By Ruth Carol, contributing writer, October 01, 2012
What do a Marine deployed in Afghanistan, a soldier stationed at an Air Force base in Texas, and a Peruvian fisherman have in common? They all have likely been treated by a military dermatologist.
Even with operations winding down in Iraq and Afghanistan, dermatologists in the military continue to treat active duty personnel stationed in the U.S. and abroad as well as treat people in medically underserved countries as part of the military’s humanitarian missions around the world.
Treating military personnel at home
With the demand for dermatology services on the rise coupled with a shortage of military dermatologists, which is due either to their deployment or exiting the military to enter private practice or retire, the U.S. military is increasingly relying on the use of teledermatology. [pagebreak]
The Southern Regional Medical Command Teledermatology program, which began in 2001, serves Air Force, Army, and Navy facilities across the United States. Patients include active duty personnel, family members, and retirees, explained retired Lt. Col. Chuck Lappan, the program’s project manager. Most dermatologic conditions can be adequately managed through teledermatology, he noted. To date, nearly 40,000 teleconsultations have been submitted. Thirty-five dermatologists answer skin-related teleconsultations.
This program improves patient access because patients can receive a clinical evaluation through a teleconsultation when an in-person visit with a dermatologist can’t be scheduled for an extended period of time or is not practical because the nearest network dermatologist is so far away, said Maj. W. Chad Cragun, MD, the program’s medical director. It also reduces lost productivity and training as the teledermatology session is conducted at the patient’s facility, eliminating the need for him or her to travel. “In many locations, patients may travel more than 250 miles round-trip to see a dermatologist,” he said. The program is an effective triage tool, as well.
Additionally, the program helps educate primary care physicians (PCPs) about dermatologic conditions, thus improving the quality of care they deliver, Lappan said. The majority of patients are referred back to the PCP for care. [pagebreak]
The program also serves as a training tool for Army and Air Force third-year dermatology residents at the San Antonio Military Medical Center. Third-year residents do a six-week rotation reviewing teleconsultations. They review the information and offer a diagnosis, treatment plan, and follow-up care. Next, the on-call dermatologist reviews the resident’s evaluation, and either agrees, partially disagrees, or disagrees with it. The actual recommendations are given by the dermatologist while the resident receives feedback on his/her evaluation via email. “Teledermatology is a valuable tool to assess how well residents can make a diagnosis and develop a treatment plan,” said Dr. Cragun, who evaluates the residents’ training. At any given time, there are approximately 20 residents undergoing such training.
The primary drawback to the program is limited follow-up with patients, Dr. Cragun said. Inconsistencies in the quality of the patient history and poor quality images can result in a limited diagnosis. Many facilities purchase high-end digital cameras and ensure the consult managers are well versed in using the equipment, he said, but others buy budget equipment and aren’t as conscientious about training the consult managers. [pagebreak]
Lappan has developed training manuals to address some of these issues, he said, but the program still has significant room to grow if awareness of it increases. Still, primary care providers with dermatologists nearby will continue to prefer to refer, Lappan predicted, because the referral is “like a fire-and-forget missile I send the patient to the network and can move on to the next patient.” Meanwhile, a teledermatology consult is like a boomerang, with the primary care provider receiving the dermatologist’s recommendation and continuing to manage the patient using his or her own discretion. Lappan also noted that because “dermatology is not a high-dollar-cost item” for the military, and teledermatology appears to be a break-even proposition rather than a cost-saver, it is likely to remain a way to extend care to underserved areas rather than taking over as the preferred method for routine dermatologic care for non-deployed personnel.
Treating military personnel in combat
Another teleconsultation program, the Army Knowledge Online (AKO) initiative, supports deployed health care professionals who can send a teleconsultation and expect to receive a reply within 24 hours. In fact, the average reply time is approximately five hours. Most of the individuals treated are active duty personnel. However, military personnel from other countries, U.S. or foreign national contractors, host nation nationals, detainees, and civilians are also among the patients. [pagebreak]
The AKO grew out of a 2003 conference of military dermatologists who noted that many soldiers were being evacuated from Iraq for dermatologic issues that could have been managed there if the deployed physicians had a formal way to consult colleagues akin to the Southern Regional program, Lappan said. The AKO began formal operations in 2004. Since then, 18 other specialties have joined the program. Unlike the Southern Regional program, the AKO teleconsultations do not transmit any patient identifying information.
