Editorial Telemedicine in Space Medicine and Extreme Terrestrial Analogs
Charles R. Doarn, MBA, FATA, and Ronald C. Merrell, MD, FACS, FATA Editors-in-Chief
T
elemedicine and telehealth have been around for quite some time. They have been applied in all sorts of conditions and situations, from disasters to patients’ homes to healthcare facilities to battlefields to space. Each application is similar, yet each is unique. We have reported to you many of the findings from research over these past two decades. This does not mean that there was not a large body of work before 1995. Indeed, there was. Telemedicine in human spaceflight is probably the first large-scale use of the concept that has become known as telemedicine, beginning in the late 1950s. As World War II was winding down, Germany’s rocket scientists had developed and used rockets as offensive weapons. In order to better understand their performance, they developed tools to monitor rocket performance during the flight phase. This technology, primitive multiplexed radio signals, which they referred to as ‘‘Messina,’’ was used to monitor rocket engine performance during flight. Similar technology developed in the late 19th Century also proved useful in monitoring the docks and water levels of the Panama Canal in the early 20th Century. The German scientists who were captured by the U.S. Army or the Soviet Army became key participants in further developing many aspects of space exploration, including telemetry and space medicine in both nations. On the U.S. side, these scientists were integrated into American engineering, science, and medicine through Operation Paperclip. This simple need to monitor something at a distance helped shepherd in the concept of wireless monitoring of a distant patient (astronaut), which we refer to as telemedicine. Many of these individuals had a role in America’s race to the moon in the 1960s and in the development of the necessary medical systems needed to support astronauts, which is known as space medicine. The first use of telemetry in monitoring a living being was by the Soviet Union on Cqutojl-2 (Sputnik 2) on November 3, 1957.1,2 A dog named Laika will forever be remembered as the first mammalian species to be sent into space. Using a telemetry system, Laika’s physiological parameters were down-linked to the Earth at timely intervals. Prior to this event, National Aeronautics and Space Administration’s (NASA’s) precursor agency, the National Advisory Committee for Aeronautics, which was convened in 1915, sent a variety of animal species into the upper atmosphere on sounding rockets but never into low Earth orbit beginning in the early 1950’s. It was December 13, 1958, when NASA sent a primate named Gordo
DOI: 10.1089/tmj.2014.9989
into space on a U.S. Army Jupiter missile and recorded biomedical data indicating that the primate could withstand the launch and ballistic reentry. This valuable information helped physicians and medical researchers understand the impact that humans might experience during all phases of spaceflight. As the race to the Moon heated up, America and the Soviet Union developed the necessary systems to launch humans into space and monitor not only their health but also the environmental parameters of the spacecraft. Although many may recognize how telemetry was used in recent Hollywood productions of Apollo 13 or Gravity, it is a fact that astronauts on the Moon were monitored from Mission Control Center—Houston in near real-time (e.g., cardiac problems during Apollo 15) and were able to provide medical guidance. This concept of telemedicine was further developed when Joe Kerwin, America’s first physician in space, lived on the Skylab, the first American Space Station. The Soviet space program was utilizing telemedicine as well. It was just not called telemedicine in the 1960s. The work by both nations led to the development of the medical care systems used during the Space Shuttle Program and the International Space Station. The technology developed for remote sensing, computer technologies, communication systems, materials, and a whole litany of innovations found their way into military applications and into our everyday life. In space, telemedicine is part of the daily routine. Of course, ground-based research activities were also underway in many places around the world in the 1960s and 1970s. In our editorial in last month’s issue,3 we mentioned Debakey’s surgical work in 1964 with Early Bird and NASA’s ground-based Space Technology Applied to Rural Papago Advanced Health Care (STARPAHC) (1974) project in Arizona. Furthermore, the Kenneth Bird Lecture Series of the American Telemedicine Association (ATA) is named after Dr. Bird for his early work at the