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. 
     According to some embodiments, 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 session and instructional from gateways for local display; gateways maintaining concurrent sessions between aggregators and dashboards, receiving session from aggregators for transmission to dashboards, and simultaneously receiving session from dashboards for transmission, with instructional, to aggregators and to other session dashboards; and dashboards generating and streaming session to gateways while displaying received session data.

Description:
TECHNICAL FIELD 
       [0001]    Embodiments of the present invention relate to a distributed telemedicine system and method providing an interactive telepresence combined with real time, streaming vital signs connectivity between a plurality of medical professionals in either fixed or mobile settings and a plurality of patients and/or physician assistants in either fixed or mobile settings at remote sites. 
       BACKGROUND 
       [0002]    Interactive telemedicine systems with telepresence have traditionally been available in stationary settings, predicated on the availability of a reliable, high bandwidth communication infrastructure between the locations of the physician and the patient, such as a rural clinic, ambulatory center, or assisted living facility, and vital-signs based telemedicine systems have traditionally been used for home monitoring of post-operative patients, preventative medicine, and for communications of patient self-administered tests where a reliable, high bandwidth communication infrastructure is not necessarily available and where the connectivity is of store-and-forward (non-interactive) nature, the remote comprising primarily of trended, incremental snapshots of streaming vital signs and/or a limited number of pre-recorded audio, video, and/or vital sign waveform snippets. 
         [0003]    Currently available telemedicine systems are of limited value in mobile applications such as emergency medical assistance at the site of an accident or during patient transport to a medical facility, where telepresence is either not available or is not interactive, and/or streaming vital signs transmission is limited to selective snapshots taken at the initiative of an Emergency Medical Technician or physician assistant, therefore limiting the clinical effectiveness of the assistance provided by the remote physician. 
         [0004]    Since the level and type of remote assistance available in such emergency situations is typically limited to the qualifications of the medical staff present within the medical facility where the fixed telemedicine terminal is located, hospitals are required to ensure adequate staffing coverage for all possible trauma conditions not knowing ahead of time the types of trauma present at the accident site. 
         [0005]    Moreover, since most telemedicine systems are structured in a point-to-point fashion, multiple physician collaborations are limited to just the personnel available at the location where the fixed telemedicine terminal is installed. 
         [0006]    Lastly, current telemedicine systems offer neither live pause, rewind, and play back capabilities which might be useful in real time remote review, assessment, and diagnosis of clinical conditions, events, and/or triggers such as arrhythmias, temporary drops in blood pressure, respiratory blockages, etc. for a more effective remote assistance of patients with critical or life threatening conditions, nor full session archiving and playback of audio, video, and streaming vital signs which could be useful for post case review related to insurance claims, liability litigation, and training or educational applications. 
         [0007]    There is thus a widely-recognized need for, and it would be highly helpful to the advancement of the current standard of critical care to have, a telemedicine system which is devoid of all the above limitations. 
       SUMMARY 
       [0008]    A distributed telemedicine system for medical remote assistance applications, the telemedicine system comprising: one or more patient monitoring devices, the patient monitoring device comprising: one or more vital signs sensors configured for physical attachment to a patient; a first communication system; a first processor configured to receive vital signs information from the one or more sensors, generate streaming vital signs based on the information and transmit at least a first portion of the streaming vital signs to an aggregator via the first communication system; and a first screen configured to display a representation of at least a second portion of the streaming vital signs; one or more aggregators, the aggregator comprising: one or more audio and video sensors; a second communication system; a third communication system; a fourth communication system; a fifth communication system; 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 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; 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 the sixth communication system and establish a communication link between the third and sixth communication system, detect the presence of the seventh communication system and establish a communication link between the fourth and seventh communication system, detect the presence of the eighth communication system and establish a communication link between the fifth and eighth communication system; a second screen configured to display an aggregated representation of at least a fourth portion of the streaming vital signs together with the site video and session controls; one or more first audio reproduction devices configured to reproduce the site audio combined with the backchannel audio as audible sounds; one or more gateways, the gateway comprising: a sixth communication system; a seventh communication system; an eighth communication system; a ninth communication system; a third processor configured to receive site audio and video from a plurality of aggregators over the seventh communication system, receive streaming vital signs from a plurality of aggregators over the sixth communication system, send the site audio and video combined with the streaming vital signs to a plurality of dashboards over the ninth communication system, receive backchannel audio from a plurality of dashboards over the ninth communication system, and transmit backchannel audio to a plurality of aggregators over the eighth communication system; a third screen configured to display session status, statistics, and configuration controls; one or more dashboards, the dashboard comprising: a tenth communication system; an audio sensor; a fourth 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; one or more audio reproduction devices configured to reproduce the site audio data received as audible sounds; a second application executed on the fourth 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; a fourth screen configured to display an aggregated representation of at least a fifth portion of the streaming vital signs combined with a representation of the site video and session controls; and one or more second audio reproduction devices configured to reproduce the site audio received as audible sounds. 
         [0009]    The telemedicine system of paragraph [0008], wherein the third and fourth communication systems are the same. 
         [0010]    The telemedicine system of any of the paragraphs [0008] to [0009], wherein the fourth and fifth communication systems are the same. 
         [0011]    The telemedicine system of any of the paragraphs [0008] to [0010], wherein the sixth and seventh communication systems are the same. 
         [0012]    The telemedicine system of any of the paragraphs [0008] to [0011], wherein the seventh and eighth communication systems are the same. 
         [0013]    The telemedicine system of any of the paragraphs [0008] to [0012], wherein the first and second gateways are the same. 
         [0014]    The telemedicine system of any of the paragraphs [0008] to [0013], wherein the second and third gateways are the same. 
         [0015]    The telemedicine system of any of the paragraphs [0008] to [0014], wherein the first and second portion of the streaming vital signs data are the same. 
         [0016]    The telemedicine system of any of the paragraphs [0008] to [0015], wherein the second and third portion of the streaming vital signs data are the same. 
         [0017]    The telemedicine system of any of the paragraphs [0008] to [0016], wherein the third and fourth portion of the streaming vital signs data are the same. 
         [0018]    The telemedicine system of any of the paragraphs [0008] to [0017], wherein the fourth and fifth portion of the streaming vital signs data are the same. 
         [0019]    The telemedicine system of any of the paragraphs [0008] to [0018], wherein at least a portion of either communication system includes a fixed network over wire, fiber optic cables, or power line in either point-to-point, shared media, bus, ring, backbone, star, backhaul, ad-hoc, mesh topology configuration or any combination thereof. 
         [0020]    The telemedicine system of any of the paragraphs [0008] to [0019], wherein at least a portion of either communication system includes a wireless network, including, without limitation, Bluetooth, Bluetooth Low Energy (BLE), Ultra Wide Band (UWB), Wireless Fidelity (Wi-Fi), radio, satellite, microwave, laser, infrared, Zig-bee, Z-Wave, or cellular such as 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), etc., in either point-to-point, shared media, bus, ring, backbone, star, backhaul, ad-hoc, mesh topology configuration or any combination thereof. 
