Subject: [NEXTEL-1] REAL-TIME EMS HELICOPTER VIDEO FEASIBILITY STUDY

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FINAL CONTRACT REPORT

REAL-TIME EMS HELICOPTER VIDEO FEASIBILITY STUDY

Dr. Debra Perina

Medical Director,
Pegasus Aeromedical Program

Project Monitor

Cheryl Lynn,,
Virginia Transportation Research Council

Contract Research
Sponsored by

Virginia
Transportation Research Council

Virginia
Transportation Research Council

(A Cooperative
Organization Sponsored Jointly by the

Virginia Department
of Transportation and

the University of
Virginia)

Charlottesville,
Virginia

November 2001

VTRC XX-XX

NOTICE

The project that is the subject of this
report was done under contract for the Virginia Department of Transportation,
Virginia Transportation Research Council.
The contents of this report reflect the views of the authors, who are
responsible for the facts and the accuracy of the data presented herein.  The contents do not necessarily reflect the
official views or policies of the Virginia Department of Transportation, the
Commonwealth Transportation Board, or the Federal Highway Administration.  This report does not constitute a standard,
specification, or regulation.

Each contract report is peer reviewed
and accepted for publication by Research Council staff with expertise in
related technical areas.  Final editing
and proofreading of the report are performed by the contractor.

Copyright 2001 by the
Commonwealth of Virginia.

FINAL CONTRACT REPORT

REAL-TIME EMS HELICOPTER VIDEO FEASIBILITY STUDY

Dr. Debra Perina

Medical Director,
Pegasus Aeromedical Program

INTRODUCTION

Deteriorating
traffic conditions and resulting safety problems on I-81 have long been a topic
of concern for the people living along the I-81 corridor, their elected
representatives, and local government administrators.  Increasing congestion along the largely four-lane highway has
resulted in increases in crash rates.  A
higher percentage of tractor-trailer traffic in the vehicle mix on I-81 has
increased the vulnerability to injury of passenger car occupants involved in
those crashes.  Fatal crashes on I-81
have remained relatively constant, in the twenties and low thirties, but the
number of injury and property damage crashes have steadily increased in recent
years.

A
significant number of motor vehicle crash victims along the I-81 corridor are
eventually transferred to UVA hospital, which is the closest level 1 trauma
center.  Although the EMS teams that are
summoned to motor vehicle crashes are trained volunteers with experience in
dealing with motor vehicle crashes, they are not doctors or nurses, and there
are times when additional expertise is needed to prevent disability or
death.  In these situations, the advice
of a more highly trained professional is needed at the crash scene.  Multiple previous research studies have
shown that the single most important factor affecting disability and death
rates from crashes is the length of time between injury and access to critical
care.  The ideal situation would be if
experienced medical providers could remotely see the crash site and be able to
give advice to EMS providers at the scene.

The
medical personnel staffing the Pegasus emergency evacuation helicopter have
extensive experience in treating critically injured crash victims and are
formally trained medical professionals with additional certifications in
critical care.  They can provide advice
to local rescue squads while in transit to pick up the crash victim.  To do this, they need as much information
about the crash and its resulting injuries as possible.  High resolution, mobile video transmissions
would allow the Pegasus staff direct audio and visual access to the crash
scene, the patient, and the care being provided, without requiring a detailed
verbal description from EMS personnel.
This effectively would allow critical care capabilities to reach crash
victims sooner than is now possible, potentially reducing morbidity and
mortality of the crash victim.  This
feasibility study was designed to determine whether the technology exists to
connect the helicopter with ground EMS personnel.

PURPOSE AND SCOPE

The
purpose of this project was to determine whether the use of ground-based video
imaging by local rescue squad personnel and Pegasus medical staff is
technically and organizationally feasible as a tool to improve pre-hospital
care provided to crash victims.  The
available technology was rated against three criteria: (1) the video feed must
be delayed by less than 60 seconds, (2) the picture quality must be adequate
for remote evaluation of trauma, and (3) the signal must be secure to protect
patient privacy.

