Telemedicine advances hold promise of savings in lives and money

MedAire responds to calls for medical assistance from its MedLink Global Response Center in Arizona. The ability of the company’s doctors to make accurate diagnoses has been enhanced by e -mail, which allows them to view digital images of injuries or symptoms. Courtesy MedAire Inc.

Two days out to sea, a member of a tanker crew becomes ill and begins to vomit violently. His skin is cold, his pulse is weak and he is beginning to drift in and out of consciousness. The ship’s medical officer does what he can with the equipment and supplies onboard, but it soon becomes clear that a choice must be made: Continue with the voyage and hope that the man’s condition stabilizes or head back to port for emergency treatment.

The decision is a balancing act between economics and the desire to protect a crew’s health and safety. If the ship turns back and the man’s condition improves in the interim, thousands of dollars could be lost in time, fuel and supplies. If the ship continues on and his condition worsens, however, the consequences could be fatal.

Before the evolution of satellite networks and portable communication devices, mariners far out to sea were on their own when it came to decisions involving emergency medical care. That began to change in the 1980s, when crews gained the ability to contact land-based medical services by telephone for guidance — the birth of maritime telemedicine.

Further advances have expanded the avenues of communication to include e-mail and live video footage transmitted via computer, along with a new tool that holds great promise for emergency care at sea: remote diagnostic monitoring of vital signs.

“Just a generation ago, it wasn’t as easy as plugging in a USB line," said Frank August, director of business development for Inmarsat, a London-based company that owns and operates a global satellite network. “It was a little more complex. Looking back on it, it looks antique in a way. I don’t believe the (maritime) industry is fully aware of the current capabilities and ease of use."

At the heart of telemedicine — loosely defined as the application of clinical medicine where information is transferred via telephone, the Internet or other networks — are satellite arrays now capable of transmitting data to all points on Earth. As medical service and equipment providers upgrade their products to better serve their maritime and aviation customers, telecommunication companies like Inmarsat and Iridium have expanded their satellite systems to keep pace.

Iridium, based in Bethesda, Md., delivers wireless coverage anywhere in the world — including the extreme polar regions — with a 66-satellite network orbiting 485 miles above the Earth. The company’s OpenPort service, developed specifically for maritime users and introduced to the market in 2008, offers multiple data links and bandwidth connections of up to 128 kilobits per second (kbps). This allows larger data files — digital images of a patient’s injury, for example — to be transmitted from ship to shore at higher speeds.

“OpenPort’s three independent phone circuits can all be used simultaneously without interfering with data transmissions, permitting the crew to speak with medical experts ashore while also sending and receiving data at the same time," said Don Thoma, Iridium’s executive vice president for marketing. “OpenPort has completed sea trials on a variety of platforms and is now moving into full commercialization. (We are) ramping up production quickly to meet the backlog of more than 5,000 units on order."

While OpenPort is not designed to transmit large real-time video footage, it can be used for highly compressed video files as well as still images. Video capability will be one of the design criteria for Iridium’s next- generation satellite network, with deployment scheduled for 2014.

Iridium’s OpenPort service, inaugurated in 2008, allows three phone circuits to transmit simultaneously. That means doctors can be receiving medical data and images while they provide medical advice to the crew by phone. Courtesy Iridium

The latest addition to Inmarsat’s 11-satellite network, the Inmarsat-4, takes telemedicine one step further. Operating in a geosynchronous orbit 22,240 miles above the Earth, the three I-4 satellites can transmit data at 432 kbps. The satellites were repositioned in February to provide coverage “just about everywhere ships are operating" except the North and South Poles, August said.

“Previously the capability for maritime equipment was 128 kbps," August said. “That speed is not necessary for telemedicine, but it expands our capability. A photo is worth 1,000 words. The benefit is being able to send them faster."

The increased capability also allows for more efficient transmission of video footage from remote locations. Live video — either standard Internet Protocol (IP) or streaming IP — can provide land-based doctors with vital information about a patient’s condition, including breathing patterns and behavior.

“The benefit of streaming IP is locked bandwidth, which guarantees there is no fluctuation in speed," August said. “With standard IP video, you’re using the Internet and it depends on a very big network you’re not in control of — there’s more chance of fuzziness or pixelization. With streaming IP, you’re controlling the speed over (the satellite provider’s) network. That can be important if you’re dealing with live video of a casualty."