         [0021]    The telemedicine system of any of the paragraphs [0008] to [0020], wherein the patient monitor and the aggregator are the same. 
         [0022]    The telemedicine system of any of the paragraphs [0008] to [0021], wherein either of the patient monitoring devices are portable. 
         [0023]    The telemedicine system of any of the paragraphs [0008] to [0022], wherein either of the aggregators are portable. 
         [0024]    The telemedicine system of any of the paragraphs [0008] to [0023], wherein either of the gateways are portable. 
         [0025]    The telemedicine system of any of the paragraphs [0008] to [0024], wherein either of the dashboards are portable. 
         [0026]    The telemedicine system of any of the paragraphs [0008] to [0025], wherein either of the screens are touch-enabled. 
         [0027]    The telemedicine system of any of the paragraphs [0008] to [0026], wherein either of the gateways are cloud-based virtual server instances. 
         [0028]    The telemedicine system of any of the paragraphs [0008] to [0027], wherein either of the gateways are physical server instances, either on-site, collocated or cloud-based. 
         [0029]    The telemedicine system of any of the paragraphs [0008] to [0028], 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 including, but not limited to, Amazon Elastic Compute Cloud (EC2) instances, Microsoft Azure instances, Google Compute Engines, Google Autoscaler, etc. 
         [0030]    The telemedicine system of any of the paragraphs [0008] to [0029], 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 in any combination thereof. 
         [0031]    The telemedicine system of any of the paragraphs [0008] to [0030], wherein at least a portion of the data transmission over either of the communication systems is secured with an encryption method including but not limited to the Secure Sockets Layer (SSL) protocol, Transport Layer Security (TLS), etc. 
         [0032]    The telemedicine system of any of the paragraphs [0008] to [0031], wherein at least a portion of the audio and/or video transmission over either of the communication systems uses the World Wide Web Consortium&#39;s (W3C) Web Real-Time Communication (WebRTC) protocol. 
         [0033]    The telemedicine system of any of the paragraphs [0008] to [0032], wherein at least a portion of the streaming vital signs data transmission over either of the communication systems uses the Internet Engineering Task Force&#39;s (IETF) WebSocket protocol. 
         [0034]    The telemedicine system of any of the paragraphs [0008] to [0033], 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 such as the Public Key Infrastructure (PKI)-based X.509 certificate, a biometric reading such as the image of a fingerprint, a retinal scan, facial recognition, or any combination thereof. 
         [0035]    The telemedicine system of any of the paragraphs [0008] to [0034], 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. 
         [0036]    The telemedicine system of any of the paragraphs [0008] to [0035], 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. 
         [0037]    The telemedicine system of any of the paragraphs [0008] to [0036], wherein either of the data packets transmitted over either of the communication systems is structured according to JavaScript Object Notation (JSON) specification. 
         [0038]    The telemedicine system of any of the paragraphs [0008] to [0037], wherein either of the packets transmitted over either of the communication systems uses a lossless compression algorithm like 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) etc. or any component, combination, or derivative thereof, such as zip, gzip, pkzip, arc, rar, etc. 
         [0039]    The telemedicine system of any of the paragraphs [0008] to [0038], wherein the streaming vital signs include, without limitation, 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, etc.; patient monitor generated alarms such as ventricular fibrillation, etc. and patient monitor generated alerts such as blood pressure lower than a preset alert limit, etc. 
         [0040]    The telemedicine system of any of the paragraphs [0008] to [0039], wherein either of the patient monitoring devices is a monitor-defibrillator. 
         [0041]    The telemedicine system of any of the paragraphs [0008] to [0040], wherein the gateway also comprises a first persistent memory device and 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 passing through the gateway. 
         [0042]    The telemedicine system of any of the paragraphs [0008] to [0041], wherein the gateway further comprises a fourth application executed on the third processor, the application configured to respond to pause, play back, rewind, and fast forward commands received over the ninth communication system, read the timestamped site audio, video, backchannel audio, and streaming vital signs stored in the first persistent memory device, 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&#39;s fourth screen, and the dashboard further comprises 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&#39;s fourth application via the tenth communication system. 
         [0043]    The telemedicine system of any of the paragraphs [0008] to [0042], wherein the gateway&#39;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&#39;s fourth application when both the ninth and the tenth communication systems resume their operation and reconnect. 
         [0044]    The telemedicine system of any of the paragraphs [0008] to [0043], wherein the aggregator also comprises a second persistent memory device and 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 received by the aggregator when either the third, fourth, or fifth communication system is inoperative, and the aggregator&#39;s second application is also configured to send the stored (catch-up) in a catch-up mode, until all the catch-up is exhausted, to the one or more gateways when all of the third, fourth, and fifth communication systems resume their operation and reconnect, and the gateway&#39;s third application is also configured to receive the timestamped catch-up from the gateway through the sixth, seventh, and eighth communication system respectively, insert and store the catch-up, until all the catch-up 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 passing through the gateway. 
         [0045]    The telemedicine system of any of the paragraphs [0008] to [0044], wherein the gateway also comprises 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 between the gateways and dashboards where the users logged in belong to the same VMG, the gateway&#39;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. 
         [0046]    The telemedicine system of any of the paragraphs [0008] to [0045], wherein the aggregator also comprises a first GPS location sensor and seventh application executed on the second processor, the application configured to read its GPS position from its first GPS sensor, initiate an assistance request combined with its GPS position indicating the type of expertise sought and transmit such assistance request to one or more gateways via the fifth communication system, wherein the gateway also comprises an eight application executed on the third processor which receives such 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, and wherein the dashboard also comprises a ninth application executed on the fourth processor, the application programmed to display the assistance request on a geolocation map using the GPS information embedded in the assistance request, wait for the logged in user to confirm, and 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. If the user does not confirm the assistance request within the preprogrammed time, the gateway&#39;s eighth application executed on the third processor 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&#39;s logged in user. If no dashboard with a logged in user belonging to the same VMG as the requesting gateway&#39;s logged in user exists at that time, the gateway&#39;s eighth application executed on the third processor is programmed to 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 but not limited to, a SMS message over a cellular network, an e-mail, a text-to-speech voice message over a cellular or traditional phone network, etc. The dashboard&#39;s ninth application executed on the fourth processor is also programmed to display 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, wait for the logged in user to confirm, and 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. 
         [0047]    The telemedicine system of any of the paragraphs [0008] to [0046], wherein the dashboard&#39;s ninth application executed on the fourth processor is also programmed to allow a dashboard user providing assistance to an aggregator user through an active end-to-end session to send a secondary assistance request based on the same or different requested second skill set to another nominated or generic user from the same VNG through the tenth communication system, and the eighth application executed on the third processor is also programmed to receive such a secondary assistance request and dispatch it to the nominated user or to the next qualified user from the same VMG and according to its programmed escalation logic. The gateway&#39;s ninth application executed on the fourth processor is further programmed to display the secondary user&#39;s pending assistance request on a geolocation map using the GPS information embedded in the original assistance request, wait for the secondary user to confirm, and 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. The fourth screen is also configured to render, when the dashboard is in such a secondary assistance mode, a replica of the primary session&#39;s streaming vital signs and site video; the 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 session dashboards. 