Massachusetts General Hospital (in the 1960s). These early activities are aptly highlighted in Bashshur and Shannon’s history of telemedicine textbook.4 As space medicine was developed in the years following World War II and the subsequent space race, there was a need to evaluate technologies, protocols, and procedures prior to using them in the extreme environment of space. Thus, the concept of a terrestrial testbed was established. A testbed can be characterized as a laboratory in a unique setting. For instance, the Russians recently finished the Mars 500 experiment, where six individuals from the European Space Agency, Russian Space Agency, and China lived in a small, self-contained complex in Moscow at the Russian Academy of Sciences’ Institute for Biomedical Problems for 500 days to simulate an exploration mission to Mars. Such a facility permits examination of technology, observation of behavior, study of a variety of processes,
ª M A R Y A N N L I E B E R T , I N C. VOL. 20
NO. 5 MAY 2014
TELEMEDICINE and e-HEALTH 405
EDITORIAL
and an opportunity to gain a greater understanding of what is missing or overlooked. Over the course of several decades, analogs have been used to support space medicine and telemedicine. These include many austere places on Earth such as alpine environments, remote jungles, barren terrain, and environments equipped with simulation systems. They have been used to study how communication delay can impact care and how telecommunications can be used to support robotic surgery at a distance and can monitor anesthesia remotely. Much of this work has been funded by NASA and the U.S. Army’s Telemedicine and Advanced Technology Research Center (TATRC) over the past 20 years. Much of the research outcome has been published in this journal. When you board an airplane to fly to the ATA meeting, you have faith and trust in the pilot. If you got on the plane and the pilot said, ‘‘This is my first time flying this Boeing 767,’’ you would be very concerned. The pilot has received a significant amount of training using simulators before he or she ever flies hundreds of people from one city to another. The same goes for human spaceflight. The cost of evaluating something for the first time in the extreme environment of space is quite enormous and in most cases is prohibitive. Thus, simulators and analog environments are used to test, evaluate, and train. There are several terrestrial analogs that have been used to support space medicine. These include the Aquarius underwater habitat off the coast of Key Largo, FL, used by NASA Extreme Environment Mission Operations (NEEMO), the Mars Houghton Crater on Devon Island in Northern Canada, the alpine regions of the Himalayas (Mt. Everest), the jungles of Ecuador, the high desert regions around the world, areas directly impacted by disasters, and high-fidelity simulations. These terrestrial analogs provide a unique setting with which to evaluate what can work and what will not. In the early 1970s, this was the purpose of the STARPAHC program—to evaluate technology in an isolated area with limited resources and determine its utility for use in space. One cannot assume that a commercial off-the-shelf device that is purchased at a box retailer will work in the extreme environment of space, the battlefield, or the middle of nowhere on Earth. Research portfolios of NASA and TATRC have provided ample opportunities to develop and evaluate innovative approaches. Such analogs are limited in resources, including supplies, expertise, and, most importantly, limited communications, all of which are of vital importance in space medicine. Climbers on Mt. Everest are always challenged by the actual climb, which is predicated on the weather. In Jon Krakauer’s book ‘‘Into Thin Air,’’5 about the 1996 disaster, which claimed several lives, he characterized many of the challenges alpinists face in summiting the world’s tallest peak. There was interest in 1998 and 1999 to determine if and how telemedicine could be used at Base Camp to monitor the climbers to perhaps provide a better system to enhance alpinist safety. NASA’s Commercial Space Center (CSC), focused on telemedicine and medical informatics, initially at Yale University and then at Virginia Commonwealth University, funded studies during
406 TELEMEDICINE and e-HEALTH M A Y 2 0 1 4
