The Intersection of Telemedicine and Wilderness Care: Past,Present,and Future

Abstract

Wilderness medicine and telemedicine seemingly exist at opposite ends of the clinical continuum. However, these 2 specialties share a common history and the literature abounds with examples of successful deployment of telemedicine to resource limited settings. The recent widespread adoption of telemedicine has important ramifications for wilderness providers. Telemedicine is inherently reliant on some sort of technology. There is a wide spectrum of complexity involved, but in general these systems rely on a hardware component, a software component, and a network system to transmit information from place to place. Today, connectivity is nearly ubiquitous through access to cellular networks, Wi-Fi, or communication satellites. However, bandwidth, defined as the amount of data which can be transmitted through a given connection over time, remains a limiting factor for many austere settings. Telemedicine services are typically organized into 4 categories: 1) live/interactive; 2) store and forward; 3) remote patient monitoring; and 4) mHealth. Each of these categories has an applicable wilderness medicine use case which will be reviewed in this paper. Though the regulatory environment remains complex, there is enormous potential for telemedicine to enhance the practice of wilderness medicine. Drones are likely to transform wilderness medicine supply chains by facilitating delivery of food, shelter, and medicines and are able to enhance search and rescue efforts. Remote consultations can be paired with remote patient monitoring technology to deliver highly specialized care to austere environments. Early feasibility studies are promising, but further prospective data will be required to define future best practices for wilderness telemedicine.

Keywords

virtual health remote care drones telehealth remote patient monitoring wilderness medicine

Introduction

Wilderness medicine and telemedicine seemingly exist on opposite ends of the clinical continuum. Care delivered in the wilderness setting is perceived as low tech and evokes images of duct tape and dirt. Telemedicine, meanwhile, is seen as high tech and is associated with gadgets and gizmos. In reality, the practice of wilderness medicine and telemedicine operationally overlap and share a rich history of serving patients in resource-limited environments.

Telemedicine has enjoyed modest but meaningful growth for decades as technology has become cheaper and regulatory barriers have eased. More recently, telemedicine utilization has exploded, driven in part by an overwhelming shift in the incentives to deliver care virtually related to the COVID-19 pandemic. Telemedicine is disrupting traditional healthcare through novel care delivery models such as remote patient monitoring and e-consults. In similar fashion, telemedicine has the potential to transform wilderness and austere care.

We will review the shared history of wilderness medicine and telemedicine and discuss how and where these specialties currently intersect. Lastly, we will describe a vision for how telemedicine can enhance the delivery of wilderness care in the future.

Definitions, Origins, and Guiding Principles

Wilderness medicine is characterized by the improvised care of patients in remote locations using limited resources, with the risk of delayed evacuation to definitive care.¹ Telemedicine can be most simply defined as the delivery of medical care from afar. In practice, both specialties manage patients either across or from great distances. For those readers less familiar with telemedicine, Table 1 outlines common definitions used in this landscape. Telemedicine services are typically organized into 4 categories: 1) live/interactive; 2) store and forward; 3) remote patient monitoring; and 4) mHealth. These categories are not mutually exclusive. For instance, mHealth is characterized by the utilization of a mobile device and can be used to deliver telemedicine through each of the other categories. These categories can be further organized along an axis of whether the service is delivered in real time (eg, video conferencing or satellite phone) vs asynchronously (eg, secure messaging or photo-sharing). Table 2 summarizes these categories with an applicable wilderness medicine use case.

Table 1

Common telemedicine terminology

Term	Definition
Telemedicine	The practice of medicine from a distance
Telehealth	The delivery of healthcare from a distance; in addition to telemedicine, telehealth includes a broader scope of activities such as education, training and healthcare logistics
Virtual health	A synonym for telehealth
Originating site	The site where a patient is located at the time of a telehealth service
Hub and spoke	A telehealth operational construct where a centralized resource (the hub) can deliver care to multiple remote locations (the spokes)

