OPTAC-X head-mounted camera technology enables pre-hospital EMS telehealth services
OPTAC-X and Mayo Clinic LTE-Global SATCOM Telehealth Technology Allows Physician Guidance in EMS Environment
ABSTRACT
Mayo Clinic Ambulance Service (MCAS) is testing a novel combination of technologies to enhance the ability to provide prehospital telemedicine connecting physicians with paramedics. MCAS partnered with start-up company OPTAC-X (Orlando, FL) to field test a novel head-mounted video camera connected with a satellite communications terminal to bring medical control emergency medicine physicians to the patient and paramedic by video. The authors believe this is the first report of a physician providing medical guidance to paramedics resuscitating an out-of-hospital cardiac arrest (OHCA) using these technologies.
ABBREVIATIONS
INTRODUCTION
Telemedicine is the use of a variety of digital, telephonic or radio communications to allow for the remote (when distance separates) exchange of medical information.1
Telemedicine use in healthcare has seen dramatic growth following the COVID-19 pandemic, and its use in emergency medical services (EMS) appears to be increasing.2,3 However, there remain challenges with existing technology and communication infrastructure to provide a robust, Health Insurance Portability and Accountability Act (HIPAA)-compliant system allowing for real-time or near real-time data sharing, remote vital-sign monitoring, and reliable video transmission.4,5 These challenges are magnified in rural locales[4] and were particularly highlighted during the recent emergency (911) cellular communication infrastructure collapse.
Mayo Clinic Ambulance Service (MCAS) is a large, multistate EMS agency encompassing 15 ground and 3 rotor-wing (including 1 dual rotor-fixed wing) sites across the upper Midwest (Minnesota and Wisconsin.) Starting with a single ground health system-affiliated MCAS site in Rochester, MN, the EMS agency partnered with a veteran owned telemedicine company (OPTAC-X, Orlando, FL), which provides telemedicine solutions connecting physicians to medics in the field by video. MCAS has 22,000 average annual 9-1-1 calls for service. The telemedicine system is unique in that it leverages a head-mounted, high-resolution (4K) camera with a visual heads-up display (HUD) connected via Wi-Fi to a satellite communication terminal (SATCOM) mounted externally on top of an ambulance, allowing for hands-free paramedic interaction with a remotely-located medical control physician. The goal of these telemedicine systems are to digitally connect with physicians to the homes or scenes of patients at time-of-injury or near time-of-illness in order to help reduce the cognitive burden of paramedics caring for complex patients, improve clinical outcomes and provide awareness to connected physicians regarding what has occurred prior to patient transport and hospital arrival.
To the authors’ knowledge, this represents the first reported case of a medically-complex patient experiencing an out-of-hospital cardiac arrest where field paramedics used this novel combination of technologies (head-mounted camera using satellite communications in a patient's home) to digitally bring an emergency medicine EM/EMS physician to the team and patient with subsequent coordination of preliminary report to the ED code team preparing to receive the patient.
CASE
A 65-year-old female patient suffered an OHCA at a residence approximately 4 miles from the receiving ED. Initial dispatch report to the responding EMS crew indicated their response was for a female having difficulty breathing with crew updated en-route that cardiopulmonary resuscitation (CPR) was being initiated by a family member. Both fire department (basic life support) and EMS (advanced life support) assets were dispatched to the residence. Estimated down-time prior to CPR initiation was brief as the family reported hearing the patient "fall" in the bathroom. The family began chest compressions under the direction of the emergency medical dispatchers and continued CPR until first responders arrived. The responding EMS crew consisted of three paramedics. On EMS arrival, the patient was both pulseless and apneic. Key timelines for the patient resuscitation are listed in Table 1.
