Defence Medical Services telemedicine now: a successful pilot of video consultations and instant messaging support to firm base training.

INTRODUCTION: Telemedicine was pioneered in the Defence Medical Services (DMS) in 1998, since then the capabilities within the DMS have not advanced in step with advances in technology. We present our findings of a pilot of remote video consultation via Skype for MODNET during an arduous course held in the UK. METHOD: Combat medical technician sick parades were live streamed via Skype to a Defence Primary Healthcare Medical Centre and medical officer (MO) support was delivered remotely. This process was augmented by the use of Pando for still images of wounds and infection sites in order to enhance decision making and situational awareness. RESULTS: Over a 3-week period, 34 consultations carried out during sick parade required the input from a remote MO, of those 34% required a prescription from an MO. None of the presentations required a face-to-face consultation, and all patients received MO-led care remotely. CONCLUSION: We have successfully demonstrated that video telemedicine consultations are safe, while simultaneously improving patient care, augmenting the distribution of medical assets and reducing costs.

Lessons from the use of telemedicine in the austere military environment and the implications for deployed surgical teams.

Over the last 20 years, there have been significant changes in UK surgical training. Civilian surgical training may no longer prepare military surgeons for the range of skills they require on operations. One method to address gaps in knowledge or experience is to use telemedicine to facilitate specialist consultations from UK-based specialists to deployed medical teams. In the UK Defence Medical Services (DMS), this capability is called real-time clinical support (RTCS). RTCS provides a direct audio-visual link from a deployed location anywhere in the world to a supporting medical specialist in the UK. RTCS is currently delivered via a combination of off-the-shelf hardware and commercially available software. This article will outline the current use of RTCS, with emphasis on deployed surgical teams in austere environments, and discuss the advantages and limitations of this capability. However, it must be emphasised that no technology can be a substitute for clinical training and experience. Although several limitations remain, the authors believe that RTCS offers potential benefits for the DMS and could be an important tool aiding deployed clinicians. It can also be argued that by engaging with the concept now, the DMS can shape future developments in this sphere.

Secure app-based secondary healthcare clinical decision support to deployed forces in the UK Defence Medical Services.

BACKGROUND: Modern instant messaging systems facilitate reach-back medical support for Defence Medical Services (DMS) by connecting deployed clinicians to remote specialists. The mobile app Pando (Forward Clinical, UK) has been used for this purpose by the DMS via the 'Ask Advice' function. We aimed to investigate the usage statistics for this technology in its first 1000 days to better understand its role in the DMS. METHODS: An observational study was undertaken using metadata extracted from the prospective database within the application server for clinical queries between June 2019 and February 2022. These data included details regarding number and name of specialties, timings, active users per day and the number of conversations. RESULTS: There were 29 specialties, with 298 specialist users and 553 requests for advice. The highest volume of requests were for trauma and orthopaedics (n=116; 21.0%), ear, nose and throat (n=67; 12.1%) and dermatology (n=50; 9.0%). There was a median of 164 (IQR 82-257) users logged in per day (range 2-697). The number of requests during each day correlated with the number of users on that day (r=0.221 (95% CI 0.159 to 0.281); p<0.001). There were more daily users on weekdays than weekends (215 (IQR 123-277) vs 88 (IQR 58-121), respectively; p<0.001). For the top 10 specialties, the median first response time was 9 (IQR 3-42) min and the median time to resolution was 105 (IQR 21-1086) min. CONCLUSION: In the first 1000 days of secure app-based reach-back by the DMS there have been over 500 conversations, responded to within minutes by multiple specialists. This represents a maturing reach-back capability that may enhance the force multiplying effect of defence healthcare while minimising the deployed 'medical footprint'. Further discussions should address how this technology can be used to provide appropriately responsive clinical advice within DMS consultant job-planned time.

