MILITARY MEDICINE, 181, 5:199, 2016

Evaluation of Miniature Wireless Vital Signs Monitor in a Trauma

Intensive Care Unit
Jonathan P. Meizoso, MD; Casey J. Allen, MD; Juliet J. Ray, MD; Robert M. Van Haren, MD, MSPH;
Laura F. Teisch, BS; Xiomara Ruiz Baez, MD; Alan S. Livingstone, MD; Nicholas Namias, MD, MBA;
Carl I. Schulman, MD, PhD, MSPH; Kenneth G. Proctor, PhD

ABSTRACT A previous study demonstrated basic proof of principle of the value of a miniature wireless vital signs
monitor (MWVSM, MiniMedic, Athena GTX, Des Moines, Iowa) for battlefield triage However, there were unanswered

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questions related to sensor reliability and uncontrolled conditions in the prehospital environment. This study deter-
mined whether MWVSM sensors track vital signs and allow for appropriate triage compared to a gold standard bed-
side monitor in trauma patients. This was a prospective study in 59 trauma intensive care unit patients. Systolic blood
pressure, temperature, heart rate (HR), skin temperature, and pulse oximetry (SpO2) were displayed on a bedside
monitor for 60 minutes. Shock index (SI) was calculated. A separate MWVSM monitor was attached to the fore-
head and finger of each patient. Data from each included pulse wave transit time (PWTT), temperature, HR, SpO2,
and a summary status termed “Murphy Factor” (MF), which ranges from 0 to 5. Patients are classified as “routine”
if MF = 0 to 1 or SI = 0 to 0.7, “priority” if MF = 2 to 3 or SI = 0.7 to 0.9, and “critical” if MF = 4 to 5 or SI ≥ 0.9.
Forehead and finger MWVSM HRs both differed from the monitor (both p < 0.001), but the few beats per minute
differences were clinically insignificant. Differences in MWVSM SpO2 (1–7%) and temperature (6–13°F) from the
monitor were site specific (all p < 0.001). Forehead PWTT (271 ± 50 ms) was less ( p < 0.001) than finger PWTT
(315 ± 42 ms); both were dissociated from systolic blood pressure (r2 < 0.05). The SI distributed patients about
equally as “routine,” “priority,” and “critical,” whereas MF overtriaged to “routine” and undertriaged to “critical”
for both sensors (all p < 0.001). Our findings suggest that MF does not accurately predict the most critical patients,
likely because erroneous PWTT values confound MF calculations. MF and the MWVSM are promising, but require fine-
tuning before deployment.

INTRODUCTION multiple casualties on the battlefield or in other austere con-

The vast majority of military trauma deaths occur prehospital
and a significant proportion of in-hospital mortality occurs in
patients with no vital signs in the field.1–3 Thus, large oppor-
tunities exist for reducing trauma mortality through innovation
in the prehospital setting.4,5
The United States Special Operations Command (SOCOM)
and the Department of Defense designed and funded the
development of a miniature wireless vital signs monitor
(MWVSM) (MiniMedic, Athena GTX, Des Moines, Iowa)
based on the success of its original wireless vital signs
monitor.6 The new system has reduced weight and size and
addressed an unmet need to acquire vital physiologic infor-
mation from small surface sensors placed on up to 5 casual-
ties simultaneously and then to wirelessly transmit this data
to miniature monitors carried by any first responder within a
100-m range. This would allow for appropriate monitoring,
triage, prioritization of transport, and tracking of changes in
Divisions of Trauma Surgical Critical Care and Burns, DeWitt Daughtry
Family Department of Surgery, Ryder Trauma Center, University of Miami
Miller School of Medicine, 1800 NW 10th Avenue, Suite T-215 (D-40),
Miami, FL 33136.
Presented at the Florida Committee on Trauma Meeting, Florida Chapter
of the American College of Surgeons, Jacksonville, FL, October 17, 2014
and at the Region IV Committee on Trauma Meeting, American College of
Surgeons, Orlando, FL, November 14, 2014.
doi: 10.7205/MILMED-D-15-00162
ditions. This particular system contains two novel features.
First, it incorporates an injury acuity algorithm termed the
Murphy Factor (MF), which summarizes overall patient
status, and is calculated from available vital signs (whether
measured by the sensor, input by the first responder, or calcu-
lated by the device); additionally, it factors in the changes
in these vital signs over the last 30 seconds. MF includes an
adjustment to overcome data drops that are common during
triage in chaotic environments. Second, the system is based
on pulse wave transit time (PWTT) rather than systolic blood
pressure (SBP). Various methods of PWTT measurement
correlate well with SBP.7
A previous study suggested that a single numeric MF
from a peripheral MWVSM could predict the need for life-
saving interventions during prehospital transport.8 Although
this prehospital study provided basic proof of concept, there
were multiple sources of variability including patient selec-
tion, injury severity, sensor placement, transport time, and
missing or intermittent data.
The present study was conducted in the controlled set-
ting of a trauma intensive care unit (TICU) for a fixed period
of time with a bedside monitor used as the gold standard
for paired comparison of vital signs. Furthermore, the shock
index (SI) was used a standard to compare the MF as both
methods provide a single number to assess overall patient
status. The SI, which is calculated by dividing the heart

