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Those medical providers deployed to remote countries and tasked with caring for military personnel must diagnose and treat diseases and nonbattle injuries that result from exposures rarely seen in developed countries. Military providers must also function with limited resources and a lack of access to physician specialists, to include medical toxicologists. There have been limited published approaches to addressing this clinical gap for medical toxicology. To address this void, the US Army Medical Department deployed an electronic mail telemedicine system to provide teleconsultations for remote health-care providers worldwide, including Iraq and Afghanistan. This study aimed to describe the types and the frequency of toxicology teleconsultation and consultant responses using electronic mail to assist physicians serving in resource-limited locations. This was a retrospective observational study in which an unblinded data extractor independently reviewed all medical toxicology email consultations. Using a previously developed data collection worksheet, the extractor recorded the type of question asked by the consultant (overdose case, envenomation, occupational exposure, etc.) and the duration of time from when the teleconsultation was placed until the consultant replied. The extractor also recorded if the patient was adult or pediatric and if the patient was US military, US contractor, or local national. The extractor also recorded how often the toxicologist provided the consulting physician with information, resources, or protocols to aid in the management of future cases. In addition, for clinical teleconsultations, the extractor documented the frequency that the consulted toxicologist (i) provided a differential diagnosis or specific diagnosis, (ii) provided specific management guidelines for a patient, and (iii) recommended to evacuate or not evacuate a patient. The results were analyzed using descriptive statistics. Of the 99 consultations evaluated, the most common consultation was for snake envenomation and antivenom recommendations (n = 23, 23 %) followed by accidental chemical exposures (n = 14, 14 %), drug testing (n = 13, 13 %), and substance abuse (n = 10, 10 %). In 41 % of consults, the toxicologist provided a differential diagnosis or specific diagnosis, and in 60 % of cases, the toxicologist provided specific management or evaluation guidelines. In 11 % of cases, the toxicologist recommended for or against evacuation of the patient. In 25 % of consults, the toxicologist provided the consulting physician with information, resources, or protocols to aid in the management of future cases. The most frequent consultations for the military telemedicine consultation service were for direct patient cases, specifically snake envenomation management and accidental chemical exposures. Our results may be used to educate physicians prior to military deployment or international humanitarian efforts and to create toxicology clinical guidelines for remote locations. Expansion of the current military teleconsultation program capabilities to include video teleconsultation may improve the effectiveness of military medical toxicology teleconsultation.

Telemedicine is a recent development, designed to assist patients with limited physical access to expert subspecialty medical care. The United States Army has established a telemedicine program, consisting of e-mail consultations from deployed health care providers to subspecialty consultants. Orthopaedic surgery became a participating consultant group in July 2007. The goal of this study is to describe the Army's telemedicine orthopaedic program and to review its progress and achievements. All consults initiated from July 2007 through April 2009 were reviewed. A total of 208 consults were received by the telemedicine orthopaedic consultation program. Predominant regions of origin were Iraq, Navy Afloat, and Afghanistan. The Army accounted for the majority of consults. Prevalent musculoskeletal complaints were fracture, sprain, neuropathy, and tendon injury. Of the 74 fracture consultations, hand and wrist fractures were most common. Symptomatic treatment or casting/splinting were the most common recommended treatments for all orthopaedic consults. Of the 170 consults requesting specific treatment recommendations for patients who likely otherwise would have been evacuated for further evaluation, surgical intervention or medical evacuation was only recommended in 25% and 16% of the consultations, respectively. The novel Army telemedicine orthopaedic consultation program developed for combat-deployed service members provides expert treatment recommendations for a variety of musculoskeletal injuries. Deployed health care providers located in austere combat environments can better determine both the necessity of medical evacuation and appropriate treatments for service members with musculoskeletal injuries when aided by orthopaedic surgery consultants, thereby limiting the number of unnecessary medical evacuations.

This paper presents and discusses the U.S. Army telemedicine support systems currently available to our deployed forces in Southwest Asia. Organization and structure of the support system are discussed, along with some of the business rules and policies developed for its use. Some of the lessons learned are directly applicable to any type of large-scale telemedicine deployment, civilian or military.