         [0048]    The telemedicine system of the paragraph [0047], wherein the eighth application executed on the gateway&#39;s third processor is also programmed to combine all backchannel audio originating from the primary and all secondary dashboard users providing assistance to the same gateway user, and send the combined audio backchannel forward to the aggregator and back to the primary and all secondary dashboards connected to the same gateway session. 
         [0049]    The telemedicine system of any of the paragraphs [0008] to [0048], wherein the third, fourth, and fifth communication systems are the same, the sixth, seventh, and eighth communication systems are the same, the first, second, and third gateways are the same, and the site audio, video, and streaming vital signs are partitioned in packets each representing such originating within the same 40 to 960 milliseconds time interval, and whereby all such packets are further combined in a single composite packet that encompasses all site audio, video, and streaming vital signs originating within the said time interval. 
         [0050]    The telemedicine system of paragraph [0049] wherein the composite data packet (payload) is further compressed, and whereby the compressed data packet may also include derived information used to detect the tampering and/or corruption of the payload including, but not limited to, an electronic signature performed with the aid of symmetric or asymmetric key scheme, a hash, a checksum, a digital watermark, a cryptographic timestamp, etc. 
         [0051]    The telemedicine system of any of the paragraphs [0008] to [0050], wherein the gateway also comprises a tenth application executed on the third processor, the application configured to take a snapshot of ECG from the gateway&#39;s first persistent memory device, perform a 12-Lead analysis through a third party analysis module including, but not limited to, GE-Marquette 12SL, Glasgow 12-Lead ECG Analysis, ZOLL Inovise, Philips EASI, etc., generate a 12 Lead ECG analysis report, and send such report to the dashboard over the ninth communication system, and the dashboard also comprises an eleventh application executed on the fourth processor, the application configured to send a 12 Lead ECG analysis request to the gateway over the tenth communication system, receive the 12 Lead analysis report, and the dashboard&#39;s fourth screen is also configured to render the said 12 Lead Analysis report. 
         [0052]    The telemedicine system of paragraph [0051] wherein the gateway&#39;s tenth application executed on the third processor is also configured to archive the generated 12 Lead ECG analysis report into the gateway&#39;s first persistent memory device, the gateway&#39;s fourth application executed on the third processor is also programmed to respond to a retrieval command of a previously generated 12 Lead ECG analysis report, and send such report to the dashboard over the ninth communication system, the dashboard&#39;s eleventh application executed on the fourth processor is also configured to send a retrieval command for a previously generated 12 Lead ECG analysis to the gateway over the tenth communication system, receive the said 12 Lead analysis report from the gateway over the tenth communication system, and the dashboard&#39;s fourth screen is also configured to render the previously generated 12 Lead Analysis report received from the gateway. 
         [0053]    The telemedicine system of any of the paragraphs [0051] to [0052], wherein the 12 Lead ECG analysis is substituted with any derivative calculation, analysis, alarm, or alert executed across any number of streaming vital signs, including but not limited to, ECG, temperature, invasive blood pressure, and respiration waveforms, trending numerical parameters such as EtCO2, SPO2, temperature, streaming ultrasound or endoscopic images, auscultation waveforms, respiration rate, heart rate, non-invasive blood pressure, etc. and/or including patient monitor generated alarms and alerts. 
         [0054]    The telemedicine system of any of the paragraphs [0050] to [0053], wherein the gateway&#39;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, etc. based on previously stored streaming vital signs received from at least a portion of all the other patients&#39; 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. 
         [0055]    The telemedicine system of paragraph [0054] wherein the gateway&#39;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 preloaded into the gateway&#39;s first persistent memory device or downloaded from an external data provider over its eighth communication system, or a combination of internally stored and externally accessed such. 
         [0056]    The telemedicine system of any of the paragraphs [0050] to [0055], wherein the gateway&#39;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&#39;s first persistent memory device alongside the currently recorded site audio, video, and streaming vital signs, the gateway&#39;s fourth application executed on the third processor is also programmed to receive a current annotation event for storage and respond to a voice or textual retrieval command of a previously stored annotation event, generate a search specification based on an algorithm including, but not limited to, voice recognition, text to speech, neural networks, fuzzy logic, artificial intelligence, Boolean, binary tree, etc., search based on the generated search specification and its associated algorithm, locate, and send 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 to the dashboard over the ninth communication system, the dashboard&#39;s eleventh application executed on the fourth processor is also configured to capture a new textual or voice recorded annotation event and send it to the gateway over the tenth communication system, and to capture a textual or voice search request for a previously stored annotation event and send it to the gateway over the tenth communication system, receive the said previously stored annotation event together with all the previously stored site audio, video, and streaming vital signs from its configurable time window from the gateway over the tenth communication system, and the dashboard&#39;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 from its configurable time window. 
         [0057]    The telemedicine system of paragraph [0056] wherein the gateway&#39;s fourth application executed on the third processor is also programmed to apply its generated search criteria to the site and/or backchannel voice recorded in the gateway&#39;s first persistent storage device and send such previously stored backchannel audio, site audio, video, and streaming vital signs in a configurable time window surrounding the time stamp of the first audio match to the dashboard over the ninth communication system, the dashboard&#39;s eleventh application executed on the fourth processor is also configured to the dashboard&#39;s eleventh application executed on the fourth processor is also configured to capture a search request to be executed over the site and/or backchannel voice recorded in the gateway&#39;s first persistent storage device, and send it to the gateway over its tenth communication system, receive the said previously stored backchannel audio, site audio, video, and streaming vital signs from its configurable time window from the gateway over the tenth communication system, and the dashboard&#39;s fourth screen is also configured to render the received backchannel audio, site audio, video, and streaming vital signs from its configurable time window. 
         [0058]    The telemedicine system of any of the paragraphs [0055] to [0057], wherein the gateway&#39;s fourth application executed on the third processor is also programmed to send either the first, last, next, or previous such search&#39;s match to the dashboard over the ninth communication system in response to a request received from it, and the dashboard&#39;s eleventh application executed on the fourth processor is also configured to request the first, last, next, or previous such search&#39;s match. 
         [0059]    The telemedicine system of any of the paragraphs [0008] to [0058], wherein the gateway also comprises a twelfth application executed on the third processor, the application configured to receive a textual or voice search request from an aggregator over the eighth communication system, generate a search specification based on an algorithm including, but not limited to, voice recognition, text to speech, neural networks, fuzzy logic, artificial intelligence, Boolean, binary tree, etc., search based on the generated search specification and its associated algorithm, locate and retrieve a previously stored procedural guidance including, but not limited to, text, hypertext, annotated text, structured text, images, audio, video, or any combination thereof, and send the first match of such previously stored procedural guidance to the requesting aggregator over the eighth communication system, the aggregator also comprises a thirteenth application executed on the second processor, the application configured to capture a textual or voice search request for a procedural guidance and send it to the gateway over the fifth communication system, and the aggregator&#39;s second screen is further configured to render the received procedural guidance in its appropriate representation, whether text, images, audio, video, or any combination thereof, either as standalone or as an overlay. 
