Telemedicine Through the Lens of Wilderness Medicine

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How telemedicine technology can translate to remote settings and change healthcare delivery in austere environments.

At 18,000ft (5486m) on a mountainside in the Himalayas, a physician encounters a trekker complaining of fatigue and shortness of breath. The trekker is tachypneic and slumped on the side of the snowy trail in the tripod position. Even if a stethoscope were available, the high winds and frigid environment would make it nearly impossible to perform an adequate lung exam. However, when the physician listens closely, she can hear a slight gurgle sound with every breath. The patient appears anxious and lips are cyanotic. These signs and symptoms are enough to start treating high altitude pulmonary edema immediately.

On the other side of the globe, a physician in a telemedicine booth interviews an asthmatic patient with a cough. The patient has a low-grade fever and stops every few words to catch his breath. Without a stethoscope, the physician decides how to care for her patient.

Wilderness medicine is providing care in a remote, austere environment. On the surface, the temperature controlled, well-lit booth of a telemedicine office seems quite different. However, the challenges present in both settings are often quite similar; patients may not have other options for care and there may not be a reliable method of auscultation, just to name two examples. The provider must not only decide upon the best course of action and the most appropriate next step but also who requires a higher level of care. The way in which these challenges are overcome demonstrates the similarities between the two specialties.

Both telemedicine and wilderness medicine rely on a special skill set. They force providers back to the basics: listening to patients and eliciting a thorough history of present illness. Performing a physical examination becomes an extension of artful observation. Without the luxury of direct auscultation and palpation, there are subtle signs that give clues to the patient’s condition: color of the skin, eyes, lips and nails, audible upper airway sounds, respiratory rate, mood, and affect.

Both specialties require the physician to adapt their care to what is available in the environment. Available personnel, even if nonmedical, may be required for assistance. For example, in telemedicine, a mother can help palpate her son’s abdomen as the physician watches for grimacing. In the case of the patient with high altitude pulmonary edema, porters can be used as EMTs and administer oxygen and transport the patient.

Treating patients is an exercise in innovation. In the wilderness, an improvised splint can be fashioned out of sticks or ski poles. Similarly, a patient with an ankle injury at home can be instructed by telemedicine to make a temporary splint with household items such as a ruler, cardboard box or pillow and duct tape.

Not only do telemedicine and wilderness medicine share characteristics, but they become further intertwined when telemedicine is applied in actual wilderness settings. In remote environments where access to care is difficult either due to distance, terrain or weather, telemedicine provides a means around these obstacles. Telemedicine has been used in Alaska, Antarctica, and other desolate environments around the globe. A patient in a small Alaskan village, who would otherwise have to travel by plane to Anchorage to see her physical therapist, can meet them through the telemedicine booth set up in her local clinic. This technology is delivering medical care in unconventional settings where it may not otherwise be available.

As telemedicine continues to grow, it can also be applied in other situations, such as humanitarian emergencies. Natural disasters reduce normally functioning hospitals into a more limited capability. Telemedicine could augment triage systems and assist the reduced number of staff if the disaster has prevented their usual staff from reaching the hospital. In disasters, telemedicine is achievable because the infrastructure for it is already in place. In the prehospital setting, telemedicine connects EMS crews to the physicians. In the aftermath of Hurricane Harvey, on-demand telehealth providers helped with medical and mental health visits.

Challenges remain in using telemedicine in remote settings. A secure and reliable internet connection is required. Equipment must be maintained and able to withstand less than ideal conditions. However, as technology evolves, equipment including generators will become smaller, lighter and more easily transported. Internet access continues to improve and using satellite internet alleviates the need for hard wired connections.

Telemedicine and wilderness medicine share similarities in how to approach and treat patients. Bringing telemedicine technology into the wild offers telemedicine and wilderness providers the chance to work synergistically to expand telemedicine applications and enhance care around the globe.

ABOUT THE AUTHORS

Clinical Assistant Professor, Thomas Jefferson University Hospital, Faculty Advisor of Wilderness and Disaster Medicine Society at Sidney Kimmel Medical College, Director of Wilderness Medicine, Department of Emergency Medicine

Senior Vice President for Healthcare Delivery Innovation, Thomas Jefferson University Associate Dean for Strategic Health Initiatives, Sidney Kimmel Medical College Vice Chair, Finance and Healthcare Enterprises, Department of Emergency Medicine

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