15:19 | 911 Call - CPR ongoing by family members |
15:21 | Ambulance and fire assets en-route to patient |
15:26 | Arrival to patient |
15:27 | Telemedicine Initiated |
15:29 | Assessment shows pulseless electrical activity (PEA); CPR started by fire department using Lund University Cardiopulmonary Assist System (LUCAS) device |
15:30 | Interosseous (IO) access to left tibia; bag mask ventilation (BMV) initiated and I-Gel airway (Size 5) placed |
15:30 – 15:39 | Continued CPR. No shock advised. Blood glucose obtained (127 mg/dL). 1 mg epinephrine via interosseous (IO) |
15:39 | Endotracheal intubation via Glidescope; 6.5 mm ETT |
15:39 | Medical control physician recommends nebulized albuterol, sodium bicarbonate, and magnesium sulfate |
15:41 | Return of spontaneous circulation (ROSC); Acute rise in EtCO2 (54); Vitals: BP 184/68, HR 124 |
15:44 | 50 mEq sodium bicarbonate administered via IO |
15:47 | Transport |
15:48 | 4 mg magnesium sulfate initiated via infusion |
15:53 | 2 mg midazolam administered for sedation |
15:56 | Emergency department arrival |
TABLE 1
Resuscitation Timeline
Family on-scene reported the patient had a history of asthma and were concerned she may have had an asthma attack after descending a flight of stairs immediately before she collapsed. As such, paramedics were suspicious for a respiratory cause of the cardiopulmonary arrest. During the resuscitation the patient remained in pulseless electrical activity (PEA) on the monitor and as such, no defibrillation was ever delivered. An EM/EMS physician provided assistance to the crew via the OPTAC-X telemedicine platform, provided recommendations beyond the already delivered advanced cardiac life support (ACLS) protocol, including nebulized albuterol sulfate through the endotracheal tube (ETT), intravenous magnesium and bicarbonate. The physician observed the field endotracheal intubation and visualized crews easily ventilating the patient with BMV following ETT placement without resistance as would be anticipated with a severe asthma exacerbation. The patient regained spontaneous circulation in the field shortly after intubation and was transported to the ED. The physician made contact with the ED resuscitation team and provided full details on patient name and date of birth to allow for preliminary review of patient medical record, as well as timeline and details of prehospital resuscitation. The patient was ultimately admitted to the intensive care unit, extubated 48-hours later and transferred to a general medical floor. A broad differential for the cause of her PEA arrest was considered but the exact etiology was never discovered. Due to the nature of this narrative case report, any patient identifying information has been withheld and patient consent was not required to be obtained.
TECHNOLOGY & DATA
As a pilot project to improve and enhance field telemedicine for paramedics treating complex and unstable patients in the prehospital setting, Mayo Clinic Ambulance Service partnered with OPTAC-X, a company providing a complete end-to-end solution with its software-as-a-platform (SaaP). The platform integrates a wearable assisted reality (AR) video device (Realwear Inc., Vuzix) with a satellite communication terminal (Kymeta Corporation, Redmond WA) and its software partner Vantiq (Walnut Creek, CA.) These technologies are managed through OPTAC-X's artificial intelligence-based network operations center (NOC) and its AI-enhanced SaaP for field telemedicine in remote or austere locations.
As this is a pilot, no images or videos were taken or stored. OPTAC-X’s global connectivity solution utilizes the Kymeta terminal, which uniquely transmits data signals via both cellular and satellite platforms, automatically switching between them when data transmission slows. During this ten-minute telemedicine encounter, 54.25 megabytes of audio and video were uploaded via cellular and 4.92 megabytes via satellite.
This system has been tested and used by USSOCOM and USASOC special operations forces (SOF) teams overseas, with successful demonstrations of connectivity in austere locations in Africa. The ongoing pilot at Mayo Clinic is assessing the feasibility and reliability of this system within a civilian EMS system that serves both urban and rural locations.
Paramedics control the headsets using voice commands to connect with on-call medical control dual EM/EMS physicians through the OPTAC-X SaaP, which utilizes Zoom’s secure video telecommunication platform. Zoom was chosen for its compliance and certifications for privacy practices. Through the OPTAC-X integrated platform with Zoom, physicians can share videos or documents to the AR devices for paramedic review, enabling them to review procedures or protocols before arriving at the scene. The successful handling of a cardiac arrest case in the basement of a patient's home illustrates the novel combination of technologies maintaining communication even when the paramedic is away from the vehicle-mounted SATCOM terminal.
During this case, the Kymeta SATCOM terminal connected to the SES-3 satellite, a GEO satellite positioned at the 103° West orbital slot, located approximately 35,782.9 km from the Earth's surface. The terminal's revolutionary electronically steered antenna (ESA) allows for data transmission with near-zero latency both while in motion and stationary (on-scene.) This "adaptive best path selection" continually scanned satellites and local cellular platforms for the optimal connectivity to maintain audio and video for end-users. The method for selecting the "Best Path" was customized for this case, ensuring the most efficient and reliable connectivity. The latency management algorithm prioritized the fastest connection based on the latency of the second or third network hops. It periodically evaluated all healthy connections, directing new traffic to the link with the lowest latency to optimize performance for this latency-sensitive application during the cardiac arrest.