         [0060]    The telemedicine system of paragraph [0059] wherein the gateway&#39;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 ninth communication system, or a combination of internally stored and externally accessed procedural guidance data. 
         [0061]    The telemedicine system of any of the paragraphs [0059] to [0060], wherein the gateway&#39;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&#39;s match over the eighth communication system in response to a request received from it, and the aggregator&#39;s thirteenth application executed on the second processor is also configured to request the first, last, next, or previous such search&#39;s match. 
         [0062]    The telemedicine system of any of the paragraphs [0057] to [0061], wherein the gateway also comprises a portable augmented reality display including, but not limited to, headset, goggle, retinal scanning device, smart glass eyewear such as Google Glass, Microsoft HoloLens, Sony SmartGlass, etc., programmed to display the said procedural guidance data received from the gateway over the fifth communication system. 
         [0063]    The telemedicine system of any of the paragraphs [0008] to [0062], wherein the gateway also comprises a haptic feedback device, the gateway&#39;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, but not limited to, heart beats, respiratory cycles, preprogrammed biological parameter limits such as temperature, EtCO2, SPO2, invasive blood pressure being reached, etc., and when patient monitor-generated alarm or alert conditions are being detected as part of the streaming vital signs being displayed. 
         [0064]    The telemedicine system of any of the paragraphs [0008] to [0063], wherein the dashboard also comprises a haptic feedback device, the dashboard&#39;s fourth 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, but not limited to, heart beats, respiratory cycles, preprogrammed biological parameter limits such as temperature, EtCO2, SPO2, invasive blood pressure being reached, etc., and when patient monitor-generated alarm or alert conditions are being detected as part of the streaming vital signs being displayed. 
         [0065]    The telemedicine system of any of the paragraphs [0062] to [0064] wherein the haptic feedback pattern is programmed to be unique for each group or individual type of biological conditions, alarms, or alert triggers. 
         [0066]    The telemedicine system of any of the paragraphs [0008] to [0065] wherein the dashboard also comprises a video sensor and its fourth processor is also configured to receive streaming video from the video sensor and transmit it as backchannel video to a gateway over the tenth communication system; the gateway&#39;s third processor is also configured to receive backchannel video from a dashboard over the ninth communication system, then transmit the received backchannel video to an aggregator over the seventh communication system and simultaneously to all other dashboards connected to the same active session over the ninth communication system; the dashboard&#39;s fourth processor is also configured to receive backchannel video originating from all the other dashboards connected to the same active session and its fourth display is also configured to render the backchannel video originating from all the other session dashboards in independent areas, each identifying its originating dashboard user; the aggregator&#39;s second processor is also configured to receive backchannel video from a gateway over its fifth communication system and its second display is also configured to render the backchannel video originating from all session dashboards in independent areas, each identifying its originating dashboard user. 
         [0067]    The telemedicine system of paragraph [0066] wherein the gateway&#39;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 or predesignated portions of the backchannel video data passing through the gateway. 
         [0068]    The telemedicine system of any of the paragraphs [0046] to [0067] wherein the dashboard also comprises a second GPS location sensor and its fourth processor is also configured to read its GPS location from the GPS sensor and transmit it as GPS alongside backchannel audio to a gateway over the tenth communication system; the gateway&#39;s third processor is also configured to receive GPS location alongside backchannel audio from a dashboard over the ninth communication system, then simultaneously transmit it alongside backchannel audio to all other dashboards connected to the same active session over the ninth communication system; the dashboard&#39;s fourth processor is also configured to receive GPS location originating from all the other dashboards connected to the same active session and its 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. 
         [0069]    The telemedicine system of the paragraph [0068] wherein the gateway&#39;s third processor is also configured to transmit GPS location received from a dashboard alongside backchannel audio to an aggregator over the eighth communication system; the aggregator&#39;s second processor is also configured to receive GPS location from a gateway over its fifth communication system and its second display is also configured to display the GPS location of all session as independent icons, each identifying its originating dashboard user. 
         [0070]    The telemedicine system of any of the paragraphs [0041] to [0069] wherein the gateway&#39;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. 
         [0071]    A 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 streaming vital signs transmissions, comprising: 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; receiving vital signs information from the vital signs sensors, generating streaming vital signs based on the information from the vital signs sensors, and transmitting at least a first portion of the streaming vital signs to an aggregator while simultaneously displaying a representation of at least a second portion of the streaming vital signs on a first screen; receiving the streaming vital signs by one or more aggregators, the aggregator having one or more audio and video sensors and one or more first audio reproduction devices; transmitting at least a third portion of the streaming vital signs to a first gateway, capturing site audio and video from the aggregator&#39;s sensors while transmitting the site audio and video to a second gateway, and simultaneously receiving backchannel audio from a third gateway, displaying an aggregated representation of at least a fourth portion of the streaming vital signs together with the site video and session controls on a second screen, and reproducing the site audio combined with the backchannel audio through the first audio reproduction devices; receiving the site audio and video by a first gateway, maintaining session status, statistics, and configuration on the first gateway via a third screen, receiving streaming vital signs by a second gateway, and sending combined backchannel audio to the aggregator from a third gateway, maintaining session information relating to a source aggregator and one or more dashboards within the gateway, 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; 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, displaying an aggregated representation of at least a fifth portion of the streaming vital signs with a representation of the site video and session controls on a fourth screen, capturing audio backchannel from the dashboard&#39;s audio sensor and sending it back to the gateway, while simultaneously reproducing the site audio combined with the backchannel audio received as audible sounds on the dashboard&#39;s second audio reproduction devices. 
         [0072]    The telemedicine method of paragraph [0071], wherein the first and second gateways are the same. 
         [0073]    The telemedicine method of any of the paragraphs [0071] to [0072] wherein the second and third gateways are the same. 
         [0074]    The telemedicine method of any of the paragraphs [0071] to [0073], wherein the first and second portion of the streaming vital signs data are the same. 
         [0075]    The telemedicine method of any of the paragraphs [0071] to [0074], wherein the second and third portion of the streaming vital signs data are the same. 
         [0076]    The telemedicine method of any of the paragraphs [0071] to [0075], wherein the third and fourth portion of the streaming vital signs data are the same. 
         [0077]    The telemedicine method of any of the paragraphs [0071] to [0076], wherein the fourth and fifth portion of the streaming vital signs data are the same. 
         [0078]    The telemedicine method of any of the paragraphs [0071] to [0077], wherein either of the patient monitoring devices are portable. 
         [0079]    The telemedicine method of any of the paragraphs [0071] to [0078], wherein either of the aggregators are portable. 
         [0080]    The telemedicine method of any of the paragraphs [0071] to [0079], wherein either of the gateways are portable. 
         [0081]    The telemedicine method of any of the paragraphs [0071] to [0080], wherein either of the dashboards are portable. 
         [0082]    The telemedicine method of any of the paragraphs [0071] to [0081], wherein either of the screens are touch-enabled. 
