How A Former iPod Chief Built The World’s Most Advanced First-Aid Kit

By Mark Sullivan April 07, 2017

The Gale high-tech first-aid kit was born on a terrifying night in Mexico.

Its creator, Ram Fish, who once led the iPod group at Apple, was on vacation with his wife and three young daughters in a small town in Baja called Los Barriles. At 10 p.m. one night, one of his daughters, Tali, started having trouble breathing while she slept.

As she struggled to get her breath, her parents become more and more frightened. “We were saying ‘What do we do? Is there a local clinic? How do we diagnose it?” Fish remembers. Little villages in Baja are great for getting away from it all—but if someone gets sick, then health care is far away, too. Fish and his wife soon learned there was no clinic nearby.

“So we called Kaiser, and luckily there was somebody running it who spoke English,” Fish says. The nurse at Kaiser was able to provide some help identifying the cause of the young girl’s breathing problem. She was having a chronic obstructive pulmonary disease (COPD) episode, probably due to an infection. Most of the time, COPD episodes sound more dangerous than they really are, Fish told me. His daughter was wheezing loudly that night, but she was still getting enough oxygen.

“Everything ended up being fine, but it was a horrible night, looking at only the most primitive diagnostic tools,” he says. “You usually just leave them sleeping, but if it gets serious you need to give them steroids, and if that doesn’t work you need to intubate.” If the COPD attack had been more serious that night in Baja, Tali could have been in real trouble.

That got Fish thinking. “Everybody is focusing on doing things in the cloud, but the place where you really control the experience is the endpoint,” he says. He began to think that focusing on tools that people could keep on hand—especially for those who live far from a clinic—could improve patient outcomes. And it might make for a solid business, too.

A Clinic to Go

Fifteen months of hard work later, Fish had a startup called 19Labs, and a new product called the Gale “clinic-in-a-box.” (The name of the product derives from Florence Nightingale, the founder of modern nursing.)

Gale is a breadbox-size chest containing diagnostic tools in the bottom drawer and medications and supplies in the top drawer. On the top is a pop-up touch screen that displays various interactive treatment guides. The guides can walk a user through the process of assessing all kinds of health problems from snake bites to ankle sprains to heart trouble. “If you are a parent, or a secretary in a school, or have a senior,” Fish says, “without any health care education you can make an assessment.”

On the touch screen, a user first chooses from broad categories like “Stings and Bites” and “Concussions in Children.” The guides then help the user narrow down to a specific problem through a series of questions and answers. The text and images in the guides were developed by researchers at Stanford and licensed by 19Labs. A voice agent is always reachable to help users with questions about the treatment guides.

The touch screen is also used for placing video calls to physicians and other caregivers, including doctors from telehealth provider Amwell. The large button on the front of the Gale box can be preprogrammed to place a telemedicine call with a finger press. Alternatively, it can be set to immediately dial 911 or a health call center.

After using the guides, a user can call on a series of diagnostic, sensor-based instruments to get at the objective facts of the problem. The drawer on the bottom front of the Gale box holds some of the most important ones, including electrocardiogram patches, an AliveCor EKG and stroke detector, a blood sample tool, a digital thermometer, a fingertip oximeter (for measuring pulse), an otoscope (inner ear exams), and a spirometer (measures lung ventilation), among others.

“The amount of stuff that’s coming up in sensor technology is just amazing,” Fish says. Gale may one day integrate data from other, less clinical, sensors like sleep monitors or health and fitness wearables, Fish says.

When a Gale user calls into a call center or telehealth service, the data collected by the sensors can be transmitted to a caregiver. Fish is careful to point out that Gale doesn’t try to replace the human caregivers. Rather, the device seeks to assist in the assessment of a problem then help get the patient connected with the right health professionals when needed.

Gale incorporates a 4G cellular radio to stay connected from remote places, and sports a large battery to ensure that it’ll have power when medical help is needed. “You can imagine one in every school, every workplace, every office,” Fish says. “In the beginning it will be public places, and in a couple of years I think we’ll see more and more things like this at home.”