[Acute abdomen masking pyelonephritis (author's transl)]. / Akutes Abdomen als Pyelonephritismaske

Analysis of 10 case histories shows that the picture of the acute abdomen may predominate in acutely exacerbated pyelonephritis. Viscero-dermal reflexes with hyperalgesia and muscular defense, visero-visceral organ reflexes with shock, vomiting, meteorism and disturbances of intestinal motility and metabolic acidosis are temptations to laparotomy. Fever in particular, pathological urinalysis, renal acidosis and occasionally hyperchloremia suggest the diagnosis of "abdominal type of acutely exacerbated pyelonephritis".

[Acute side-effects of drugs. Causes and prevention]. / Akute Arzneimittel-Nebenwirkungen. Ursachen und Vermeidung

A successful therapy with causative acting drugs (e.g. antibiotics, hormones) or with symptomatic acting drugs (e.g. antihypertensive, psychopharmacological drugs, anticoagulants) cannot be practicable without secondary effects. These unavoidable "side-effects" either are of no consequence or, these have to be risked and to be controlled, especially in long-term-therapy. Often, it is impossible to foresee allergic reactions. Avoidable "side-effects" may be dangerous in case of patient's self-medication, medical negligence or in case of drug interactions. 5 classes of drugs with possible threatening secondary effects are demonstrated: glykosides, sulfonylureas (antidiabetics), coumarin derivatives (anticoagulants), corticosteroids and parenteral contrast mediums.

[Mushroom poisoning. New possibilities for treatment]. / Pilzvergiftungen. Neue Therapiemöglichkeiten

Poisonous species of fungi in Germany are very few. Dangerous is the ingestion of raw, spoiled or poisonous mushrooms. There exist no reliable tests to determine whether a mushroom is safe except by expert examination and identification of the mushroom. In clinical practice the classification of mushroom poisoning is possible in muscarine-syndrome, gastroenteritic syndrome and in two-phase-syndrome. 90-95% of lethal mushroom poisonings are due to ingestion of Amanita phalloides. In severe cases extensive hepatic necrosis occurs, characterized by profound abnormalities in liver function caused by hepatic coma. In deep coma mortality rates amount to 70% or more. A new therapeutic measure (coated charcoal hemoperfusion)-first applied in liver failure by Chang (1972) and Williams (1973)-has been performed in 3 patients with severe poisoning after ingestion of Amanita phalloides (each patient had eaten at least 7-10 fungi Amanita phalloides). Two of the patients survived.

[Cardiovascular emergencies--endocrine and metabolic crises. Practical hints for the physician in emergency service]. / Kardiovaskuläre Notfälle -- endokrine und Stoffwechselkrisen. Praktische Hinweise für den Arzt im Notdienst.

50% of hospitalized medical emergency cases are cardiological and respiratory emergencies. Myocardial infarction, cardiogenic shock, ventricular arrhythmias and left ventricular failure often cause sudden death occurring within 1 or 2 hours. Therefore immediate management is necessary already in the prehospital phase of cardiovascular events. This does also apply for acute respiratory failure due to obstructive ventilatory disorders. Acute exacerbations of chronic obstructive pulmonary disease frequently are masked and may be misinterpreted as encephalopathy or alcohol withdrawal syndrome. Sedation may be dangerous. Also neuroglucopenic syndrome and hyperosmolar coma are occasionally interpreted wrongly. Thyrotoxic crisis, adrenal crisis and hypercalcemia are characterized by lethargy, mental disturbance and weakness, by dehydration, myopathy, nausea, constipation, diarrhea or tenesms or arrhythmias. In this situation of varied symptoms the most important action is to think of endocrine emergency, which may have multiple etiologies.

[Elimination of toxic peptides from amanita phalloides by charcoal perfusion in vitro (author's transl)]. / Elimination von Knollenblätterpilzgift (Amanitine) durch Kohle-Perfusion in vitro

Charcoal perfusion in vitro resulted in virtually complete detoxication of an extract from 170 g of Amanita phalloides in aqueous or plasma protein solution. After 4 min of perfusion the amanitin content was reduced to 1-2% after 15 min it was less than 1% of the starting material. Under the same conditions toadstool toxin was eliminated from plasma protein solution too: after 4 min of perfusion a dose of remaining material, corresponding to the LD70 of the starting material, was nontoxic in mice.

