Distributed telemedicine system and method

• US 10,430,552 B2
• Filed: 12/31/2016
• Issued: 10/01/2019
• Est. Priority Date: 12/31/2015
• Status: Active Grant

• Current Assignee: Dan M. Mihai
• Original Assignee: Dan M. Mihai
• Inventors: Mihai, Dan M.
• Primary Examiner(s): Olson, Jason C
• Application Number:
  US15/396,421
• Publication Number:
  US 20170193182A1
• Time in Patent Office: 1,004 Days
• Field of Search: 705 2
• CPC Class Codes: A61B 5/002 Monitoring the patient using a local or closed circuit, e.g. in a room or building A61B5/0017 takes precedence
• CPC Class Codes: A61B 5/0022 Monitoring a patient using a global network, e.g. telephone networks, internet
• CPC Class Codes: G16H 40/67 for remote operation
• CPC Class Codes: G16H 80/00 ICT specially adapted for facilitating communication between medical practitioners or patients, e.g. for collaborative diagnosis, therapy or health monitoring

Abstract

A vital-signs enhanced telemedicine system and method allowing a plurality of medical teams assisting a plurality of patients to interact with and get assistance from a plurality of remote physicians via a plurality of audio, video, and vital signs transmissions and interactive remoting sessions including alarms, analysis, recording, and live playback capabilities.

The system includes patient monitoring devices generating streaming vital signs, alarms and alerts (monitoring); aggregators generating streaming audio, video, and GPS for transmission in combination with monitoring received (session) and receiving sessions and instructions from gateways for local display; gateways maintaining concurrent sessions between aggregators and dashboards, receiving sessions from aggregators for transmission to dashboards, and simultaneously receiving sessions from dashboards for transmission, with instructions, to aggregators and to other session dashboards; and dashboards generating and streaming session to gateways while displaying received session data.

Claims

1. A distributed telemedicine system for medical remote assistance applications, the telemedicine system comprising:

a. one or more patient monitoring devices, the patient monitoring device comprising;

i. one or more vital signs sensors configured for physical attachment to a patient;

ii. a first communication system;

iii. a first processor configured to receive vital signs information from the one or more sensors, generate streaming vital signs data based on the information and transmit at least a first portion of the streaming vital signs data to an aggregator via the first communication system;

iv. a first screen configured to display a representation of at least a second portion of the streaming vital signs;

b. one or more aggregators, the aggregator comprising;

i. one or more audio and video sensors;

ii. a second communication system;

iii. a third communication system;

iv. a fourth communication system;

v. a fifth communication system;

vi. a second processor configured to receive site audio and video from the audio and video sensors and streaming vital signs from the one or more patient monitoring devices via the second communication system, transmit at least a third portion of the streaming vital signs data to a first gateway via the third communication system, transmit the site audio and video to a second gateway via the fourth communication system, and receive backchannel audio data from a third gateway via the fifth communication system;

vii. a first application executed on the second processor, the application configured to detect the presence of the first communication system and establish a communication link between the first and second communication system, detect the presence of a sixth communication system and establish a communication link between the third and sixth communication system, detect the presence of a seventh communication system and establish a communication link between the fourth and seventh communication system, detect the presence of an eighth communication system and establish a communication link between the fifth and eighth communication system;

viii. a second screen configured to display an aggregated representation of at least a fourth portion of the streaming vital signs data together with the site video and session controls;

ix. one or more first audio reproduction devices configured to reproduce the backchannel audio data received as audible sounds;

c. at least one first gateway comprising;

i. a sixth communication system;

ii. a ninth communication system;

iii. a third processor configured to receive streaming vital signs data from a plurality of aggregators over the sixth communication system and send the streaming vital signs to a plurality of dashboards over the ninth communication system;

iv. a third screen configured to display session status, statistics, and configuration controls;

d. one or more second gateways, the gateway comprising;

i. a seventh communication system;

ii. the ninth communication system;

iii. a fourth processor configured to receive site audio and video from a plurality of aggregators over the seventh communication system and send the site audio and video data to a plurality of dashboards over the ninth communication system;

iv. a fourth screen configured to display session status, statistics, and configuration controls;

e. one or more third gateways, the gateway comprising;

i. an eighth communication system;

ii. the ninth communication system;

iii. a fifth processor configured to receive backchannel audio data from a plurality of dashboards over the ninth communication system and transmit backchannel audio data to a plurality of aggregators over the eighth communication system;

iv. a fifth screen configured to display session status, statistics, and configuration controls;

f. one or more dashboards, the dashboard comprising;

i. a tenth communication system;

ii. an audio sensor;

iii. a sixth processor configured to receive site audio and video and streaming vital signs data from a gateway over the tenth communication system and to send audio backchannel data to a gateway over the tenth communication system;

iv. one or more audio reproduction devices configured to reproduce the site audio data received as audible sounds;

v. a second application executed on the sixth processor, the application configured to detect the presence of the ninth communication system and establish a communication link between the ninth and tenth communication system;

vi. a sixth screen configured to display an aggregated representation of at least a fifth portion of the streaming vital signs and clinical alarms and alerts with a representation of the site video received together with session controls;

vii. one or more second audio reproduction devices configured to reproduce the site audio data received as audible sounds.

2. The telemedicine system of claim 1, wherein the third, fourth, and sixth communication systems comprise the same systems.

3. The telemedicine system of claim 2, wherein the sixth, seventh, and eighth communication systems the same systems.

4. The telemedicine system of claim 3, wherein the first, second, and third gateways comprise the same gateways.

5. The telemedicine system of claim 4, wherein the first, second, third, fourth, and fifth portion of the streaming vital signs data comprise the same portions.

6. The telemedicine system of claim 5, wherein at least a portion of either communication system includes a fixed network over wire, fiber optic, or power line cables in either point-to-point, shared media, bus, ring, backbone, star, backhaul, ad-hoc, or mesh topology configuration.

7. The telemedicine system of claim 6, wherein at least a portion of either communication system includes a wireless network, including radio, satellite, microwave, laser, infrared, or cellular including Time Division Multiple Access (TDMA), Code Division Multiple Access (CDMA), Global System for Mobile Communications (GSM), Long-Term Evolution (LTE), Extended Long-Term Evolution (XLTE), in either point-to-point, shared media, bus, ring, backbone, star, backhaul, ad-hoc, or mesh topology configuration.

8. The telemedicine system of claim 7, wherein either of the gateways are cloud-based virtual or physical server instances.