Fish isn’t ready to talk about how much Gale will cost yet, but says that the idea is to drive the price tag down by leveraging consumer electronics-like economies of scale and making money from ongoing services rather than just selling boxes. 19Labs, which now has 12 employees, hopes to finish pilot programs in South Dakota and Canada this year, then begin to make Gale more widely available to clinics. It plans to sell the Gale hardware for an initial cost that will include basic medical supplies and sensor instruments. A monthly fee will cover the device’s cellular connectivity and access to a cloud-based device management and health content platform.

Soaking Up SRI’s Mojo

19Labs is housed in a small office in a long, thin, two-story building located on the campus of SRI International in Menlo Park, California. SRI, originally known as the Stanford Research Institute, is the place where the very first internet packet was sent back in 1969. Hundreds of tech inventions have been created there over the years, such as the AI assistant that became Apple’s Siri. Numerous small tech companies, and a few high-profile venture capital firms have gathered themselves around the campus, as if to soak up some of that historic mojo.

When I walk in Fish is on a video conference call with a couple of his engineers, his medical director (and former astronaut) Dr. Scott Parazynski, and a developer from one of the country’s largest research hospitals. The hospital has developed a technology that could be integrated into Gale. Fish is rapidly and loudly throwing questions at the developer about everything from core technologies to business model to integration specifics to marketing tactics. The developer is keeping up pretty well.

The more you see the product, the more you can see the technology, design, and product marketing lessons Fish has brought not only from Apple but also another former employer, Samsung, where he worked on the Simband health wearable.

“From every company I worked at I took a few great ideas,” Fish says. He absorbed Apple’s obsession with quality and its desire to “surprise and delight” customers. At Samsung, he learned from the company’s culture of very hard work at high speed to deliver products before anybody else.

“The secret as a leader is to then apply these themes selectively, and balance the inherent conflict between those great ideas,” he says. “Companies tend to get religious—dogmatic around specific ideas—and at Apple, quality became one such dogmatic idea. Quality is critical, but perfection exists only in our dreams. Reality is never perfect. So aspire, but don’t get dogmatic about it, and know when to compromise.”

Part of a System

A common theme you’ll hear repeated by venture capitalists these days is the idea that products should be vertically integrated, providing as many layers of a given service as possible. VCs like companies that own hardware, software, and services. For instance, Apple controls the iPhone hardware, the operating system and many major apps, and services such as the App Store, iCloud, and Apple Music.

But that holistic approach can be difficult for startups, because it requires multiple internal groups focused on very different technologies, yet all working closely together on an integrated experience. Fish favors a different approach. “It’s smarter to play to your own strengths than to try to do something vertically,” he says. “And that’s a mistake that a lot of VCs in the Valley make when they tell startups ‘don’t give a damn, go transform the industry, take out the existing player, do everything from A to Z,’ rather than saying ‘No, build the things that you’re good at and then empower others.’”

Fish’s philosophy is to build a tech platform that can then pull in the best-in-class sensor products from companies like AliveCor. Rather than creating the medical supplies or sensor devices that come with Gale, 19Labs makes Gale into a platform for selling those products. If the Gale box finds its way into many clinics, schools, or homes, it could become a valuable distribution channel for partner companies.

Fish promoted this idea when he worked at Samsung, too. Samsung brought Fish in to lead the creation of the Simband. But rather than selling a one-size-fits all device including a few sensors that would fit the needs of most people, Fish (with Samsung executive Young Sohn) decided to make the Simband a prototype on which developers could create custom wearable devices with a specific set of sensors.

Since 19Labs hopes to sell Gale to health care providers—not consumers—this approach makes sense. Some health organizations may require specific or more specialized devices. A big part of 19Labs’ job is to make sure the hardware, software, and sensors all work together, and integrate with health providers’ systems.

While 19Labs is starting out by selling Gale to health clinics in far-flung places, Fish believes health care providers might eventually decide to buy the “clinic in a box” for homes, schools, and community centers.

By doing so, a provider might save money in the end, because patients would be able to utilize health services at the right times. “For the health care company, if they bring somebody too late to the hospital it can cost tens of thousands of dollars,” Fish says. “And if they keep them in the hospital it’s thousands of dollars a day more.”

Gale could help health care companies assess and deal with a problem before it becomes severe, and more difficult and costly to treat. It could also save money by enabling earlier hospital releases. “A mother might be able to bring her baby home sooner, if the family has the technology to monitor it,” Fish says.

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