Remote Rx

Even if doctors still made house calls, they probably couldn't help the 30 troops who man a remote U.S. Army communications outpost on Hill 1326 in Bosnia.

In good weather, the hill is a two- to three-hour Humvee drive from the nearest paved road. It takes even longer in the winter, when the troops must either pile into camouflaged Sno-Cats or wait for the twisting, snow-packed, one-lane dirt road to be plowed. Either way, the trip isn't easy because the only road to the hill was mined by both sides in the former Yugoslavia's bloody civil war.

Hill 1326 is two miles from the Bosnian border with the Republic of Srebska and about 30 miles southeast of Tuzla, home of the main base for U.S. peace-keeping forces in Bosnia. The hill does feature a landing pad for med-evac helicopters, but the weather in Bosnia is often too gray, windy or snowy for choppers to fly.

Contemplating the stark, barbed-wire enclosure of the Hill 1326 encampment on a blustery February day, Army medic Sgt. Kuanh Francis said, "This is the most remote place I've ever been" in eight years of military service.

Despite his isolation, Francis is well-equipped to treat the soldiers stationed on Hill 1326 for injuries large and small, thanks to two small satellite antennas that perch atop the sand-bagged wall surrounding his medical tent. Those dishes link Francis and a powerful suite of telemedicine gear to a worldwide military telemedicine network that can instantly bring any kind of medical specialist to him rather than risk bringing a patient to the specialists.

In combat medicine, the first challenge is to treat patients quickly during the "golden hour,'' which is the short period of time when proper medical treatment can mean the difference between life and death. In the view of Gen. Richard Kiley, commander of the Army Medical Corps-Europe as well as the command surgeon for the United States Army-Europe, the telemedicine system in Bosnia has created a "platinum hour.''

Kiley, interviewed at his headquarters at the Landstuhl Regional Medical Center in Germany, said the telemedicine system, code-named Primetime III, "allows us to project sophisticated capabilities out to even the most remote medical stations.''

Kiley said combat medics such as Francis "are the biggest beneficiaries of this system,'' which can link such remote spots as Hill 1326 with doctors in Germany or stateside specialists at such hospitals as the prestigious Walter Reed Army Medical Center in Washington, D.C. Putting himself in the medics' place, Kiley said, "It's good to have the world's experts sitting at the end of the camera.''

With Primetime III, medics are equipped with a suite of telemedicine gear that consists of a telephone and a rugged Dolch Computer Systems Inc. Pentium-class computer hooked up to a variety of diagnostic equipment, including a video camera, a PictureTel Corp. video teleconferencing system (VTC) and a general-purpose medical scope for eye, ear, nose and throat examinations. Altogether, the gear costs about $58,000 per site and weighs about 12 pounds. The medics send images at rates from 64 kilobits/sec to 512 kilobits/sec via the DemandNet service from Hughes Global Services, which provides very small-aperture satellite terminals to support the Bosnian operation.

Primetime III is the third telemedicine system developed and fielded by the Army under the management of the tri-service Telemedicine and Advanced Technology Research Center. Primetime I was fielded in 1991 to support U.S. forces in Somalia; it was a rudimentary system that featured a still camera, with medics sending pictures back to stateside hospitals via e-mail. Primetime II, deployed to support U.S. peace-keeping forces in Macedonia, added tele-radiology and VTC capabilities to the original system.

With Primetime III, the Army added wide-band video and tele-dentistry. Army medical officials declined to provide a total cost for Primetime III. But Kiley said the Army's 5th Signal Command wanted $15 million a year just to provide the communications circuits needed to support the system.

Spider Bites and Sinus Infections

Primetime III has performed well in the Bosnian operation, but it hasn't performed very often because the operation has had so few casualties. Although it has great potential for saving lives on the battlefield, Primetime III is used largely to treat minor ailments.

Staff Sgt. Gene Pinkston, who preceded Francis as the medic on Hill 1326, used the telemedicine system during his tour, tapping into it more than anyone else in Bosnia. "Bosnia has some obnoxious insects crawling around out there...and I had to deal with a spider bite that resulted in a rash on a soldier's arm," he said. "I got his vital signs and then used the telemedicine system to contact a specialist in the rear. He confirmed a diagnosis of cellulitis, which is an effect of the bacteria that the bug carried rather than the bite itself.... I applied treatment on the spot and followed up with the specialist daily until the condition cleared up."

Pinkston also performed a minor operation for a sinus infection, again carried out under the guidance of a specialist through a telemedicine consult. Both conditions could have resulted in evacuations if Pinkston did not have the access to specialists provided by the telemedicine system.

While most of the telemedicine experiences in Bosnia were of the aches, sprains, fevers and rashes type, there was at least one instance in which the technology proved itself a lifesaver, according to Dale Garaux, the Landstuhl-based telemedicine coordinator for Electronic Data Systems Corp.

A physician's assistant at Camp Colt, in northern Bosnia, one day found himself experiencing what is known as paroxysmal supraventricular tachycardia, which is a rapid heartbeat that could easily turn into a life-threatening arrhythmia. This is the kind of condition that in the past would have demanded an emergency med-evac.

Instead, Garaux said the physician's assistant used the telemedicine system to call the 405th Combat Support Hospital in Tuzla and do a consult on himself along with a physician and a cardiologist. By studying EKG images sent over the video link, the cardiologist could oversee a medical technician administering medication to the physician's assistant. Eventually, the heart rate slowed to a regular rhythm, and an urgent evacuation was called off.