9. The telemedicine system of claim 8, wherein either of the gateways are a server cluster system capable of redirecting, recording, or modifying communication between transmitters and receivers with manual or automatic computing resource scaling.

10. The telemedicine system of claim 9, wherein at least a portion of the data transmission over either of the communication systems uses as baseline protocols either Transmission Control Protocol/Internet Protocol (TCP/IP), User gram Protocol (UDP), Internet Control Message Protocol (ICMP), or their FastPath Stack successor.

11. The telemedicine system of claim 10, wherein at least a portion of the data transmission over either of the communication systems is secured with an encryption method consisting of the Secure Sockets Layer (SSL) protocol or Transport Layer Security (TLS).

12. The telemedicine system of claim 11, wherein at least a portion of the audio and/or video transmission over either of the communication systems uses the World Wide Web Consortium'"'"'s (W3C) Web Real-Time Communication (WebRTC) protocol.

13. The telemedicine system of claim 12, wherein at least a portion of the streaming vital signs data transmission over either of the communication systems uses the Internet Engineering Task Force'"'"'s (IETF) WebSocket protocol.

14. The telemedicine system of claim 13, wherein access to either of the communication systems is protected with either single or multiple factor authentication schemes consisting of a user ID/password, a digital certificate including the Public Key Infrastructure (PKI)-based X.509 certificate, a biometric reading including the image of a fingerprint, a retinal scan, or facial recognition.

15. The telemedicine system of claim 14, wherein the audio, video, and streaming vital signs data transmitted over either of the communication systems are partitioned in fixed size packets each representing a time interval configurable to any value between 20 milliseconds and 2 seconds.

16. The telemedicine system of claim 15, wherein either of the communication systems transmit new packets of either audio, video, or vital signs data at constant time intervals, programmable between 40 to 960 milliseconds.

17. The telemedicine system of claim 16, wherein either of the data packets transmitted over either of the communication systems is structured according to JavaScript Object Notation (JSON) specification.

18. The telemedicine system of claim 17, wherein either of the packets transmitted over either of the communication systems uses a compression algorithm including OPUS, iSAC, iLBC, VP8, VP9, VP10, H.264, H.265, Huffman Coding, arithmetic coding, context-free weighing (CTW), RunLength Limited (RLL), Lempel-Ziv 77 (LZ77), Lempel-Ziv 78 (LZW78), Lempel-Ziv-Storer-Symanski (LZSS), Lempel-Ziv-Markov (LZM), Lempel-Ziv-Welch (LZW), Burrows-Wheeler Transform (BZT), Brotti, Zopfli, Sequitur, Prediction by Partial Matching (PPM) including zip, gzip, pkzip, arc, rar, and may also include derived information used to detect the tampering and/or corruption of the payload including an electronic signature performed with the aid of symmetric or asymmetric key scheme, a hash, a checksum, a digital watermark, and a cryptographic timestamp.

19. The telemedicine system of claim 18, wherein the streaming vital signs include waveforms such as 3, 5, 7, or 12-lead electrocardiogram (ECG), respiration, invasive blood pressure, and temperature;

trending numeric parameters such as blood oxygen saturation level (SPO2), End-Tidal CO2 (EtCO2), heart rate, respiration rate, non-invasive blood pressure, temperature, streaming ultrasound images, streaming endoscopic images, stethoscope ascultation patterns;

patient monitor generated alarms including ventricular fibrillation, and patient monitor generated alerts including blood pressure lower than a preset alert limit.

20. The telemedicine system of claim 19, wherein either of the patient monitoring devices is a monitor-defibrillator.

21. The telemedicine system of claim 19, wherein either of the patient monitoring devices is a single parameter sensor with communication capabilities.

22. The telemedicine system of claim 19, wherein either of the patient monitoring devices is a multiple parameter sensor with communication capabilities.

23. The telemedicine system of claim 19, wherein the patient monitor and the aggregator are the same.

24. The telemedicine system of claim 19, wherein the aggregator, the first gateway, the second gateway, and the third gateway comprise the same component.

25. The telemedicine system of claim 19, wherein the first gateway, the second gateway, the third gateway, and the dashboard comprise the same component.

26. The telemedicine system of claim 19, wherein either of the aggregators are portable.

27. The telemedicine system of claim 19, wherein either of the aggregators are smart phones.

28. The telemedicine system of claim 19, wherein either of the dashboards are portable.

29. The telemedicine system of claim 19, wherein either of the screens are touch-enabled.

30. The telemedicine system of claim 19, wherein the first, second, and third gateways are the same and they also comprise:

a. a first persistent memory device

b. a third application executed on the third processor, the application configured to capture and store within the first persistent memory device a timestamped copy of all the site audio, video, backchannel audio, and streaming vital signs data passing through the gateway.

31. The telemedicine system of claim 30, wherein the gateway further comprises:

a. a fourth application executed on the third processor, the application configured to;

i. respond to pause, play back, rewind, and fast forward commands received over the ninth communication system;

ii. read the timestamped site audio, video, backchannel audio, and streaming vital signs data stored in the persistent memory device;

iii. apply a controlled time offset for each such function requested, and send it to one or more dashboards over the ninth communication system to provide the requested pause, play back, rewind, and fast forward functionality within the dashboard'"'"'s fourth screen;

and the dashboard further comprises;

a. a fifth application executed on the fourth processor, the application configured to read user input and transmit pause, play back, rewind, and fast forward commands to the gateway'"'"'s fourth application via the tenth communication system.

32. The telemedicine system of claim 30, wherein the gateway'"'"'s third application is also programmed to capture and store within the first persistent memory device a timestamped copy of all the site audio, video, backchannel audio, textual chat messages, and streaming vital signs received by the gateway even if either the ninth or the tenth communication systems are inoperative, to be made available under the request and control of the dashboard by the gateway'"'"'s fourth application when both the ninth and the tenth communication systems resume their operation and reconnect.

33. The telemedicine system of claim 32, wherein the aggregator also comprises:

a. a second persistent memory device;

b. a fifth application executed on the second processor, the application configured to capture and store a persistent, timestamped copy of all the site audio, video, and streaming vital signs data received by the aggregator when either the third, fourth, or fifth communication system is inoperative; and

i. the aggregator'"'"'s second application is also configured to send the catch-up data in a catch-up mode, until all the catch-up data is exhausted, to the one or more gateways when all of the third, fourth, and fifth communication systems resume their operation and reconnect; and

ii. the gateway'"'"'s third application is also configured to receive the timestamped catch-up data from the gateway through the sixth, seventh, and eighth communication system respectively, insert and store the catch-up, until all the catch-up data is exhausted, in its correct timestamp order within the first persistent memory device simultaneously with it storing in the same first persistent memory a timestamped copy of all the current site audio, video, backchannel audio, and streaming vital signs data passing through the gateway.