[Acute respiratory insufficiency caused by plunging goiter (author's transl)]. / Akute respiratorische insuffizienz infolge Tauchkropf

Acute respiratory insufficiency and unconsciousness are symptoms which may lead to misinterpretation. In cases of unclear acute respiratory insufficiency one should think of the rare plunging goiter with acute tracheostenosist, especially in female patients over 40 years. Diagnosis can easily be found if the patient is thoroughly observed. Resection of the retrosternal struma is the only possible therapy. One case of plunging goiter is described here.

[Anorexia nervosa. A catamnestic analysis]. / Anorexia nervosa. Eine katamnestische Analyse.

Over a period of 10 years 25 patients, 24 of them females, with anorexia nervosa were observed. The disease is characterized by marked loss of weight, amenorrhoea, low blood pressure and early-onset behavioural disorders towards members of the family and friends. Anaemia, peripheral oedema and pronounced muscular weakness due to electrolyte imbalance may be observed in advanced cases. The disease commences in puberty by more or less obvious loss of weight following reduced food intake, rarely it is caused by vomiting and laxative abuse. Patients tend to deny connections between reduced food intake and loss of weight. There is no standardized treatment. Therapy should be initiated by the psychiatrist. In severe cases parenteral nutrition and intensive care may be required. This is particularly true in complicated cases such as occurrence of infection, serious electrolyte disorders or coagulation defects. The earlier a diagnosis is made the better the prognosis. Manifest disease of more than 5 years' duration decreases the chances for cure considerably.

[Postpartum hemophilia A with factor VIII inhibitor]. / Hemmkörperhämophilie A post partum.

An abnormal life-threatening haemorrhagic diathesis occurred 6 weeks after delivery in a 25-year-old female. The reason was a spontaneously acquired factor VIIIC inhibitor haemophilia. The clinical presentation was characterised by extensive deep-seated soft-tissue haemorrhages of the extremities, a retroperitoneal haemorrhage, haematuria and recurrent joint bleedings. The activity of factor VIIIC decreased to below 1% of normal. The factor VIII inhibitor reached a maximum of 122 Bethesda units. The recurrent knee joint haemorrhages responded well to treatment with an activated prothrombin complex concentrate (Feiba). Repeated Feiba administration did not lead to an increase of the factor VIII inhibitor. It disappeared completely within 16 months and did not recur during a second pregnancy. The pregnancy was without complications and delivery on time resulted in a healthy child. Six months after the second pregnancy both mother and child showed no evidence of a disorder of haemostasis.

[Insulin injection aid. Experiences with its use in Type II diabetes patients]. / Insulin-Injektionshilfe. Erfahrungen mit dem Einsatz bei Typ-II-Diabetikern.

This article reports on the experience gained with an insulin injection aid for use by type II diabetics. The baseline data provided by a questionnaire survey are discussed in detail. The "pen" proved simple to use and was readily accepted. A number of shortcomings were identified and improvements suggested. The significantly superior metabolic control observed in patients using such aids is briefly discussed. In addition, detailed consideration is given to the models presently available and desirable future prospects are identified.

[Study of a carrier solution for the lidocaine infusion therapy in myocardial infarct]. / Prüfung einer Trägerlösung für die Lidocain-Infusionstherapie bei Myokardinfarkt.

Corafusin, an infusion solution containing lidocaine, electrolytes and sorbitol, was tested during 4-day continuous infusion of patients with myocardial infarction. The serum sodium level remained constant within the normal range whereas initially reduced serum potassium and magnesium concentration increased to normal within 24 hours. Both sodium and water balance were generally equilibrated during the entire test period. Testing of lactate and non-esterified fatty acids revealed a significant decrease within the first 24 hours. On the basis of these findings it can be concluded that the infusion solution tested is suited for lidocaine infusion therapy of patients with myocardial infarction.