Telemedicine also saved a U.S. soldier stationed in Sarajevo from a grueling treatment for a monkey bite, according to Lt. Col. Tom Semarge, the biomedical information systems officer at Landstuhl. Some species of monkeys, Semarge said, carry a virulent form of herpes that requires a painful series of pharmacological treatments.

But telemedicine— and a bit of serendipity— saved the soldier from that treatment, Semarge said. "My wife is a veterinarian stationed here," he said. "We had people in Sarajevo take a digital photograph of the monkey and send it here over the telemedicine system. My wife looked at the monkey and knew that it was not the kind that carried herpes.'' As to how a U.S. soldier managed to sustain a monkey bite in the distinctly nonsimian environs of Sarajevo, Semarge said both the monkey and the soldier were hanging out in the same bar.

Garaux said Primetime III also helped the Army manage its X-rays in an almost assembly-line fashion.

"The Army did not even send a radiologist to Tuzla,'' which is the site of the main U.S. base supporting first the multinational Implementation Force and then its successor, the Stabilization Force, Garaux said. Instead, using tele-radiology, the Army "took thousands of pictures and sent them to Tazar,'' site of the U.S. support base in Hungary. There, Garaux said, radiologists read the X-rays and used e-mail or the telephone to send the results back to Bosnia.

"In Bosnia, we had to either bring the patient to the health care or bring the health care to the patient, '' Kiley said.

The High-Tech Medic

In this era of telemedicine, the Army is revamping its doctrine to feature medics trained in medicine and computers. The goal of this so-called Medical Detachment Telemedicine (MDT) will be to save lives on the battlefield, whenever that time comes.

"We have essentially made no progress in the care of soldiers in the field since the Civil War," said Brig. Gen. Russ Zajtchuk, commander of the U.S. Army Medical Research and Materiel Command, headquartered at Fort Detrick, Md. Zajtchuk, who also heads the Defense Department's Telemedicine Test Bed, said, "Of course, because of the advances in surgery and other treatments, we have made significant progress in getting wounded and sick soldiers to the hospital and keeping them alive. But in the actual care on the field— no.

"Now," he added, "the requirements are that we find wounded people quickly, use telemedicine to mentor the medics and then find ways to evacuate. Basically, we are finding ways to empower the people who are delivering care to the soldier."

Putting the MDT in place, however, is a long process, according to Col. Daniel Gower, president of the U.S. Army Medical Department Board. But some surrogate units are being set up. The Army will demonstrate the MDT concept in an exercise planned to take place in the Pacific in about a year, and units will be deployed by 2000.

While many physicians are still resistant to the idea of telemedicine, Zajtchuk conceded that "the line commanders have been getting quite convinced that telemedicine is the way to go. I expect it to take around a couple of years for it to become pervasive in the military. We are very close now."

-- Robinson is a free-lance writer based in Portland, Ore.

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Primetime III Components

Hardware: International Mobile Satellite Organization "B" satellite transceiver and dish; Rugged Dolch Pentium computer; PictureTel Corp. video teleconferencing system; low-cost video camera

Software: Standard Microsoft Corp. Office automation and e-mail software

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Telemedicine links with hospital automation system

BY BRIAN ROBINSON

Telemedicine is an impressive technology for extending medical resources into the field, but it wouldn't be of much use to the soldiers on Hill 1326 in Bosnia who are without other improvements in the military's medical systems. That has been the goal of the giant automation program known as the Composite Healthcare System.

The CHCS program began in 1983, with an award in 1988 to Science Applications International Corp. Servicing more than 9 million people at some 575 medical treatment facilities worldwide, CHCS has been one of the most successful military information technology programs of the 1990s. As far as bang for the buck is concerned, the Defense Department has calculated the total benefits of CHCS at about $4.1 billion for a program cost of just $2.8 billion.

"CHCS has been particularly useful in Bosnia in the forward hospital on the Hungary border," according to David Brooks, group senior vice president with SAIC and the CHCS program manager there. "Basically, the health providers there have used it to build a little version of Walter Reed Hospital or Landschule."

CHCS combines into one integrated database everything there is to know about a patient that passes through the DOD's medical system. Its goal is to provide information to any U.S. military medical practitioner anywhere in the world on any patient they encounter, telling them what past treatment they've had, what conditions should be noted, whether they are allergic to particular medications and so on.

The next version of CHCS will incorporate elements of other programs, such as the Patient Accounting and Reporting Realtime Tracking System (PARRTS), which gives military commanders an exact location of a patient at any given time. Previously, commanders had to call a particular facility to locate a patient, and there was no easy way to find out when someone was admitted or moved, or which unit they ended up with, according to Maj. Catherine Beck, a project officer with the Telemedicine and Advanced Technology Research Center.

"It gives us an immediate insight into the patient load," Beck said. "In the past, we've had to wait up to six months to get that. It also means we can code for statistical information of what particular injuries we are seeing in any given situation."

That kind of data has been useful in situations where a given disease has laid a whole unit low. PARRTS can identify that type of situation instantly, and people can be flown out to deal with it, otherwise it could take months before the pattern was noted. And by then it could have been too late," Beck said.

Beck said she is looking forward to the use of telemedicine in far-forward positions. "It will provide data on the various diseases that people in the front line are suffering from, which means we can quickly see if such things as biological weapons are being used," she said. "And that will allow us to budget much more precisely for the use of personnel and supplies."

This is all stoking a revolution in health care in the military. "There's no doubt that field medicine will not be practiced in the future as it has been in the past," said Brig. Gen. Russ Zajtchuk.