Since its inception, nearly 10,500 teleconsultations have been made from more than 50 foreign locations and the U.S. Navy at sea. Health care providers in Iraq and Afghanistan have been the biggest users of the program, Lappan noted. Initially, 41 percent of the teleconsultations were for dermatology, but that has tapered off to between 22 percent and 30 percent in the past few years largely due to the wind down, he noted. Another reason is that PCPs are becoming more knowledgeable about dermatologic conditions; thus, their usage of the program has decreased.
Still, dermatology remains the most-often-requested teleconsultation. Because dermatology is such a visual specialty it lends itself well to teleconsultation, Dr. Cragun said. “Images often speak a thousand words and are easily sent via teleconsultation systems.” [pagebreak]
Various rashes top the list of common dermatologic complaints, Lappan said. Also common are cutaneous leishmaniasis, scabies, blister beetles, and spider bites, not to mention infections that are fungal, bacterial, and viral in nature. Then there are the occasional patients with chronic conditions, such as psoriasis, that worsen during deployment. One patient had a strange looking mole on the nape of his neck that changed in appearance, Lappan recalled. The provider, a flight surgeon, requested a teleconsultation asking if he should remove the mole for cosmetic purposes. The consulting dermatologist said it looked like a malignant melanoma. The patient was evacuated and had surgery five days later. A pathology report determined that the lesion was malignant melanoma.
Treating civilians around the world
Pounding the pavement on another continent, military dermatologists are busy treating civilians as part of New Horizons, a U.S. Southern Command-sponsored program that combines the provision of medical services and the building of critical community structures that takes place annually in Latin American and Caribbean countries.
Requests for these missions are submitted to the U.S. State Department by the governments of the various countries, explained Lt. Col. Stephanie Schaefer, MD, USAF, who is currently on assignment in Guam, but had previously helped plan these missions for Lackland Air Force Base in Texas. Each year, a list of humanitarian missions is assigned to the larger military medical centers, such as Lackland. [pagebreak]
“Since these are peacetime activities aimed at improving the health and well-being of citizens in the areas visited, they portray a totally different impression of our uniformed personnel and not the war-fighting image that most see in the media,” she said. Because these missions are often carried out in conjunction with health care providers and security personnel from the host nation’s military, they allow an opportunity to teach each other different ways of practicing medicine and also help the host nation’s military gain trust and credibility among its people. This is important in areas where the host nation military is not a well trusted or respected entity, usually because of previous civil war or past issues with corruption. It also lends credibility to the local medical community when they are seen working as a team with a U.S. medical team that is known for its high level of education and clinical skills, Dr. Schaefer said.
The military humanitarian missions are akin to civilian medical missions; the main difference is that the medical teams are comprised of military personnel. Once the communities are decided upon, local government agencies and health ministries advertise the dates and location of the missions. “Invariably a long line of people await the arrival of the medical team each morning,” Dr. Schaefer said.
In 2012, medical services were provided in 11 locations in Peru during a six-week period. But before that, military engineers worked with their Peruvian counterparts to construct a new town community center in Tambo de Mora, which was devastated by an earthquake and tsunami in 2007. The town center includes a library, clinic, auditorium, playground, and a central park area. They also added an emergency room facility to the clinic in Independencia. Then they set up a mobile field hospital in a remote area of Huancavelica where the medical services were provided. [pagebreak]
Col. Steven E. Ritter, USAF, MC, FS, was among the 15 health care providers on the recent Peru mission. “We saw more than 7,000 people in 10 days,” he said. Dr. Ritter treated several cases of lupus, severe eczema, and deep fungal infections. “I saw the worst case of head lice in my life this past trip,” he added.
A man came hobbling in with a debilitating in-grown toenail that he had for three months. Dr. Ritter, who serves as the director of dermatologic surgery at Wilford Hall Medical Center at Lackland Air Force Base when he’s not on a mission, fixed the nail and prescribed antibiotics. “It wasn’t a big deal, but nobody there could fix it for him,” Dr. Ritter said, adding, “It’s not always looking for the zebra or rare things. We love those cases because we’re dermatologists. We like to take pictures so we can go back and teach about them. But the majority of my time is spent educating patients about common, simple conditions.” For example, people in many of these countries think all white patches are leprosy. They don’t understand that white patches may just be dry skin or eczema. Additionally, pigment problems have a social stigma attached to them. One patient with vitiligo burst out bawling after Dr. Ritter explained that it was not caused by parasites and it was not contagious as she had been told previously. Patients are often given erroneous information such as suggestions that their skin condition will cause their hair to fall out or infertility. [pagebreak]
On a mission in Bolivia, patients complained about getting tingly after taking a shower or getting wet; they were concerned something was wrong. Dr. Ritter, who finally realized that they were describing goosebumps, was able to explain that goosebumps are a normal reaction and nothing to worry about. It is gratifying to educate patients and let them know that certain conditions are treatable and are not harmful, he said.