MILITARY MEDICINE, Vol. 181, May Supplement 2016 199

 Evaluation of MWVSM in a Trauma ICU
rate (HR) by the SBP, has previously been shown to cor-
relate with markers of cellular hypoxia and shock, such
as lactate and central venous oxygenation.9–11 It is also
an indicator of patients requiring transfusion and a pre-
dictor of mortality.12 We test the hypothesis that changes
in multiple parameters obtained from the MWVSM corre-
late favorably with conventional vital signs and SI in critically
ill trauma patients.
MATERIALS AND METHODS
Study Protocol and Patient Selection
This study was conducted at the Ryder Trauma Center (Uni-
versity of Miami/Jackson Memorial Hospital) and approved
by the Institutional Review Board at Jackson Memorial Hos-
pital and the University of Miami Leonard M. Miller School
of Medicine, Miami, Florida. A prospective observational
trial was performed in a convenience sample of 59 TICU
patients from October 2013 to July 2014. Eligible patients
were adults (>17 years old) with an arterial catheter who were
admitted to the TICU. Patients meeting inclusion criteria were
enrolled from 8 a.m. to 5 p.m. on Mondays to Fridays during
the study period.
Data from each MWVSM were compared to data simulta-
neously obtained with a bedside vital signs monitor (GE Solar
8000M multichannel monitor, GE Healthcare, Milwaukee,
Wisconsin) in the TICU. This monitor collected the fol-
lowing standard vital signs: HR, SBP, core body temper-
ature as measured by Foley catheter, and pulse oximetry
(SpO2). The test system is composed of two components:
a patient sensor that is affixed to either the forehead or an
extremity and a handheld unit. The patient sensor weighs
3.8 oz and uses two AAA alkaline batteries. The handheld
monitor is 4.0 × 2.5 × 0.79 inches in size, weighs 4.2 oz,
and uses two AAA alkaline batteries. Communication between
MWVSM devices is achieved with Communication Zigbee
(802.15.4) Wireless Protocol with a range of 100-m line
of sight.
The patient sensor records physiologic variables (skin
temperature, SpO2, HR, and PWTT) every second and trans-
mits every 5 seconds to the monitor. Other information is
manually input with the handheld unit, including Glasgow
Coma Score, medications, and fluids. In addition to record-
ing and storing continuous data, the sensor computes MF,
which is a proprietary algorithm that incorporates changes
in the last 30 seconds to derive a summary status alarm that
reflects injury acuity (0–5 scale). The MF requires data
from a minimum of two sources. The MF signal quality
is theoretically more reliable with more available data. All
information is wirelessly transmitted up to 100 m to a
handheld monitor, which the medic can use to monitor
up to five patients simultaneously. The software revision
was 0.0.xx2.
Data from both the MWVSM and the conventional vital
signs monitor were recorded every 5 minutes. Paired com-
200
parisons were made between the MWVSM and conven-
tional monitor measurements for HR, SpO2, and temperature.
Correlations were made between PWTT measured by the
MWVSM and SBP measured by the conventional monitor.
SI was calculated using the conventional bedside HR
and SBP. To compare the two indices, MF was classi-
fied using manufacturer specifications, where “routine” is
MF = 0 to 1, “priority” is MF = 2 to 3, and “critical” is
MF = 4 to 5. Normal SI ranges from 0.5 to 0.7 and was
classified as “routine” if SI = 0 to 0.7, “priority” if SI =
0.7 to 0.9, and “critical” if SI ≥0.9. The study team deter-
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mined values for SI a priori. Prior investigators have found
that SI >0.9 is associated with injuries requiring immediate
attention,10 while others have used a similar breakdown to
the present study.12
Statistical Analyses
Data were analyzed using SPSS version 22.0 (IBM Corpora-
tion, Armonk, New York). Data are reported as mean ± SD
if normally distributed or as median (interquartile range) if
not normally distributed. Independent data were compared
with paired Student’s t test. Categorical data were compared
using χ2 test or Fisher’s exact test as appropriate. Significance
was assessed at p < 0.05.
RESULTS
The study population was comprised of 59 TICU patients,
aged 47 ± 20 years with a male preponderance (80%).
Mechanism of injury was blunt in 60% and penetrating in
27%; nontraumatic cases made up 13%. These basic demo-
graphics are similar to our usual TICU population.
Actual SBP was 129 ± 20 mm Hg. Corresponding PWTT
with the MWVSM averaged 314 ± 2 ms with the finger
sensor and 271 ± 2 ms with the forehead sensor. Forehead
PWTT (271 ± 50 ms) was significantly less ( p < 0.0001)
than peripheral PWTT (315 ± 42 ms), but this is logical
as it takes longer for the pulse wave to transmit to the
periphery. However, peripheral and forehead PWTT were
