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  1. 1. AIR FORCES REALTIME MEDICINEBy Dawn M. Yankeelov During the past three years, the Air Force has developed a telemedicine capability. Today, service personnel and their families from Alaska to Bosnia are benefiting—and the process is just beginning.A fter a heavy air attack in a remote telemedicine. A “Star Trek” future of capabilities can be instituted to talk to overseas location, military ser- medical care delivery, which has arrived specialists on the other side of the ocean. vicemen are waiting for immedi- on U.S. Air Force bases and other For a modest five figure investment, add aate hospitalization. One is experiencing Department of Defense divisions, is put to video camera and high bandwidth withinternal hemorrhaging, another has use. High-tech telecommunications for supporting robotics controls to create real-crushed bone fragments causing excruci- data transfer and combat control, which time interactive patient management.ating pain, and still others are experienc- have led the way for high-tech medical This reality-based approach toing nausea from unknown chemical solutions, become lifesavers. medicine has not yet actually seen awarfare. The nearest hospital is more than With a basic PC, a phone line, battlefield situation. However, it has1,500 miles away.Enter the world of and a modem, simple store and forward entered the lives of thousands of
  2. 2. servicemen stationed on Air Force readiness, according to Dr.Benge.On basesbases in the United StatesTelemedicine everywhere in the U.S., military physicianstraining also began in October 1996 in will move to eliminate the need for sub-Bosnia and Saudi Arabia to serve troops specialists in every location. “This willalready there. downsize the number of people and The Department of Defense equipment required, avoid costly travel forfirst cataloged success with telemedi- patients to the large medical centers, andcine in 1993 when a serviceman’s save space ultimately,” Dr. Benge said.severe skin rash wasdiagnosed from For example, digital radiologySomalia. Doctors were baffled and used eliminates the need for expensive X-raytelepathology to transmit a mic- film to be stored. Dr. Benge explained,roscopic image of the rash to a derm- “Tons and tons of equipment, chemicalsatologist at the Walter Reed Army and water could be eliminated for thisMedical Hospital in Washington, D.C. specialty. The space needed to store X-rayA microscope in Somalia was operated film could be reallocated.”via computer tomake diagnosis and The environment benefits directlytreatment possible. just in the use of telemedicine in radiology “Air Force medical services alone,because the U.S. Air Force canhave been involved for the last 3 1/2 eliminate the requirements to reclaimyears in Department of Defense dem- silver ions from water after developingonstrations, trying t o prove or deter- film. It’s a near instantaneous payoff, Dr.mine how best to utilize communica- Benge added.tions for better patient management,” Telemedicine in the Air ForceDr. Michael James Benge, Director of generally uses an interactive video systemStrategic Man- agement in the U.S. Air integrated with biomedical telemetry,Force Surgeon General’s Office and except in areas where high bandwidth isoverseer of Air Force medical oper- cost prohibitive. Store and forwardations,said. “It’s so dependent on image systems, that use “snapshots” instead ofcapture. And in the early analysis, it’s real-time television, work as well. Theyvery profitable for all involved. allow a physician at a specialty medical Through 2001, telemedicine complex or teaching hospital to examinetraining will be completed for combat and treat patients at multiple
  3. 3. S POTLIGHTSsatellite locations, such as rural hospitals specialist can review any type of X-rayand clinics. examination, including an MRI, CAT scan Integrated into the video system, or ultrasound. Investments in equipmentand based on the requirements of the setup range from $15,000 for storage andremote medical facility, are a number of forward to $200,000 per site for probesdiagnostic devices. The remotely con- and live television feeds.trolled examination camera has a power- Telemedicine was unveiled forful zoom-focus capability that allows a broad military use in June 1995, when thedermatologist to examine small details of Pentagon conducted a tri-service exhibita patient’s skin. An electronic stethoscope featuring live demonstrations ofpermits a cardiologist to do a complete telemedicine in support of day-to-daycardiological examination. Specific operations. At that time, then Secretary ofcamera adapters and resolution capabili- Defense William J. Perry told the Airties enhanced by remote controlled optics Force News Service, “Telemedicine isprovides an ophthalmologist a clear view not just a new use of old technologies. Itof the retina at the referring site. A combines cutting-edge telecommunica-Telemedicine’s enormous potential in the battlefield is demonstrated by this exhibition, in which anattending physician assists a distant surgeon who uses electro-mechanical manipulators, lights andtelevision cameras to view the patient, communicate with the on-site physician and actually performsome of the surgical procedures.