the 1998 and 1999 climbing season to determine the utility of telemedicine in this environment. This seminal work, published in this journal, set the stage for new approaches for remote monitoring and using wireless communications in an extreme environment.6,7 Conceptually, it makes perfect sense to monitor the physiological status of an individual from a remote site, especially if there is a limited or nonexistent capability. In space or other austere environments, this is a necessary tool. Two decades ago, the tools and communications systems were bulky and cumbersome to use. Today, as a result of work by NASA and many others, simple sensors or other devices can easily be attached to a smartphone. Even the cameras on these are of exceptional quality. NASA established the CSC to support its international telemedicine activities. In addition to the research effort on Mt. Everest, research was also conducted on the use of telemedicine in surgery, or telesurgery. Although surgical intervention is not a current capability on the International Space Station, future long-duration missions of exploration of Mars will require some sort of intervention. The concepts of telesurgery, borne out of both NASA and military activities, were established in the mid-1990s. Computer Motion and Intuitive Surgical are two commercial entities that came out of this period, although they are one company now. As bandwidth became more widely available, research funded by TATRC and conducted with NASA-funded researchers led to a significant amount of knowledge of surgical capabilities in various analog settings. These included evaluation of robotics during NEEMO missions8 and evaluation of wireless telerobotic surgery in the desert using unmanned airborne vehicles.9 As long as a spacecraft is in low earth orbit or even near the Moon, communications is in real-time or near real-time. During a human mission to Mars, communication delay will be measured in minutes. In fact, one-way transmission is as much as 22 minutes one way when the Earth and Mars are at their farthest distance. We have often heard Dr. Jay Sanders say, ‘‘When an astronaut steps on to the surface of Mars and grabs her chest and says ‘Houston, I have a problem,’ Houston responds 44 minutes later, ‘What kind of problem is it?’’’ We all know the ‘‘Golden Hour’’ has long since passed. So research was done at the Mars Houghton Crater to simulate delays in communications.10 Further research on tele-ultrasound was conducted in the Antarctic and other locations, providing greater understanding of how telemedicine benefits space medicine.11–14 Telemedicine was used extensively in the jungles of Ecuador for surgical care and anesthesia monitoring using the World Wide Web.15,16 In addition, the Arizona Telemedicine Program work in Panama has also proved useful.17 Our intent has been to illustrate how telemedicine developed and supported space medicine and how these tools and procedures can be vetted in extreme terrestrial analogs. Those articles cited here are only but a few examples that highlight this work. In the telemedicine and space medicine community, there is a small but very productive research team distributed worldwide. Therefore, the work cited here comes from that very limited cadre of researchers. Much has been published from these discipline experts not only here but in other venues as well. Several of our colleagues involved in our growing
EDITORIAL
field have been influenced in some way from this body of work, and they have gone on to great things both nationally and internationally. Telemedicine is a necessary tool for space medicine. Men and women are placed into austere environments with limited resource, limited communications, and limited capabilities to return to definitive care on Earth. The growth of this field of telemedicine has benefited from research in testbeds and from operational experience. The lessons learned have found their way into all that we do in healthcare today.
REFERENCES 1. Doarn CR, Nicogossian AE, Merrell RC. Application of telemedicine in the United States Space Program. Telemed J 1998;4:19–30. 2. Nicogossian AE, Pober DF, Roy SA. Evolution of telemedicine in the space program and earth applications. Telemed J E Health 2001;7:1–15. 3. Merrell RC, Doarn CR. The Journal, telemedicine, and the Internet. Telemed J E Health 2014;20:293–294. 4. Rashshur RL, Shannon GW. History of telemedicine: Evolution, context, and transformation. New Rochelle, NY: Mary Ann Liebert, Inc. Publishers, 2009. 5. Krakauer J. Into thin air: A personal account of the Mt. Everest disaster. New York: Villard, 1997. 6. Angood PB, Satava R, Doarn C, Merrell R, E3Group. Telemedicine at the top of the world: The 1998–1999 Everest Extreme Expedition. Telemed J E Health 2000;6:315–325. 7. Satava R, Angood PB, Harnett B, Macedonia C, Merrell R. The physiologic cipher at altitude: Telemedicine and real-time monitoring of climbers on Mount Everest. Telemed J E Health 2000;6:303–313. 8. Doarn CR, Anvari M, Low T, Broderick TJ. Evaluation of teleoperated surgical robots in an enclosed undersea environment. Telemed J E Health 2009;15: 325–335.
