Charles Lappan - Academia.edu (original) (raw)

Papers by Charles Lappan

Military Medicine, Nov 1, 2009

Global operations place large numbers of military and nonmilitary personnel in austere environmen... more Global operations place large numbers of military and nonmilitary personnel in austere environments. Aeromedical evacuation for cardiovascular issues is periodically required. The Army Knowledge Online (AKO) Telemedicine Consultation Program was initiated by the Office of the Surgeon General to electronically link deployed medical providers with subspecialty consultants to assist and guide triage and disposition. Electronic consultation triggered a text page to an on-call staff cardiologist at Brooke Army Medical Center. Cardiology teleconsultations for the first 3.5 years were analyzed. Two hundred seven cardiology teleconsults were managed, with an average response time of 4 hours 54 minutes. The three most prevalent reasons for teleconsultation were electrocardiographic abnormalities, chest pain syndromes, and syncope. Six evacuations were avoided; 29 evacuations were facilitated. An estimated $144,000 was saved, plus intangible benefits. Cardiology teleconsultation provides a valuable service to deployed providers, decreases medical evacuation costs, and facilitates transfer of patients to appropriate facilities.

Military Medicine, Oct 1, 2009

The user has requested enhancement of the downloaded file.

Arthritis care & research, Jan 11, 2016

Teleneurology in Practice, 2015

Prehospital and disaster medicine

In April 2004, the US Army Medical Department approved the use of the Army Knowledge Online (AKO)... more In April 2004, the US Army Medical Department approved the use of the Army Knowledge Online (AKO) electronic e-mail system as a teleconsultation service for remote teledermatology consultations from healthcare providers in Iraq, Kuwait, and Afghanistan to medical subspecialists in the United States. The success of the system has resulted in expansion of the telemedicine program to include 11 additional clinical specialty services: (1) burn-trauma; (2) cardiology; (3) dermatology; (4) infectious disease; (5) nephrology; (6) ophthalmology; (7) pediatric intensive care; (8) preventive and occupational medicine; (9) neurology; (10) rheumatology; and (11) toxicology. The goal of the program is to provide a mechanism for enhanced diagnosis of remote cases resulting in a better evacuation system (i.e., only evacuation of appropriate cases). The service provides a standard practice for managing acute and emergent care requests between remote medical providers in austere environments and rea...

Military Medicine, 2014

A retrospective evaluation of the Department of Defense teledermatology consultation program from... more A retrospective evaluation of the Department of Defense teledermatology consultation program from 2004 to 2012 was performed, focusing on clinical application and outcome measures such as consult volume, response time, and medical evacuation status. A retrospective review of the teledermatology program between 2004 and 2012 was evaluated based on defined outcome measures. In addition, 658 teledermatology cases were reviewed to assess how the program was utilized by health care providers from 2011 to 2012. As high as 98% of the teledermatology consults were answered within 24 hours, and 23% of consults within 1 hour. The most common final diagnoses included eczematous dermatitis, contact dermatitis, and evaluation for nonmelanoma skin cancer. The most common medications recommended included topical corticosteroids, oral antibiotics, antihistamines, and emollients. Biopsy was most commonly recommended for further evaluation. Following teleconsultation, 46 dermatologic evacuations were "avoided" as the patient was not evacuated based on the consultants' recommendation. Consultants' recommendations to the referring provider "facilitated" 41 evacuations. Telemedicine in the U.S. military has provided valuable dermatology support to providers in remote locations by delivering appropriate and timely consultation for military service members and coalition partners. In addition to avoiding unnecessary medical evacuations, the program facilitated appropriate evacuations that may otherwise have been delayed.

Journal of Medical Toxicology, 2014

Those medical providers deployed to remote countries and tasked with caring for military personne... more 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 electronic mail telemedicine 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 US military, 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 guidelines for remote locations. Expansion of the current military teleconsultation program capabilities to include video teleconsultation may improve the effectiveness of military medical toxicology teleconsultation.