         [0083]    The telemedicine method of any of the paragraphs [0071] to [0082], wherein either of the gateways are cloud-based virtual server instances. 
         [0084]    The telemedicine method of any of the paragraphs [0071] to [0083], wherein either of the gateways are physical server instances, either on-site, collocated or cloud-based. 
         [0085]    The telemedicine method of any of the paragraphs [0071] to [0084], wherein either of the gateways are server cluster systems, and whereby the server cluster system is redirecting, recording, or modifying communication between transmitters and receivers with manual or automatic computing resource scaling. 
         [0086]    The telemedicine method of any of the paragraphs [0071] to [0085], wherein at least a portion of the data is transmitted using either Transmission Control Protocol/Internet Protocol (TCP/IP), User gram Protocol (UDP), Internet Control Message Protocol (ICMP), or their FastPath Stack successor in any combination thereof as baseline protocols. 
         [0087]    The telemedicine method of any of the paragraphs [0071] to [0086], wherein at least a portion of the data transmission is encrypted with a method including but not limited to the Secure Sockets Layer (SSL) protocol, Transport Layer Security (TLS), etc. 
         [0088]    The telemedicine method of any of the paragraphs [0071] to [0087], wherein at least a portion of the audio and/or video is transmitted using the World Wide Web Consortium&#39;s (W3C) Web Real-Time Communication (WebRTC) protocol. 
         [0089]    The telemedicine method of any of the paragraphs [0071] to [0088], wherein at least a portion of the streaming vital signs data is transmitted using the Internet Engineering Task Force&#39;s (IETF) WebSocket protocol. 
         [0090]    The telemedicine method of any of the paragraphs [0071] to [0089], 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 such as the Public Key Infrastructure (PKI)-based X.509 certificate, a biometric reading such as the image of a fingerprint, a retinal scan, facial recognition, or any combination thereof. 
         [0091]    The telemedicine method of any of the paragraphs [0071] to [0090], wherein the audio, video, and streaming vital signs is partitioned for transmission in fixed size packets each representing a time interval configurable to any value between 20 milliseconds and 2 seconds. 
         [0092]    The telemedicine method of any of the paragraphs [0071] to [0091], wherein new packets of either audio, video, or vital signs data are transmitted at constant time intervals, programmable between 40 to 960 milliseconds. 
         [0093]    The telemedicine method of any of the paragraphs [0071] to [0092], wherein either of the data packets transmitted over either of the communication systems is structured according to JavaScript Object Notation (JSON) specification. 
         [0094]    The telemedicine method of any of the paragraphs [0071] to [0093], wherein either of the packets transmitted is compressed using a lossless compression algorithm like 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) etc. or any component, combination, or derivative thereof, such as zip, gzip, pkzip, arc, rar, etc. 
         [0095]    The telemedicine method of any of the paragraphs [0071] to [0094], wherein 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, etc.; patient monitor generated alarms such as ventricular fibrillation, etc. and patient monitor generated alerts such as blood pressure lower than a preset alert limit, etc. 
         [0096]    The telemedicine method of any of the paragraphs [0071] to [0095], wherein either of the patient monitoring devices is a monitor-defibrillator. 
         [0097]    The telemedicine method of any of the paragraphs [0071] to [0096], wherein a timestamped copy of all the site audio, video, backchannel audio, and streaming vital signs data passing through the gateway is stored within a first persistent memory device on the gateway. 
         [0098]    The telemedicine method of any of the paragraphs [0071] to [0097], wherein the dashboard also reads user input and transmits pause, play back, rewind, and fast forward commands to the gateway, and the gateway also reads the timestamped site audio, video, backchannel audio, and streaming vital signs stored in its first persistent memory device, applies a controlled time offset for each such function requested, sends it back to the requesting dashboard, and the dashboard also displays the received video on its fourth screen and renders the received audio through its second audio reproduction device. 
         [0099]    The telemedicine method of any of the paragraphs [0071] to [0098], 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. 
         [0100]    The telemedicine method of any of the paragraphs [0071] to [0099], wherein the aggregator also stores a timestamped copy of all the site audio, video, and streaming vital signs received by the aggregator in a second persistent memory device even when it loses connectivity with the gateway, and when it reconnects with the gateway, also sends the stored (catch-up) to the gateway in parallel with its normal transmission, in a catch-up mode, until all the catch-up is exhausted, and the gateway also inserts and stores the received catch-up, in its correct timestamp order, on its first persistent memory device. 
         [0101]    The telemedicine method of any of the paragraphs [0071] to [0100], wherein the gateway also groups a plurality of gateway login accounts and a plurality of dashboard login accounts into Virtual Medical Groups (VMG), only allowing 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 wherein 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. 
         [0102]    The telemedicine method of any of the paragraphs [0071] to [0101], wherein the aggregator also reads its location position from a first GPS sensor, initiates an assistance request combined with its GPS position indicating the type of expertise sought, and transmits such assistance request to one or more gateways; the gateway also receives such 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; the dashboard also displays the assistance request on a geolocation map using the GPS information embedded in the assistance request, waits for the logged in user to confirm, and 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. 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&#39;s logged in user. If no dashboard with a logged in user belonging to the same VMG as the requesting gateway&#39;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 but not limited to, a SMS message over a cellular network, an e-mail, a text-to-speech voice message over a cellular or traditional phone network, etc. 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, waits for the logged in user to confirm, and 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. 
         [0103]    The telemedicine method of any of the paragraphs [0071] to [0102], wherein 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 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. The dashboard also displays the secondary user&#39;s pending assistance request on a geolocation map using the GPS information embedded in the original assistance request, waits for the secondary user to confirm, and 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. When the dashboard is in such a secondary assistance mode, it displays a replica of the primary session&#39;s streaming waveforms, trending parameters, clinical alarms and alerts, and site video, and reproduces a replica of the site audio combined with the composite backchannel audio originating from all session dashboards. 
         [0104]    The telemedicine method of the paragraph [0103], wherein the gateway also combines all backchannel audio originating from the primary and all secondary dashboard users providing assistance to the same gateway user, and sends the combined audio backchannel forward to the aggregator and back to the primary and all secondary dashboards connected to the same gateway session. 
         [0105]    The telemedicine method of any of the paragraphs [0071] to [0104], 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 originating within the said time interval. 
         [0106]    The telemedicine method of paragraph [0105] wherein the composite data packet (payload) is further compressed to reduce its size, and whereby the compressed packet may also include derived information used to detect the tampering and/or corruption of the payload including, but not limited to, an electronic signature performed with the aid of symmetric or asymmetric key scheme, a hash, a checksum, a digital watermark, a cryptographic timestamp, etc. 
         [0107]    The telemedicine method of any of the paragraphs [0071] to [0106], wherein the dashboard also sends a 12 Lead analysis request to the gateway, the gateway also takes a snapshot of ECG from its first persistent memory device, performs a 12-Lead analysis through a third party analysis module including, but not limited to, GE-Marquette 12SL, Glasgow 12-Lead ECG Analysis, Zoll Inovise, Philips EASI, etc., generates a 12 Lead ECG analysis report, and sends such report back to the dashboard, and the dashboard also receives the 12 Lead analysis report, and renders it on its fourth display. 