34. The telemedicine system of claim 19, wherein the first, second, and third gateways are the same and they also comprise:

a. a sixth application executed on the third processor, the application configured to group a plurality of gateway login accounts and a plurality of dashboard login accounts into Virtual Medical Groups (VMG) and only allow the communication of site audio, video, backchannel audio, and vital signs data between the gateways and dashboards where the users logged in belong to the same VMG, and

i. the gateway'"'"'s third screen also configured to allow a system administrator to create, modify, and remove VMGs through the allocation and deallocation of individual gateway and dashboard login accounts to VMGs, in either an exclusive or a shared fashion.

35. The telemedicine system of claim 34, wherein the aggregator also comprises:

a. a first GPS location sensor;

b. a seventh application executed on the second processor, the application configured to;

i. read its GPS position from its first GPS sensor;

ii. initiate an assistance request combined with its GPS position indicating the type of expertise sought;

iii. transmit the assistance request to one or more gateways via the fifth communication system; and

the gateway also comprises;

a. an eighth application executed on the third processor which is programmed to;

i. receive the assistance requests;

ii. forward the assistance request to one or more of the dashboards whose logged in users belong to the same VMG as the user logged into the requesting gateway and according to a preprogrammed priority based on their type of expertise registered with the system; and

iii. if the user does not confirm the assistance request within the preprogrammed time, forward the assistance request, according to a preprogrammed escalation logic and based on their type of expertise registered with the system, to another dashboard whose logged in user belongs to the same VMG as the requesting gateway'"'"'s logged-in user;

or

iv. if no dashboard with a logged in user belonging to the same VMG as the requesting gateway'"'"'s logged-in user exists at that time, hail the next recipient according to a programmed escalation logic and based on their type of expertise registered with the system through an external channel including a SMS message over a cellular network, an e-mail, a text-to-speech voice message over a cellular or traditional phone network

the dashboard also comprises;

a. a ninth application executed on the fourth processor, the application programmed to;

i. display the assistance request on a geolocation map using the GPS information embedded in the assistance request

ii. wait for the logged in user to confirm, and

iii. if the user is logged in and confirms the request within a programmed window of time, initiate an end-to-end audio, video, and streaming vital signs session between the dashboard and the requesting aggregator through the connecting gateway, or

iv. if the user hailed though an external channel and logs into the dashboard, display the pending assistance request on a geolocation map using the GPS information embedded in the assistance request, and

v. wait for the logged in user to confirm, and

vi. if confirmed within a programmed window of time, initiate an end-to-end audio, video, and streaming vital signs session between the dashboard and the requesting aggregator through the connecting gateway.

36. The telemedicine system of claim 35, wherein the dashboard'"'"'s ninth application executed on the fourth processor is also programmed to:

a. allow a dashboard user already providing assistance to an aggregator user through an active end-to-end session to send a secondary assistance request based on second skill set which can be the same or different from their own to another nominated or generic user from the same VNG through the tenth communication system, or

b. if not already providing assistance to a gateway user, display a pending assistance request on a geolocation map using the GPS information embedded in the original assistance request, and

c. wait for the user to confirm, and

d. if confirmed within a programmed window of time, initiate a secondary dashboard session with the same gateway user as the dashboard user placing the secondary assistance request, and

e. the dashboard'"'"'s fourth screen is also configured to render, when the dashboard is in such a secondary assistance mode, a replica of the primary session'"'"'s streaming, waveforms, trending parameters, clinical alarms and alerts, and site video; and

f. the dashboard'"'"'s second audio reproduction device is also configured to reproduce, when the dashboard is in such a secondary assistance mode, a replica of the site audio combined with the composite backchannel audio originating from all the session'"'"'s active dashboards, and

the gateway'"'"'s eighth application executed on the third processor is also programmed to;

a. receive such a secondary assistance request, and

b. dispatch it to the nominated user or to the next qualified user from the same VMG and according to its programmed escalation logic.

37. The telemedicine system of claim 36, wherein the eighth application executed on the gateway'"'"'s third processor is also programmed to:

a. combine all backchannel audio originating from the primary and all secondary dashboard users providing assistance to the same gateway user, and

b. send the combined audio backchannel forward to the aggregator and back to the primary and all secondary dashboards connected to the same gateway session.

38. The telemedicine system of claim 30, wherein:

a. the third, fourth, and fifth communication systems are the same, and

b. the sixth, seventh, and eighth communication systems are the same, and

c. the first, second, and third gateways are the same, and

d. the site audio, video, and streaming vital signs data are partitioned in packets each representing such data originating within the same 40 to 960 milliseconds time interval, and

e. all such packets are further combined in a single composite data packet that encompasses all site audio, video, and streaming vital signs data originating within the said time interval.

39. The telemedicine system of claim 30, wherein the gateway also comprises:

a. a tenth application executed on the third processor, the application configured to;

i. take a snapshot of ECG data from the gateway'"'"'s first persistent memory device;

ii. perform a 12-Lead analysis through a third-party analysis module including, GE-Marquette 12SL, Glasgow 12-Lead ECG Analysis, ZOLL Inovise, Philips EASI;

iii. generate a 12 Lead ECG analysis report, and

iv. send such report to the dashboard via the gateway successively over the fourth, eighth, and the ninth communication systems, and

the dashboard also comprises;

a. an eleventh application executed on the fourth processor, the application configured to;

i. send a 12 Lead ECG analysis request to the gateway over the tenth communication system, and

ii. receive the 12 Lead analysis report, and

the dashboard'"'"'s fourth screen is also configured to render the said 12 Lead Analysis report.

40. The telemedicine system of claim 39 wherein:

a. the gateway'"'"'s tenth application executed on the third processor is also configured to archive the generated 12 Lead ECG analysis report into the gateway'"'"'s first persistent memory device;

b. the gateway'"'"'s fourth application executed on the third processor is also programmed to;

i. respond to a retrieval command of a previously generated 12 Lead ECG analysis report; and

ii. send such report to the dashboard over the ninth communication system;

c. the dashboard'"'"'s eleventh application executed on the fourth processor is also configured to;

i. send a retrieval command for a previously generated 12 Lead ECG analysis to the gateway over the tenth communication system; and

ii. receive the said 12 Lead analysis report from the gateway over the tenth communication system; and

d. the dashboard'"'"'s fourth screen is also configured to render the previously generated 12 Lead Analysis report received from the gateway.