While advances in technology have accelerated the transfer of medical data from ship to shore, the information, images and video are only useful if there is an accurate diagnosis. Since the mid-1980s, land-based medical response centers have been taking calls from mariners confronting health-care emergencies at sea. Board-certified emergency physicians and registered nurses are available 24 hours a day, seven days a week to provide expertise in the treatment, transportation, hospitalization and evacuation of sick or injured personnel.

MedAire Inc., based in Tempe, Ariz., has provided medical expertise to mariners and aviators for more than two decades through its global emergency response centers. The company, which also provides medical training and onboard supplies for mariners operating in remote environments, has seen telemedicine evolve from single-link phone calls to multiple-link exchanges and remote monitoring of vital signs.

“Clients are just now leveraging the Internet more," said Jill Drake, marketing director for MedAire. “They call us for an initial diagnosis, then can follow up via e-mail on a laptop computer. With e-mail you can send a picture of a wound, and it’s often easier to read and understand a diagnosis when it’s in e-mail form. For many people on ships, English isn’t their first language."

Remote Diagnostic Technologies’ Tempus IC monitor allows crew to collect and transmit data on a patient’s vital signs, including EKG results, to shoreside medical services. Courtesy Remote Diagnostic Technologies Ltd.

MedAire is partnering with Remote Diagnostic Technologies Ltd. (RDT) of the United Kingdom to promote RDT’s Tempus IC. The monitor enables non-medical users to collect and transmit a patient’s vital signs — including pulse rate, blood pressure and electrocardiogram (EKG) results — to shoreside medical services like MedAire’s MedLink Global Response Center in Phoenix, Ariz.

“It’s virtually like being in a hospital emergency room because you’re receiving information directly from a vessel," Drake said.

Tempus IC, which received marketing approval from the U.S. Food and Drug Administration in October, also provides video and audio feeds over a range of channels including Bluetooth, Wi-Fi and standard telephone connections. The laptop-sized monitor has a list price of $65,000, but the price comes down if additional units are purchased, said Roz Thomas, head of sales and marketing for RDT. All of the company’s commercial shipping clients using Tempus IC have multiple units in service, she said.

Michael Hite, director of Maritime Medical Access (MMA), a remote-service provider at George Washington University, said maritime companies that aren’t ready to make the jump to multi-functional monitors can still dramatically improve emergency care by using digital cameras.

“The increase in availability of high-resolution cameras has significantly dropped the price of these items," he said. “The increased resolution lets clients send pictures of, for example, rashes with astonishing clarity. This increase in technology gives (medical providers) more information to diagnose and to treat appropriately."

While some maritime companies might be reluctant to embrace telemedicine because of the cost of equipment and service, Hite said the investment inevitably pays off in long-term savings, reduced liability and the retention of qualified mariners.

“When signing new clients, we frequently hear how it is an additional expense and how the value perceived does not meet the price tag," he said. “However, once the service is used, that all changes. Really, it only takes one case where we either treat appropriately and avoid a vessel diversion, or we direct an immediate evacuation versus waiting two days to (get to) port, to recover the cost of the service for years to come."

Hite said companies with vessels that never venture more than a couple of hours from shore can benefit from telemedicine in the same ways that oceangoing operators do. Taking care of emergency medical situations by consulting a land-based service provider also eases the burden on a strained maritime resource: the U.S. Coast Guard.

“The question that comes up is, •We’re so close to shore, why do I need your service? In a pinch, we can just call the USCG,’" Hite said. “While that is true, there are expenses associated with evacuating people off of a vessel. There is additional risk for the vessel crew and the helicopter crew. Also, just because you request a medevac doesn’t mean that you will get one."

Companies offering satellite service and land-based medical guidance were reluctant to provide specifics on fees, citing client confidentiality. Hite said MMA’s service involves an annual contract with unlimited usage and the fee paid up front. He said the cost can range from $750 a year to $6,000 a year depending on crew size, the distance the vessel ventures out to sea, the level of training of personnel aboard and many other factors.

“There is competition and the price has come down," said August of Inmarsat. “The completion of global coverage held a lot of providers off. I think that global coverage gives all maritime companies the confidence that we can provide what they need."

RDT’s Thomas stressed the human element for companies unsure about whether to make the move to telemedicine. “It’s not just about cost or preventing your ship from going where it doesn’t need to be," she said. “It’s also about quality of care, knowing from an occupational health standpoint that you’re providing the best care possible for people on board and that you have left no stone unturned." •

By Professional Mariner Staff