9. Harnett BM, Doarn CR, Rosen J, Hannaford B, Broderick TJ. Evaluation of unmanned airborne vehicles and mobile robotic telesurgery in an extreme environment. Telemed J E Health 2008;14:539–544. 10. Harnett BM, Doarn CR, Russell KM, Kapoor V, Merriam NR, Merrell RC. Wireless telemetry and Internet technologies for medical management: A Martian analogy. Aviat Space Environ Med 2001;72:1125–1131. 11. Otto C, Shemenski R, Scott JM, Hartshorn J, Bishop S, Viegas S. Evaluation of tele-ultrasound as a tool in remote diagnosis and clinical management at the Amundsen-Scott South Pole Station and the McMurdo Research Station. Telemed J E Health 2013;19:186–191. 12. McBeth P, Crawford I, Tiruta C, Xiao Z, Zhu GQ, Shuster M, Sewell L, Panebianco N, Lautner D, Nicolaou S, Ball CG, Blaivas M, Dente CJ, Wyrzykowski AD, Kirkpatrick AW. Help is in your pocket: The potential accuracy of smartphoneand laptop-based remotely guided resuscitative telesonography. Telemed J E Health 2013;19:924–930. 13. Kirkpatrick AW, Blaivas M, Sargsyan AE, McBeth PB, Patel C, Xiao Z, Pian L, Panebianco N, Hamilton DR, Ball CG, Dulchavsky SA. Enabling the mission through trans-Atlantic remote mentored musculoskeletal ultrasound: Case report of a portable hand-carried tele-ultrasound system for medical relief missions. Telemed J E Health 2013;19:530–534. 14. Biegler N, McBeth PB, Tevez-Molina MC, McMillan J, Crawford I, Hamilton DR, Kirkpatrick AW. Just-in-time cost-effective off-the-shelf remote telementoring of paramedical personnel in bedside lung sonography—A technical case study. Telemed J E Health 2012;18:807–809. 15. Doarn CR, Fitzgerald S, Rodas E, Harnett B, Prabe-Egge A, Merrell RC. Telemedicine to integrate intermittent surgical services into primary care. Telemed J E Health 2002;8:131–137. 16. Cone SW, Gehr L, Hummel R, Rafiq A, Doarn CR, Merrell RC. Case report of remote anesthetic monitoring using telemedicine. Anesth Analg 2004;98: 386–388. 17. Vega S, Marciscano I, Holcomb M, Erps KA, Major J, Lopez AM, Barker GP, Weinstein RS. Testing a top-down strategy for establishing a sustainable telemedicine program in a developing country: The Arizona Telemedicine Program–US Army–Republic of Panama Initiative. Telemed J E Health 2013;19:746–753.
ª M A R Y A N N L I E B E R T , I N C . VOL. 20
NO. 5 MAY 2014
TELEMEDICINE and e-HEALTH 407
Charles R. Doarn, MBA, FATA, and Ronald C. Merrell, MD, FACS, FATA Editors-in-Chief
T
elemedicine and telehealth have been around for quite some time. They have been applied in all sorts of conditions and situations, from disasters to patients’ homes to healthcare facilities to battlefields to space. Each application is similar, yet each is unique. We have reported to you many of the findings from research over these past two decades. This does not mean that there was not a large body of work before 1995. Indeed, there was. Telemedicine in human spaceflight is probably the first large-scale use of the concept that has become known as telemedicine, beginning in the late 1950s. As World War II was winding down, Germany’s rocket scientists had developed and used rockets as offensive weapons. In order to better understand their performance, they developed tools to monitor rocket performance during the flight phase. This technology, primitive multiplexed radio signals, which they referred to as ‘‘Messina,’’ was used to monitor rocket engine performance during flight. Similar technology developed in the late 19th Century also proved useful in monitoring the docks and water levels of the Panama Canal in the early 20th Century. The German scientists who were captured by the U.S. Army or the Soviet Army became key participants in further developing many aspects of space exploration, including telemetry and space medicine in both nations. On the U.S. side, these scientists were integrated into American engineering, science, and medicine through Operation Paperclip. This simple need to monitor something at a distance helped shepherd in the concept of wireless monitoring of a distant patient (astronaut), which we refer to as telemedicine. Many of these individuals had a role in America’s race to the moon in the 1960s and in the development of the necessary medical systems needed to support astronauts, which is known as space medicine. The first use of telemetry in monitoring a living being was by the Soviet Union on Cqutojl-2 (Sputnik 2) on November 3, 1957.1,2 A dog named Laika will forever be remembered as the first mammalian species to be sent into space. Using a telemetry system, Laika’s physiological parameters were down-linked to the Earth at timely intervals. Prior to this event, National Aeronautics and Space Administration’s (NASA’s) precursor agency, the National Advisory Committee for Aeronautics, which was convened in 1915, sent a variety of animal species into the upper atmosphere on sounding rockets but never into low Earth orbit beginning in the early 1950’s. It was December 13, 1958, when NASA sent a primate named Gordo
DOI: 10.1089/tmj.2014.9989