41. The telemedicine system of claim 40, wherein the gateway'"'"'s tenth application executed on the third processor is also configured to perform, display, and archive derivative calculations, analysis, and derive alarms or alerts executed across any number of streaming vital signs, including ECG, temperature, invasive blood pressure, and respiration waveforms, trending parameters including EtCO2, SPO2, temperature, respiration rate, heart rate, non-invasive blood pressure, ultrasound and endoscopic images, auscultation waveforms, and/or including the patient monitor generated alarms and alerts.

42. The telemedicine system of claim 41, wherein the gateway'"'"'s tenth application executed on the third processor is also configured to use machine learning algorithms included but not limited to, neural networks, fuzzy logic, artificial intelligence, based on previously stored streaming vital signs data received from at least a portion of all the other patients'"'"' vital signs received and stored in its first persistent memory device.

43. The telemedicine system of claim 42 wherein the gateway'"'"'s tenth application executed on the third processor is also configured to use for its machine learning algorithms externally provided historical streaming vital signs data either:

a. preloaded into the gateway'"'"'s first persistent memory device;

or

b. downloaded from an external data provider over its eighth communication system;

or

c. a combination of internally stored and externally accessed such data.

44. The telemedicine system of claim 39, wherein:

a. the gateway'"'"'s tenth application executed on the third processor is also configured to archive a time stamped textual and/or voice recording annotation event into the gateway'"'"'s first persistent memory device alongside the currently recorded site audio, video, and streaming vital signs data, and

b. the gateway'"'"'s fourth application executed on the third processor is also programmed to;

i. receive a current annotation event for storage;

ii. respond to a voice or textual retrieval command of a previously stored annotation event;

iii. generate a search specification based on an algorithm including voice recognition, text to speech, neural networks, fuzzy logic, artificial intelligence, Boolean, binary tree;

iv. search based on the generated search specification and its associated algorithm;

v. locate, and send such previously stored annotation event together with all the previously stored backchannel audio, site audio, video, and streaming vital signs data in a configurable time window surrounding the time stamp of the first annotation event match to the dashboard over the ninth communication system; and

c. the dashboard'"'"'s eleventh application executed on the fourth processor is also configured to;

i. capture a new textual or voice recorded annotation event, and

ii. send it to the gateway over its tenth communication system;

iii. capture a textual or voice search request for a previously stored annotation event, and

iv. send it to the gateway over the tenth communication system;

v. receive the said previously stored annotation event together with all the previously stored site audio, video, and streaming vital signs data from its configurable time window from the gateway over the tenth communication system, and

d. the dashboard'"'"'s fourth screen is also configured to render the received annotation event synchronized and together with all the received site audio, video, and streaming vital signs data from its configurable time window.

45. The telemedicine system of claim 44 wherein:

a. the dashboard'"'"'s eleventh application executed on the fourth processor is also configured to;

i. capture a search request to be executed over the site and/or backchannel voice recorded in the gateway'"'"'s first persistent data storage device, and

ii. send it to the gateway over its tenth communication system, and

iii. receive the said previously stored backchannel audio, site audio, video, and streaming vital signs data from the gateway over its tenth communication system, and

b. the gateway'"'"'s fourth application executed on the third processor is also programmed to;

i. apply its generated search criteria to the site and/or backchannel voice data recorded in the gateway'"'"'s first persistent data storage device, and

ii. send such previously stored backchannel audio, site audio, video, and streaming vital signs data in a configurable time window surrounding the time stamp of the first audio match to the dashboard over the ninth communication system, and

c. the dashboard'"'"'s fourth screen is also configured to render the received backchannel audio, site audio, video, and streaming vital signs data from its configurable time window.

46. The telemedicine system of claim 45, wherein:

a. the gateway'"'"'s fourth application executed on the third processor is also programmed to send either the first, last, next, or previous such search'"'"'s match to the dashboard over the ninth communication system in response to a request received from it, and

b. the dashboard'"'"'s eleventh application executed on the fourth processor is also configured to request the first, last, next, or previous such search'"'"'s match.

47. The telemedicine system of claim 46, wherein:

a. the gateway also comprises a twelfth application executed on the third processor, the application configured to;

i. receive a textual or voice search request for a procedural guidance, and

ii. generate a search specification based on an algorithm including voice recognition, text to speech, neural networks, fuzzy logic, artificial intelligence, Boolean, binary tree and

iii. search based on the generated search specification and its associated algorithm, and

iv. locate and retrieve a previously stored procedural guidance including text, hypertext, annotated text, structured text, images, audio, or video, in response to a textual or voice search request received from the aggregator over the eighth communication system, and

v. send the first match of such previously stored procedural guidance to the requesting aggregator over the eighth communication system, and

b. the aggregator also comprises a thirteenth application executed on the second processor, the application configured to;

i. capture a textual or voice search request for a procedural guidance, and

ii. send it to the gateway over the fifth communication system, and

c. the aggregator'"'"'s second screen is further configured to render the received procedural guidance in its appropriate representation, whether text, images, audio, or video, either as standalone or as an overlay.

48. The telemedicine system of claim 47 wherein the gateway'"'"'s twelfth application executed on the third processor is also configured to search and retrieve procedural guidance data downloaded from an external data provider over its eighth communication system, or a combination of internally stored and externally accessed procedural guidance data.

49. The telemedicine system of claim 48, wherein:

a. the gateway'"'"'s twelfth application executed on the third processor is also programmed to send to the aggregator either the first, last, next, or previous such search'"'"'s match over the eighth communication system in response to a request received from it, and

b. the aggregator'"'"'s thirteenth application executed on the second processor is also configured to request the first, last, next, or previous such search'"'"'s match.

50. The telemedicine system of claim 49, wherein the gateway also comprises a portable augmented reality display including headset, goggle, retinal scanning device, and smart glass eyewear programmed to display the said procedural guidance data received from the gateway over the fifth communication system.

51. The telemedicine system of claim 50, wherein:

a. the gateway also comprises a haptic feedback device, and

b. the gateway'"'"'s second screen is also configured to trigger and actuate the haptic feedback device in response to a selection of preprogrammed biological conditions detected in the streaming vital signs being displayed including heart beats, respiratory cycles, preprogrammed biological parameter limits including temperature, EtCO2, SPO2, invasive blood pressure being reached, and when patient monitor-generated alarm or alert conditions are being detected as part of the streaming vital signs being displayed.