METHODOLOGY

Companies with technology that could potentially work for
this proposed project were identified through a literature search, web
searches, attendance at conferences where technology was being demonstrated,
and word of mouth among manufacturers, medical researchers, and EMS agencies or
organizations.  Each of these companies
was contacted and  each provided
information and /or demonstrations of their product.  In cases where similar research was being conducted, the principal
investigator was contacted for information on the scope of their project, the
technology being employed, and any problems encountered to date.

In the search for acceptable equipment, each ”lead”
identified through the above process, was followed up through direct contact by
the principal investigator along with the assistance of the telemedicine
department at the University of Virginia.
Each company contacted was also queried as to any knowledge they might have
of other companies who could potentially provide the desired technology if they
could not.  The principal investigator
then made a determination as to whether the equipment was technically
acceptable for the implementation phase of this project.

The following is a list of companies and contacts
investigated during this phase of the project.
Information obtained and the contact outcome are noted for each
identified company.

Meridian
Company, Noah Rifkin

NavTec
Systems, Geoff Leighton

ARNAV
Systems, Frank Williams

University
of Texas, Houston, Dreams project, Doug Tindell

University
of Maryland, Marian LaMonte, M.D

CISCO
Project, Southwest Research, Tucson, Arizona

ARINC
– David Miller

New
York State EMS Authority, Carol Phielman

U.S.
Coast Guard, Commander Art French, M.D

American
Airlines, Kendall Greene, M.D

Uniformed
University Casualty Research Center, Joe Heck, M.D.

WESCAM
and subsidiary Broadcast Sports Technology, Norm Boese, Mark Merrill

In addition to identifying equipment necessary to perform
the project, it was also necessary to determine other entities that would need
to partner with the study team for project completion.  Identified partners included ground EMS
providers, other hospitals in the proposed study area, and other state or
governmental agencies that might be impacted and/or were necessary for project
completion.  For the project to be
successful, participation and cooperation was necessary from the parties listed
below.  The principal investigator,
along with other members of the study team met with each identified group.

RESULTS

Literature review

The use of real-time remote audiovisual links have been
employed in the care of patients by telemedicine since the early 1980’s This
technology was totally dependent on connections with T1 data transmission lines
that required hard-wired connections between sites.  Real-time video links without hard wire connections have only
been possible in the last few years, with ground to ground linkages
accomplished through the use of microwave or cellular technology.

Currently there are four ongoing ground-based projects
investigating the feasibility of this technology to enhance patient care in EMS
vehicles.  These studies are located at
the University of Maryland, and in Houston Texas (Dreams Project), Las Vegas,
Nevada, and New York State.  To date
there has been no successful real-time video imaging connecting aircraft with
ground unit by non-military personnel.

Within the past three years, two clinical trials have been
preformed by military personnel with variable results.  These trials were performed by the U.S.
Coast Guard and the U.S. Navy and produced mixed results.  Problems noted in both these trials included
grainy, suboptimal resolution of the video and unacceptable delay in
transmission time between connected sites.
As a result, all further testing by these two entities was suspended
pending further technological advances.

Company and Partner Interviews

The following is a list of companies and contacts
investigated during this phase of the project.
Information obtained and the contact outcome are noted for each
identified company.

1.
Meridian Company, Noah Rifkin - This company represents
clients that are looking for specific cutting edge technology and puts
appropriate manufacturers in contact with potential customers.  Mr. Rifkin had no direct knowledge of
manufacturers or companies with real-time video technology as proposed for this
project, but did note the use of “some communication linkages” beyond normal
radio transmissions between New York EMS systems and receiving hospitals.  He referred the principal investigator to
Carol Phielman who was spear-heading the project.  Additionally, Mr. Rifkin offered to investigate other potential
sources of equipment that might be useful in this video project, but subsequently
could not identify other companies beyond those already identified by the
project director.

