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Chung RT, Legault GL, Stowe JS, Miller KE, Moccia MA, Cooper MR, Little JR, Gensheimer WG. Applying a Military Teleophthalmology Mobile App in a Noncombat Emergent Care Setting. Mil Med 2023; 188:e2909-e2915. [PMID: 36394286 DOI: 10.1093/milmed/usac345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 09/29/2022] [Accepted: 10/21/2022] [Indexed: 08/31/2023] Open
Abstract
INTRODUCTION Teleophthalmology has a natural role in the military due to the inherent organization of its medical system, which provides care to patients in remote locations around the world. Improving access to ophthalmic care enhances force readiness because ocular trauma and disease can cause vision impairment or blindness and can occur anywhere service members are located. Recently, a secure, Health Insurance Portability and Accountability Act-compliant mobile phone application (app) for teleophthalmology called Forward Operating Base Expert Telemedicine Resource Utilizing Mobile Application for Trauma (FOXTROT) was beta tested in Afghanistan and demonstrated that this solution can improve and extend ophthalmic care in a deployed environment. There are few civilian or military teleophthalmology solutions for ocular trauma and disease in an urgent or emergent ophthalmic care setting. Civilian teleophthalmology solutions have largely been developed for disease-specific models of care. In this work, we address this gap by testing the FOXTROT app in a non-deployed, emergent care setting. MATERIALS AND METHODS We evaluated the use of the teleophthalmology mobile phone app (FOXTROT) in a non-deployed military setting at the Malcolm Grow Medical Clinics and Surgery Center at Joint Base Andrews in Maryland. Consults from the emergent care center were placed by providers using the app, and the on-call ophthalmologist responded with treatment and management recommendations. The primary outcomes were response within the requested time, visual acuity tested in both eyes, agreement between the teleophthalmology and the final diagnosis, and the number of communication or technical errors that prevented the completion of consults. The secondary outcomes were average response time and the number of consults uploaded to the medical record. RESULTS From October 2020 to January 2022, 109 consults were received. Ten consults had communication or technical errors that prevented the completion of consults within the app and were excluded from the analysis of completed consults. Of the 99 completed consults, responses were given within the requested time in 95 (96.0%), with the average response time in 11 minutes 48 seconds (95% confidence interval, 8 minutes 57 seconds to 14 minutes 41 seconds). Visual acuity was tested in both eyes in 56 (56.6%). There was agreement between the teleophthalmology diagnosis and the final diagnosisin 40 of 50 (80.0%) consults with both a teleophthalmology and final diagnosis. Ninety-eight (99.0%) consults were uploaded to the patient's medical record. CONCLUSIONS Beta testing of a teleophthalmology mobile phone app (FOXTROT) in a noncombat emergent care setting demonstrated that this solution can extend ophthalmic care in this environment at a military treatment facility. However, improvements in the reliability of the platform are needed in future developments to reduce communication and technical errors.
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Affiliation(s)
- Robert T Chung
- Geisel School of Medicine at Dartmouth, Hanover, NH 03755, USA
| | - Gary L Legault
- Department of Ophthalmology, Brooke Army Medical Center, Fort Sam Houston, TX 78234, USA
- Department of Surgery, Uniformed Services University, Bethesda, MD 20814, USA
| | - Jennifer S Stowe
- US Army Aeromedical Research Laboratory, Fort Rucker, AL 36362, USA
| | - Kyle E Miller
- Department of Surgery, Uniformed Services University, Bethesda, MD 20814, USA
- Department of Ophthalmology, Naval Medical Center Portsmouth, Portsmouth, VA 23708, USA
| | - Michelle A Moccia
- Warfighter Eye Center, Joint Base Andrews, Joint Base Andrews, MD 20762, USA
| | - Mabel R Cooper
- Telemedicine & Advanced Technology Research Center (TATRC), Fort Detrick, MD 21702, USA
| | - Jeanette R Little
- Telemedicine & Advanced Technology Research Center (TATRC), Fort Detrick, MD 21702, USA
- Digital Health Innovation Center (DHIC), Fort Gordon, GA 30905, USA
- US Army Medical Research and Development Command (MRDC), Fort Detrick, MD 21702, USA
| | - William G Gensheimer
- Geisel School of Medicine at Dartmouth, Hanover, NH 03755, USA
- Section of Ophthalmology, White River Junction VA Medical Center, White River Junction, VT 05001, USA