into space on a U.S. Army Jupiter missile and recorded biomedical data indicating that the primate could withstand the launch and ballistic reentry. This valuable information helped physicians and medical researchers understand the impact that humans might experience during all phases of spaceflight. As the race to the Moon heated up, America and the Soviet Union developed the necessary systems to launch humans into space and monitor not only their health but also the environmental parameters of the spacecraft. Although many may recognize how telemetry was used in recent Hollywood productions of Apollo 13 or Gravity, it is a fact that astronauts on the Moon were monitored from Mission Control Center—Houston in near real-time (e.g., cardiac problems during Apollo 15) and were able to provide medical guidance. This concept of telemedicine was further developed when Joe Kerwin, America’s first physician in space, lived on the Skylab, the first American Space Station. The Soviet space program was utilizing telemedicine as well. It was just not called telemedicine in the 1960s. The work by both nations led to the development of the medical care systems used during the Space Shuttle Program and the International Space Station. The technology developed for remote sensing, computer technologies, communication systems, materials, and a whole litany of innovations found their way into military applications and into our everyday life. In space, telemedicine is part of the daily routine. Of course, ground-based research activities were also underway in many places around the world in the 1960s and 1970s. In our editorial in last month’s issue,3 we mentioned Debakey’s surgical work in 1964 with Early Bird and NASA’s ground-based Space Technology Applied to Rural Papago Advanced Health Care (STARPAHC) (1974) project in Arizona. Furthermore, the Kenneth Bird Lecture Series of the American Telemedicine Association (ATA) is named after Dr. Bird for his early work at the Massachusetts General Hospital (in the 1960s). These early activities are aptly highlighted in Bashshur and Shannon’s history of telemedicine textbook.4 As space medicine was developed in the years following World War II and the subsequent space race, there was a need to evaluate technologies, protocols, and procedures prior to using them in the extreme environment of space. Thus, the concept of a terrestrial testbed was established. A testbed can be characterized as a laboratory in a unique setting. For instance, the Russians recently finished the Mars 500 experiment, where six individuals from the European Space Agency, Russian Space Agency, and China lived in a small, self-contained complex in Moscow at the Russian Academy of Sciences’ Institute for Biomedical Problems for 500 days to simulate an exploration mission to Mars. Such a facility permits examination of technology, observation of behavior, study of a variety of processes,
ª M A R Y A N N L I E B E R T , I N C. VOL. 20
NO. 5 MAY 2014
TELEMEDICINE and e-HEALTH 405
EDITORIAL
and an opportunity to gain a greater understanding of what is missing or overlooked. Over the course of several decades, analogs have been used to support space medicine and telemedicine. These include many austere places on Earth such as alpine environments, remote jungles, barren terrain, and environments equipped with simulation systems. They have been used to study how communication delay can impact care and how telecommunications can be used to support robotic surgery at a distance and can monitor anesthesia remotely. Much of this work has been funded by NASA and the U.S. Army’s Telemedicine and Advanced Technology Research Center (TATRC) over the past 20 years. Much of the research outcome has been published in this journal. When you board an airplane to fly to the ATA meeting, you have faith and trust in the pilot. If you got on the plane and the pilot said, ‘‘This is my first time flying this Boeing 767,’’ you would be very concerned. The pilot has received a significant amount of training using simulators before he or she ever flies hundreds of people from one city to another. The same goes for human spaceflight. The cost of evaluating something for the first time in the extreme environment of space is quite enormous and in most cases is prohibitive. Thus, simulators and analog environments are used to test, evaluate, and train. There are several terrestrial analogs that have been used to support space medicine. These include the Aquarius underwater habitat off the coast of Key Largo, FL, used by NASA Extreme Environment Mission Operations (NEEMO), the Mars Houghton Crater on Devon Island in Northern Canada, the alpine regions of the Himalayas (Mt. Everest), the jungles of Ecuador, the high desert regions around the world, areas directly impacted by disasters, and high-fidelity simulations. These terrestrial analogs provide a unique setting with which to evaluate what can work and what will not. In the early 1970s, this was the purpose of the STARPAHC program—to evaluate technology in an isolated area with limited resources and determine its utility for use in space. One cannot assume that a commercial off-the-shelf device that is