dissociated from SBP. For SBP vs. peripheral PWTT the
correlation, although weak, was statistically significant
(r2 = 0.0385, p < 0.001). There was no significant correla-
tion between SBP and forehead PWTT (r2 = 0.0007, p =
0.513) (Fig. 1).
Actual core temperature was 100 (3.2) °F. Correspond-
ing skin temperature with the MWVSM finger sensor was
86.8 ± 8.4°F and with the forehead sensor was 93.1 ±
4.7°F. Clearly these measures were dependent on sensor
location. Paired temperature differences between core tem-
perature and skin temperature (with both finger and fore-
head sensors) were statistically significant ( p < 0.001).
Furthermore, the paired differences between forehead
and finger sensors (6–13°F) were statistically significant
( p < 0.001).
MILITARY MEDICINE, Vol. 181, May Supplement 2016
 Evaluation of MWVSM in a Trauma ICU
FIGURE 1. (A) Peripheral sensor pulse wave transit time (PWTT) (ms) vs.
systolic blood pressure (SBP) (mm Hg). Pearson correlation = −0.1961;
r2 = 0.038; n = 604; p < 0.001. (B) Forehead sensor PWTT (ms) vs.
SBP (mm Hg). Pearson correlation = 0.0259; r2 = 0.00067; n = 640;
p = not significant.
Actual HR was 102 ± 18 beats per minute (bpm), compared
to 105 ± 22 bpm with the finger sensor and 104 ± 21 bpm
with the forehead sensor. Although the differences between
conventional and MWVSM HR were statistically significant
( p < 0.001), a difference of only 2 bpm cannot be considered
clinically significant. Measurements between the forehead and
finger sensors were similar ( p = 0.35).
Finally, median SpO2 was 100 (2)%. This was compared
to 100 (3)% with the finger sensor and 93 ± 8.3% with the
MILITARY MEDICINE, Vol. 181, May Supplement 2016
forehead sensor. Similar to HR, conventional and MWVSM
measurements were statistically ( p < 0.001) different, but
clinically insignificant. Paired differences between the fin-
ger and forehead sensors were also significantly different
( p < 0.001).
Table I shows the differences between HR, SpO2, and
temperature using the bedside monitor and the MWVSM.
Figure 2 compares MF and SI in all three severity cate-
gories and demonstrates inappropriate triage by both fore-
head and peripheral sensors. According to the SI, the patients
were distributed about equally in the “routine,” “priority,”
and “critical” categories; however, MF significantly overtriaged
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patients to the “routine” category and undertriaged patients
to the “critical” category in both sensors (all p < 0.001).
DISCUSSION
The present study is the second from our group that eval-
uates the MWVSM for potential trauma triage. The major
new findings are that peripheral and forehead PWTT were
dissociated from SBP and that relative to SI, MF signifi-
cantly overtriaged patients to the “routine” category and
undertriaged patients to the “critical” category for either
the forehead or peripheral sensor. These observations sup-
port the conclusion that MF does not accurately predict
the most critical patients likely because erroneous PWTT
values confound the MF calculation. The concept of MF and
the MWVSM is promising, but requires further fine-tuning
before deployment.
The military WVSMs before this miniature version were
smaller than conventional monitors, but still bulky and
difficult to transport for SOCOM.6 The MWVSM offers a
(theoretical) logistic advantage for continuous monitoring
of multiple casualties on the battlefield from remote loca-
tions. We demonstrated basic proof of concept that the MF
can summarize overall patient status in the prehospital set-
ting.8 This follow-up study aimed to critically evaluate the
MWVSM in the controlled setting of a TICU to demonstrate
whether data obtained from the MWVSM correlates with the
conventional vital signs monitor. Furthermore, we aimed to
correlate MF with SI, a previously validated measure that is
able to accurately predict early mortality and need for mas-
sive transfusion after blunt trauma.10,13,14
MWVSM HR is reasonably accurate. Although the values
are statistically significant, a 2 to 3 bpm difference is clini-
cally insignificant. Data from the peripheral MWVSM sensor,
but not the forehead sensor, agrees with conventional SpO2;
this can be expected secondary to different perfusion patterns
in the forehead and periphery. However, skin temperature
from either sensor differs from the actual core temperature. It
is unclear what, if any, additional vital information is provided
by measuring skin temperature from either site.
The most significant finding is that PWTT is poorly cor-
related with SBP regardless of sensor placement. We believe
that the inaccuracies in triaging patients using the MF are
secondary to this discrepancy in PWTT as the MF uses
201
 Evaluation of MWVSM in a Trauma ICU