Telemedicine and e-Health, 2006

This paper presents and discusses the U.S. Army telemedicine support systems currently available ... more This paper presents and discusses the U.S. Army telemedicine support systems currently available to our deployed forces in Southwest Asia. Organization and structure of the support system are discussed, along with some of the business rules and policies developed for its use. Some of the lessons learned are directly applicable to any type of large-scale telemedicine deployment, civilian or military.

Neurology, 2012

This study evaluated usage of the Army Knowledge Online (AKO) Telemedicine Consultation Program f... more This study evaluated usage of the Army Knowledge Online (AKO) Telemedicine Consultation Program for neurology and traumatic brain injury (TBI) cases in remote overseas areas with limited access to subspecialists. We performed a descriptive analysis of quantity of consults, response times, sites where consults originated, military branches that benefitted, anatomic locations of problems, and diagnoses. This was a retrospective analysis that searched electronic databases for neurology consults from October 2006 to December 2010 and TBI consults from March 2008 to December 2010. A total of 508 consults were received for neurology, and 131 consults involved TBI. For the most part, quantity of consults increased over the years. Meanwhile, response times decreased, with a mean response time of 8 hours, 14 minutes for neurology consults and 2 hours, 44 minutes for TBI consults. Most neurology consults originated in Iraq (67.59%) followed by Afghanistan (16.84%), whereas TBI consults mainly originated from Afghanistan (40.87%) followed by Iraq (33.91%). The most common consultant diagnoses were headaches, including migraines (52.1%), for neurology cases and mild TBI/concussion (52.3%) for TBI cases. In the majority of cases, consultants recommended in-theater management. After receipt of consultant's recommendation, 84 known neurology evacuations were facilitated, and 3 known neurology evacuations were prevented. E-mail-based neurology and TBI subspecialty teleconsultation is a viable method for overseas providers in remote locations to receive expert recommendations for a range of neurologic conditions. These recommendations can facilitate medically necessary patient evacuations or prevent evacuations for which on-site care is preferable.

Military Medicine, 2009

Global operations place large numbers of military and nonmilitary personnel in austere environmen... more Global operations place large numbers of military and nonmilitary personnel in austere environments. Aeromedical evacuation for cardiovascular issues is periodically required. The Army Knowledge Online (AKO) Telemedicine Consultation Program was initiated by the Office of the Surgeon General to electronically link deployed medical providers with subspecialty consultants to assist and guide triage and disposition. Electronic consultation triggered a text page to an on-call staff cardiologist at Brooke Army Medical Center. Cardiology teleconsultations for the first 3.5 years were analyzed. Two hundred seven cardiology teleconsults were managed, with an average response time of 4 hours 54 minutes. The three most prevalent reasons for teleconsultation were electrocardiographic abnormalities, chest pain syndromes, and syncope. Six evacuations were avoided; 29 evacuations were facilitated. An estimated $144,000 was saved, plus intangible benefits. Cardiology teleconsultation provides a valuable service to deployed providers, decreases medical evacuation costs, and facilitates transfer of patients to appropriate facilities.

Military Medicine, 2009

The user has requested enhancement of the downloaded file.

American Journal of Ophthalmology, 2011

Journal of surgical orthopaedic advances, 2011

Telemedicine is a recent development, designed to assist patients with limited physical access to... more Telemedicine is a recent development, designed to assist patients with limited physical access to expert subspecialty medical care. The United States Army has established a telemedicine program, consisting of e-mail consultations from deployed health care providers to subspecialty consultants. Orthopaedic surgery became a participating consultant group in July 2007. The goal of this study is to describe the Army's telemedicine orthopaedic program and to review its progress and achievements. All consults initiated from July 2007 through April 2009 were reviewed. A total of 208 consults were received by the telemedicine orthopaedic consultation program. Predominant regions of origin were Iraq, Navy Afloat, and Afghanistan. The Army accounted for the majority of consults. Prevalent musculoskeletal complaints were fracture, sprain, neuropathy, and tendon injury. Of the 74 fracture consultations, hand and wrist fractures were most common. Symptomatic treatment or casting/splinting we...