purchased at a box retailer will work in the extreme environment of space, the battlefield, or the middle of nowhere on Earth. Research portfolios of NASA and TATRC have provided ample opportunities to develop and evaluate innovative approaches. Such analogs are limited in resources, including supplies, expertise, and, most importantly, limited communications, all of which are of vital importance in space medicine. Climbers on Mt. Everest are always challenged by the actual climb, which is predicated on the weather. In Jon Krakauer’s book ‘‘Into Thin Air,’’5 about the 1996 disaster, which claimed several lives, he characterized many of the challenges alpinists face in summiting the world’s tallest peak. There was interest in 1998 and 1999 to determine if and how telemedicine could be used at Base Camp to monitor the climbers to perhaps provide a better system to enhance alpinist safety. NASA’s Commercial Space Center (CSC), focused on telemedicine and medical informatics, initially at Yale University and then at Virginia Commonwealth University, funded studies during
406 TELEMEDICINE and e-HEALTH M A Y 2 0 1 4
the 1998 and 1999 climbing season to determine the utility of telemedicine in this environment. This seminal work, published in this journal, set the stage for new approaches for remote monitoring and using wireless communications in an extreme environment.6,7 Conceptually, it makes perfect sense to monitor the physiological status of an individual from a remote site, especially if there is a limited or nonexistent capability. In space or other austere environments, this is a necessary tool. Two decades ago, the tools and communications systems were bulky and cumbersome to use. Today, as a result of work by NASA and many others, simple sensors or other devices can easily be attached to a smartphone. Even the cameras on these are of exceptional quality. NASA established the CSC to support its international telemedicine activities. In addition to the research effort on Mt. Everest, research was also conducted on the use of telemedicine in surgery, or telesurgery. Although surgical intervention is not a current capability on the International Space Station, future long-duration missions of exploration of Mars will require some sort of intervention. The concepts of telesurgery, borne out of both NASA and military activities, were established in the mid-1990s. Computer Motion and Intuitive Surgical are two commercial entities that came out of this period, although they are one company now. As bandwidth became more widely available, research funded by TATRC and conducted with NASA-funded researchers led to a significant amount of knowledge of surgical capabilities in various analog settings. These included evaluation of robotics during NEEMO missions8 and evaluation of wireless telerobotic surgery in the desert using unmanned airborne vehicles.9 As long as a spacecraft is in low earth orbit or even near the Moon, communications is in real-time or near real-time. During a human mission to Mars, communication delay will be measured in minutes. In fact, one-way transmission is as much as 22 minutes one way when the Earth and Mars are at their farthest distance. We have often heard Dr. Jay Sanders say, ‘‘When an astronaut steps on to the surface of Mars and grabs her chest and says ‘Houston, I have a problem,’ Houston responds 44 minutes later, ‘What kind of problem is it?’’’ We all know the ‘‘Golden Hour’’ has long since passed. So research was done at the Mars Houghton Crater to simulate delays in communications.10 Further research on tele-ultrasound was conducted in the Antarctic and other locations, providing greater understanding of how telemedicine benefits space medicine.11–14 Telemedicine was used extensively in the jungles of Ecuador for surgical care and anesthesia monitoring using the World Wide Web.15,16 In addition, the Arizona Telemedicine Program work in Panama has also proved useful.17 Our intent has been to illustrate how telemedicine developed and supported space medicine and how these tools and procedures can be vetted in extreme terrestrial analogs. Those articles cited here are only but a few examples that highlight this work. In the telemedicine and space medicine community, there is a small but very productive research team distributed worldwide. Therefore, the work cited here comes from that very limited cadre of researchers. Much has been published from these discipline experts not only here but in other venues as well. Several of our colleagues involved in our growing
EDITORIAL
field have been influenced in some way from this body of work, and they have gone on to great things both nationally and internationally. Telemedicine is a necessary tool for space medicine. Men and women are placed into austere environments with limited resource, limited communications, and limited capabilities to return to definitive care on Earth. The growth of this field of telemedicine has benefited from research in testbeds and from operational experience. The lessons learned have found their way into all that we do in healthcare today.