Table 2

Categories of telehealth

Category	Description	Wilderness use case
Live interactive communication	The use of a telecommunication modality such as radio or video conferencing to simultaneously connect providers to patients or other providers	An altitude specialist connects to a provider in the field to triage a possible high altitude pulmonary edema patient
Store and forward	The transfer of medical information such as pictures and texts from one location to another	A provider uses a securely transmitted picture to grade a frostbite injury in the field
Remote patient monitoring	The use of a connected or wearable device to collect and transfer medical information to a remote provider	While backpacking, a diabetic sends her blood glucose values via a bluetooth enabled glucometer to her endocrinologist
mHealth	The use of mobile or wireless technology to support the delivery of healthcare	A wilderness emergency medical technician uses a digital wilderness medicine field guide on her smartphone to guide care

Telemedicine was born in a recognizable form with the telephone in the 1880s. The era of modern telemedicine began in the 1960s as the National Aeronautics and Space Administration (NASA) struggled with the problem of how to monitor the health of its astronauts in the most austere of all environments—space. It did not take long for leaders at NASA to realize that the telemedicine systems they were building had important terrestrial applications. In the 1970s, NASA collaborated with the Indian Health Services and private enterprise to form the Space Technology Applied to Rural Papago Advanced Health Care (STARPAHC) to support healthcare delivery to native tribes in rural Arizona.² In the 1980s, STARPAHC infrastructure formed the blueprint for a so-called “spacebridge” to support virtual disaster relief efforts after an earthquake devastated parts of Armenia.³ In the intervening decades, these telemedicine systems have been applied to an ever-expanding scope of resource-limited settings including the developing world, natural disasters, combat medicine, Everest, the polar regions, and maritime environments.⁴^-12

The rules surrounding the delivery of telemedicine services are complex, rapidly changing, and vary from country to country (or state to state). While wilderness medicine providers should seek to understand the nuanced details specific to their practice location, there are guiding principles that apply more universally:

Telemedicine is best conceived as a set of tools to support healthcare delivery rather than a siloed subspecialty. In many cases, these tools are initially seen as cutting edge or disruptive but are eventually subsumed into “business as usual” (eg, it is not called teleradiology anymore, it is just radiology).

The standard of care in the wilderness environment is not dependent on whether the care was delivered through telemedicine or in-person care.

The site of care is defined by the location of the patient at the time the healthcare service was delivered.

Understanding these guiding principles can help wilderness providers navigate the complex local regulatory environment inherent to telemedicine delivery. Additionally, Table 3 outlines common regulatory pitfalls in the United States, along with practical solutions, for the aspiring austere telemedicine provider.

Table 3

Common telemedicine regulatory pitfalls in the United States

Pitfall	Example	Explanation	Solution
Unlicensed care	An altitude specialist licensed in Colorado provides a video consult for a patient in Wyoming hoping to climb Everest	Telemedicine tools make it dangerously convenient to practice medicine across state lines without a license	In the United States, innovations such as the interstate medical licensure compact (www.imlcc.org) make it easier, though not cheaper, to obtain licensure
Site of practice	An academic emergency physician begins to provide volunteer telemedicine support to a local search and rescue organization without notifying her administrator	A site of practice formally dictates where a physician can practice medicine; if a provider does not specifically designate telemedicine within the site of practice, he or she risks being uncovered by malpractice coverage	Always update your supporting administrator or policy holder when delivering a new telemedicine service to ensure site of practice remains up to date
Health Insurance Portability and Accountability Act (HIPAA)	A provider relies on FaceTime to support a camp nurse at a local summer camp	Personal emails, text, and video conferencing platforms such as FaceTime are not typically secure and do expose the provider to a potential HIPAA violation	Proactively use HIPAA-compliant platforms for telemedicine delivery whenever possible
Undocumented care/Malpractice risk	A volunteer medical director for a local search and rescue team provides a video consult to a first responder but fails to document the encounter	Malpractice claims involving telemedicine have been historically low but will likely rise in step with increased telemedicine adoption; proper documentation is critical to mitigate malpractice risk.	Preserve a written record of all telemedicine encounters for at least 7 y

Technology

Telemedicine is inherently reliant on some sort of technology. There is a wide spectrum of complexity involved, but in general these systems rely on a hardware component, a software component, and a network system to transmit information from place to place. Each component of telemedicine technology should be both secure and reliable whenever possible. Today, connectivity in some form is nearly ubiquitous through access to cellular networks, Wi-Fi, or communication satellites. However, bandwidth, defined as the amount of data which can be transmitted through a given connection over time, remains a limiting factor for many austere settings. Live, interactive video consultations are best utilized when there is ample bandwidth and low latency (ie, delay), while asynchronous communications are more appropriate for low-bandwidth scenarios. The ideal telemedicine network is high bandwidth and low latency to best mimic an in-person interaction. It is worth reminding providers that personal emails, SMS texting, and applications such as FaceTime are not secure and, while convenient, could expose the provider to the risk of a Health Insurance Portability and Accountability Act–related fine. A summary of common telemedicine technologies along with their application to the wilderness environment is found in Table 4.