Treating a skin disease that has plagued an individual for years with a simple, long-lasting therapy or removing a small benign growth that no longer interferes with the person’s activities of daily living are the most gratifying experiences of these missions, Dr. Schaefer said. On the other hand, providing follow-up advice to a patient who is awaiting biopsy results can be difficult, she said. But that’s where the local medical providers can sometimes help if they are able to follow up with the patient. Another challenge is diagnosing a dermatologic condition that requires long-term treatment with medications not readily available in these locations.
Dr. Ritter concurred. “It’s difficult to see patients with severe skin disease who are not receiving any type of treatment. Back home, these patients would get an extensive work-up and be prescribed biologics,” he said. Even if these medications were available there, they would be too costly. “An average worker makes less than $20 a day and a tube of medicine costs $80,” he said. In many cases, Dr. Ritter will discuss alternative treatments that may be more readily available and stress the importance of hygiene. [pagebreak]
Imparting medical knowledge is a secondary goal of military missions. Most of the education occurs when seeing patients with the local physicians and medical extenders, the latter of whom are often the only medical provider in these small rural communities, Dr. Schaefer said. “We try to teach medical extenders in each region how to evaluate patients, triage, and diagnose and treat simple, common ailments.” They use a set of laminated reference cards printed in numerous languages by the American Academy of Dermatology as a leave-behind tool. Sometimes, military providers present after-hour lectures. Dr. Ritter, who participates in at least one mission a year, often leaves behind a textbook or two.
Long-lasting relationships are often fostered during these missions, Dr. Schaefer noted. Sometimes, these result in future visits to each other’s medical centers or training in U.S. military medical institutions. Dr. Ritter still keeps in touch with people from his first mission in Bolivia as well as individuals in El Salvador. “I enjoy interacting with other members of the military and working with medical students,” he said. “I have made good friends through the years in the host nations.” [pagebreak]
Treating military personnel on the front lines
Approximately 25 percent of all patients he saw during his tour of duty in Iraq had dermatologic complaints, noted Douglas J. Pugliese, MD, MPH, now an assistant professor of clinical dermatology at the University of Pennsylvania’s Perelman School of Medicine. He treated a lot of fungal and bacterial skin infections. They were almost always methicillin-resistant Staphylococcus aureus (MRSA) infections, he said. This limited the type of antibiotics that could be given as the more effective ones can cause phototoxicity not a good side effect for individuals deployed in the sunny desert. Heat rashes occurred especially during the summer months when the temperature soared to 115 degrees. The 70 pounds of protective gear worn by the Marines and soldiers didn’t help the situation, but it did save lives, he noted. Dr. Pugliese also had to consider cutaneous leishmaniasis whenever a wound or ulcer did not heal, as the disease is endemic to Iraq because it is transmitted by sand flies. “Especially earlier in the war, soldiers and Marines were sleeping in blown-out buildings where they would get bitten,” he said. Wounds from penetrating injuries often resulted in acinetobacter infections because the soil and water were contaminated with the gram negative bacteria. In parts of northern Iraq and Afghanistan, malaria was a big concern.
Dr. Pugliese was not yet a dermatologist when he was deployed in Fallujah. Consequently, he used teledermatology to consult with the dermatologist at the combat support hospital in Baghdad. Emailing pictures for a teleconsultation was much safer than sending a solder or Marine in a helicopter to Baghdad. Using a vehicle to transport them was even more dangerous because of explosive devices. It also keeps them from having to come out of the field. Dr. Pugliese was able to manage most dermatologic cases with guidance from the dermatologist. Patients requiring a biopsy, however, had to go to the Army hospital in Germany because he lacked pathology capabilities. (Soldiers in Afghanistan today can be biopsied in-country and have their specimens sent to Germany to be read.)
After the buildup in Iraq and Afghanistan, most soldiers and Marines had the ability to shower once a week, which significantly reduced the number and morbidity of skin infections, he said. Having facilities in which to sleep reduced the incidence of cutaneous leishmaniasis, as well. In addition, the use of clothing made of dry weave material kept Marines and soldiers dry in a moist environment. Boots designed to perform better in the desert reduced blistering and other skin problems on the feet.
To learn more about more about how better armor protects soldiers, see the online-only slideshow.