         [0108]    The telemedicine method of paragraph [0107] wherein the gateway also archives the generated 12 Lead ECG analysis report into the gateway&#39;s first persistent memory device, the dashboard also sends a retrieval command for a previously generated 12 Lead ECG analysis to the gateway, the gateway also responds to a retrieval command of a previously generated 12 Lead ECG analysis report and sends such report to the dashboard, and the dashboard receives the said 12 Lead analysis report from the gateway and renders it on its fourth display. 
         [0109]    The telemedicine method of any of the paragraphs [0107] to [0108], wherein the 12 Lead ECG analysis is substituted with any derivative calculation, analysis, alarm, or alert executed across any number of streaming vital signs, including but not limited to, ECG, temperature, invasive blood pressure, and respiration waveforms, trending numerical parameters such as EtCO2, SPO2, temperature, streaming ultrasound or endoscopic images, auscultation waveforms, respiration rate, heart rate, non-invasive blood pressure, etc. and/or including patient monitor generated alarms and alerts. 
         [0110]    The telemedicine method of any of the paragraphs [0107] to [0109], wherein the gateway uses machine learning algorithms included but not limited to, neural networks, fuzzy logic, artificial intelligence, etc. based on previously stored streaming vital signs received from at least a portion of all the other patients&#39; 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. 
         [0111]    The telemedicine method of paragraph [0110] wherein the gateway uses for its machine learning algorithms externally provided historical streaming vital signs data either preloaded into the gateway&#39;s first persistent memory device or downloaded from an data provider, or a combination of internally stored and externally accessed such. 
         [0112]    The telemedicine method of any of the paragraphs [0107] to [0111], wherein the dashboard also captures a new time stamped textual or voice recorded annotation event and sends it to the gateway, the gateway also receives the time stamped textual and/or voice recording annotation event and stores it into the gateway&#39;s first persistent memory device alongside the currently recorded site audio, video, and streaming vital signs, the dashboard also captures a textual or voice search request for a previously stored annotation event and sends it to the gateway, 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, but not limited to, voice recognition, text to speech, neural networks, fuzzy logic, artificial intelligence, Boolean, binary tree, etc., 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 the dashboard also receives the said previously stored annotation event together with all the previously stored site audio, video, and streaming vital signs from its configurable time window from the gateway and renders it on its fourth display. 
         [0113]    The telemedicine method of paragraph [0112] wherein the dashboard also captures a search request to be executed over the site and/or backchannel voice recorded in the gateway&#39;s first persistent storage device and sends it to the gateway, the gateway also applies its generated search criteria to the site and/or backchannel voice recorded in the gateway&#39;s first persistent storage device and sends such previously stored backchannel audio, site audio, video, and streaming vital signs in a configurable time window surrounding the time stamp of the first match back to the dashboard, and the dashboard receives the said backchannel audio, site audio, video, and streaming vital signs from its configurable time window from the gateway and renders it on its fourth display. 
         [0114]    The telemedicine method of any of the paragraphs [0112] to [0113], wherein the dashboard also requests the first, last, next, or previous such search&#39;s match, and the gateway also sends either the first, last, next, or previous such search&#39;s match, as requested, back to the dashboard. 
         [0115]    The telemedicine method of any of the paragraphs [0071] to [0114], wherein the aggregator also captures a textual or voice search request for a procedural guidance and sends it to the gateway, the gateway also responds to such a request by generating a search specification based on an algorithm including, but not limited to, voice recognition, text to speech, neural networks, fuzzy logic, artificial intelligence, Boolean, binary tree, etc., searching based on the generated search specification and its associated algorithm, locating and retrieving a previously stored procedural guidance including, but not limited to, text, hypertext, annotated text, structured text, images, audio, video, or any combination thereof, and sending the first match of such previously stored procedural guidance to the requesting aggregator, and the aggregator also renders the received procedural guidance in its appropriate representation, whether text, images, audio, video, or any combination thereof, either as standalone or as an overlay. 
         [0116]    The telemedicine method of paragraph [0115] 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. 
         [0117]    The telemedicine method of any of the paragraphs [0115] to [0116], wherein the aggregator also requests the first, last, next, or previous such search&#39;s match, and the gateway also locates and sends to the aggregator either the first, last, next, or previous such search&#39;s match, as requested. 
         [0118]    The telemedicine method of any of the paragraphs [0115] to [0117], wherein the gateway also displays the said procedural guidance data received from the gateway on a portable augmented reality display including, but not limited to, headset, goggle, retinal scanning device, smart glass eyewear such as Google Glass, Microsoft HoloLens, Sony SmartGlass, etc. 
         [0119]    The telemedicine method of any of the paragraphs [0071] to [0118], 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, but not limited to, heart beats, respiratory cycles, preprogrammed biological parameter limits such as temperature, EtCO2, SPO2, invasive blood pressure being reached, etc., and when patient monitor-generated alarm or alert conditions are being detected as part of the streaming vital signs being displayed. 
         [0120]    The telemedicine method of any of the paragraphs [0071] to [0119], 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, but not limited to, heart beats, respiratory cycles, preprogrammed biological parameter limits such as temperature, EtCO2, SPO2, invasive blood pressure being reached, etc., and when patient monitor-generated alarm or alert conditions are being detected as part of the streaming vital signs being displayed. 
         [0121]    The telemedicine method of any of the paragraphs [0119] to [0120] wherein the haptic feedback pattern is programmed to be unique for each group or individual type of biological conditions, alarms, or alert triggers. 
         [0122]    The telemedicine method of any of the paragraphs [0071] to [0121] wherein the dashboard also captures streaming video from a built-in video sensor and transmits it as backchannel video alongside backchannel audio to a gateway; the gateway also receives backchannel video alongside backchannel audio from a dashboard, then transmits the received backchannel video alongside backchannel audio to an aggregator and simultaneously to all other dashboards connected to the same active session; the dashboard also receives backchannel video originating from all the other dashboards connected to the same active session and renders the backchannel video originating from all the other session dashboards in independent sections on its fourth display, each identifying its originating dashboard user; the aggregator also receives backchannel video from a gateway and renders the backchannel video originating from all session dashboards in independent sections on its second display, each identifying its originating dashboard user. 
         [0123]    The telemedicine method of paragraph [0122] 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. 
         [0124]    The telemedicine method of any of the paragraphs [0102] to [0123] wherein the dashboard also captures GPS location from a built-in GPS sensor and transmits it as GPS alongside backchannel audio to a gateway; the gateway also receives GPS location alongside backchannel audio from a dashboard, then simultaneously transmits it alongside backchannel audio to all other dashboards connected to the same active session; the dashboard also receives GPS location originating from all the other dashboards connected to the same active session and displays on its geolocation map the GPS location of all the other session dashboards as independent icons, each identifying its originating dashboard user. 
