Page 126 - JSOM Summer 2019

Local laboratory personnel reviewed these smears and made FIGURE 2 Initial blood culture results obtained from a local
a diagnosis of Plasmodium falciparum malaria. At this time, hospital, received 48 hours after presentation.
the differential diagnosis was dengue fever, septic arthritis, HEMOCULTURE
and Lyme disease because the patient had traveled from an Date du prélèvement 23/09/2017
endemic area approximately 2 weeks earlier. And there was a Heure du prélèvement 21h30
report of possible host nation laboratory findings of positive Pousse sur flacon d'hémoculture Positive à J+2
Lyme serology. Examen après coloration de Gram Baciles Gram Négatif

Germe 1 identifié En cours
A second email from the consultant recommended initiating
a regimen of vancomycin and/or clindamycin and amoxicillin. Germe 2 identifié En cours
The medic contacted the USARAF senior PA to determine if Conclusion En cours...
there were any alternative options while awaiting the results of
the new blood tests, which included blood cultures. Commu- status, the team decided to complete the course of therapy with
nication was accomplished through synchronous consultation artemether/lumefantrine, begin treatment with ertapenem (1g
to seek additional guidance regarding illness management and daily), and to evacuate the patient (estimated evacuation time
evacuation concerns. After a brief phone call, the visual assess- was 36 hours). Throughout the patient’s course, acetaminophen
ment was conducted using a prototype “Telehealth in a Bag” was used as an antipyretic, and its analgesic properties were
(THIAB; Figure 1) device and additional support was requested frequently augmented with ketorolac IV/IM for pain control.
from an infectious disease specialist using the ADvanced VIr- His malarial chemoprophylaxis was consequently discontinued
tual Support for OpeRational Forces (ADVISOR) system. The while taking the artemether/lumefantrine. Chemoprophylaxis
ADVISOR system is designed for deployed caregivers to call a was resumed once the treatment course was complete.
phone number that connects to an automated call distribution
(ACD) system that offers a menu of options for the caregiver From the initial presentation, it took 120 hours to evacuate
to select a specialty consultant. The ACD system then contacts the patient to Landstuhl, Germany. It took 48 hours to CA-
1
the on-call physician and connects the caller directly to the ex- SEVAC the patient after the initial request. Within 12 hours of
pert consultant. If the physician is unable to accept the call, arriving in Germany, the Soldier received a diagnosis of Salmo-
the ACD system automatically calls a second/back-up on-call nella paratyphi infection from cultures redrawn in Germany.
physician. Similarly, if that physician cannot take the request,
the ACD system forwards the request immediately to an on-call Clinical Questions
emergency department that either provides appropriate consul-
tation or finds a local on-call specialist to assist. 1 The following clinical questions were considered before the
original synchronous call to the ADVISOR infectious disease
FIGURE 1 Screen view of the THIAB system in use with this patient. specialist:
Communication occurred between the PA and the medic on the
ground, almost 5,200 miles away.
1. Is more immediate evacuation required based on the pa-
tient’s clinical course?
2. What is the appropriate treatment for gram-negative
bacteremia?

Consultation(s)

Local:
None. No local US clinical assets; USARAF surgeon and PA
located almost 4,000 miles away in Italy. Unit surgeon located
5,600 miles away in Fort Drum, NY.

Telemedicine:
• The medics initiated it with an e-mail sent to the Army
Teleconsultation Program for Deployed Providers distri-
bution list. A response received about 4 hours later in-
cluded a request for additional subjective and objective
information, labs, and the guidance to get the patient
Initial Treatment
to US clinical care/physician as soon as possible. Emails
Due to the reported positive findings of malaria on the blood were also sent to the USARAF PA to assist in providing
smears, treatment was started with artemether/lumefantrine, care based on the medic’s scope of practice and avail-
and intravenous access was obtained. The patient received ability of treatment options.
1000mL of normal saline intravenously over 8 hours while • Forty-eight hours later, a call was made to the USARAF
the medics monitored vital signs, fluids in and out, and gen- PA, as the patient was not improving despite appropri-
eral progress. The patient showed no improvement. Subse- ate treatment for malaria. After a brief clinical evalu-
quently, the blood cultures obtained on the previous day grew ation using the THIAB system, the USARAF PA used
gram-negative rods (Figure 2). the ADVISOR system to contact an infectious disease
specialist. Guidance and treatment assistance options
After an additional consultation with the ADVISOR infec- were provided. Treatment was initiated while awaiting
tious disease specialist, to relay updates on the patient’s clinical evacuation – approximately 18 to 36 hours away.

124 | JSOM Volume 19, Edition 2 / Summer 2019