Table 4

Common telemedicine technologies found in the wilderness environment

Technology	Type	Application	Comments
Radios	Hardware	Short-distance live interactive communication	Largely exempt from HIPAA regulations, though providers should avoid sharing private health information over radio whenever possible
Video conferencing	Software	Live interactive communications modality used to approximate an in-person visit between patient and provider, or as a consult	The current technologic standard of care for virtual visits
Satellite phones	Hardware	Communication device able to facilitate live interactive audio asynchronous or messaging/texting	Dominant telemedicine communication device when cellular or Internet not otherwise available
Secure messaging/texting	Software	Asynchronous communication modality most often used for lower acuity medical concerns	Favored telemedicine modality of patients because of ease and convenience
Smartphone	Hardware and software	Foundational device for telemedicine used to facilitate live interactive visits, remote patient monitoring, mHealth, along with store and forward messaging	Very nearly ubiquitous, even in austere settings
Peripheral	Hardware	A device, such a digital stethoscope, used at the originating site to enhance the capabilities of the physical exam via a virtual visit	A wide-ranging set of technologies able to mimic the capabilities found in a typical doctor’s office in order to perform an enhanced virtual physical exam
Wearable	Hardware	A device that transmits biometric data such as vital signs or blood glucose from the patient to a remote provider	Increasingly small, lightweight, and affordable

Drones, also known as unmanned aerial vehicles, merit special mention because of their potential to impact wilderness telemedicine at multiple levels. Drones can be used to provide an ad hoc communication network that is both high bandwidth and low latency to provide real-time video feeds; drones also have the potential to transform medical supply chains.^13,14 The downstream implications for the field of wilderness medicine are considerable and will be discussed in further detail in the following section.^15,16

The Intersection of Wilderness and Telemedicine

Broadly speaking, patient assessment in a wilderness environment is centered around a patient care arc which involves an initial evaluation, stabilization, ongoing monitoring, and then evacuation as necessary. We will use this condensed patient assessment paradigm to explore how wilderness medicine and telemedicine currently intersect.

Initial Evaluation

Care in a wilderness setting often begins with an evaluation of the scene. On a formal search and rescue (SAR) mission, this can involve the deployment of a hasty team to evaluate scene safety and triage the number and severity of injuries. This in turn informs the subsequent allocation of resources for the remaining mission.

Recently, drones have been used to augment this initial scene assessment with promising results. A recently published case series described the first use of a drone in an SAR mission to triage an incident as a body recovery rather than a full rescue.¹⁷ The utilization of a drone likely reduced the overall mission risk to first responders by limiting the scope of the response. A similar case report described the use of a drone to conduct a sweep of a search area, thereby increasing the efficiency of the responding hasty team.¹⁸ In a simulated disaster scenario, drones have been used to assess for breathing to facilitate rapid virtual triage.¹⁹ These early feasibility reports suggest that drones will have an important role in scene assessment and triage. Following triage, telemedicine modalities such as live interactive video can be used to facilitate a patient-assisted physical exam.²⁰ Remotely proctored examinations through physician extenders have long been in operational use across a wide range of specialties,²¹ but the efficacy of this practice has not yet been studied using wilderness first responders (or similar).

Stabilization and Management

After the initial evaluation, the wilderness provider typically pivots to the stabilization and subsequent management of the victim. In austere environments, this can involve exotic or rare conditions where prolonged care is often required. In some cases, this care is best informed by a specialist who is not on scene. Wilderness providers have been using online medical direction through radio or phones for decades. This, of course, is a form of telemedicine. More recently, wilderness providers have begun to leverage a wide variety of digital technologies to enhance patient diagnostics, inform medical decision-making, and expand therapeutic options in resource-limited settings.

