Bridges to the future are needed not only to service this great need of trauma care, but perhaps, in time and with game-changing technologies, to prevent and obviate it. The use of the word “innovation” is common in medicine today, where everyone from startup companies to the boards of established companies ceaselessly search to profit from the next “big thing” in medicine. Telemedicine, the delivery of health care and the exchange of health-care information across distances, holds particular promise in trauma care, particularly when existing limitations (supply, distance, etc.) render it either more acceptable than existing conventional services or indeed the only option available.

Telemedicine is defined by the Telemedicine Information Exchange (1997) as the “use of electronic signals to transfer medical data (photographs, X-ray images, audio, patient records, videoconferences, etc.) from one site to another via the Internet, Intranets, PCs, satellites, or videoconferencing telephone equipment in order to improve access to health care.” According to the Telemedicine Report to Congress (1997), “telemedicine can mean access to health care where little had been available before. In emergency cases, this access can mean the difference between life and death. In particular, in those cases where fast medical response time and specialty care are needed, telemedicine availability can be critical.”

Telemedicine interactions are generally classified as either prerecorded (also called “store-and-forward”) or real-time (also called “synchronous”). In the former, information is acquired and stored before being sent to an expert for interpretation at some later time. E-mail is a common method of store-and-forward interaction today. In contrast, in real-time interactions, there is minimal appreciable delay between the information’s collection, transmission, and display. Interactive communication between individuals at the sites is therefore possible. Videoconferencing is a common method of real-time interaction.

The common thread for all telemedicine applications is that a client (e.g., patient or health-care worker) obtains advice or—as we will likely see in the future with haptics (tactile feedback technologies which recreate the sense of touch) and robotics—direct intervention from someone with more expertise, even when the parties are separated by space, time, or both.

As human beings spread throughout every environment on the globe and even into space, the need for the technology to push health care to the patient has followed. Telemedicine has thus developed into many different entities that at their core deliver information over great distances thus improving access to medical care. Describing its broad scope, Reid defines telemedicine as “the use of advanced telecommunications technologies to exchange health information and provide health care services across geographic, time, social, and cultural barriers” [1]. The need to overcome these varied barriers has driven the growth of telemedicine into multiple outlets and practices.

Telemedicine can be classified by the type of interaction between the client and health care expert in contrast with the content of information being transmitted [2]. In “store and forward” telemedicine, there is an inherent delay in the interpretation of the data but access to advanced technologies aids the definitive care of the patient. Cardiology event monitors, diagnostic images, or expert e-mail consultation are examples of “store and forward” technologies. Real time interactions allow an immediate assessment of the patient, data, and situation to expedite appropriate care with the remote assistance of a subject matter expert. One such example are simple audio feeds broadcast over various networks that provide first responders the ability to interact with Emergency Medicine physicians and appropriately triage patients to specialty centers. Tertiary care hospitals use networked programs to link with rural or suburban areas over high-speed lines or private point-to-point connections for telecommunication amongst providers. The information transmitted can range from text and audio to more sophisticated interactions such as images, video, or robotic interfaces that may allow a combination of several interfaces.

The term “telepresence” describes the ability of health care providers to interact in real time with telecommunication equipment, allowing for immediate feedback and assistance. Adapted for trauma, telepresence allows experienced trauma surgeons or critical care providers to bridge the experience and access gap to trauma care that may exist in rural settings [3]. Telemedicine serves as an interface for inter-hospital trauma care between echelons of care, in the prehospital setting to guide the care of first responders, or as a mobile system deployed to disaster settings [3].

In its simplest form, telemedicine began as a sort of public health service in the middle ages, where bonfires in Europe were lit to signal the spread of bubonic plague. Outside of simple mail service, the technology slowly developed until the telegraphy was utilized in the 1800s by American Civil War surgeons to create casualty lists and request supplies. The telephone allowed further advances in the early twentieth century, ranging from simple communication to the transmission of heart sounds from an amplified stethoscope. A telepsychiatry program at the Nebraska Psychiatric Institute was developed by Dr. Cecil Wittson in the 1950s and expanded in the 1960s to encompass real-time consultation via closed-circuit television [4].

Early modern telemedicine is associated with another technological boon of the twentieth century—the National Aeronautics and Space Administration (NASA). NASA expanded on the telelinks that relayed biometric data collected from animals sent into space to develop the Integrated Medical and Behavioral Laboratories and Measurement Systems (IMBLMS) program in 1964. IMBLMS sought to move past simple monitoring to actual assistance of an astronaut in the delivery of self-aid or buddy-aid when a return from orbit was impractical [5]. This technology matured in a terrestrial form through a partnership between NASA, the Papago Indian Reservation, Indian Health Service, and the Department of Health, Education, and Welfare with Arizona’s Space Technology Applied to Rural Papago Advanced Health Care (STARPAHC). The service was provided from 1972–1975, and delivered health care in the underserved Papago Reservation through a van staffed by paramedics who broadcast data such as X-ray images over a two-way microwave transmission to physicians at the Public Health Service Hospital [6]. Given limitations in technology and timeliness of the care that could be provided, nearly all of these efforts focused on routine care.