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Breeze J, Gensheimer W, Berg C, Sarber KM. Head Face and Neck Surgical Workload From a Contemporary Military Role 3 Medical Treatment Facility. Mil Med 2021; 187:93-98. [PMID: 34056658 DOI: 10.1093/milmed/usab221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 05/08/2021] [Accepted: 05/18/2021] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION Previous analyses of head, face, and neck (HFN) surgery in the deployed military setting have focused on the treatment of injuries using trauma databases. Little has been written on the burden of disease and the requirement for follow-up care. The aim of this analysis was to provide the most comprehensive overview of surgical workload in a contemporary role 3 MTF to facilitate future planning. METHOD The operating room database and specialty surgical logbooks from a U.S.-led role 3 MTF in Afghanistan were analyzed over a 5-year period (2016-2020). These were then matched to the deployed surgical TC2 database to identify reasons for treatment and a return to theatre rate. Operative records were finally matched to the deployed Armed Forces Health Longitudinal Technology Application-Theater outpatient database to determine follow up frequency. RESULTS During this period, surgical treatment to the HFN represented 389/1989 (19.6%) of all operations performed. Surgery to the HFN was most commonly performed for battle injury (299/385, 77.6%) followed by disease (63/385, 16%). The incidence of battle injury-related HFN cases varied markedly across each year, with 117/299 (39.1%) being treated in the three summer months (June to August). The burden of disease, particularly to the facial region, remained constant throughout the period analyzed (mean of 1 case per month). CONCLUSIONS Medical planning of the surgical requirements to treat HFN pathology is primarily focused on battle injury of coalition service personnel. This analysis has demonstrated that the treatment of disease represented 16% of all HFN surgical activities. The presence of multiple HFN sub-specialty surgeons prevented the requirement for multiple aeromedical evacuations of coalition service personnel which may have affected mission effectiveness as well as incurring a large financial burden. The very low volume of surgical activity demonstrated during certain periods of this analysis may have implications for the maintenance of surgical competencies for subspecialty surgeons.
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Affiliation(s)
- John Breeze
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham B15 2TH, UK
| | - William Gensheimer
- Warfighter Eye Center, Malcolm Grow Medical Clinics and Surgery Center, Joint Base Andrews, MD 20762, USA
| | - Craig Berg
- Department of Neurosurgery, 88th SGC/SGCO, Wright-Patterson Air Force Base, Dayton, OH 45433, USA
| | - Kathleen M Sarber
- Department of Otolaryngology, 96th Medical Group, Eglin AFB, FL 32542, USA
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Altman AHH, Carius BM, Justin GA, Schauer SG, Escandon MA, Maddry JK, Mazzoli RA, Legault GL. A Sub-Analysis of U.S. Africa Command Area of Operations Transportations for Ophthalmic Concerns, 2008-2018. Mil Med 2021; 187:e1148-e1152. [PMID: 33825888 DOI: 10.1093/milmed/usab134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 03/28/2021] [Accepted: 03/30/2021] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION American military personnel in U.S. Africa Command (AFRICOM) operate in a continent triple the size of the USA without mature medical facilities, requiring a substantial transportation network for medical evacuation. We describe medical transportation based on ophthalmic complaints analyzed from the U.S. Transportation Command Regulating and Command and Control Evacuation System (TRAC2ES) database from 2008 to 2018. METHODS We conducted a retrospective review of all TRAC2ES records for medical evacuations for ophthalmic complaints from the AFRICOM theater of operations conducted between January 1, 2008 and December 31, 2018. We analyzed free-text data in TRAC2ES for ophthalmic diagnostic and therapeutic interventions performed before established patient movement requests. An expert panel analyzed evacuations for their indications and interventions. RESULTS Nine hundred and sixty-one total records originating within AFRICOM were identified in TRAC2ES. Forty-three cases (4%) had ophthalmic complaints. The majority of transports were routine (72%) and originated in Djibouti (83%), and all were transported to Landstuhl Regional Medical Center. The majority of patients were evacuated without a definitive diagnosis (60%). Leading ophthalmic diagnoses were chalazion (14%), corneal abrasion/ulcer (14%), and posterior vitreous detachment (12%). More than one-quarter of patients were transported without recorded evaluation and approximately half (51%) did not receive any intervention before evacuation. Consultation with an ophthalmologist occurred in only 16 (37%) cases. By majority, the expert panel deemed 12 evacuations (28%) potentially unnecessary. CONCLUSION Evacuations were primarily routine often for disease etiology and further diagnostic evaluation. These findings support opportunities for telemedicine consultation to avoid potentially unnecessary transportation. Increased ophthalmic care and enhanced data collection on transports would support process improvement, optimize ophthalmic care by ensuring proper disposition of patients thus limiting unnecessary evacuations, and ultimately strengthen the entire fighting force.