2.
NavTec Systems, Geoff Leighton  -This is a British based company that
specializes in microwave real-time video connections between two ground points.
The company is currently working on
achieving aircraft transmissions from air to ground through satellite up-link
connections.  The signal is analog and
thus cannot be secured against other users accessing the signal.

3.
ARNAV Systems, Frank Williams – This system employs
computerized real-time flight following techniques using aircraft identifiers
and microwave and radar transmissions.
Point-to-point movement of aircraft is accomplished through this
mechanism.  This company does not employ
video feed nor have a platform that would support video equipment in addition
to what currently exists.  They were
unaware of companies with such technology.

4.
University of Texas, Houston, Dreams project, Doug
Tindell -  This project is utilizing
real-time audio and video to connect Houston EMS with the University of Texas
in Houston.  The transmission signal is
compressed through microwave and analog techniques.  The project has been complicated by lack of ability to transmit
over distances,  due to large buildings
in downtown Houston blocking the microwave signals.  The analog transmission also is problematic for security of the
signal against other entities that might attempt to access the transmission.  The equipment is first or second generation
real-time video from WESCAM, and is a variant of that utilized in the military
demonstrations.

5.
University of Maryland, Brain Attack project, Marian
LaMonte, M.D. This project is using real-time telemedicine video feed through
microwave transmissions to connect ground EMS agencies in Baltimore City and
the  University of Maryland receiving
hospital.  This technology is only being
employed in cases of suspected stroke patients to allow the neurologists to
complete a neurological examination on the patient prior to arrival to the hospital,
in order to shorten the interval between onset of systems and use of
thrombolytic drugs.  The equipment
utilized was developed within the biomedical department at the University of
Maryland by researcher Peter Wu.  There
is an assigned bandwidth for EMS in Maryland; however, the equipment used in
this test could not use the normal EMS band, because it interfered with the
band set aside for routine transmissions from aircraft.  Interest was expressed in working to
overcome this obstacle, but further research and development was projected to
take 8-9 months.

6.
CISCO Project, Southwest Research, Tucson, Arizona –
This project is just beginning and is projected to connect ground EMS with
receiving hospitals in a real-time video connection.  This is projected to include aircraft linkages within a year
after beginning the project.  Equipment
is expected to be obtained from Broadcast Sports Technologies.

7.
ARINC – David Miller – ARNIC is based in Annapolis
Maryland and works with clients to put together specific system needs by
identifying equipment or equipment components necessary to build the desired
system.  This company was contacted
following the meeting with the Virginia Department of Aviation on the referral
of its director, Ken Weigand.  Mr.  Miller indicated that he was not aware of
any system capable of providing real-time video/audio feed

8.
New York State EMS Authority, Carol Phielman – This
project uses  photos taken at the
incident scene and then transmitted to the receiving hospital.  These photos are used by medical personnel
to aid in determining the potential extent of a patient’s injuries based on the
mechanism of injury.  This project uses
static displays and no video or audio transmissions.  The information is also not real time, with the photo’s reaching
the hospital at or about the same time as the patient.

9.
U.S. Coast Guard, Commander Art French, M.D. – The
Coast Guard in conjunction with other branches of the military has an interest
in this type of technology from two perspectives:  (1) to be able to provide surveillance of other craft remotely by
officers on land through a video stream from a Coast Guard vessel, and (2) to
be able to offer instructions to Coast Guard personnel to provide medical care
to patients encountered on the high seas.
The Coast Guard conducted limited tests off the U.S. coast approximately
two years ago with variable success.
Equipment was provided from WESCAM, and was similar to that supplied to
other branches of the military for demonstration purposes(see below).  Problems encountered included an analog
signal that did not protect against others intercepting the signal.  Video quality was grainy with such poor
resolution that individuals on land could not make out sufficient detail to be
able to perform the required mission.
The mode of data transmission was by satellite up-link.

