Surgeon captain H.J. Prins was invited at the International Symposium on Telemedicine in the Brussels Military Hospital to give a short account of the telemedicine project within the Dutch Armed Forces. This expert, based at the Central Military Hospital in Utrecht, first offered a brief, yet interesting history of the general subject before entering into the specific details of the telemedical efforts in the Dutch Army, which are being focused on teleradiology. A story full of challenges to accept and difficulties to overcome with the aim of delivering optimised medical care and education for the soldiers and their families in times of war and peace .
Telemedicine is the marriage between high-performance communication technology and medical expertise, born out of the need to manage and transmit pictures, stored in PACS (Picture Archiving and Communications Systems) at radiology departments. Today, teleradiology constitutes the most advanced of all telemedical applications, which have stretched out to various specialities. Telemedicine thanks its giant success to the growing demands for a cost reducing health care delivery system.
The American ministry of defence has taken up a leading role in this process by deploying several initiatives to electronise the battlefield medicine. Captain Prins describes the picture of a wounded soldier surrounded by high-tech devices such as personal status monitors, meditags and helmet mounted videocameras. Digital transmission and storage form the key to all these innovative techniques. Captain Prins considers the absence of distortion and the wide dynamic range as the major benefits of digitalisation while no loss of information nor any increase of noise is being caused. The only disadvantage lies in the great amount of information carried by a digital image which forces scientists to develop smart ways of data compression.
The Dutch armed forces were or still are involved in peace-keeping activities in Cambodia and in former Yugoslavia. The government has stated that the quality of the medical care provided during these operations should equal the health care offered in the Netherlands, as Prins testifies. This task has been assigned to a medical company with an additional surgical team, including a general surgeon, an anaesthesiologist and a radiographer fitted out with stationary and mobile x-ray equipment as well as an ultrasound machine, to make his own diagnoses. This expert team is responsible for high-quality care delivery without the possibility of consultation like it would be in a regular hospital.
The Dutch Army developed a telemedicine system precisely to meet these consultation needs, as Prins explains. A computer with a 17 inch monitor is connected with a storage phosphor reader, a digitiser, an ultrasound machine, a cardiograph and a videocamera. The whole set comes in two-fold. Conventional x-ray machines produce x-rays on photo-stimulable phosphor screens for reasons of reusability. The generated data are transferred to the computer's harddisk or to CD-Rom. The specialist views and interprets the data on the monitor while a videoprinter is printing out the images. They are transmitted to the Central Military Hospital (CMH) by a Vsat-connection where they are discussed with experts via a telephone connection.
The CMH also has a connection with both the Central Sickbay of the Navy in Den Helder and the Defence Selection and Recruiting Centre in Amsterdam. Radiographers who are likely to be sent out to the field hospital already can train themselves with an identical system, present at CMH where one has just started out with the digitalisation of the radiology department itself. Prins insists that the telemedicine system is of no use in acute traumatic situations since the members of the expert team are too busy with life and limb saving procedures on such occasions. Only afterwards, they will be able to think telemedicine and consult their colleagues in the Netherlands to optimise the treatment results. In no way ever, telemedicine will substitute the local expertise of the surgical team.
Finally, Captain Prins summarises some of the problems telemedicine has encountered in the Dutch Army. At first, surgeons had difficulty accepting the system because of the low level grade of the injuries. Maybe, also psychological reasons may have entered the game since physicians were not used to diagnosing cases on a monitor screen. Insufficient bandwidth for transmission of real time ultrasound- and video pictures often led to poor quality. Yet, the system's operability during emergencies can only be proven if it is used on a daily basis. Prins announces that the system soon will be evaluated. The final outcome will determine the telemedical future of the Dutch Armed Forces. Read more about related subjects on the Symposium web site.