REFERENCES 1. Doarn CR, Nicogossian AE, Merrell RC. Application of telemedicine in the United States Space Program. Telemed J 1998;4:19–30. 2. Nicogossian AE, Pober DF, Roy SA. Evolution of telemedicine in the space program and earth applications. Telemed J E Health 2001;7:1–15. 3. Merrell RC, Doarn CR. The Journal, telemedicine, and the Internet. Telemed J E Health 2014;20:293–294. 4. Rashshur RL, Shannon GW. History of telemedicine: Evolution, context, and transformation. New Rochelle, NY: Mary Ann Liebert, Inc. Publishers, 2009. 5. Krakauer J. Into thin air: A personal account of the Mt. Everest disaster. New York: Villard, 1997. 6. Angood PB, Satava R, Doarn C, Merrell R, E3Group. Telemedicine at the top of the world: The 1998–1999 Everest Extreme Expedition. Telemed J E Health 2000;6:315–325. 7. Satava R, Angood PB, Harnett B, Macedonia C, Merrell R. The physiologic cipher at altitude: Telemedicine and real-time monitoring of climbers on Mount Everest. Telemed J E Health 2000;6:303–313. 8. Doarn CR, Anvari M, Low T, Broderick TJ. Evaluation of teleoperated surgical robots in an enclosed undersea environment. Telemed J E Health 2009;15: 325–335.
9. Harnett BM, Doarn CR, Rosen J, Hannaford B, Broderick TJ. Evaluation of unmanned airborne vehicles and mobile robotic telesurgery in an extreme environment. Telemed J E Health 2008;14:539–544. 10. Harnett BM, Doarn CR, Russell KM, Kapoor V, Merriam NR, Merrell RC. Wireless telemetry and Internet technologies for medical management: A Martian analogy. Aviat Space Environ Med 2001;72:1125–1131. 11. Otto C, Shemenski R, Scott JM, Hartshorn J, Bishop S, Viegas S. Evaluation of tele-ultrasound as a tool in remote diagnosis and clinical management at the Amundsen-Scott South Pole Station and the McMurdo Research Station. Telemed J E Health 2013;19:186–191. 12. McBeth P, Crawford I, Tiruta C, Xiao Z, Zhu GQ, Shuster M, Sewell L, Panebianco N, Lautner D, Nicolaou S, Ball CG, Blaivas M, Dente CJ, Wyrzykowski AD, Kirkpatrick AW. Help is in your pocket: The potential accuracy of smartphoneand laptop-based remotely guided resuscitative telesonography. Telemed J E Health 2013;19:924–930. 13. Kirkpatrick AW, Blaivas M, Sargsyan AE, McBeth PB, Patel C, Xiao Z, Pian L, Panebianco N, Hamilton DR, Ball CG, Dulchavsky SA. Enabling the mission through trans-Atlantic remote mentored musculoskeletal ultrasound: Case report of a portable hand-carried tele-ultrasound system for medical relief missions. Telemed J E Health 2013;19:530–534. 14. Biegler N, McBeth PB, Tevez-Molina MC, McMillan J, Crawford I, Hamilton DR, Kirkpatrick AW. Just-in-time cost-effective off-the-shelf remote telementoring of paramedical personnel in bedside lung sonography—A technical case study. Telemed J E Health 2012;18:807–809. 15. Doarn CR, Fitzgerald S, Rodas E, Harnett B, Prabe-Egge A, Merrell RC. Telemedicine to integrate intermittent surgical services into primary care. Telemed J E Health 2002;8:131–137. 16. Cone SW, Gehr L, Hummel R, Rafiq A, Doarn CR, Merrell RC. Case report of remote anesthetic monitoring using telemedicine. Anesth Analg 2004;98: 386–388. 17. Vega S, Marciscano I, Holcomb M, Erps KA, Major J, Lopez AM, Barker GP, Weinstein RS. Testing a top-down strategy for establishing a sustainable telemedicine program in a developing country: The Arizona Telemedicine Program–US Army–Republic of Panama Initiative. Telemed J E Health 2013;19:746–753.
ª M A R Y A N N L I E B E R T , I N C . VOL. 20
NO. 5 MAY 2014
TELEMEDICINE and e-HEALTH 407
