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 Table of Contents  
COMMENTARY
Year : 2022  |  Volume : 24  |  Issue : 3  |  Page : 162-164

Telemedicine – A way forward for medical consultation at high altitude


1 Department of Anaesthesia and Critical Care, Siachen Military Hospital, Leh-194104, Ladakh, India
2 Aviation Medicine, Siachen Military Hospital, Leh-194104, Ladakh, India
3 Medical Branch, Leh-194104, Ladakh, India
4 Department of Anaesthesia and Critical Care, Command Hospital, Pune, Maharashtra, India
5 Department of Accident and Emergency, Siachen Military Hospital, Ladakh, India

Date of Submission28-Jan-2021
Date of Decision22-May-2021
Date of Acceptance30-May-2021
Date of Web Publication01-Apr-2022

Correspondence Address:
Lt Col (Dr) Saurabh Sud
Department of Anaesthesia and Critical Care, Siachen Military Hospital, Ladakh-194401
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jmms.jmms_20_21

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  Abstract 


The recent advances in telemedicine have offered real and practical opportunities to health-care providers in sharing expertise and resources in health care over distances. In India, telemedicine has revolutionized the health-care system by minimizing the cost, avoiding the long-distance travels and in timely providing specialist care in remote areas. The Indian Army is also reaping the benefits of telemedicine, by providing round-the-clock medical care to the troops deployed in high-altitude areas.

Keywords: COVID-19, guidelines, pandemics, satellite communications, telemedicine, United States National Aeronautics and Space Administration


How to cite this article:
Sud S, Bhardwaj S, Jairam A, Dwivedi D, Garg A. Telemedicine – A way forward for medical consultation at high altitude. J Mar Med Soc 2022;24, Suppl S1:162-4

How to cite this URL:
Sud S, Bhardwaj S, Jairam A, Dwivedi D, Garg A. Telemedicine – A way forward for medical consultation at high altitude. J Mar Med Soc [serial online] 2022 [cited 2022 Aug 14];24, Suppl S1:162-4. Available from: https://www.marinemedicalsociety.in/text.asp?2022/24/3/162/342382




  Introduction Top


Medical education for a long has consisted of classroom lectures, presentations, and laboratory experiences with increased emphasis on patient care safety and patient satisfaction. In our country where people are residing in far-flung areas and medical facilities are bare minimal, alternative methods are beginning sorted for. Telemedicine has played an important role in fulfilling this endeavor by online learning, diagnosing, and providing treatment via video conference, podcasts, and online simulation. “Tele” is a Greek word meaning “distance” and “mederi” is a Latin word meaning “to heal.”[1] The World Health Organization defines telemedicine as, “The delivery of healthcare services, where distance is a critical factor, by all healthcare professionals using information and communication technologies for the exchange of valid information for diagnosis, treatment, and prevention of disease and injuries, research and evaluation and for the continuing education of health-care providers, all in the interests of advancing the health of individuals and their communities.”[2]


  History of Telemedicine Top


The oldest record of use of telemedicine goes back to the first half of the 20th century when electrocardiogram (ECG) was transmitted over telephone lines in the USA.[3] In 1959, first time live video consultation was done by the doctors at the University of Nebraska, who used interactive telemedicine to transmit neurological examinations.[4] In the 1960s, the National Aeronautics and Space Administration took telemedicine to the next level when it started transmitting physiological parameters from spacecraft and the space suits during the space missions.[2] In India, telemedicine was formally launched on March 30, 2000, by the Indian Space Research Organization (ISRO) when it established the first telemedicine unit in the village of Aragonda, in Chittoor district of Andhra Pradesh, linking it to Apollo Chennai hospital and provided live cardiac teleconsultations.[2]