DISCUSSION
Demand for prehospital care services in the United States (US) is significant with over 30 million patients requesting 911 service for medical care in 2020.7
A significant percentage of those calls are rural with long transport times.8,9
Medical control physicians having robust visual and audio communication on-scene can help ease cognitive load of paramedics by offering alternate thoughts in complex cases, oversee low volume, high risk procedures and prepare receiving clinical teams and resources with better information prior to arrival. This is especially important in rural areas with limited or non-existent cellular connectivity with long In addition, the ability to see patients along with paramedic teams should lower the risk and liability on paramedic teams in situations where patients refuse treatment or do not require ambulance transport. We also see significant potential for this technology to be used in community paramedic programs (CPP) bringing physicians online aiding in decision making for return to the hospital, wound care or patient education clarification.
To date, the majority of prehospital cases utilizing video telemedicine center around telestroke and involve a fixed camera located internally within the ambulance.10-14
Little work has been done exploring the use of telemedicine dismounted from the ambulance for medical resuscitations or motor vehicle collisions. Within our own EMS system, we have previously attempted to deploy a telemedicine system using a portable camera and microphone (Teledoc Health, Purchase, NY) connected via a cellular hotspot. However, this technology routinely failed due to either the inability of the cellular hotspot to connect to regional towers or limited bandwidth to support video connection. The unique aspect of this case is the novel combination of technologies allowing the remotely located physician the ability to provide real-time guidance to the paramedic crew by video with near-zero latency in connectivity, while simultaneously allowing the paramedics to remain hands-free as they continuously provide patient care.
Historically, when paramedics need to contact medical control for care recommendations or orders, this has one of the crew members stepping away from patient care to utilize a radio or phone for communication, thus removing them from direct patient care and requiring them to
Describe what they see to the physician. This loss of a single team member from a traditional 2-person EMS crew during a high-acuity situation can have detrimental impacts on patient care.
Unique to this case, the paramedic utilizing the headset with medical control was separated from the ambulance and satellite communications terminal (in the patient's basement) and was able to remain connected via local WiFi.
Most mobile cellular services are currently building their respective fifth-generation (5G) networks and 5G-capable systems claim to have peak upload speeds of nearly 10 gigabits per second (Gbps) whereas fourth-generation (4G) systems peak at 150 megabits per second (Mbps).16
To upload 4K video, communication systems need approximately 50 Mbps for uninterrupted video.16 However, upload speeds are often less than optimal, and in a head-to-head test published in January 2023, the mobile carrier T-Mobile reportedly had the fastest upload speed at 17.9 Mbps.
Having redundancy or alternate communication options for prehospital care teams is critical as healthcare advances towards a future with increased telemedicine capabilities through video and remote monitoring. Recently, the federal government’s "FirstNet" cellular band that runs on AT&T’s system for first responders went down18
, along with 911 systems in four states6, effectively shutting down prehospital communication and putting millions of patient lives at risk. In rural or more austere locations, cellular service may be weak or absent, prohibiting any cellular data transmission.
In summary, we present the first case of prehospital management of OHCA using this novel combination of technologies. The use of a head-mounted camera allowing for the paramedic to remain hands-free while caring for the patient, WIFI connectivity to a satellite communications terminal and video connectivity with an emergency medicine physician opens the door for future research in out of hospital resuscitative needs and complex care being delivered by prehospital clinicians in urban and rural locales.
References:
1.
Bonvissuto DS, Seed S. What Is Telemedicine? 2023 Available from: https://www.webmd.com/covid/how-does-telemedicine-work. Accessed 4/2/2024
Google Scholar
2.
Bestsennyy O, Gilbert G, Harris A, Rost J. Telehealth: A quarter-trillion-dollar post-COVID-19 reality? 2021 https://www.mckinsey.com/industries/healthcare/our-insights/telehealth-a-quarter-trillion-dollar-post-covid-19-reality. Accessed 3/13/2024
Google Scholar
3.
Pearl RW, Wayling B. The Telehealth Era Is Just Beginning: More gains in quality, affordability, and accessibility are on the way. 2022 https://hbr.org/2022/05/the-telehealth-era-is-just-beginning. Accessed 3/13/2024
Google Scholar
4.
Mehrotra, A. ∙ Ray, K. ∙ Brockmeyer, D.M. ...
Rapidly Converting to “Virtual Practices”: Outpatient Care in the Era of Covid-19
Catalyst non-issue content. 2020; 1
Google Scholar
5.