[Drug therapy of shock]. / Medikamentöse Schock-Therapie.

Shock is to define by clinical symptoms, measurable haemodynamic and metabolic changes, clotting failure and disorders of fluid, electrolyte and acid-base balance. It is essential to remove hypovolemia, acidosis, cardiovascular failure, pulmonary and renal insufficiency. Quite a lot of proved and controversial pharmacological substances are placed at physician's disposal. However, the mortality of cardiogenic shock and gram-negative septic shock is more than 80% respectively 30%, often caused by shock lung or irreversible injury to the kidneys. Shock due to depletion of extracellular fluid, poisoning and acute pancreatitis require specific treatment.

[Myelosarcoma--an unusual heart tumor. Differential diagnosis of hypertrophic and non-obstructive cardiomyopathy]. / Myelosarkom--ein ungewöhnlicher Herztumor. Differentialdiagnose der hypertrophen und nicht obstruktiven Kardiomyopathie.

Heart tumours are seldom; secondary malignant tumours occur more often than primary heart tumours and there are no characteristic symptoms. According to the location and extent, tumours of the heart can cause practically all the known cardiological symptoms, not only in the discrete, but also in the dramatic form. Frequent symptoms are disrhythmia , myocardial insufficiency and pericardial effusion. In the case of uncertain cardial symptoms a possibly malignant heart disease should be looked for by means of ultrasonics, computer tomography, myocardszintigraphy and if necessary angiocardiography. If a diagnosis is made in time, the patient can be helped either by surgery, or in cases of secondary, malignant infiltrations the patient can often be treated successfully with chemotherapy or radiation. In cases of unusual heart tumours ( myelosarcoma ) this differential diagnosis should also be taken into consideration.

[Hepatic coma in liver cirrhosis. Prevention and treatment]. / Coma hepaticum bei Leberzirrhose. Prophylaxe und Therapie.

The prognosis of hepatic coma is poor if the patient has jaundice, ascites, defects in clotting factors, a low serum-albumin level and haemorrhage from oesophageal varices. After 5 years, the survival rate is less than 20%. Approved methods of intensive care are recommended. Cerebral oedema, respiratory and renal failure, infection and lactate acidosis are dangerous complications with the necessity to early treatment. The difficulty of parenteral nutrition depends on the extent of liver cell failure. In spite of the rise in blood ammonia mixtures of selected amino acids should be given in small doses. In selected cases temporary hepatic support and detoxification methods are indicated in hepatic coma. Charcoal haemoperfusion decreases the depth of coma and regulates the electroencephalogram, some patients fully recover consciousness. But there is no long-term improvement of survival-rates in cases complicated by bleeding oesophageal varices and by septic circulatory failure. The lethality of the first bleeding from varices is about 50%. Diagnostic endoscopy is necessary, sclerosing of oesophageal varicosis and laser-coagulation can be life-saving in hepatic pre-coma. The mortality of surgical procedures is more than 60%. Emergency anastomosis shunting portal blood has a better prognosis than ligation of the varices or oesophageal and high gastric transsection operations, demonstrated by surgical management in 248 cases. Even with this long-term succes is unusual.

[Acute liver failure in abdominal Wilson's disease in early adulthood]. / Akutes Leberversagen bei abdominellem Morbus Wilson im frühen Erwachsensenalter.

The acute abdominal form of Wilsons's disease was observed in three female patients aged 17, 18 and 30 years. Clinically uncharacteristic general symptoms and jaundice were dominant. Chemical pathology showed high bilirubin values with predominance of direct bilirubin, signs of hepatic and renal insufficiency and haemolytic anaemia. There were no neurologic symptoms and the Kayser-Fleischer ring was absent. Coeruloplasmin in blood was normal, copper concentration in blood and urine was clearly increased. Diagnosis of Wilsons's disease could only be established at post mortem by quantitative copper estimation in liver tissue. The patients succumbed 1--4 weeks after onset of symptoms through hepatic failure.