TABLE I. Summary of Conventional and miniature wireless vital signs monitor (MWVSM) Vital Signs

Heart Rate (bpm) Skin Temperature, Pulse Oximetry SpO2 (%) Temperature (°F)
Bedside Monitor 102 ± 18 100 (2) 100 (3)
n = 757 n = 736 n = 624
Peripheral MWVSM Sensor 105 ± 22 100 (3) 87 ± 8
n = 721 n = 568 n = 728
Paired Difference Sensor vs. Monitor p < 0.001 p < 0.001 p < 0.001
Forehead MWVSM Sensor 104 ± 21 93 ± 8.3 93 ± 5
n =721 n = 612 n = 745
Paired Difference Sensor vs. Monitor p < 0.001 p < 0.001 p < 0.001
Paired Difference Sensor vs. Sensor p = 0.350 p < 0.001 p < 0.001

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FIGURE 2. (A) Percentage of patients with peripheral sensor Murphy
Factor (MF) vs. Shock Index (SI) in each acuity category. (B) Percentage of
patients with forehead sensor MF vs. SI in each acuity category.
PWTT in its summary status alarm algorithm. Unfortunately,
the algorithm for calculating the MF is proprietary and we
are unaware of the weight that PWTT carries in the calcula-
tion. MF derived from both sensors overtriaged patients to the
“routine” category and undertriaged patients to the “critical”
category; overall, MF inappropriately triaged approximately
50% of patients relative to SI.
The MWVSM was developed for use in chaotic military
mass casualty environments when triage and transport deci-
sions are difficult. MF is an overall summary status alarm
that would theoretically aid the combat medic to make life
and death decisions. The MWVSM will never replace a
well-trained medic, but it can provide useful information
under times of stress. Woodford et al15 have also previously
demonstrated the benefit of an automated continuous vital
signs analysis system with decision support capabilities in
prehospital care. Furthermore, a significant amount of work
regarding WVSM and machine learning has been done
by the U.S. Army Institute of Surgical Research. Liu and
Holcomb studied the WVSM, which is the predecessor to
the MWVSM, in 305 patients and found that the WVSM
improved accuracy in identifying patients requiring lifesav-
ing intervention.6 The same group has used automated sys-
tems incorporating nonstandard vital signs, including HR
variability (HRV) and HR complexity (HRC), and found
that these improve the prediction of mortality and lifesaving
interventions in trauma patients.16,17
Several other noninvasive strategies have been pro-
posed to triage trauma patients.6,15,16,18–21 King et al18 pro-
spectively analyzed 75 trauma patients requiring prehospital
helicopter transport and found that HRV predicted base
excess and the requirement of lifesaving interventions; HRV
more accurately identified critical patients than trauma center
criteria or prehospital vital signs. Indeed, the current “stan-
dard” vital signs measures used to identify patients in shock
have been questioned; Eastridge used the Joint Theater
Trauma Registry to study 7,180 military combat casualties
and found that SBP ≤ 100 mm Hg is a better indicator
of true hypotension and hypoperfusion in military trauma
than the traditional 90 mm Hg.22 Ryan et al19 found HRV
to be a predictor of morbidity and mortality in the hemo-
dynamically stable trauma patient. HRC also analyzes HR