52. The telemedicine system of claim 51, wherein:

a. the dashboard also comprises a haptic feedback device, and

b. the dashboard'"'"'s fourth screen is also configured to trigger and actuate the haptic feedback device in in response to a selection of preprogrammed biological conditions detected in the streaming vital signs being displayed including heart beats, respiratory cycles, preprogrammed biological parameter limits including temperature, EtCO2, SPO2, invasive blood pressure being reached, and when patient monitor-generated alarm or alert conditions are being detected as part of the streaming vital signs being displayed.

53. The telemedicine system of claim 52 wherein the haptic feedback pattern is programmed to be unique for each group or individual type of biological conditions, alarms, or alert triggers.

54. The telemedicine system of claim 30 wherein:

a. the dashboard also comprises a video sensor, and

b. the dashboard'"'"'s fourth processor is also configured to;

i. receive streaming video from the video sensor, and

ii. synchronize the video stream with the backchannel audio, and

iii. transmit it as backchannel video to a gateway over the tenth communication system, and

c. the gateway'"'"'s third processor is also configured to;

i. receive backchannel video from a dashboard over the ninth communication system, and

ii. transmit the received backchannel video to an aggregator over the eighth communication system and simultaneously to all other dashboards connected to the same active session over the ninth communication system, and

d. the dashboard'"'"'s fourth processor is also configured to receive backchannel video originating from all the other dashboards connected to the same active session, and

e. the dashboard'"'"'s fourth display is also configured to render the backchannel video originating from all the other session dashboards in independent sections, each identifying its originating dashboard user, and

f. the aggregator'"'"'s second processor is also configured to receive backchannel video from a gateway over its fifth communication system, and

g. the aggregator'"'"'s second display is also configured to render the backchannel video originating from all session dashboards in independent sections, each identifying its originating dashboard user.

55. The telemedicine system of claim 54 wherein the gateway'"'"'s third application executed on the third processor is further configured to capture and store within the first persistent memory device a timestamped copy of all the backchannel video data passing through the gateway.

56. The telemedicine system of claim 30 wherein:

a. the dashboard also comprises a second GPS location sensor;

b. the dashboard'"'"'s fourth processor is also configured to;

i. read its GPS location data from its second GPS sensor, and

ii. transmit said GPS data to a gateway over the tenth communication system;

c. the gateway'"'"'s third processor is also configured to;

i. receive GPS location data from a dashboard over the ninth communication system, and

ii. simultaneously transmit said GPS data to all other dashboards connected to the same active session over the ninth communication system;

d. the dashboard'"'"'s fourth processor is also configured to;

i. receive GPS location data originating from all the other dashboards connected to the same active session, and

ii. the dashboard'"'"'s geolocation map is also configured to display the GPS location of all the other session dashboards as independent icons, each identifying its originating dashboard user.

57. The telemedicine system of claim 56 wherein:

a. the gateway'"'"'s third processor is also configured to transmit GPS location data received from a dashboard to an aggregator over the eighth communication system;

b. the aggregator'"'"'s second processor is also configured to receive GPS location data from a gateway over its fifth communication system, and

c. the aggregator'"'"'s second display is also configured to display the GPS location of all session as independent icons, each identifying its originating dashboard user.

58. The telemedicine system of claim 57 wherein the gateway'"'"'s third application executed on the third processor is further configured to capture and store within the first persistent memory device a timestamped copy of all the GPS location data passing through the gateway.

59. The telemedicine system of claim 58 wherein the gateway'"'"'s third application executed on the third processor is further configured to export any and all of its stored audio, video, vital signs, and GPS data to an external memory device and make it available for retrieval through a Web page, a Web service, or a TCP socket interface.

60. The telemedicine system of claim 59 wherein the gateway'"'"'s third application executed on the third processor is further configured to automatically purge old records of its stored audio, video, vital signs, and GPS data according to a preprogrammed record retention policy.

61. A distributed telemedicine method for allowing a plurality of medical teams assisting a plurality of patients to interact with and get assistance from a plurality of remote physicians via a plurality of audio, video, and vital signs transmissions, comprising:

a. monitoring one or more patients with patient monitoring devices, the patient monitoring device having one or more vital signs sensors configured for physical attachment to a patient, and

b. receiving vital signs information from the vital signs sensors, and

c. generating streaming vital signs data based on the information from the vital signs sensors, and

d. transmitting at least a first portion of the streaming vital signs data to an aggregator while simultaneously displaying a representation of at least a second portion of the streaming vital signs data on a first screen;

e. receiving the streaming vital signs send by one or more patient monitoring devices by an aggregator, the aggregator having one or more audio and video sensors and one or more first audio reproduction devices, and

f. transmitting at least a third portion of the streaming vital signs data from the aggregator to a first gateway, and

g. capturing site audio and video from the aggregator'"'"'s sensors while transmitting the site audio and video to a second gateway, and simultaneously receiving backchannel audio from a third gateway, and

h. displaying an aggregated representation of at least a fourth portion of the streaming vital signs data together with the site video and session controls on a second screen, and

i. reproducing the backchannel audio received by the aggregator through its first audio reproduction devices;

j. receiving the site audio and video by a first gateway, and

k. maintaining session status, statistics, and configuration on the gateway via a third screen, and

l. receiving streaming vital signs data by a second gateway, and

m. sending backchannel audio to the aggregator from a third gateway, and

n. maintaining session information relating to a source aggregator connected to one or more dashboards within the gateway, and

o. sending site audio and video combined with the streaming vital signs to one or more session dashboards while simultaneously receiving backchannel audio from one or more session dashboards and transmitting the combined backchannel audio to the source aggregator;

p. receiving site audio and video and streaming vital signs by a dashboard, the dashboard having one or more audio sensors and one or more second audio reproduction devices, and

q. displaying an aggregated representation of at least a fifth portion of the streaming vital signs data and clinical alarms and alerts with a representation of the site video and session controls on a fourth screen, and

r. capturing audio backchannel data from the dashboard'"'"'s audio sensor and sending it back to the gateway, while simultaneously reproducing the site audio as audible sounds on the dashboard'"'"'s second audio reproduction devices.

62. The telemedicine method of claim 61, wherein the third, fourth, and sixth communication systems comprise the same system.

63. The telemedicine method of claim 62, wherein the sixth, seventh, and eighth communication systems comprise the same system.