In 1978, Dr. R. Adams Cowley simulated a response to a crash of a DC-6 airplane wherein providers were able to transmit images of burn victims in real-time via satellite to a burn unit in San Antonio and medical centers throughout the Washington DC area [7]. The use of satellites for medical support in disaster management was first seen during the coordination of international rescue assets after the Mexico City earthquake of 1985 [8]. Satellite transmission has become the mainstay of large data transmission but its cost and large platform size often limits its wide scale application. The expanded use of devices with access to broadband global area networks (BGAN) now allow for a portable communication device to provide telemedicine in areas devoid of local networks. Cost can still be an issue, though BGAN systems have the upload and download speeds to perform video teleconferencing in contrast to cheaper very small aperture satellite systems. Used in multiple configurations, devices with BGAN connectivity have been used in remote settings such as rural Africa to provide real-time ultrasound interpretation [9]. The military has incorporated devices with BGAN connectivity to aid first responders in the triage and treatment of casualties [10]. In areas where the infrastructure exists, wireless cellular-based broadband has enabled a wide array of potential therapeutic interventions through the use of smartphones and laptops with applications to acquire, interpret, and transmit data. Modern trauma telemedicine and telepresence centers often use a combination of such systems to interact in the prehospital and inter-hospital settings [3].

The use of telemedicine has amassed impressive evidence supporting its use as a reliable, reproducible technology feasible across multiple platforms and venues of care. Central to its utility is the ability to improve access to health care, but a significant cost advantage lies in its ability to improve the triage of trauma patients. Rogers et al. [11] in 2001 described a tele-trauma program in rural Vermont in an observational study evaluating the impact of a real-time telemedicine consult with a trauma surgeon and a community hospital emergency department. In 41 consultations consisting mostly of motor vehicle collisions (49 %) and/or blunt trauma (95 %), 31 were transferred to the tertiary care center, of which three cases were considered lifesaving. Patient disposition was the predominant query, and 15 % of cases were kept at the referring facility. Eighty percentage of providers surveyed felt that telemedicine improved patient care.

Duchesne et al. conducted a comparative analysis of outcomes before and after the introduction of telemedicine in the management of trauma patients treated at seven rural emergency departments in Mississippi [12], demonstrating both improved rural evaluation and management. The hospitals utilized remote controlled video cameras to evaluate the management of traumatically injured patients over 5 years, comparing 351 historical controls directly transferred to the trauma center with 463 virtual consults. Of the virtual consults, only 51 patients were triaged to the trauma center despite telemedicine patients having a higher Injury Severity Score (18 vs. 10, p < 0.001), with no differences in patient age, sex, method of transportation, or mortality. An impressive difference in hospital cost was found between the groups (USD 1,126,683 vs. 7,632,624, p < 0.001) suggesting telemedicine significantly improved evaluation and management of rural trauma patients at reduced costs without significant changes in mortality.

In a retrospective analysis of one of the more robust telemedicine centers in the USA, Latifi et al. described their early experience of a telemedicine system involving five rural hospitals and a Level I trauma center in southern Arizona [13]. In a retrospective analysis of 59 tele-consults involving a mix of general surgery (41 %) and trauma patients (59 %), 29 % of patients were held at their referring hospital for ongoing care while six tele-consults led to potentially lifesaving therapy. Reducing transfers saved an average of USD 19,698 per air transport or USD 2,055 per ground transport, again suggesting a telepresence can effectively improve trauma outcomes while reducing costs.

In a study of telemedicine for 70 burn patients, Saffle et al. described a 55.7 % reduction in emergent transfers to a burn center compared with a historical cohort [14]. Ten patients were effectively discharged from their referral center’s emergency department. In addition to the decreased transfers, this strategy allowed for more effective utilization of the increasingly limited resource of the modern burn center. Interestingly, estimates of burn sizes by burn center physicians correlated between telemedicine and direct inspection estimates, though both differed significantly from the estimates of the referring physician, suggesting not only a reduction in the overtriage or undertriage inherent in initial burn assessment but also the diagnostic integrity of the telemedicine system on a clinical variable likely to have significant impacts on care and patient outcome. Notably, the telemedicine interaction was also viewed favorable by both providers and patients.