When 50-year-old Stephen Clarke, an equestrian judge from Cheshire, boarded a Bmi flight from Chicago to Manchester he wasn't expecting to make aviation history. But a few hours before landing he developed severe chest pains. Thanks to the quick reactions of cabin staff and to a new telemedicine device which Bmi had installed only 10 months earlier, Clarke became the first commercial air passenger to have a live echocardiogram (ECG) recorded in-flight and beamed by satellite to ground-based doctors in Phoenix, Arizona. The specialists diagnosed a heart attack and instructed the flight attendants how to give emergency treatment while the pilot radioed ahead to paramedics. On landing at Manchester Clarke was whisked to intensive care where he made a good recovery.
Clarke was the beneficiary of Tempus 2000, a portable kit designed to allow someone in a remote situation with no medical training to collect a person's vital signs. This information – which can include blood pressure, pulse, respiration, blood oxygen and body temperature – is sent in real time to the airline's medical centre via the satellite phone system.
Tempus is stored in a portable, bright orange box, and the equipment is so user-friendly that the blood pressure cuff self-inflates and the ECG leads are pre-positioned in a harness which the flight attendant can place on the passenger. A wrist keypad fitted with a camera takes high-resolution pictures so that the doctors can see their patient – they can write or draw on these images to help crew ask where it hurts or to show them how to perform a procedure. Data on-screen is viewed simultaneously by the doctors, who can remotely operate the display while talking into the crew member's earpiece.
"Tempus gives doctors [on the ground] eyes as well as ears," says Roz Thomas of Remote Diagnostic Technologies (RDT) Ltd, the UK-based company which designed Tempus. "The only thing the doctor can't do is physically put the harness on the patient, but they can start and stop the readings. It brings emergency room data to the doctor."
Clarke said: "I could have died. The treatment reduced the damage to my heart and means I have a good long-term prognosis. I probably got better medical attention than if I'd had been at home."
Simon Ray, a cardiologist at Wythenshawe Hospital who treated Clarke, was equally complimentary. "We were all very impressed. The doctors in Phoenix had a good-quality ECG which allowed them to act confidently and decisively, and they got the cabin crew to do all right things. This seems to me a very significant advance. It should be much more widely available."
That was in 2003. Four years later, while Tempus has been taken up by a range of corporate, private, military and head of state aircraft, only two other major commercial airlines have invested in the technology. Emirates has fitted it to all its A340-500s and says it will install the device on its new long-range B777s and A380-800s; Virgin began installing it fleet-wide this summer.
A Virgin spokesperson said: "The various diagnostic tools [Tempus] contains will enable MedLink and any assisting medical volunteer to assess more accurately if someone is suffering from a minor or a more serious condition – this will enable us to make smarter decisions if a diversion is necessary."
Medlink provides 24-hour advice from specialists in emergency medicine to around 80 international carriers (including Bmi) from its base in Phoenix, Arizona. As well as talking cabin crew through helping a sick passenger, the company advises on whether to divert the flight and where to land to find a hospital with the facilities needed to treat the passenger. RDT designed Tempus to be compatible with MedLink so that cabin crew would talk to doctors via the device. It is certainly a safer bet than relying on a medical professional to come forward to assess a patient. In 2006, a doctor volunteered in only 47 per cent of cases where one was requested, according to MedAire, which runs the MedLink global response medical centre for airlines.
The slow take-up of Tempus seems surprising given that it can not only help to save a passenger's life, but also save airlines from making unnecessary and costly medical diversions. Figures for the number of medical diversions vary widely, but British Airways has said they occur at a rate of around one per 5,000 flights per week, and that it makes around 50 medical diversions a year, around half of which turn out not to be serious.
BA ran a trial using Tempus several years ago, but the head of in-flight medical services, Dr Nigel Dowdall, says he is not yet persuaded that it can improve on the decision-making process that already goes on between the pilot and the medical team on the ground about whether to divert.
"Does the additional information make any difference to the outcome? If it does then hopefully it will become something that airlines carry. But MedLink is not convinced that having that equipment is going to make any difference to the decision they make."
He also points out that Tempus can't do anything to help treat a passenger once the diagnosis is known. Virgin says that once Tempus is installed cabin crew would continue to seek assistance from passing doctors if needed. Jill Drake, a spokesperson for MedAire, says airlines without Tempus are "not necessarily" at a disadvantage because "not all medical situations require the use of telemedicine device readings".
Tempus works within airlines' satellite communications to allow it to send its data at the same time. "We had to make some changes to the reliability [of the data service]," says Graham Murphy, managing director of RDT. "It could be as low as 30 per cent and take you 10 attempts to get data off the aircraft. For a product like ours it wasn't reliable enough."
So RDT had to create its own technology, using special "hardened modems" to keep the connections open. Murphy explains: "When you get signal fade a normal modem gives up and makes another call – that's the right thing to do on the ground but not on a plane, because it takes quite a long time to set up the call."
The company also set up localised data centres near each of the six global ground-earth stations which receive satellite signals from aircraft passing overhead. These data centres decode calls into a digital format so that, instead of travelling thousands of miles via telephone lines, the data is sent over a fast, reliable and secure internet connection to a data centre in London, from where it is transmitted to MedLink.
Tempus was designed to be easy to install; nevertheless, it is not compatible with British Airways' current fleet because, unusually, the necessary wiring is not available in every seat [the device connects to the satellite phone]. But there are ways around this. "Tempus works over ethernet and wifi as well as traditional satellite communications," says Murphy, "so if and when BA is ready it will probably be transmitted over this."
Dr Ray Johnston, head of the Aviation Health Unit at the Civil Aviation Authority, also believes that more concrete information is needed about Tempus. "Conceptually, the more information you have the better the decision-making process, but we need evidence, not anecdotes."
With its slow rollout, it may be some time before Tempus's usefulness is proven on a large scale. But in the case of defibrillators, this didn't stop them from becoming a widespread piece of medical equipment. Most aircraft now stock automated external defibrillators (AEDs), although there is no European legislation requiring that they carry them (the FAA in the US made them compulsory in 2004).
When an AED is applied it will indicate whether a shock to a person's heart is needed, but it can be used for only two types of abnormal heart rhythm. Dr Johnston has overseen research on use of AEDs in aircraft and says: "Only 30 per cent of remedial rhythms on board an aircraft are amenable to a defibrillator."
Nevertheless airlines have been carrying them for about 10 years. Graham Murphy says: "If you do the hard cost–benefit analysis then the numbers don't add up, but it's more a matter of public opinion. On a personal level I'm still glad that airlines carry them."
About Tempus he says: "The airlines that have chosen to install the equipment were prepared to do their own analysis and they believe that it does make a difference."
Murphy says he is talking to a couple of other major carriers about installing Tempus, but until then it looks as if it's up to a handful of airlines to carry the flag for telemedicine.