         [0125]    The telemedicine method of the paragraph [0124] wherein the gateway also transmits GPS location data received from a dashboard alongside backchannel audio to an aggregator; the aggregator also receives GPS location data from a gateway and displays the GPS location of all session as independent icons, each identifying its originating dashboard user, on its second display. 
         [0126]    The telemedicine method of any of the paragraphs [0102] to [0125] 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. 
         [0127]    The telemedicine method of any of the paragraphs [41] to [0126] 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. 
         [0128]    The telemedicine method of any of the paragraphs [41] to [0127] wherein the patient monitor and the aggregator are the same. 
         [0129]    While multiple embodiments are discussed, still other embodiments of the present invention will become apparent to those skilled in the art from the following detailed description, which shows and describes illustrative embodiments of the invention, Accordingly, the drawings and detailed description are to be regarded as illustrative in nature and not restrictive. 
     
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
         [0130]      FIG. 1  illustrates a vital-signs enhanced distributed telemedicine system, whereby, according to some embodiments of the present invention, the streaming vital signs and the site audio and video are transmitted from the aggregators to separate gateways over two separate communication systems, and backchannel audio, video, and GPS data are received by the aggregators from separate gateways over a third communication system. 
           [0131]      FIG. 2  illustrates a vital-signs enhanced distributed telemedicine system, whereby, according to some embodiments of the present invention, the streaming vital signs and the site audio and video are transmitted from the aggregators to the same gateways over the same communication system, and backchannel audio, video, and GPS data are received by the aggregators from the same gateways over the same communication system as well. 
           [0132]      FIG. 3  illustrates a vital-signs enhanced distributed telemedicine system, whereby, according to some embodiments of the present invention, the streaming vital signs and the site audio and video are transmitted from the aggregators to the gateways over the same communication system, the backchannel audio, video, and GPS are received by the aggregators from the gateways over the same communication system, and one dashboard connects, alternatively, with two concurrent remote assistance sessions originating from two separate gateways. 
           [0133]      FIG. 4  illustrates a vital-signs enhanced distributed telemedicine system, whereby, according to some embodiments of the present invention, the streaming vital signs and the site audio and video are transmitted from the aggregators to the gateways over the same communication system, the backchannel audio, video, and GPS are received by the aggregators from the gateways over the same communication system as well, and two dashboards participate concurrently in the same remote assistance session originating from the same gateway. 
           [0134]      FIG. 5  illustrates a vital-signs enhanced distributed telemedicine system whereby the main internal blocks of a patient monitor, aggregator, gateway, dashboard, and their internal and external connections are identified. 
           [0135]      FIG. 6  illustrates a computer system that can constitute the platform for a patient monitor, aggregator, and/or dashboard, according to the embodiments of the present invention. 
           [0136]      FIG. 7  illustrates a server cluster system that can constitute the platform for a gateway, according to the embodiments of the present invention. 
           [0137]      FIG. 8  illustrates communication and timing between a patient monitor, aggregator, gateway, and dashboard, according to the embodiments of the present invention. 
           [0138]      FIG. 9  illustrates a typical assistance request and escalation logic and workflow for a gateway, according to the embodiments of the present invention. 
           [0139]      FIG. 10  illustrates typical assistance request logic and workflows for a primary dashboard and a secondary dashboard within the same session, according to the embodiments of the present invention. 
       
    
    
       [0140]    While the invention is amenable to various modifications and alternative forms, specific embodiments have been shown as examples by the way of the drawings and are described in detail below. The invention is, however, intended to cover all modifications, equivalents, and alternatives falling within the scope of the invention as defined by the appended claims, and thus not limited to neither the particular embodiments nor the particular examples discussed herein. 
       DETAILED DESCRIPTION 
       [0141]      FIG. 1  illustrates a vital-signs enhanced distributed telemedicine system  100 , including a patient monitoring device  10 , configured for physical attachment to patient  5 , communicating with an aggregator  20 , which is communicating with a first gateway  50 , a second gateway  50 ′, and a third gateway  50 ″, which are further communicating to a dashboard  70 , according to embodiments of the present invention. The monitoring device  10  may include a display screen  11  configured to display vital signs information about the patient  5 , according to embodiments of the present invention. The aggregator  20  may include a display screen  21  configured to display vital signs information received in its monitoring pane  31 , video from its video sensing device in its video pane  32 , and render backchannel audio received from a gateway through its audio reproducing device  22 , according to embodiments of the present invention. The gateways  50 ,  50 ′, and  50 ″ may include a display screen  51 ,  51 ′, and  51 ″ respectively, configured to display status and configuration information, according to embodiments of the present invention. The dashboard  70  may include a display screen  71  configured to display vital signs information received in its monitoring pane  81 , video received in its video pane  82 , and render audio received from a gateway through its audio reproducing device  72 , according to embodiments of the present invention. 
         [0142]      FIG. 2  illustrates a vital-signs enhanced distributed telemedicine system  100 ′, including two patient monitoring devices  10  and  10 ′, configured for physical attachment to patients  5  and  5 ′, respectively, communicating with an aggregator  20 , which is communicating with a gateway  50 , which is further communicating to a dashboard  70 , according to embodiments of the present invention. The monitoring devices  10  and  10 ′ may include a display screen  11  and  11 ′, respectively, configured to display vital signs information about the patients  5  and  5 ′, respectively, according to embodiments of the present invention. The aggregator  20  may include a display screen  21  configured to display vital signs information received in its monitoring pane  31 , video from its video sensing device in its video pane  32 , and render backchannel audio received from a gateway through its audio reproducing device  22 , according to embodiments of the present invention. The gateway  50  may include a display screen  51  configured to display status and configuration information, according to embodiments of the present invention. The dashboard  70  may include a display screen  71  configured to display vital signs information received in its monitoring pane  81 , video received in its video pane  82 , and render audio received from a gateway through its audio reproducing device  72 , according to embodiments of the present invention. 
         [0143]      FIG. 3  illustrates a vital-signs enhanced distributed telemedicine system  100 ″, including two patient monitoring devices  10  and  10 ′, configured for physical attachment to patients  5  and  5 ′, respectively, communicating with two aggregators  20  and  20 ′, respectively, which are communicating with a gateway  50 , which is further communicating to a dashboard  70 , according to embodiments of the present invention. The monitoring devices  10  and  10 ′ may include a display screen  11  and  11 ′, respectively, configured to display vital signs information about the patients  5  and  5 ′, respectively, according to embodiments of the present invention. The aggregators  20  and  20 ′ may include a display screen  21  and  21 ′, respectively, configured to display vital signs information received in its monitoring pane  31  and  31 ′, respectively, video from its video sensing device in its video pane  32  and  32 ′, respectively, and render backchannel audio received from a gateway through its audio reproducing device  22  and  22 ′, respectively, according to embodiments of the present invention. The gateway  50  may include a display screen  51  configured to display status and configuration information, according to embodiments of the present invention. The dashboard  70  may include a display screen  71  configured to display vital signs information received in its monitoring pane  81 , video received in its video pane  82 , and render audio received from a gateway through its audio reproducing device  72 , according to embodiments of the present invention. 
