A Catch-22 Is Keeping Telemedicine Off the Battlefield

Say telemedicine, and you might imagine two-way video or perhaps haptic sensors and augmented reality—features that need enormous bandwidth. But field studies from a successful telemedicine network built by military doctors show that low-bandwidth chat and text features are often all that’s needed. The real barriers to wider adoption of telemedicine are bureaucracy and misperceptions.

Army Lt. Col. Chris Colombo, the director of virtual health and telecritical care at the Madigan Army Medical Center in Washington, is one of the brains behind the National Emergency Tele-Critical Care Network. It’s an experimental effort to connect doctors and other experts with nurses, field medics, and other care providers who need additional instruction on how to care for a patient. As Colombo and his fellow authors describe in the July issue of Critical Care Medicine, the network is simply a way to connect individuals caring for patients with doctors using mobile applications and elastic cloud computing. 

“Our teams have experienced numerous successes,” Colombo writes. They include: “1) treating tension pneumothorax, while local experts were managing a cardiac arrest in a different location; 2) stabilizing respiratory failure, while the local tele-ICU system suffered communications failure; 3) avoiding hospitalizations through remote home monitoring and delivery of home oxygen therapy; and 4) supporting end-of-life care at a small hospital and in a home with a family, both unaccustomed to this experience.”

Neither these outcomes nor battlefield medicine usually require streaming video or other data-intensive features. “Most of the medic-in-the-field needs are easily handled through synchronous voice and asynchronous data. So ‘Hey, take a picture of the wound you are wondering about or the rash you are wondering about,’” he said in an interview. “You can send a pretty decent high-res photograph and compress the file size with very limited bandwidth, certainly enough to support voice with today’s technology.”

Colombo said that for most battlefield medical emergencies requiring the attention of an expert far away, voice communication is enough. “We’ve had them document vital signs for several hours of care and then take a photo of that [chart] and send it. Then the [doctor] or surgeon on the other end can get a sense of ‘Oh, your patient is trending this way. This happened, at this hour; you’ve given these medications.’ They are now up to speed using almost no bandwidth.” 

That matters at a time as the military struggles to extend and connect more things to battlefield networks and adversaries get better at electronic warfare.

But, Colombo said, the folks who organize exercises and write requirements generally don’t understand just how little bandwidth is needed to improve medical care in the field. Because the assumption is that telemedicine will require lots of back-and-forth video, the inclination is to give none rather than not enough. “The perception is that we’re going to be streaming high-def video 24/7,” he said. 

That’s one problem. Another is that in order to prove that telemedicine has value, they need to get it into more exercises and eventually into military doctrine and requirements. But in order to do that, they have to show it has value. 

“The trouble is there’s no requirement in military doctrine for telemedicine because we know that doctrine evolves so much more slowly than reality. There was no doctrine for cutting through hedgerows in France in World War II either,” he said.

He recounted experiences where he would talk with the organizers of large field exercises, exercises where commanders wanted to test telemedicine concepts, but he would then encounter a Kafkaesque situation: 

“If I continually say, ‘We need to do this,’ and everybody says, ‘Well, where is the requirement?’ I say, ‘Well, I can’t generate a requirement until I prove it has value. I can’t prove it has value until you’re willing to do it. But you’re not willing to do it unless it’s required.’ And it’s a self-licking ice-cream cone.”

To get around the problem, Colombo and his team have brought their own internet capability to exercises just to show how easy it was to extend telemedicine services. “What we really need to do is get out into the field with folks and if we have to bring our own internet, so be it, and show them the value, have the distinguished guest walk by [and ask] ‘What’s happening here?’ Oh, they’re sending text messages back and forth so that the medic knows how to mix up that drug dose correctly.’ And then people see this has value even at low bandwidth.”

Ideally, Colombo said, doctrine and requirements will catch up to allow at least low-bandwidth telemedicine. And that, he said, will be a great deal better than what is common today.