While medical diagnostics have been traditionally limited in wilderness settings, this paradigm is changing. The application of ultrasound in austere settings has been widely studied and has been shown to improve outcomes.²² Ultrasound has been more recently combined with telemedicine tools to facilitate remotely proctored exams coupled with real-time assessments by experts.²³^-25 This powerful combination has the potential to expand the utility of ultrasound in austere settings by lowering technical and experience barriers. In addition to ultrasound, a recent study has demonstrated the feasibility of capturing electrocardiograms in extreme environments; this should add to the armamentarium of diagnostics available to future wilderness providers.²⁶

After the wilderness provider has taken the patient’s history, performed a physical examination, and captured available data, treatment is initiated. Here, again, telemedicine is expanding the scope for what is possible in wilderness settings. Simulation studies have demonstrated the feasibility of utilizing drones to deliver automated external defibrillators to remote areas.²⁷ Early testing has also shown that drones can be used to deliver blood products to austere settings.²⁸

Remote consultations are a common example of telemedicine in the wilderness environment; these remote “e-consults” have been in use for decades for the management of conditions such as frostbite and altitude illness.²⁹^-31 More recently, a simulation study demonstrated the feasibility of a telementoring process to manage life-threatening hemorrhage through nonphysicians in an austere environment.³² Remote consultations and telementoring allow direct medical support of field personnel (or patients themselves) and are helpful in delivering specialized expertise to inform treatment or the decision to evacuate (see next section). In practice, these consultations are delivered through a variety of modalities, including email, texting, videoconferencing, radio, and satellite phones. The choice of modality is typically predicated on available technology and bandwidth.

Monitoring and Evacuation

After a patient has been stabilized, the care plan transitions to a monitoring phase to detect subsequent deterioration. A decision is then made on the necessity of an evacuation. Remote patient monitoring (RPM) is a distinct category of telemedicine (Table 2) with the potential to transform the monitoring phase of wilderness care during prolonged extractions. Early studies have proven that RPM tools can function in extreme environments.^33,34 In addition to transmitting critical vital sign information, these wearable sensors also relay geolocation data which has the potential to facilitate locating victims during SAR missions. Connected devices such as continuous glucose monitors are also being deployed in wilderness environments.³⁵ Pairing RPM with remote consultations to handle issues such as altitude illness or diabetic emergencies is likely to be synergistic. Lastly, the utilization of telemedicine, including remote monitoring, has been shown to reduce evacuations in both civilian and military settings.^36,37 Early data suggest that similar results are possible in wilderness environments as well.^25,38

International Telemedicine

Wilderness medicine providers have a long history of providing international telemedicine. Use cases abound, ranging from formal specialist consultations to Antarctica to less formal “advice” for expedition frostbite injuries offered through the British Mountaineering Council (https://www.thebmc.co.uk/how-to-get-expert-frostbite-advice). The rules governing remote care by an out-of-country provider vary widely by country. In Nepal, for example, telemedicine delivered by an out-of-country provider would be unsanctioned without the presence of a local licensed provider at the distant site (https://nmc.org.np/other-guide-lines). In contrast, Mexico has no specific guidance related to international telemedicine. Antarctica represents its own special use case, as it is not a sovereign nation. The general trend is that countries are more tolerant of cross border provider-to-provider consultations than for direct patient care through live, interactive medium such as video. However, just as the US-based provider needs to understand the regulatory environment at the state level, the maxim holds that providers delivering care internationally must understand the regulatory environment at the country level.

Other Telemedicine Applications

Remote second opinions have historically been used (formally or informally) to virtually manage conditions such as frostbite or altitude illness. One can think of a remote second opinion as a type of virtual curbside consultation. In this scenario, the remote expert develops a care plan, which is then relayed to a different provider licensed in the state where the patient is located. The local provider then reviews the care plan directly with the patient. By avoiding direct interaction with the patient, the remote expert is typically not required to be licensed where the patient is located. Most US states allow this construct, but it is worth confirming with the relevant local medical board whether remote second opinions are sanctioned.