  4. 4. A corpsman examines battlefield casualties and prepares to administer first aid in this telemedicine simulation. His helmet-mounted television camera and voice communications link allow him to transmit real-time images of the wounds, plus his comments and questions, to a doctor located in a Mobile Medical Mentoring Vehicle, located several miles from the battle area. Thus, the corpsman does not have to make difficult medical decisions alone.tions systems with specialized medical equip- services to approximately 1 million people.ment to project medical care in real-time Capt. Linda Eaton, now in charge ofanywhere in the world.” the fully operational program that began During one international demonstra- several years ago, outlined the followingtion, doctors at the exhibit consulted via program goals:satellite with doctors at the Air Force’s 60th • To improve access and quality careMedical Group Hospital at Zagreb, Croatia, a rural bases;about previous cases. Doctors also held live • To increase beneficiary andteleconsultations with medical units in Haiti and provider satisfaction with health careI Macedonia by satellite. delivery; • To prepare providers for support ofTRICARE Southwest: An International deployed forces via teleconsulting;Telemedicine Network • To improve and facilitate cross- The first successful wide-scale service referrals;andprogram implemented in the Air Force was • To be cost-effective or cost-directed by Capt. Ken Bonner, now of MATMO neutral.(Medical Advanced Technology Management “A paradigm shift must occurOffice). His success led to his current involve- through telemedicine training. Physicians arement with the efforts to set up telemedicine in not up to speed on their thinking about itsRiyadh, Saudi Arabia, where about 7,000 U.S. benefits, but through education the messagetroops reside. “The Air Force realizes that you is getting out that this type of support is anhave to move information, not people. The important tool,” Capt. Eaton said.delivery of quality health care is verbal, textual The plan is to have a telemedicineand image-based,” Capt. Bonner said. network organized to function as a compre- The TRICARE Southwest hensive system for the whole region, creatingTelemedicine Pilot Project is an approved a “virtual health care delivery system.” TheDepartment of Defense, Health Affairs (MHSS newly embraced technologies include digitalProponent Committee), proof-of-concept compression, store and forward, automatedproject initiated in Region VI. The region medical records, video e-mail and computercovers Oklahoma, Arkansas and major portions networks. OC-3, DS3, and T1 bandwidth onof Eastern Texas and Western Louisiana. The demand technology, coupled with theDepartment of Defense medical plan in this DICOM standard for medical informationregion is centered around two military medical interchange, supports the multimedia mixcenters-Wilford Hall Medical Center and necessary for gathering and analyzingBrooke Army Medical Center. They provide information.
  5. 5. For example, doctor-to-doctor added. “The only difference is that you Dr. Reed oversees a pilot projectcontact includes the transmission of can’t actually touch the patient.” between Offutt AFB in Nebraska andmedical records, transmission of medical The teleradiology and the Whiteman AFB in Knonoster, Mo. “Weimages, video consultations and rules- telepathology system were the most are trying to help smaller facilities, likebased messaging. Doctor-to-patient supported at the program’s outset. At Whiteman, with low bandwidth tocontact includes remote patient monitor- Wilford Hall, eight telemedicine stations examine snapshots and answer ques-ing, delivery of health information and have been established. Brooke Army tions,” Dr. Reed said. “You can’t make thevideo consultations. Medical Center has a central suite and physician transmit. We haven’t gotten Military treatment facilities telemedicine sites in cardiology, dermatol- over that speed bump. Physicians are notinvolved with the TRICARE implementa- ogy, ophthalmology, surgery and pediat- used to using the technology. Our energytion include Corpus Christi Naval Hospital rics. Other specialists who have conducted of activation needs to be here to achievein Corpus Christi, Tex., Goodfellow Clinic telemedicine consultations from Wilford total success. The next generation ofin San Angelo, Tex., Dyess Hospital in Hall represented endocrinology, gastroen- doctors will be ready.”Abilene, Tex., Ft. Polk Hospital in terology, ophthalmology, rheumatology The program’s first four monthsLeesville, La., and Laughlin Hospital in and urology. When expanded to all the involved fewer than 50 patients butDel Rio, Tex. Between 50-100 patients per region’s military installations, the proved the system’s premises. Totalmonth stand to be served by telemedicine TRICARE project could become the savings can climb well into five-figureat each facility. Full program implementa- largest telemedicine network sums per specialty, according to militarytion is to occur in late 1997. “The patients models for Offutt AFB and Whitemanseem to accept the technology. In most Air Force Surgeon General’s Office, AFB.cases, they see a specialist on the screen Air Combat Command, Langley, VA Dr. Reed notes that telemedicine istalking with them and the attending “Everyone thinks that the particularly useful for dermatologists andphysician,” Capt. Eaton said. “Downtime standard “Star Trek” real -TV transmis- ophthalmologists—an important point withand costly travel is avoided. A typical sion approach is the only way to go, but the emphasis on eyesight for Air Forcespecialist may be booked two to four we are using email and digital cameras to pilots, and the ongoing threat of chemicalweeks in advance. This changes the time do telemedicine. With essential ISDN and biological weapons in the Middle East.frame in favor of the patient.” connections, we use store and forward “You don’t need video of retinas or ear “All patients I’ve worked with capabilities to get the job done,” Lt. Col. drums or skin rashes. Photos work. Listen-think it’s a great idea, “ Lt. Col. Dr. Gary Dr. Hadley Reed of Air Combat Com- ing to a heartbeat can also be had by email.Gronseth, a Wilford Hall neurologist, mand said. An audio clip, for example,” he said.
