TOXICOLOGY INVESTIGATION Wartime Toxicology: Evaluation of aMilitaryMedical Toxicology Telemedicine Consults Service to Assist Physicians Serving Overseas and in Combat (2005–2012)

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 elec tronic mail te lemedicine 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 USmilitary, 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 There is no prior publication, conflict of interest, or copyright constraint. The views expressed in this article are those of the authors and do not reflect the official policy or position of the Department of the US Air Force, Department of Defense, or the US government. J. K. Maddry (*) :D. Sessions :V. S. Bebarta Medical Toxicology, San Antonio Military Medical Center, 8906 Azalea Pointe, San Antonio, TX 78255, USA e-mail: [email protected] D. Sessions e-mail: [email protected] V. S. Bebarta e-mail: [email protected] K. Heard Rocky Mountain Poison and Drug Center, Denver, CO, USA e-mail: [email protected] C. Lappan Southern Regional Medical Command, Fort SamHouston, TX, USA e-mail: [email protected] J. McManus Georgia Regents University, Augusta, GA, USA e-mail: [email protected] J. Med. Toxicol. (2014) 10:261–265 DOI 10.1007/s13181-014-0398-z