Telemedicine (known in this context as ground-based medical support) has been leveraged to support in-flight emergencies for decades. An in-depth review of in-flight emergencies is beyond the scope of this article, but excellent reviews are available elsewhere.³⁹ Generally speaking, the wilderness medicine provider is more likely to consume this service than provide it. Aviation telemedicine is typically audio only; because of this limitation, the telemedicine systems supporting aviation telemedicine typically lag the capabilities available through hospitals or clinics. Controversy remains on whether the regulatory jurisdiction is dictated by the airspace in which the emergency has occurred, or whether jurisdiction is predicated on the aircraft’s home country. In many ways, maritime telemedicine mirrors aviation telemedicine. The rules and responsibilities surrounding telemedicine at sea are described (albeit opaquely) by the Maritime Labour Convention.¹² Interested readers can find a more comprehensive description of maritime telemedicine in this review.⁴⁰

The Future

The future of wilderness telecare appears bright and will be driven at least in part by incremental progress to make telemedicine technology faster, lighter, and cheaper. Expansion of low-orbit satellites and 5G networks will increase both bandwidth and accessibility in austere settings. Increased interoperability between smartphones and electronic health records will better link wilderness providers to hospitals and clinics.

We predict that in short order the use of drones in SAR and disaster response will become the standard of care. Drones will be used to initially sweep remote or dangerous terrain. After a victim has been found, the drone will be used to deliver food, water, shelter, and medical supplies. Additionally, drones will be used to deliver a wearable device to the scene to facilitate wilderness RPM to relay critical physiologic data. In the future, drones will also function as a mobile lab by delivering point-of-care testing into the hands of wilderness first responders.⁴¹ A drone-based communication network will provide a video link between incident commander, medical lead, and first responder to enhance situational awareness. If needed, this network will facilitate telementoring of life-saving procedures, from the administration of epinephrine to needle decompression of a pneumothorax. In time, drones will also be used to transport the victim from the field.⁴²

In the future, low-cost wearable devices in wilderness settings will enhance geolocation of both victims and rescuers during SAR missions. These devices will relay continuous vital signs of injured patients to both first responders and medical directors and will facilitate a heat map of available resources. These data will inform predictive algorithms to drive evacuation decisions and overall risk models. Resource-limited environments are typically data limited as well. In the future, remote consultants will have the benefit of remote patient monitoring data to enhance treatment decisions. These data generated from wearable devices will be transmitted through cloud-based services directly to providers to monitor physiology and clinical status before and after interventions. Wearable devices worn by wilderness athletes will allow expedition leaders to track peak exercise performance; these data will be used to time summit bids to increase the probability of summit success. Lighter, cheaper, and more connected telemedicine technology will improve telemedicine capabilities for in-flight emergencies and telemedicine at sea.

Wilderness education will continue its pivot to a digital medium.⁴³ The COVID-19 pandemic has proven that large wilderness medicine conferences can be successfully delivered virtually. Hybrid conferences that offer in-person and virtual options are likely to have expanded reach. In the future, the wilderness first responder curriculum should include scenarios to practice telemedicine competencies such as applying wearable devices; using a peripheral, simulating telementored procedures; and relaying patient assessments through video. Wilderness medicine fellowships should also include telemedicine competencies such as drone operation, delivering effective remote consultation, and how to telementor life- or limb-saving procedures.

Telehealth will also drive innovations in wilderness medicine research. As the field of emergency medicine has recognized, the adoption of a virtual consent process will likely facilitate wider study recruitment in austere environments.⁴⁴ Future researchers will leverage data (responsibly) generated from smartphones and RPM to derive clinical decision support algorithms designed for austere settings. Feasibility studies will give rise to prospective research that defines the future standards of care for wilderness telemedicine best practice.

Conclusions

The widespread adoption of telemedicine is reshaping healthcare delivery in both hospitals and austere environments. Though the regulatory environment remains complex, there is enormous potential for telemedicine to enhance the practice of wilderness medicine. Drones are likely to transform wilderness medicine supply chains by facilitating delivery of food, shelter, and medicines. Remote consultations will be paired with remote patient monitoring technology to deliver highly specialized care to austere environments. Early feasibility studies are promising, but further prospective data will be required to define future best practices for wilderness telemedicine.

Footnotes

Acknowledgements

Author contributions: Manuscript concept and design (CBD); drafting of the manuscript (CBD, LP); editing of manuscript (CBD, AKL, HP, DC, AW, JL, LP); approval of final manuscript (all authors).

Financial/Material Support: None.

Disclosures: None.

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