64. The telemedicine method of claim 63, wherein the first, second, and third gateways comprise the same gateway.

65. The telemedicine method of claim 64, wherein the first, second, third, fourth, and fifth portion of the streaming vital signs data comprise the same portion.

66. The telemedicine method of claim 65, wherein at least a portion of either communication system includes a fixed network over wire, fiber optic, or power line cables in either point-to-point, shared media, bus, ring, backbone, star, backhaul, ad-hoc, or mesh topology configuration.

67. The telemedicine method of claim 66, wherein at least a portion of either communication system includes a wireless network, including radio, satellite, microwave, laser, infrared, or cellular including Time Division Multiple Access (TDMA), Code Division Multiple Access (CDMA), Global System for Mobile Communications (GSM), Long-Term Evolution (LTE), Extended Long-Term Evolution (XLTE), in either point-to-point, shared media, bus, ring, backbone, star, backhaul, ad-hoc, or mesh topology configuration.

68. The telemedicine method of claim 67, wherein either of the gateways are cloud-based virtual or physical server instances.

69. The telemedicine method of claim 68, wherein either of the gateways are a server cluster system capable of redirecting, recording, or modifying communication between transmitters and receivers with manual or automatic computing resource scaling.

70. The telemedicine method of claim 69, wherein at least a portion of the data transmission over either of the communication systems uses as baseline protocols either Transmission Control Protocol/Internet Protocol (TCP/IP), User gram Protocol (UDP), Internet Control Message Protocol (ICMP), or their FastPath Stack successor.

71. The telemedicine method of claim 70, wherein at least a portion of the data transmission over either of the communication systems is secured with an encryption method consisting of the Secure Sockets Layer (SSL) protocol or Transport Layer Security (TLS).

72. The telemedicine method of claim 71, wherein at least a portion of the audio and/or video transmission over either of the communication systems uses the World Wide Web Consortium'"'"'s (W3C) Web Real-Time Communication (WebRTC) protocol.

73. The telemedicine method of claim 72, wherein at least a portion of the streaming vital signs data transmission over either of the communication systems uses the Internet Engineering Task Force'"'"'s (IETF) WebSocket protocol.

74. The telemedicine method of claim 73, wherein access to either of the communication systems is protected with either single or multiple factor authentication schemes consisting of a user ID/password, a digital certificate including the Public Key Infrastructure (PKI)-based X.509 certificate, a biometric reading including the image of a fingerprint, a retinal scan, or facial recognition.

75. The telemedicine method of claim 74, wherein the audio, video, and streaming vital signs data transmitted over either of the communication systems are partitioned in fixed size packets each representing a time interval configurable to any value between 20 milliseconds and 2 seconds.

76. The telemedicine method of claim 75, wherein either of the communication systems transmit new packets of either audio, video, or vital signs data at constant time intervals, programmable between 40 to 960 milliseconds.

77. The telemedicine method of claim 76, wherein either of the data packets transmitted over either of the communication systems is structured according to JavaScript Object Notation (JSON) specification.

78. The telemedicine method of claim 77, wherein either of the packets transmitted over either of the communication systems uses a compression algorithm including OPUS, iSAC, iLBC, VP8, VP9, VP10, H.264, H.265, Huffman Coding, arithmetic coding, context-free weighing (CTW), RunLength Limited (RLL), Lempel-Ziv 77 (LZ77), Lempel-Ziv 78 (LZW78), Lempel-Ziv-Storer-Symanski (LZSS), Lempel-Ziv-Markov (LZM), Lempel-Ziv-Welch (LZW), Burrows-Wheeler Transform (BZT), Brotti, Zopfli, Sequitur, Prediction by Partial Matching (PPM) including zip, gzip, pkzip, arc, rar, and may also include derived information used to detect the tampering and/or corruption of the payload including an electronic signature performed with the aid of symmetric or asymmetric key scheme, a hash, a checksum, a digital watermark, and a cryptographic timestamp.

79. The telemedicine method of claim 78, wherein the streaming vital signs include waveforms including 3, 5, 7, or 12-lead electrocardiogram (ECG), respiration, invasive blood pressure, and temperature;

trending numeric parameters including blood oxygen saturation level (SPO2), End-Tidal CO2 (EtCO2), heart rate, respiration rate, non-invasive blood pressure, temperature, streaming ultrasound images, streaming endoscopic images, stethoscope ascultation patterns;

patient monitor generated alarms including ventricular fibrillation, and patient monitor generated alerts including blood pressure lower than a preset alert limit.

80. The telemedicine method of claim 79, wherein either of the patient monitoring devices is a monitor-defibrillator.

81. The telemedicine method of claim 79, wherein either of the patient monitoring devices is a single parameter sensor with communication capabilities.

82. The telemedicine method of claim 79, wherein either of the patient monitoring devices is a multiple parameter sensor with communication capabilities.

83. The telemedicine method of claim 79, wherein the patient monitor and the aggregator are the same.

84. The telemedicine method of claim 79, wherein the aggregator, the first gateway, the second gateway, and the third gateway comprise the same component.

85. The telemedicine method of claim 79, wherein the first gateway, the second gateway, the third gateway, and the dashboard comprise the same component.

86. The telemedicine method of claim 79, wherein either of the aggregators are portable.

87. The telemedicine method of claim 79, wherein either of the aggregators are smart phones.

88. The telemedicine method of claim 79, wherein either of the dashboards are portable.

89. The telemedicine method of claim 79, wherein either of the screens are touch-enabled.

90. The telemedicine method of claim 79, wherein the first, second, and third gateways are the same and they also capture and store a timestamped copy of all the site audio, video, backchannel audio, and streaming vital signs data passing through the gateway.

91. The telemedicine method of claim 90, wherein:

a. the dashboard also reads user input and transmits pause, play back, rewind, and fast forward commands to the gateway, and

b. the gateway also reads the timestamped site audio, video, backchannel audio, and streaming vital signs data stored in its first persistent memory device, and

c. applies a controlled time offset for each such function requested, and

d. sends it back to the requesting dashboard, and

e. the dashboard also displays the received video on the dashboard'"'"'s fourth screen, and

f. the dashboard also renders the received audio through its second audio reproduction device.

92. The telemedicine method of claim 90, wherein the gateway also stores within the first persistent memory device a timestamped copy of all the site audio, video, backchannel audio, textual chat messages, and streaming vital signs data received by the gateway even if it loses connectivity with the dashboard, and makes it available to the dashboard under its request and control when the dashboard reconnects with the gateway.