10.
American Airlines, Kendall Greene, M.D. – American
Airlines along with it’s partner, British Airways, has investigated ways to
provide real-time flight data from cockpit video for Trans-Atlantic
Flights.  To date, no equipment has been
tested which performed in a manner desired by the companies.  Video feed was grainy, choppy, and had up to
a minute delay in feedback to video feed.
The equipment tested used satellite up-link technology for
transmission.  This was very costly, but
did allow for appropriate security of video feed.  Presently, the video quality precludes use for the level of
routine cockpit monitoring presently desired by these commercial airlines.  ARNAV systems has been used in the past for
flight-following of commercial aircraft, but recent advances in satellite
tracking have resulted in this method being preferred.

11.
Uniformed University Casualty Research Center, Joe
Heck, M.D. The U.S. Military has had an interest in this type of technology
specifically as it relates to enhancing the survival of battlefield
casualties.  In theory, if physicians
could provide remote assessments through video linkages and instructions to
field medics, the survival rate of casualties would be higher.  The military conducted two field
demonstrations of state-of –the-art technology roughly two years ago before
putting further efforts on hold.  WESCAM
was the company that provided the technology utilized in the
demonstrations.  There were several
problems encountered with the technology.
Poor video resolution resulted in physicians not being able to provide
direction at times.  A delay of up to
one minute in video feed resulted in delays in direction of care that would
have negatively impacted survival.
Finally, the transmission signal was analog resulting in inability to
appropriately secure the transmission from interference and interception by
other entities.

12.
WESCAM and subsidiary Broadcast Sports Technology, Norm
Boese, Mark Merrill – WESCAM and it’s subsidiary, Broadcast Sports Technology,
have been the major supplier of real-time video equipment for several of the
projects identified in the course of this feasibility study.  This company was contacted early on in the
study, and the equipment available at that time was capable of analog only
transmission and had delayed transmission time due to satellite up-link
transmission requirements when used in aircraft.  The limitations of this type of technology were well demonstrated
by previous projects identified in other portions of this text.  In March 2001, the company was again
contacted for an update.  At this time,
further modifications had just been implemented in their equipment making
digital transmission possible and augmented microwave transmission feasible
between an aircraft and the ground.
This had not been technically feasible prior to this time.  Break-though technology occurred largely due
to funding by the FOX Network sports channel primarily for NASCAR
transmissions.  The new product debuted
at the Indianapolis 500 in March and exceeded expectations.  The product was then shown at the Paris air
show in June 2001.  The third
demonstration of this technology occurred in Charlottesville in July 2001 (see
results section of this document).

Necessary partners in this endeavor included ground EMS
providers, other hospitals in the proposed study area, and other state or
governmental agencies that might be impacted and/or were necessary for project
completion.   For the project to be successful,
participation and cooperation was necessary from each potential partner, and
the Principal Investigator and other members of the research team met with
each.   The outcome from these meetings
is detailed below.

1.
Rockingham Memorial Hospital – Kent Folsum, MD,
Emergency Department Director and Mary
Ann Noland, the Emergency Department
Nurse Manager attended the meeting.  Dr.
Folsum expressed interest in the project on behalf of Rockingham Memorial
Hospital and was particularly interested in the potential for video connections
to eventually exist between EMS units and receiving hospitals if the technology
being tested proves useful.  He pledged
support of the current project and offered to train local EMS agencies and
orient Rockingham Memorial ED physicians and staff on the nature of the project
and our proposed protocols.  We
discussed the potential for accident victims on the I-81 corridor, who are
currently taken to Rockingham Memorial before transfer to UVA, to  be transported to UVA as a result of this
project.  Dr. Folsum did not feel this
would create any negative impact on his census or operations.  It was agreed by both parties that the
accident victim would be taken to Rockingham Memorial Hospital first if the
ground transport time to there was shorter than the air transport time to UVA.