  6. 6. TELEMEDICINE ... video teleconferencing suites at the five Mental health patients can also primary medical sites in Alaska, evenbe evaluated through telemedicine. “In the long-distance physical therapy manipula-past, as much as three days would be lost tion and teledentistry were introduced.to travel to see if a patient would require Real-world use included an oral surgeonhospitalization through a psychiatric wanting the advice of an orthodontistevaluation,” Dr. Reed said. before operating, a preoperative evalua- Dr. Reed sees widespread tion for wisdom teeth extraction and aimplementation of telemedicine in the periodontic evaluation for gum diseaseU.S. Air Force within 5-10 years. “People and treatment. “Over the first ninedo not realize that disease and non-battle months, 31 dental consults were per-injuries are more of a concern in warfare. formed, saving more than 190 days andTelemedicine can give near instantaneous $40,000 in travel expenses,” Col. Fredtracking of the health of a force, if used Nolan, Jr. said.efficiently.” Equipment choices supported the use of low bandwidth, since high band-3rd Medical Group, Elmendorf Air width circuits at 1.54 mbps and ISDNForce Base, Anchorage, Alaska were not available. A pair of switched 56 In Alaska, telemedicine may Kbps data circuits was installed at eachserve approximately 40 percent of the location. The CLI Eclipse 8100 Modelpopulation in the near future, since the was selected for video teleconferencing atDepartment of Defense administers the 15 frames per second with full duplexhealth care of active military, retired audio. The need for store and forwardmilitary and dependents through an became apparent early in 1996, sointricate partnership. Capt. Greg D. software and hardware under the nameCarson, clinical systems engineer for MD/TV was selected. An object cameratelemedicine in Alaska, claims tremen- was also available at all locations.dous program success. “The reduced Col. Nolan reports that emer-patient travel to Elmendorf from four gency orthopedic care has worked out, asother program nodes is particularly in the case of a patient who had fallen onwelcomed based on the weather the duty, fracturing his little finger. There wasmilitary faces here, in addition to the a question handled via telemedicine as todistances between medical clinics,” he whether surgery would be required. “Thepointed out. human response to telemedicine in Alaska The other Alaska sites involved has been very positive. Providers doare Adak Clinic at Adak Naval Station, describe the need to reach out and touchKodiak Clinic at the U.S. Coast Guard the patient, but go on to state they putStation in Kodiak, Eielson Clinic at their hands in their pockets. The initialEielson AFB, and Bassett Army Hospital shyness disappears quickly and the face-at Ft. Wainwright. Involved with the DoD to-face relationships become a stronghealthcare initiative in the winter wonder- point,” he said.land are Veterans Affairs and the IndianHealth Service. Overseas and Beyond Air evacuations, particularly in Well into 1997, telemedicine willAlaska, often may be risky, delaying become an integral part of the militaryaccess to critical care or preventing it presence overseas, starting in Saudialtogether. The state comprises 25 percent Arabia. Next, up to nine clinics will beof all U.S. Iand acreage and covers the outfitted in nearby Kuwait, Oman andsame north-south distance as the entire Bahrain, at a cost of $50,000 per installa-lower 48 states. It presents a challenge to tion.provide specialty medical professionals INMAR-SAT-based systems,from the 3rd Medical Group to Adak which can be set up anywhere, willClinic, at the Adak Naval Station some represent Phase II for DoD supporting the1,500 miles away. Located in the Aleutian U.S. efforts in Bosnia. “People have notIslands, Adaks NAS is the most remote put telemedicine into enough peacetimesite in the network. Meanwhile, the Coast care yet. We need to get our people intoGuard clinic on Kodiak Island is an air using this on a daytoday basis,” Dr.flight from Anchorage, subject to extreme Benge, who oversees the ongoingweather conditions, and is a free-standing telemedicine launch in the U.S. Air Force,family practice clinic. said. “Telemedicine is very glamorous,but With dedicated data circuits (56 it is still a concept trying to size itself andKbps), store and forward technology, and find itself, in terms of applications.”