202 MILITARY MEDICINE, Vol. 181, May Supplement 2016

 Evaluation of MWVSM in a Trauma ICU
time sequences and has been found by several groups to
correlate with the need for lifesaving interventions in the
prehospital setting.16,21 Continuous near-infrared spectroscopy
can predict the need for transfusion in patients deemed
hemodynamically stable with an SBP >90 mm Hg and may
prove to be an excellent adjunct to physiologic monitoring
in the future.20
Limitations to this study include the use of a conve-
nience sample, which is not randomized and thus subject
to bias. No interventions were performed based on results
from the MWVSM. Furthermore, we do not have data
regarding whether any of these patients required blood prod-
uct transfusion or other interventions. The MF depends on
the reliability of input signals and these are sometimes lost
when patients are in extremis; in this present study, some
data were lost even when patients were not in extremis.
If the overall purpose of the MWVSM is to identify those
patients who are in shock (i.e., cold, clammy, hypotensive,
and tachycardic) then the device needs further fine-tuning to
avoid data drops. Additionally, the MWVSM is designed to
collect continuous data however the data analyzed included
only snapshots at every 5 minutes compared to the con-
ventional monitor. Our previous study demonstrated that a
MF >3 in the prehospital setting was associated with the
need for lifesaving intervention upon arrival to the trauma
center. The current findings suggest that MF is not a reli-
able indicator of shock because it undertriages a propor-
tion of the most severely injured patients. Together, this
suggests that a significant number of patients could be mis-
classified by MF.
In summary, in a TICU population at an urban level I
trauma center, the MWVSM demonstrated poor correlation
between PWTT and SBP. We believe this was responsible
for the inaccurate triage using the MF when compared to the
previously validated SI. Improvements in measuring PWTT
are required to obtain more accurate MF values. The use of
noninvasive blood pressure rather than PWTT may provide
another option for improved identification of patients in
shock using the MWVSM. Newer modalities such as HRV,
HRC, and near-infrared spectroscopy will likely be benefi-
cial in future wireless vital signs devices for more accurate
and timely diagnosis and treatment of combat casualties.
Further work is required to validate the MWVSM for use by
SOCOM in the battlefield.
ACKNOWLEDGMENTS
This work was supported in part by the Office of Naval Research (Grant
No. N140610670) and the U.S. Army Medical Research & Materiel Com-
mand (Grant No. 09078015).
JPM was directly responsible for all aspects of this study. He partici-
pated in the collection, analysis, and interpretation of data, and drafting
and revision of the manuscript, figures, and tables. CJA, JJR, RMVH, LFT,
and XRB participated in the experimental design, collection of data, and
revision of the manuscript, figures, and tables. ASL, NN, and CIS were
medically responsible for the patients and participated in the review and
MILITARY MEDICINE, Vol. 181, May Supplement 2016
revision of the manuscript, figures, and tables. KGP had overall responsi-
bility for the study, including conception and experimental design; analy-
sis and interpretation of the data; drafting and revision of the manuscript,
figures, and tables; statistical expertise and evaluation; obtaining funding
for this project; and supervision.
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MILITARY MEDICINE, Vol. 181, May Supplement 2016