Tilhou AS, Jain A, DeLeire T. Telehealth Expansion, Internet Speed, and Primary Care Access Before and During COVID-19. JAMA Network Open, 2024. 7(1): p. e2347686-e2347686
Google Scholar
6.
Lenthang MC, Cheung B. Major 911 outages in 4 states leave millions without an easy way to contact authorities. Lumen Technologies said some customers “experienced an outage” when a third-party company “physically cut our fiber” while “installing a light pole.” 2024 https://www.nbcnews.com/news/us-news/major-911-outages-4-states-leave-millions-way-contact-local-authoritie-rcna148345. Accessed 4/2/2024
Google Scholar
7.
National_ and A.o.S.E. Officials. 2020 NATIONAL EMERGENCY MEDICAL SERVICES ASSESSMENT. 2020 https://nasemso.org/wp-content/uploads/2020-National-EMS-Assessment-Reduced-File-Size.pdf. Accessed 4/6/2024
Google Scholar
8.
National_Advisory_Committee_on_Rural_Health_and_Human_Services, ACCESS TO EMERGENCY MEDICAL SERVICES IN RURAL COMMUNITIES-POLICY BRIEF AND RECOMMENDATIONS TO THE SECRETARY. 2022 https://www.hrsa.gov/sites/default/files/hrsa/advisory-committees/rural/access-to-ems-rural-communities.pdf. Accessed 4/6/2024
Google Scholar
9.
National_Rural_Health_Association EMS Services in Rural America: Challenges and Opportunities. 2019 https://www.ruralhealth.us/getmedia/cc0078fa-14d2-47eb-98a6-2bb6722e540c/2019-NRHA-Policy-Document-EMS-Services-in-Rural-America-Challenges-and-Opportunities.pdf#:∼:text=In%20the%20face%20of%20this%20glaring%20healthcare%20disparity,%20rural%20Emergency. Accessed 4/6/2024
Google Scholar
10.
Amadi-Obi, A. ∙ Gilligan, P. ∙ Owens, N. ...
Telemedicine in pre-hospital care: a review of telemedicine applications in the pre-hospital environment
International Journal of Emergency Medicine. 2014; 7:29
Crossref
Scopus (82)
Google Scholar
11.
Chowdhury, S.Z. ∙ Wardman, D. ∙ Cordato, D. ...
Optimising Prehospital Pathways to Improve Acute Stroke Reperfusion Therapy Delivery: Systems-Based Approaches
SN Comprehensive Clinical Medicine. 2021; 3:2558-2575
Crossref
Google Scholar
12.
Ranta, A. ∙ Audebert, H.J. ∙ Ioane-Cleverley, L.
Pre-hospital telestroke and expanded hyper-acute telestroke network solutions to reduce geographic inequities: a brief review from the South Pacific
Frontiers in Stroke. 2024; 3
Crossref
Google Scholar
13.
Stores H, Avinger J. Telestroke: Taking telemedicine mobile to curb stroke damage-Century Ambulance reduces brain tissue loss by connecting neurologists to perform NIHSS assessment in the field. Technology, 2019
Google Scholar
14.
Van Hooff, R.J. ∙ Cambron, M. ∙ Van Dyck, R. ...
Prehospital unassisted assessment of stroke severity using telemedicine: a feasibility study
Stroke. 2013; 44:2907-2909
Crossref
Scopus (52)
Google Scholar
15.
Tsai, B.M. ∙ Sun, J.T. ∙ Hsieh, M.J. ...
Correction: Optimal paramedic numbers in resuscitation of patients with out-of-hospital cardiac arrest: A randomized controlled study in a simulation setting
PLoS One. 2020; 15:e0244400
Crossref
Scopus (1)
Google Scholar
16.
4G.CO.UK. How fast are 4G and 5G? https://www.4g.co.uk/how-fast-is-4g/#:∼:text=4G%20offers%20maximum%20real%2Dworld,achievable%20in%20controlled%20laboratory%20environments. Accessed 3/31/2024
Google Scholar
17.
Wyrzykowski R. USA 5G Experience Report January 2023. 2023 https://www.opensignal.com/reports/2023/01/usa/mobile-network-experience-1#:∼:text=Key%20Findings&text=T%2DMobile%20wins%20both%20the,the%20speeds%20Verizon's%20users%20experience. Accessed 3/27/2024
Google Scholar
18.
Barr L. FirstNet outage concern for some law enforcement leaders. 2024 https://abcnews.go.com/Politics/fistnet-outage-concern-law-enforcement-leaders/story?id=107599252. Accessed 3/31/2024
Google Scholar
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