93. The telemedicine method of claim 92, wherein:

a. the aggregator also stores a timestamped copy of all the site audio, video, and streaming vital signs data received by the aggregator in a second persistent memory device even when it loses connectivity with the gateway, and

b. when it reconnects with the gateway, the aggregator also sends the catch-up data to the gateway in parallel with its normal live data transmission, in a catch-up mode, until all the catch-up data is exhausted, and

c. the gateway also inserts and stores the received catch-up data, in its correct timestamp order, on its first persistent memory device.

94. The telemedicine method of claim 79, wherein the first, second, and third gateways are the same and:

a. the gateway groups a plurality of gateway login accounts and a plurality of dashboard login accounts into Virtual Medical Groups (VMG), and

b. the gateway only allows the communication of site audio, video, backchannel audio, and vital signs between the gateways and dashboards where the users logged in belong to the same VMG, and

c. the gateway allows a system administrator to create, modify, and remove VMGs through the allocation and deallocation of individual gateway and dashboard login accounts to VMGs, in either an exclusive or a shared fashion.

95. The telemedicine method of claim 94, wherein:

a. the aggregator also reads its location position from a first GPS sensor, and

b. initiates an assistance request combined with its GPS position indicating the type of expertise sought, and

c. transmits the assistance request to one or more gateways;

d. the gateway also receives the assistance requests and forwards them to one or more of the dashboards whose logged in users belong to the same VMG as the user logged into the requesting gateway and according to a preprogrammed priority based on their type of expertise registered with the system;

e. the dashboard also displays the assistance request on a geolocation map using the GPS information embedded in the assistance request, and

f. waits for the logged in user to confirm, and

g. if confirmed within a programmed window of time, initiates an end-to-end audio, video, and streaming vital signs session between the dashboard and the requesting aggregator through the connecting gateway, or

h. If the user does not confirm the assistance request within the preprogrammed time, the gateway forwards the assistance request, according to a preprogrammed escalation logic and based on their type of expertise registered with the system, to another dashboard whose logged in user belongs to the same VMG as the requesting gateway'"'"'s logged in user, or

i. If no dashboard with a logged in user belonging to the same VMG as the requesting gateway'"'"'s logged in user exists at that time, the gateway hails the next recipient, according to a programmed escalation logic and based on their type of expertise registered with the system, through an external channel including a SMS message over a cellular network, an e-mail, a text-to-speech voice message over a cellular or traditional phone network and

j. the dashboard also displays the pending assistance request on a geolocation map using the GPS information embedded in the assistance request when the user hailed though an external channel logs into the dashboard, and

k. waits for the logged in user to confirm, and

l. if confirmed within a programmed window of time, initiates an end-to-end audio, video, and streaming vital signs session between the dashboard and the requesting aggregator through the connecting gateway.

96. The telemedicine method of claim 95, wherein:

a. a dashboard user providing assistance to an aggregator user through an active end-to-end session sends a secondary assistance request based on the same or different requested second skill set to another nominated or generic user from the same VNG, and

b. the gateway receives such a secondary assistance request and dispatches it to the nominated user or to the next qualified user from the same VMG and according to its programmed escalation logic, and

c. the dashboard also displays the secondary user'"'"'s pending assistance request on a geolocation map using the GPS information embedded in the original assistance request, and

d. waits for the secondary user to confirm, and

e. if confirmed within a programmed window of time, initiates a secondary dashboard session with the same gateway user as the dashboard user placing the secondary assistance request, and

f. when the dashboard is in such a secondary assistance mode, it;

i. displays a replica of the primary session'"'"'s streaming waveforms, trending parameters, clinical alarms and alerts, and site video on its fourth display, and

ii. reproduces a replica of the site audio combined with the composite backchannel audio originating from all session dashboards on its second audio reproduction device.

97. The telemedicine method of claim 96, wherein:

a. the gateway also combines all backchannel audio originating from the primary and all secondary dashboard users providing assistance to the same gateway user, and

b. sends the combined audio backchannel forward to the aggregator and back to the primary and all secondary dashboards connected to the same gateway session.

98. The telemedicine method of claim 90, wherein the site audio, video, and streaming vital signs data are partitioned in packets each representing such data originating within the same 40 to 960 milliseconds time interval, and whereby all such packets are further combined in a single composite data packet that encompasses all site audio, video, and streaming vital signs data originating within the said time interval.

99. The telemedicine method of claim 98, wherein:

a. the dashboard also sends a 12 Lead analysis request to the gateway, and

b. the gateway also takes a snapshot of ECG data from its first persistent memory device, and

c. performs a 12-Lead analysis through a third-party analysis module including GE-Marquette 12SL, Glasgow 12-Lead ECG Analysis, ZOLL Inovise, Philips EASI and

d. generates a 12 Lead ECG analysis report, and

e. sends such report back to the dashboard, and

f. the dashboard also receives the 12 Lead analysis report, and

g. renders it on its fourth display.

100. The telemedicine method of claim 99 wherein:

a. the gateway also archives the generated 12 Lead ECG analysis report into the gateway'"'"'s first persistent memory device, and

b. the dashboard also sends a retrieval command for a previously generated 12 Lead ECG analysis to the gateway, and

c. the gateway also responds to a retrieval command of a previously generated 12 Lead ECG analysis report, and

d. sends such report to the dashboard, and

e. the dashboard receives the said 12 Lead analysis report from the gateway, and

f. renders it on its fourth display.

101. The telemedicine method of claim 100, wherein the gateway also performs, displays, and archives derivative calculation, analysis, alarm, or alert executed across any number of streaming vital signs, including ECG, temperature, invasive blood pressure, and respiration waveforms, trending numerical parameters including EtCO2, SPO2, temperature, streaming ultrasound or endoscopic images, auscultation waveforms, respiration rate, heart rate, non-invasive blood pressure, and/or including patient monitor generated alarms and alerts.

102. The telemedicine method of claim 101, wherein the gateway uses machine learning algorithms including neural networks, fuzzy logic, artificial intelligence, based on previously stored streaming vital signs data received from at least a portion of all the other patients'"'"' vital signs received and stored in its first persistent memory device to improve the accuracy of at least a portion of all of its derivative calculations, analyses, alarms, or alerts.

103. The telemedicine method of claim 102 wherein the gateway uses for its machine learning algorithms externally provided historical streaming vital signs data either preloaded into the gateway'"'"'s first persistent memory device or downloaded from an external data provider, or a combination of internally stored and externally accessed such data.