2.
Stonewall Jackson Hospital – Colleen Arnold, MD, is the
director of the Emergency Department, as well as the local EMS Medical
Director, so she could speak to involvement of the area EMS squads as well as the
ED.  Dr. Arnold expressed great interest
in this project, as her hospital is the recipient of all serious accident
victims in the southern portion of the proposed project study area.  Stonewall Jackson Hospital is a small
community hospital that lacks many resources to effectively care for a major
trauma patient.  Dr. Arnold felt
that  this study might result in
accident victims being transported to a trauma center sooner and that they
might even bypass Stonewall Jackson altogether which in her opinion was totally
appropriate.  She further indicated that
the local EMS agencies would be happy to participate in the study, and that she
would help facilitate and train the squads as needed.

Dr. Folsum is also the Regional EMS Medical
Director for this council, and thus was able to articulate the desire of the
Council to participate in the implementation phase of this study.  Issues discussed included ways to in-service
the ground EMS providers of the equipment, recurrent training that would be
necessary periodically during the study period, and the best ways to accomplish
data collection regarding performance of the equipment being tested.

3.
Virginia Department of Aviation – Ken Weigand,
Director, represented the Department at this meeting.   The Aviation Department expressed ongoing interest in the
project and a desire to be kept informed as the project moves forward.  The Department of Aviation is currently in a
competitive bid process for grant monies from NASA and the FAA to be a test bed
for new technologies that can be integrated in aircraft to enhance
communication capabilities.  The
helicopter video project is in line with other proposals as emerging technology
in aviation and could potentially dove-tail nicely with the efforts of this
technology test-bed.

4.
Virginia Department of State Police – Colonel Gerald
Massengill, along with all District Sergeants and the State Police Chief Pilot,
were present for the meeting.  The State
Police expressed interest in the project and a desire to be kept informed regarding
equipment identified and employed in this regard.  Equipment similar to that necessary for this project has
significant appeal and application to the law enforcement mission.   The State Police agreed to assist in this
project by allowing the portable video equipment that is to be operated by EMS
to be carried in the trunk of their vehicles.
Since State Police are almost always the first responding unit to an
accident scene, they would be responsible for giving the equipment to the first
responding EMS unit at the scene of the accident and re-securing the equipment
after it’s use.  Nothing further would
be expected from the officers , leaving them free to perform their traffic
control duties.  There were also
discussions that the State Police are constructing a network of microwave
towers along I-64 and I-81.  This
microwave network is obviously envisioned as being totally secure and for law
enforcement purposes only.  Within these
discussions the opportunity to potentially use this network as part of the
communication system for the proposed project was offered and is potentially
viable, depending on the in-aircraft equipment chosen.

Currently, there are 3 research projects attempting to use
real-time video linkages between ground
EMS units and hospitals to enhance patient care.  There are no  projects utilizing this technology in an aeromedical setting
linking aircraft to ground based locations.
This type of technology is constantly undergoing modifications, with
advancements occurring in a rapid fashion.

Equipment Demonstration

A public demonstration of the WESTCAM equipment was held at
Charlottesville-Albemarle Airport on July 17, 2001.  The demonstration was attended by members of the news media, with
subsequent coverage on local TV (See Table 1).
During this demonstration the selected equipment performed according to
expectations.  It was easy for ground
EMS personnel to use and the video quality was real-time and of sufficient
resolution to permit treatment decisions to be made by providers.  Thus, acceptable technology currently exists
to allow the implementation portion of this study to proceed.

