Dr Daniel Grace / Virtual Doctors Medical Director and Portfolio GP / Brecon, UK
Telemedicine is an expanding field and increasingly relied upon. Dr Grace explores its relevance to expedition medicine and its innovative uses in improving global health. He introduces ‘The Virtual Doctors‘, a telemedicine charity that supports rural health centres in Zambia and Malawi through connections with UK doctors and discusses medicolegal and ethical considerations for those considering utilising telemedicine technologies in their practice.
What is telemedicine?
Telemedicine is defined as “the remote diagnosis and treatment of patients by means of telecommunications technology1”. Telemedical interactions can occur between two clinicians, between a patient and a clinician or between a patient and their remotely monitored wearable health technology2.
Telemedicine emerged in the early 1960s, and mainly consisted of still image transfer with some early video conferencing. It was mostly limited to visual specialties like radiology and dermatology but has become ubiquitous as technology has progressed.
It was initially adopted by the military, private healthcare companies and offshore oil and gas industries to provide remote medical ‘top cover’. With the COVID-19 pandemic and concerns regarding infection control and isolation, interest in telemedicine increased exponentially. Remote consulting is now commonplace and has arguably changed the face of medicine forever.
Telemedicine in austere and wilderness environments: considerations
Telemedicine can be applied to a wide range of scenarios. It can be used for remote consultation, diagnosis and prescribing, clinical image sharing, electrocardiograms, real-time telemetry and radiological interpretation. In theory, telemedicine offers a perfect solution for medicine in remote and wilderness settings, with access to every medical speciality on demand. In reality, there are some key logistical challenges to appreciate.
Cost can be a significant obstacle and depends on two main factors: the type of telemedical equipment being used and the way data is transferred.
Simple telemedical systems offer an email-based or bespoke messaging system to exchange clinical information. These systems run on a user’s smartphone, tablet, or computer, with data being transferred through an internet connection. The cost depends on the amount of data transferred with large video files being the most expensive.
Systems that use video-calling technology require much higher data transfer rates and bandwidth capabilities. Most commercial platforms used within the NHS and private sector tend to use this set-up, however, they have the advantage of country-wide broadband and 3G-5G infrastructure. In contrast, remote and wilderness locations rely on cellular or satellite data transfer and so costs, speeds and reliability can vary hugely.
Telemedical systems can be synchronous (real-time) or asynchronous. There are pros and cons to both strategies. Synchronous approaches are better for real-time diagnosis and management advice but require constant clinician or admin staff availability. This adds expense and can be challenging if multiple expeditions are occurring in different time zones.
The quality of telemedical platforms and the quantity and detail of data that can be delivered is important. It impacts on the quality of advice offered by the remote clinician and therefore on the patient experience.
Progressing from sole text or video-based services; devices such as the TytoCare medical examination kit3 can be bought for $299 (£238). These allow clinicians to remotely examine the ears and throat and auscultate the heart and chest. However this particular device is only available in the USA at the time of writing, and such products appear to be geared towards use predominantly in the home.
The military are pioneers when it comes to technology and innovation due to the environments they operate in. The US military used a $14 million grant to connect surgeons to frontline combat medics using a device called the Lifebot 5.4,5 This device, offers multi-lead ECG, oxygen sats, non-invasive and invasive blood pressure readings, end-tidal carbon dioxide, temperature, multiple exam cameras, embedded ultrasound with a plug-in probe, and an onboard server to record the full patient history. However, the Lifebot 5 retails for around $20,000 (£15,945) which is prohibitively expensive for most organisations.
In addition, as the technology becomes more sophisticated, the power requirements increase. Whilst it may be possible to use a device such as the Lifebot in a field hospital or an offshore oil rig, where there is a definitive power source, it will be difficult in an off-grid wilderness setting. The use of solar panels or similar may assist but require pre-expedition planning, budget and probably a static base camp.
Telemedicine in austere and wilderness environments: case studies
The Yale-Mount Everest telemedicine project
In 1999 the Yale-Mount Everest Telemedicine Project used two Inmarsat phones to transmit video and audio data from base camp, via a folding satellite dish, to the INMARSAT satellite above the Indian Ocean.6 The team discussed several cases using this set-up with three stand-out cases as follows.
Firstly, a patient with reduced visual acuity and retinal haemorrhages was remotely reviewed, diagnosed with high altitude retinopathy and advised not to ascend further.