         [0144]      FIG. 4  illustrates a vital-signs enhanced distributed telemedicine system  100 ′″, including a patient monitoring device  10 , configured for physical attachment to patient  5 , communicating with an aggregator  20 , which is communicating with a gateway  50 , which is further communicating to dashboards  70  and  70 ′, according to embodiments of the present invention. The monitoring device  10  may include a display screen  11  configured to display vital signs information about the patient  5 , according to embodiments of the present invention. The aggregator  20  may include a display screen  21  configured to display vital signs information received in its monitoring pane  31 , video from its video sensing device in its video pane  32 , and render backchannel audio received from a gateway through its audio reproducing device  22 , according to embodiments of the present invention. The gateway  50  may include a display screen  51  configured to display status and configuration information, according to embodiments of the present invention. The dashboards  70  and  70 ′ may include a display screen  71  and  71 ′, respectively, configured to display vital signs information received in its monitoring pane  81  and  81 ′, respectively, video received in its video pane  82  and  82 ′, respectively, and render audio received from a gateway through its audio reproducing device  72  and  72 ′, respectively, according to embodiments of the present invention. 
         [0145]      FIG. 5  illustrates a patient monitoring device  10 , an aggregator  20 , a gateway  50 , and a dashboard  70 , according to embodiments of the present invention. Patient monitoring device  10  may include one or more bio sensors  120  configured for physical attachment to a patient, a processor  100  configured to receive information from one or more sensors  120  and to generate streaming vital signs based on the information, a web service  110 , a wired communication system  160 , a wireless communication system  180 , a non-volatile storage device  140 , and a display  11  configured to display at least a portion of the patient&#39;s vital signs, according to embodiments of the present invention. Aggregator  20  may include a processor  200  configured to receive audio-video information from a built-in webcam  270 , a monitor-facing web client  250 , a gateway-facing web client  252 , a wired communication system  260 , a wireless communication system  280 , a non-volatile storage device  240  for storing catch-up, a display  21  configured to display at least a portion of the patient&#39;s vital signs and the video from the Webcam  270 , and a speaker  290  configured to render backchannel audio received from the gateway  50 , according to embodiments of the present invention. Gateway  50  may include a processor  500  configured to maintain session information across a plurality of aggregators  20  and dashboards  70 , an aggregator-facing web service  510 , a dashboard-facing web server  512 , a wired communication system  560 , a wireless communication system  580 , a non-volatile storage device  540  for persistent storage of all sessions&#39; audio, video, and vital signs, and a display  51  configured to display session status and configuration information, according to embodiments of the present invention. Dashboard  70  may include a processor  700  configured to receive audio-video information from a built-in webcam  770 , a web browser  754 , a wired communication system  760 , a wireless communication system  780 , a non-volatile storage device  740 , a display  71  configured to display at least a portion of the patient&#39;s vital signs and the video received from the gateway  50 , and a speaker  790  configured to render audio received from the gateway  50 , according to embodiments of the present invention. 
         [0146]      FIG. 6  is an example of a computer system  800  with which embodiments of the present invention may be utilized. For example, patient monitors  10 , aggregators  20 , gateways  50 , and dashboards  70  may be or incorporate a computer system  800 , according to embodiments of the present invention. According to the present example, the computer system includes a bus  801 , at least one processor  802 , at least one communication port or coprocessor  806 , a main volatile memory  804  for code execution and transient storage, a read-only memory  803  for initial boot and/or program storage, at least one non-volatile storage device  801  for persistent storage of programs, session audio, video, streaming vital signs, and GPS, instructional, analysis input, etc., an audio-video capture port or coprocessor  808 , and an audio playback port or coprocessor  807 , according to embodiments of the present invention. 
         [0147]      FIG. 7  is an example of a server cluster system  900  that can constitute the platform for a gateway, according to some of the embodiments of the present invention. According to the present example, the server cluster  900  may contain an input firewall appliance  901 , a load balancer bus  910 , at least two front-end servers  920  and  920 ′, an application bus  911 , at least four application servers  930 ,  930 ′,  930 ″ and  930 ′″, a storage bus  912 , and at least two storage servers  940  and  940 ′, whereby the firewall appliance  901  and each of the servers  920 ,  930 , and  940  can have a configuration similar to the computer system  800  or an enhanced alternative thereof. 
         [0148]      FIG. 8  illustrates communication and timing between a patient monitor  102 , aggregator  202 , gateway  502 , and dashboard  702 , according to the embodiments of the present invention. For example, the aggregator may send a connection request  42  (which may also include a request for clinical assistance element) to the gateway  502  which establishes a session between the aggregator and the gateway, then send a connection request  32  to the patient monitor  102  which establishes a local session between the aggregator  202  and the patient monitor  102 . The sequencing of the connection requests  42  and  32  can also be reversed, and someone skilled in the art would easily recognize. Once the local session between the patient monitor  102  and the aggregator  202  is established, the patient monitor  102  starts sending to the aggregator  202  packets  33 ,  34 ,  35 , etc. consisting of vital signs information, alarms, and alerts, at regular time intervals, for example 240 milliseconds in duration, according to embodiments of the present invention. The interval between these packets can be programmed to any value from 40 to 960 milliseconds, according to embodiments of the present invention. Upon receipt of packets  33 ,  34 , and  35  from the patient monitoring device  102 , the aggregator  202  passes then on further to the gateway  502  as packets  43 ,  44 , and  45 , respectively. If a session between the gateway  502  and the dashboard  702  is not in place yet, like for example in the case of packet  43 , the gateway  502  will store these packets internally. When the dashboard  702  sends a connection request  62  to the gateway  502  which connects the dashboard  702  to a previously established session between the same gateway  502  and the requesting aggregator  202 , the aggregator  202  starts relaying any pending packets received from the patient monitor  102  to the gateway  502 , but only if the pending packets are not overwritten by newer such packets received from the patient monitor  102 , in order to avoid the transmission of “stale” audio, video, and vital signs. Upon receipt of such packets  43 ,  44 , and  45  from the aggregator  202 , the gateway  502  relays them further to the dashboard  702  as packets  63 ,  64 , and  65 , respectively. To keep the timing diagram simple, and also because this would be very easy for someone skilled in the art to envision, the catch-up transmission of “stale” data packets interleaved with the transmission of “live” data packets from the aggregator  202  to the gateway  502  is not depicted here. 
         [0149]      FIG. 9  illustrates a typical assistance request and escalation logic and workflow for a gateway, according to the embodiments of the present invention. 
         [0150]      FIG. 10  illustrates typical assistance request logic and workflows for a primary dashboard user and a secondary dashboard user within the same session, according to the embodiments of the present invention. 
         [0151]    Various modifications and additions can be made to the exemplary embodiments discussed without departing from the scope of the present invention. For example, while the embodiments described above refer to the particular features, the scope of this invention also includes embodiments having different combinations of features and embodiments that do not include all of the described features. The scope of the present invention is therefore intended to embrace all such modifications, alternatives, and variations that fall within the scope of the claims, together with all the equivalents thereof.