  Telemedicine in Indian Army Top


Indian Army troops are deployed at various high-altitude areas (HAA) (Ladakh and Eastern India region) which are far-flung and get cut off from the rest of the world during winter months. To monitor troops physical and mental status via continuous connectivity; the Indian Army, as a pilot project, in 2003 established telemedicine centers. Glaciered areas in northern India due to its inhospitable terrain owing to subzero temperatures (−30°C to −65°C), extreme heights 2700 m (9000 feet) to 7010 m (23000 feet) above sea level, strong wind blizzards (185–300 km/h), and massive crevasses, has always been the most difficult platform to provide medical management, namely firsthand specialist consultation to the patients or evacuating the patient for the same.[5] The majority of the posts in HAA are managed by young medical officers (MO)/nursing assistants (NA) or battlefield nursing assistants (BFNA). A hospital at HAA was established in the 1980s at an altitude of around 3352 m (11,000) feet, for looking after the physical and mental health of Siachen troops. This hospital has medical specialist, surgical specialist, and anesthesiologists with a dental medical officer with an advance radiological center (computed tomography scan and digital X-ray) and a hyperbaric treatment center. To provide quick and effective treatment at the posts, in 2012, medicine nodes were established at various posts of HAA, enabling them to directly connect with the specialist of our hospital in real time.Glaciered areas due to its topography, operational commitment and troops deployment, has been divided into different zones. The telemedicine nodes have been strategically placed, equally distributed in all zones and vary between altitudes of 3352 meter to 5790 meter (11000 feet to 19000 feet). Due to extreme low temperature, these telemedicine nodes are kept in a specially designed heated room for effective functioning. These telemedicine nodes at posts are operated by MOs/NA/BFNAs, as they are imparted training in our hospital before induction to HAA.

[TAG:2]Components of Telemedicine System in High Altitude Area[/TAG:2]

The telemedicine system established in HAA consists of three parts, telemedicine consultation center (TCC), telemedicine specialty center (TSC), and communication medium.[1] TCC is the place/post where the patients are present and they have equipment for communicating, scanning/converting, and transforming patient's available medical information, which is presently available in different posts of HAA.[1] Telemedicine Specialty Centre (TSC) is the place where the specialists are present like our hospital situated at HAA.[1]

The telemedicine systems established in HAA consists of an interface between software, hardware and a communication channel, which connects different posts of HAA to our hospital and our hospital to various tertiary care army hospitals in northern part of the country, resulting in exchange of information and enabling teleconsultancy between these locations.[1] The hardware includes computer, scanner, printer, videoconferencing equipment, stethoscope, otoscope, electrocardiogram (ECG) leads etc. The software enables in acquisition of patient's information (films, images, reports etc). The communication medium consists of both wired and wireless medium and helps in connecting two locations.

Classification of telemedicine system

Telemedicine is classified on the bases of “timing of information is being transmitted” and according to the “individuals involved.”[2] Depending upon the timing of the information being transmitted, it is further subdivided into three (i) store-and-forward or asynchronous telemedicine – in this, the sender at TCC can transfer digital images/information database to TSC at a convenient point of time and the receiver at TSC can review the data at his convenient time. The digital image is taken by the digital camera, stored, and then forwarded by computer from TCC to TSC. This is being routinely used in nonemergency situations, i.e., teleradiology, teledermatology.(ii) Real time or synchronous telemedicine or “Interactive television.” It employs video conferencing as both sender and receiver are online at the same point of time and helps in live transfer of information and real-time “face to face” consultation. This is generally done for urgent or emergency cases like pain abdomen, pain chest, etc. This is the maximum type of telemedicine consultancy seen in our area (iii) remote monitoring type of telemedicine, also known as self-testing or self-monitoring. This uses a range of technological devices to monitor clinical signs and health of a patient remotely.

Telemedicine classification based upon the “interaction between the individuals involved” is also further subdivided into two – (i) health professional to patient – this involves communication between TCC and TCS and provides direct medical/surgical consultation and treatment and (ii) health professional to health professional – it involves communication between one TCS to higher TCS where super specialties are present.

Training of telemedicine being imparted at our hospital

The success of telemedicine depends on the training being imparted to the concerned people. We not only provide operational training, but also provide maintenance training for telemedicine equipment. Training is imparted using “PREP” mnemonic where “P-preparation, R-recognize, E-execution, P-problem solving.”[6] Under “Preparation,” all the units, specialist officers, MOs, NAs, and BFNAs getting deployed in HAA area are physically and mentally trained to use the telemedicine equipments. They are taught to have “PACE” (Primary, Alternate, Contingency, Emergency) plan for telemedical support. We train all the concerned persons to “Recognize” the emergencies and know when and how to call. Emphasis is given on being proactive in their approach and adopting “call early, call often” approach. They are also taught how to provide a detailed history and rapid complete examination findings over a closed-loop communication through telemedicine system for “Execution” of efficient and effective telemedicine consultation. Last part of the training involves “Problem solving” which basically involves teaching them how to pass information regarding sick patients in shortest possible time if one or more modes of telemedicine are nonfunctional, i.e., spending precious time over trying to make a nonworking video connection work when a simple phone call can be good enough for clinical guidance for managing a sick patient.