Secondly, a patient with suspected high altitude pulmonary oedema had their chest ultrasound and i-stat readings remotely assessed by an ITU doctor who advised on management.
Lastly, a sherpa with a traumatic shoulder injury from a yak was remotely diagnosed, via ultrasound, with a supraspinatus tear, and treated with a steroid injection.
These cases were a useful illustration of telemedicine’s capabilities but it is debatable how much they changed the clinical management decisions.
Real-time tele-echocardiography
A 26-year old man, stationed at the USA Mcmurdo Antarctic research base, presented to the medical clinic complaining of chest pain8; worse when lying flat. He was haemodynamically stable with normal blood results. His ECG showed ST elevation in leads II, aVL, and V2–V6.His CXR showed an enlarged cardiac silhouette. He had a working diagnosis of pericarditis with a possible pericardial effusion. An echo was performed which was reported remotely as showing a ‘‘small pericardial effusion, of approximately 1 m in thickness.’’
Four days later, the scan was repeated, this time with telemedical input from a cardiology team in the Emergency Telemedicine Suite at the University of Texas. A video feed of the clinic room allowed the cardiologists to coach the operator to achieve optimal views. This scan showed normal left and right ventricular systolic function with no evidence of tamponade, avoiding the need for costly extraction.
Swimming the Amazon
In 2009, Slovenian Martin Strel swam the entire length of the Amazon River from high in the Andes to Belém, Brazil. There was one physician on the support boat, supported remotely by the Amazon Virtual Medical Team (AVMT). 129 real-time consultations took place during the journey over a 66 day period.10
Remotely guided ultrasonography on Everest
An ultrasound system was connected via satellite phone to a laptop, this streamed a video to an advanced ultrasound operator. The expert guided novice operators in performing pulmonary surveys on two asymptomatic participants. The equipment performed well despite the cold, hypobaric conditions, and the remote expert was able to guide and identify comet tails suggestive of pulmonary interstitial fluid within 25 minutes.11
The Virtual Doctors
The Virtual Doctors are a UK-based charity that uses a smartphone app to connect clinical officers working in rural Zambia with volunteer doctors, based predominantly in the UK (see slideshow images). They offer remote diagnostic and treatment advice for complicated patient cases; aiming to improve rural healthcare provisions. The charity currently supports 233 health facilities in 37 Districts across 5 provinces. It covers a population of about 3.5 million people, around 20% of the population.
It aims to reduce unnecessary hospital referrals and develop a sustainable system that can be incorporated into existing healthcare systems. There are currently around 200 volunteer NHS doctors who give up their time to support the charity across many specialties.
The service has been hugely beneficial with one user commenting that the service has changed the way she works. She can now treat more patients in the clinic, saving them time, transport costs and the stress of being away from their families. Another user reports that patients receive a diagnosis as if there was a doctor at the facility. They feel this helps patients recover faster and return to their livelihoods, which in turn contributes to national development.
This simple yet effective telemedical solution has been such a success in Zambia, that the charity is rolling out their scheme in Malawi later this year. To get involved please see the end of the article.
Robotic Dogs
Spot, a four-legged robot from robotics company Boston Dynamics, was used at Brigham and Women’s Hospital in Massachusetts during the coronavirus pandemic.12 With an iPad and two-way radio on the robot, healthcare workers were able to have a video conference with patients and remotely control Spot as the robot walked through rooms with isolated patients.
Medicolegal and Ethical Considerations
Clinicians consulting via a telemedicine platform must ensure that they adhere to the GMC’s ‘Good Medical Practice’ guidelines13 (or their registered body’s equivalent) and that they act within their professional competencies.
Clinicians may require different levels of training, experience and seniority, depending on the type of advice being given and the relative experience, knowledge and expectations of the receiving party.
For example, to ensure that appropriate specialist advice is given, The Virtual Doctors looks for doctors who have either completed or are approaching their CCT, or those who have worked in a low resource, tropical medicine setting.
As with all clinical work, it is important to have appropriate medical indemnity to cover your practice. Arrangements vary between organisations, countries, roles, and with the degree of senior support provided. It is best to discuss this directly with indemnity organisations – try both those of your home country and those of the host country.