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Affiliation(s)
- Adam H H Altman
- Brooke Army Medical Center, Joint Base San Antonio-Fort Sam Houston, TX 78234, USA
| | - Brandon M Carius
- Brooke Army Medical Center, Joint Base San Antonio-Fort Sam Houston, TX 78234, USA.,121 Field Hospital, Camp Humphreys, APO, AP 96205, Republic of Korea
| | - Grant A Justin
- Brooke Army Medical Center, Joint Base San Antonio-Fort Sam Houston, TX 78234, USA.,Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Steven G Schauer
- Brooke Army Medical Center, Joint Base San Antonio-Fort Sam Houston, TX 78234, USA.,Uniformed Services University of the Health Sciences, Bethesda, MD, USA.,U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, TX 78234, USA
| | - Mireya A Escandon
- 59th Medical Detachment Wing, Joint Base San Antonio-Lackland, San Antonio, TX 78236, USA
| | - Joseph K Maddry
- Brooke Army Medical Center, Joint Base San Antonio-Fort Sam Houston, TX 78234, USA.,Uniformed Services University of the Health Sciences, Bethesda, MD, USA.,59th Medical Detachment Wing, Joint Base San Antonio-Lackland, San Antonio, TX 78236, USA
| | - Robert A Mazzoli
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA.,Madigan Army Medical Center, Tacoma, WA 98431, USA
| | - Gary L Legault
- Brooke Army Medical Center, Joint Base San Antonio-Fort Sam Houston, TX 78234, USA
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The epidemiology and outcomes of combat ocular trauma among local nationals managed at a deployed military hospital in Afghanistan. Eye (Lond) 2021; 35:2155-2163. [PMID: 33580187 DOI: 10.1038/s41433-020-01316-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 09/24/2020] [Accepted: 11/11/2020] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND/OBJECTIVES There is limited published data on combat ocular trauma (COT) among local nationals managed at deployed United States (US) and United Kingdom (UK) military hospitals in recent conflicts. We report the epidemiology and outcomes of COT from a deployed military hospital in Afghanistan. SUBJECTS/METHODS In this retrospective case series, consecutive injuries requiring ophthalmic surgery at a military hospital in Afghanistan where the sole US and UK ophthalmologist(s) were deployed between January 2017 and September 2019 were reviewed. The main outcomes were mean post-operative visual acuity (VA) in open and closed globe injury and the incidence of retinal detachment after open globe repair. RESULTS There were 102 eyes of 84 patients who had ocular injuries and underwent ophthalmic surgery at the military hospital. Most patients were male (81 [96%]) and were local nationals (71 [85%]). Blast exposure (82 [80%]) was the most common mechanism of injury. Mean post-operative VA was 1.24 ± 2.29 logMAR (20/348 Snellen equivalent) in open globe injury and 1.59 ± 1.17 logMAR (20/778 Snellen equivalent) in closed globe injury. After open globe repair, retinal detachment developed in 8 of 18 (44%) eyes. CONCLUSIONS COT injuries often resulted in poor post-operative VA and retinal detachment after open globe repair was common. The high incidence and severity of COT sustained by local civilians and combatants in this study may support programs to increase the availability and wear of combat eye protection among local nationals partnered with US and coalition troops.
