitting data might be able to do two or three kilobits a second on a good day," says Smith. "Today's digital radios can do around 40 or 45 kilobits per second. A really good cell system--assuming you don't get disconnected halfway through--gives you maybe 60 or 100 kilobits a second. Now, by way of comparison, when you go to mesh, you're talking about one–three megabits (roughly 1,000–3,000 kilobits) a second. That's a quantum leap."

     The downside to mesh is limited range between nodes. It's ideal for an urban venue like Tucson, where you can place a lot of nodes, but poorly suited for less-dense suburban or rural environments.

     Familiar 700MHz and 800MHz radio frequencies don't offer the bandwidth necessary for broadband transmissions, and they also carry limitations of repeaters and range. But as more of that spectrum becomes available to public safety, there is talk of combining some existing bands to create more capability.

     "There are efforts to pair up some bands within that range--to give up some that are available to public safety, take others and group them together," says McGinnis. "That would allow at least wideband, and potentially broadband."

     Wireless data cards for laptops may be a solution for some applications, short of video. Using that method, Fowler was recently able to append monitor/defibrillator data to an electronic patient-care report, then upload it wirelessly, via a local mesh network, to the Web.

     "Two minutes after we pushed 'transmit' on the monitor/defibrillator," he says, "I was looking at every heartbeat, every 12-lead, every blood pressure reading. It was pretty amazing, because one of our big challenges is getting the 12-leads to the hospitals. This means we can inexpensively transmit these somewhat-complex files and put them in the hands of people who need them to help make decisions."

     WiMax is an emerging medium that offers the broadband capability of mesh, but with fewer distance limitations: Its signals can travel up to 30 miles. This technology is several years away, though, and implementing it isn't going to be cheap.

     In the meantime, cities can turn to mesh--increasingly affordable, now that it's wireless--and rural areas may find satellite their best bet.

     "Rural areas have been challenged with cell phone signals, and will continue to be challenged with wireless data transfer," Fowler says. "Satellite is likely going to be the method that solves that conundrum until we have an extended WiMax-type environment. Satellite phones are out there, of course, but the bandwidth is narrow. We have to aim for something faster. But that's the fun of it right now: It's an area that's in development, and we're seeing it change virtually day by day."

The Big Picture
     The burden of fulfilling all this potential, of realizing this sci-fi life, isn't going to fall on field providers. Inevitably, it's the higher-ups--system planners, administrators, medical directors--who will have to construct systems with a big-picture view of the future in mind.

     "Now they really are medical system planners," says Glushak. "They have to see the enhanced capabilities and obligations they have in terms of managing patients in the context of the whole system. They have to make sure the design of their systems meets the medical goals of this new era. That means deconstructing the capabilities of their systems, looking at the communications and interagency relationships and the tools they currently have, and seeing what needs to be enhanced, and how each piece of the puzzle is going to fit together to accomplish their goals in the future."

     This means, for instance, picking not the cheapest 12-lead monitor, but one that can interface with everything else you have or might want to add. Is it compatible with the receiving unit to which it will be streaming data? With data storage and QA and billing processes? With the equipment and processes of that cardiac or trauma team that might be plugged into the process?

     And that leads us to the vendors. They will have to change too. Greater interoperability will be required of their products. Discrete equipment from discrete manufacturers will have to interface.

     "Until recently, the concept of interoperability was applied strictly to communications, rather than things such as the data inside a monitor," says Smith. "Soon, interoperability and open architecture are going to be requirements. You simply can't progress otherwise. Data has to flow smoothly from one place to another."

     "A lot of vendors don't understand the importance of this. They tend to have protective policies with regards to sharing any data coming out of their equipment," says Glushak. "We have to convince them that that's actually a reason to avoid using them. Until the day a vendor can provide for all the needs of a whole system, no matter how many pieces of the puzzle they have, there's going to be another piece, a key link in the chain, that they're not going to be able to interface with. And that will make your integrated system planning grind to a halt."

Things To Do
     There's an urgency to getting EMS leaders up to speed on these matters, and it's this: Bandwidth is finite, even in the mesh range (4.9 GHz)--and it's not going to last. If EMS doesn't get active, it may not have the bandwidth to do the futuristic things technology now permits.

     Consequently, say McGinnis, Smith and an array of others, there's an imperative to get educated and get seats at the tables where such decisions are being made.

     "EMS has to get in there and make a claim to those frequencies," McGinnis says. "There are going to be all sorts of other folks in there, not just public safety. There's also talk about using mesh networks for things like video cameras to monitor roadways or high-crime areas. We are going to be the most bandwidth-intensive public-safety agency out there, and we need to make sure there's enough bandwidth for EMS."

     EMS is alarmingly underrepresented on virtually all state interoperability executive committees--that's a good place to start.

     "If we're not there," McGin-nis warns, "those statewide interoperability plans are going to grow up and allocate bandwidth to everybody but EMS. We cannot be our own worst enemies on this. We have to have the vision to recognize what this new technology can do for us and our patients."

     "We have to take this all very, very seriously," adds Fowler. "It's a very important time in our industry."

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