104. The telemedicine method of claim 103, wherein:

a. the dashboard also captures a new time stamped textual or voice recorded annotation event and sends it to the gateway, and

b. the gateway also receives the time stamped textual and/or voice recording annotation event, and

c. stores it into the gateway'"'"'s first persistent memory device alongside the currently recorded site audio, video, and streaming vital signs data, and

d. the dashboard also captures a textual or voice search request for a previously stored annotation event, and

e. sends it to the gateway, and

f. the gateway also responds to a voice or textual retrieval command of a previously stored annotation event by generating a search specification based on an algorithm including voice recognition, text to speech, neural networks, fuzzy logic, artificial intelligence, Boolean, binary tree, searching based on the generated search specification and its associated algorithm, locating, and sending such previously stored annotation event together with all the previously stored backchannel audio, site audio, video, and streaming vital signs in a configurable time window surrounding the time stamp of the first annotation event match back to the dashboard, and

g. the dashboard also receives the said previously stored annotation event together with all the previously stored site audio, video, and streaming vital signs data from its configurable time window from the gateway, and

h. renders it on its fourth display.

105. The telemedicine method of claim 104 wherein:

a. the dashboard also captures a search request to be executed over the site and/or backchannel voice data recorded in the gateway'"'"'s first persistent data storage device, and

b. sends it to the gateway, and

c. the gateway also applies its generated search criteria to the site and/or backchannel voice data recorded in the gateway'"'"'s first persistent data storage device, and

d. sends such previously stored backchannel audio, site audio, video, and streaming vital signs data in a configurable time window surrounding the time stamp of the first match back to the dashboard, and

e. the dashboard receives the said backchannel audio, site audio, video, and streaming vital signs data from its configurable time window from the gateway, and

f. renders it on its fourth display.

106. The telemedicine method of claim 105, wherein:

a. the dashboard also requests the first, last, next, or previous such search'"'"'s match, and

b. the gateway also sends either the first, last, next, or previous such search'"'"'s match, as requested, back to the dashboard.

107. The telemedicine method of claim 106, wherein:

a. the aggregator also captures a textual or voice search request for a procedural guidance, and

b. sends it to the gateway, and

c. the gateway also responds to such a request by generating a search specification based on an algorithm including voice recognition, text to speech, neural networks, fuzzy logic, artificial intelligence, Boolean, binary tree, searching based on the generated search specification and its associated algorithm, locating and retrieving a previously stored procedural guidance including text, hypertext, annotated text, structured text, images, audio, or video, and sending the first match of such previously stored procedural guidance to the requesting aggregator, and

d. the aggregator also receives the requested data, and

e. renders the received procedural guidance in its appropriate representation, whether text, images, audio, or video, either as standalone or as an overlay.

108. The telemedicine method of claim 107 wherein the gateway also searches and retrieves procedural guidance data downloaded from an external data provider, or a combination of internally stored and externally accessed procedural guidance data.

109. The telemedicine method of claim 108, wherein:

a. the aggregator also requests the first, last, next, or previous such search'"'"'s match, and

b. the gateway also locates and sends to the aggregator either the first, last, next, or previous such search'"'"'s match, as requested.

110. The telemedicine method of claim 109, wherein the gateway also displays the said procedural guidance data received from the gateway on a portable augmented reality display including headset, goggle, retinal scanning device, and smart glass eyewear.

111. The telemedicine method of claim 110, wherein the gateway also triggers and actuates a built-in haptic feedback device in response to a selection of preprogrammed biological conditions detected in the streaming vital signs being displayed including heart beats, respiratory cycles, preprogrammed biological parameter limits including temperature, EtCO2, SPO2, invasive blood pressure being reached, and when patient monitor-generated alarm or alert conditions are being detected as part of the streaming vital signs being displayed.

112. The telemedicine method of claim 111, wherein the dashboard also triggers and actuates a built-in haptic feedback device in response to a selection of preprogrammed biological conditions detected in the streaming vital signs being displayed including heart beats, respiratory cycles, preprogrammed biological parameter limits including temperature, EtCO2, SPO2, invasive blood pressure being reached, and when patient monitor-generated alarm or alert conditions are being detected as part of the streaming vital signs being displayed.

113. The telemedicine method of claim 112 wherein the haptic feedback pattern is programmed to be unique for each group or individual type of biological conditions, alarms, or alert triggers.

114. The telemedicine method of claim 90 wherein:

a. the dashboard also captures streaming video data from a built-in video sensor, and

b. transmits it as backchannel video to a gateway;

c. the gateway also receives backchannel video from a dashboard, and

d. transmits the received backchannel video to an aggregator and simultaneously to all other dashboards connected to the same active session;

e. the dashboard also receives backchannel video originating from all the other dashboards connected to the same active session, and

f. renders the backchannel video originating from all the other session dashboards in independent sections on its fourth display, each identifying its originating dashboard user;

g. the aggregator also receives backchannel video from a gateway, and

h. renders the backchannel video originating from all session dashboards in independent sections on its second display, each identifying its originating dashboard user.

115. The telemedicine method of claim 114 wherein the gateway also captures and stores within the first persistent memory device a timestamped copy of all the backchannel video data passing through it.

116. The telemedicine method of claim 90 wherein:

a. the dashboard also captures GPS location data from a built-in GPS sensor, and

b. transmits it as GPS data to a gateway;

c. the gateway also receives GPS location data from a dashboard, and

d. simultaneously transmits it to all other dashboards connected to the same active session;

e. the dashboard also receives GPS location data originating from all the other dashboards connected to the same active session, and

f. displays on its geolocation map the GPS location of all the other session dashboards as independent icons, each identifying its originating dashboard user.

117. The telemedicine method of the claim 116 wherein:

a. the gateway also transmits GPS location data received from a dashboard alongside backchannel audio to an aggregator;

b. the aggregator also receives GPS location data from a gateway, and

c. displays the GPS location of all session as independent icons, each identifying its originating dashboard user, on its second display.

118. The telemedicine method of claim 117 wherein the gateway also captures and stores within its first persistent memory device a timestamped copy of all the GPS location data passing through the gateway.

119. The telemedicine method of claim 118 wherein the gateway also exports any and all of its stored audio, video, vital signs, and GPS data to an external memory device and also makes it available for retrieval through a Web page, a Web service, or a TCP socket interface.

120. The telemedicine method of claim 119 wherein the gateway is further configured to automatically purge old records of its stored audio, video, vital signs, and GPS data according to a preprogrammed record retention policy.