Similarly, if you are providing international medical advice, you may need to be registered as a practitioner in the “receiving country.” It is wise to consult with the organisation that authorises registration in your field of practice within that country.
Data security, transmission and retention are important and complex medicolegal issues to consider. These usually become apparent during the initial set-up of a telemedicine service and are important to have clear policies for. This is a vast topic, but briefly, some points to consider are:
- Where is data stored and is this secure?
- Which country are the servers located in?
- How long will data be stored?
- Can data be exported overseas?
- Who has access to the data?
- Is there a safeguarding policy?
- What happens if data is hacked?
- Are their means of transferring data secure?
The above list is by no means exhaustive, but it gives an insight into the non-medical logistical demands of establishing a robust telemedical service.
Take Home Messages:
- Telemedicine is an exciting area that is rapidly changing the way we practice medicine.
- Technology will continue to evolve but cost remains a barrier to its widespread use.
- Education of local care providers may be more cost-effective and will improve health inequities.
- Value is only added if input from remote sources will change clinical management decisions on the ground.
- Having good telemedical support, or top cover is valuable for expedition medics and may impact favourably on indemnity provision and costs.
Daniel works as a portfolio GP, a travel health physician, and a trainee BASICs doctor. He is also proud to be the volunteer medical director for The Virtual Doctors. If you are interested in volunteering with them please contact daniel.grace@virtualdoctors.org
References
1) Catalyst N. What Is Telehealth? NEJM Catalyst [Internet]. 2018 Feb 1 [cited 2022 May 21] Available from: https://catalyst.nejm.org/doi/full/10.1056/CAT.18.0268
2) Tuckson RV, Edmunds M, Hodgkins ML. Telehealth. New England Journal of Medicine. 2017 Oct 19;377(16):1585–92
DOI:10.1056/NEJMsr1503323
3) TytoCare | On Demand Medical Exams. Anytime. Anywhere. [Internet]. TytoCare. [cited 2022 May 25]. Available from: https://www.tytocare.com/
4) LifeBot 5 – LifeBot [Internet]. [cited 2022 May 25]. Available from: https://www.lifebothealth.com/products/lifebot-5/
5) Murray P. LifeBot 5 – The Portable Emergency Room [Internet]. Singularity Hub. 2012 [cited 2022 May 25]. Available from: https://singularityhub.com/2012/12/26/lifebot-5-the-portable-emergency-room/
6) White AP, Angood P. Advancing technologies in clinical medicine: the Yale-Mount Everest telemedicine project. Yale J Biol Med. 1999;72(1):19–27. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2578958/
7) Bhende MP, Karpe AP, Pal BP. High altitude retinopathy. Indian J Ophthalmol. 2013 Apr;61(4):176–7.
https://journals.lww.com/ijo/Fulltext/2013/61040/High_altitude_retinopathy.7.aspx
8) Otto CA, Shemenski R, Drudi L. Real-time tele-echocardiography: diagnosis and management of a pericardial effusion secondary to pericarditis at an Antarctic research station. Telemed J E Health. 2012 Sep;18(7):521–4.
https://doi.org/10.1089/tmj.2011.0266
9) McMurdo Station Antarctica (photo credit: Tas50) https://commons.wikimedia.org/wiki/File:McMurdo_Station_Antarctica_Station_Sign.jpg
10) Telemedicine for Patient Management on Expeditions in Remote and Austere Environments: A Systematic Review – PubMed [Internet]. [cited 2022 May 25]. Available from: https://pubmed.ncbi.nlm.nih.gov/33423896/
11) Otto C, Hamilton DR, Levine BD, Hare C, Sargsyan AE, Altshuler P, et al. Into Thin Air: Extreme Ultrasound on Mt Everest. Wilderness & Environmental Medicine. 2009 Sep;20(3):283–9.
https://pubmed.ncbi.nlm.nih.gov/19737030/
12) Statt N. Boston Dynamics’ Spot robot is helping hospitals remotely treat coronavirus patients [Internet]. The Verge. 2020 [cited 2022 May 25]. Available from: https://www.theverge.com/2020/4/23/21231855/boston-dynamics-spot-robot-covid-19-coronavirus-telemedicine
13) Good Medical Practice, General Medical Council [Internet]. 2019 [cited 2022 Aug 27] Available from:
https://www.gmc-uk.org/-/media/documents/good-medical-practice—english-20200128_pdf-51527435.pdf