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Gensheimer WG, Miller KE, Stowe J, Little J, Legault GL. Military Teleophthalmology in Afghanistan Using Mobile Phone Application. JAMA Ophthalmol 2020; 138:1053-1060. [PMID: 32852513 DOI: 10.1001/jamaophthalmol.2020.3090] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance The coronavirus disease 2019 pandemic has highlighted the need to expand telemedicine solutions. Objective To beta test a secure teleophthalmology mobile app at military treatment facilities in Afghanistan. Design, Setting, and Participants This prospective case series included 16 military treatment facilities at diverse roles of care including forward operating bases in Afghanistan and 1 location outside of Afghanistan. Thirty point-of-care medics and medical professionals were included from September to November 2019. Interventions Users placed teleophthalmology consults on their mobile phone using the mobile eye care app, and an expeditionary ophthalmologist stationed at a military hospital in Afghanistan responded. Users graded the mobile app using a rating scale from 1 to 5, with 1 being very dissatisfied and 5 being very satisfied. Main Outcomes and Measures Mean initial response time, agreement between the teleophthalmology diagnosis and final diagnosis, treatment and management following recommendations outlined in the Joint Trauma System clinical practice guidelines, prevention of the need for aeromedical evacuation, user satisfaction, and security and the Health Insurance Portability and Accountability Act compliance of consult. Results There were 28 consults placed over 6 weeks by 18 different users that were received by the expeditionary ophthalmologist. The mean (SD) patient age was 30.3 (9.8) years. Most patients were male (26 [93%]) and active duty US military (22 [78%]). The mean initial response time was 3 minutes 58 seconds (95% CI, 2 minutes 30 seconds to 5 minutes 26 seconds). There was agreement between the teleophthalmology diagnosis and final diagnosis in 24 consults (86%; 95% CI, 72%-100%). The treatment and management followed recommendations outlined in the Joint Trauma System Clinical Practice Guidelines for Eye Trauma: Initial Care in 28 consults (100%). Teleophthalmology consultation prevented the need for aeromedical evacuation in 4 consults (14%; 95% CI, 0.7%-28%). The patient returned to duty in 15 consults (54%; 95% CI, 34%-73%). Median overall satisfaction was 5 (minimum, 3; maximum, 5). All 28 consults (100%) were secure and compliant with the Health Insurance Portability and Accountability Act. Conclusions and Relevance While only a limited number of consults were evaluated, this study suggests that teleophthalmology mobile phone apps may improve and extend ophthalmic care in combat zones.
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Affiliation(s)
- William G Gensheimer
- Warfighter Eye Center, Malcolm Grow Medical Clinics and Surgery Center, Joint Base Andrews, Maryland.,Department of Surgery, Division of Ophthalmology, Uniformed Services University, Bethesda, Maryland
| | - Kyle E Miller
- Department of Surgery, Division of Ophthalmology, Uniformed Services University, Bethesda, Maryland.,Department of Ophthalmology, Navy Medical Center Portsmouth, Portsmouth, Virginia
| | - Jennifer Stowe
- US Army Aeromedical Research Laboratory, United States Army Medical Research and Development Command, Fort Rucker, Alabama
| | - Jeanette Little
- Telemedicine and Advanced Technology Research Center, United States Army Medical Research and Development Command, Fort Detrick, Maryland
| | - Gary L Legault
- Department of Surgery, Division of Ophthalmology, Uniformed Services University, Bethesda, Maryland.,Department of Ophthalmology, Brooke Army Medical Center, San Antonio, Texas
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Prolonged deployed hospital care in the management of military eye injuries. Eye (Lond) 2020; 34:2106-2111. [PMID: 32616869 DOI: 10.1038/s41433-020-1070-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 06/22/2020] [Accepted: 06/23/2020] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND/OBJECTIVES Prolonged hospital care is described as deployed medical care, applied beyond doctrinal planning timelines and military medical planning envisages that in future conflicts, patients will have to be managed for up to 5 days without evacuation to their home country. We aimed to investigate the effect of prolonged hospital care on visual outcomes in the management of open and closed globe injures. METHODS We conducted a retrospective cohort study in the setting of British military operations in Afghanistan. We included consecutive UK military patients with ocular trauma evacuated from Afghanistan between December 2005 and April 2013. We assessed outcome using best-corrected visual acuity (VA) 6-12 months after injury. RESULTS All patients were male, with a mean age of 25. Outcomes adjusted for ocular trauma score (OTS) at presentation were similar to previous reports of military ocular trauma. The mean time to arrival at a centre with an ophthalmologist was 1.74 days. Both patients with penetrating open globe injuries and patients with hyphaema and an OTS of 3 or less displayed an association between worsening 6-12 month VA and time between injury and repair or assessment by an ophthalmologist. CONCLUSION Time to specialist ophthalmic care contributes to outcome after military open and closed globe injuries, supporting deployment of ophthalmologists on military operations.
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