[TAG:2]Our Experience of Telemedicine System in High Altitude Area[/TAG:2]

Since the establishment of telemedicine, nodes at HAA, around 594 consultations have taken place between various telemedicine node posts and our hospital. The commonest medical problem was myalgia, myocardial infarction, gastroeosophageal reflux disease, gastritis, acute mountain sickness (AMS), high altitude pulmonary edema (HAPE), high altitude cerebral edema (HACE) and pulmonary thromboembolism. The surgical cases included frost bite, chill blains, appendicitis, cholecystitis, ureteric colic, different fractures, low backache and minor and major burns. Out of all the cases maximum consultation was for frost bite and AMS. Literature shows that routine/nonurgent consultation forms 70% of telemedicine consultations, which was 69% in our case.[6] The urgent/immediate consultations were lesser in our case as compared to global data (13% vs. 15%), whereas emergent consultations were higher than the global rate (14% vs. 10%).[6] This increase seen was due to proactive approach on the part of medical caregivers, as emergency treatment and evacuation was needed for these patients due to their deployment in HAA where evacuation is only possible by helicopters, which itself is dependent upon the weather conditions. The functionality of telemedicine equipment is difficult to be maintained especially during winter months (December to March) due to extremely low temperatures. The hardware gets damaged/malfunctions, software gets corrupted, and the communication wires get embedded in snow, which are difficult to locate and extract. The electricity needed to run these telemedicine equipments is also a big constraint, as the batteries get discharge very fast and take very long time to recharge. The generators which are the backbone of electricity in HAA also suffer huge wear and tear, leading to malfunctioning. Avalanches also have led to loss of telemedicine and electricity generating equipments, as has been seen no of times in our area. The replacement and spare parts take days to weeks to reach the posts as helicopter sorties and link by foot are suspended for days due to incremental weather.

During the current pandemic of highly infectious COVID-19, we have been regularly conducting live telemedicine sessions, so as to update all the troops with the latest precautions, guidelines, and treatment modalities, so as to ensure that the troops while proceeding on leave after deinduction from glacier are well versed with the do's and don'ts and able to take care of themselves en route and their family members at home.


  Conclusion Top


To conclude, telemedicine has helped in routine interaction of specialists officers/MO,s/NA's/BFNA's with the troops deployed in HAA posts which are far flung, helping in knowing there mental and physical conditions and diagnosing their surgical and medical conditions and providing early treatment consultations. Telemedicine has also enabled in identifying medical and surgical emergencies at an early stage, timely evacuation of the same as well as on site effective management when evacuation is not possible owing to inclement weather. The MO's/NA's deployed at HAA, due to their training in telemedicine will find it easier to operate “Service E- Health Assistance and Teleconsultation-(SEHAT)” telemedicine programme. Seeing the tremendous success of telemedicine in HAA, this model can be replicated in other peripheral hospitals.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Dasgupta A, Deb S. Telemedicine: A new horizon in public health in India. Indian J Community Med 2008;33:3-8.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Chellaiyan VG, Nirupama AY, Taneja N. Telemedicine in India: Where do we stand? J Family Med Prim Care 2019;8:1872-6.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Kay M, Santos J and Takane M. Telemedicine Opportunities and developments in member states [Internet]. 2nd ed. Geneva, Switzerland: WHO press; 2010. Available from: https://www.who.int/goe/publications/goe_telemedicine_2010.pdf [Last accessed on 2019 Feb 01].  Back to cited text no. 3
    
4.
Serper M, Volk ML. Current and future applications of telemedicine to optimize the delivery of care in chronic liver disease. Clin Gastroenterol Hepatol 2018;16:157-61.e8.  Back to cited text no. 4
    
5.
Jindal AK. The highest battlefield of the world: Medical problems and solutions. Med J Armed Forces India 2009;65:170-2.  Back to cited text no. 5
    
6.
Nettesheim N, Powell D, Vasios W, Mbuthia J, Davis K, Yourk D, et al. Telemedical support for military medicine. Mil Med 2018;183:e462-70.  Back to cited text no. 6
    




 

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Abstract
Introduction
History of Telem...
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