Table 1

Attendance List

Westcam EMV Video Demonstration

Organization

Email

Greg
Cross

VDOT
Rural ITS Planning

[email-masked]

Michael
D. Berg

Director,
Thomas Jefferson EMS Council

[email-masked]

Nick
Saunders

Virginia
State Police, Chief Pilot

[email-masked]

Cathy
Seigermom Wolz

Media
Office, UVa health Systems

[email-masked]

Lori
Lichorobuc

NBC29

[email-masked]

Lewis
Jenkins

TJEMS
council member

[email-masked]

Brett
Henyon

Pegasus-flight
crew member and project contact

[email-masked]

Jon
DuFresne

VDOT-Intelligent
Transportation Systems Division

[email-masked]

Gary
Allen

Va.
Transp. Research Council

[email-masked]

Art
French

Commander
U.S. Coast Guard, assigned to NHTSA

[email-masked]

Matt
Mueda

NHTSA

[email-masked]

Gene
Sullivan

Director,
UVa Telemedicine Department

[email-masked]

Kent
R. Folsum M.D.

ED
Director, Rockingham Memorial Hospital

Regional
EMS Medical Director

[email-masked]

Steve
Shergold

VDOT-Intelligent
Transportation Systems Division

[email-masked]

Jim
McGowan

UVA,
Patient Care Services Administrator, Emergency Services

[email-masked]

Michael
Patterson

UVa
Telemedicine

[email-masked]

DISCUSSION

During the course of this study many problems were encountered.  This type of technology has only recently
been available, and in some cases is still in research and development.  This made identifying companies and other
projects very difficult, as there was essentially no central clearinghouse of
such technology.  Additionally, this
study sought to place the technology in an aviation environment, where limited
experience existed and the equipment largely untested.  Some companies that had the necessary
technology and were close to meeting the project needs were not willing to
share the information or provide technology for proprietary reasons.

Once the appropriate technology was identified as available
through WESCAM and Broadcast Sports Technology, efforts to customize the
equipment for this project were successful, culminating in the local
demonstration of the technology.  This
demonstration showed that the video signal is of sufficient quality to allow
medical personnel to make treatment decisions.
There is virtually no delay in signal transmission resulting in true
real-time receipt of information.  The
signal is digitized, and thus secure against other entities inadvertently
accessing the signal.  This protects
patient confidentiality when treating accident victims and transmitting
information between ground personnel and the helicopter crew.  Finally, the ability to augment microwave
transmission of the signal allows for air-to ground transmission over longer
distances making aircraft connects between Charlottesville and I-81 possible.

In addition to the equipment necessary for completion of the
project, significant cooperation and partnerships must be in place for
successful implementation of the helicopter video project.  Key partnerships have been developed between
Rockingham Memorial Hospital, Stonewall Jackson Hospital, Central Shenandoah
EMS Council, and the Virginia State Police.
Each of these groups has a vested interest in the project and have
agreed to participate in a multi-year pilot test of the equipment.  In addition, the Virginia State Department
of Aviation has indicated ongoing interest in this project.

Limitations of this study include the fact that
technological advances are occurring so rapidly with the type of equipment
necessary for this project, that it is possible the technology identified for
this study may be outdated in a few months.
Likewise, it is possible that other appropriate equipment exists that
may not have been discovered by the investigators.

CONCLUSIONS

1.
Real-time video imaging is technically feasible between
ground-based units.  This was clearly
shown in the public demonstration of the identified equipment in July 2001.

2.
Images produced by the video equipment are of sufficient
signal quality to allow aeromedical crew to make patient care decisions
remotely.

3.
Digitalization of the transmission signals allows for
encryption of information, thus insuring security of the signal and patient
confidentiality

RECOMMENDATIONS

Real-time Video Connections are technically feasible between
ground-based EMS agencies and helicopter medical crews.  WESCAM and it’s subsidiary, Broadcast Sports
Technology, is the only company identified in the course of this feasibility
study that can provide this video imaging in digital format.  This type of transmission
is necessary to maintain patient confidentiality and the security of
transmission signals between sources.
Accordingly, it is recommended that WESCAM be the sole-source company to
provide the real-time video imaging technology for Phase II, the implementation
phase, of this project.