Military Medicine, Nov 1, 2009

Global operations place large numbers of military and nonmilitary personnel in austere environmen... more Global operations place large numbers of military and nonmilitary personnel in austere environments. Aeromedical evacuation for cardiovascular issues is periodically required. The Army Knowledge Online (AKO) Telemedicine Consultation Program was initiated by the Office of the Surgeon General to electronically link deployed medical providers with subspecialty consultants to assist and guide triage and disposition. Electronic consultation triggered a text page to an on-call staff cardiologist at Brooke Army Medical Center. Cardiology teleconsultations for the first 3.5 years were analyzed. Two hundred seven cardiology teleconsults were managed, with an average response time of 4 hours 54 minutes. The three most prevalent reasons for teleconsultation were electrocardiographic abnormalities, chest pain syndromes, and syncope. Six evacuations were avoided; 29 evacuations were facilitated. An estimated $144,000 was saved, plus intangible benefits. Cardiology teleconsultation provides a valuable service to deployed providers, decreases medical evacuation costs, and facilitates transfer of patients to appropriate facilities.

Military Medicine, Oct 1, 2009

The user has requested enhancement of the downloaded file.

Arthritis care & research, Jan 11, 2016

Teleneurology in Practice, 2015

Prehospital and disaster medicine

In April 2004, the US Army Medical Department approved the use of the Army Knowledge Online (AKO)... more In April 2004, the US Army Medical Department approved the use of the Army Knowledge Online (AKO) electronic e-mail system as a teleconsultation service for remote teledermatology consultations from healthcare providers in Iraq, Kuwait, and Afghanistan to medical subspecialists in the United States. The success of the system has resulted in expansion of the telemedicine program to include 11 additional clinical specialty services: (1) burn-trauma; (2) cardiology; (3) dermatology; (4) infectious disease; (5) nephrology; (6) ophthalmology; (7) pediatric intensive care; (8) preventive and occupational medicine; (9) neurology; (10) rheumatology; and (11) toxicology. The goal of the program is to provide a mechanism for enhanced diagnosis of remote cases resulting in a better evacuation system (i.e., only evacuation of appropriate cases). The service provides a standard practice for managing acute and emergent care requests between remote medical providers in austere environments and rea...

Military Medicine, 2014

A retrospective evaluation of the Department of Defense teledermatology consultation program from... more A retrospective evaluation of the Department of Defense teledermatology consultation program from 2004 to 2012 was performed, focusing on clinical application and outcome measures such as consult volume, response time, and medical evacuation status. A retrospective review of the teledermatology program between 2004 and 2012 was evaluated based on defined outcome measures. In addition, 658 teledermatology cases were reviewed to assess how the program was utilized by health care providers from 2011 to 2012. As high as 98% of the teledermatology consults were answered within 24 hours, and 23% of consults within 1 hour. The most common final diagnoses included eczematous dermatitis, contact dermatitis, and evaluation for nonmelanoma skin cancer. The most common medications recommended included topical corticosteroids, oral antibiotics, antihistamines, and emollients. Biopsy was most commonly recommended for further evaluation. Following teleconsultation, 46 dermatologic evacuations were "avoided" as the patient was not evacuated based on the consultants' recommendation. Consultants' recommendations to the referring provider "facilitated" 41 evacuations. Telemedicine in the U.S. military has provided valuable dermatology support to providers in remote locations by delivering appropriate and timely consultation for military service members and coalition partners. In addition to avoiding unnecessary medical evacuations, the program facilitated appropriate evacuations that may otherwise have been delayed.

Journal of Medical Toxicology, 2014

Those medical providers deployed to remote countries and tasked with caring for military personne... more 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 electronic mail telemedicine 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 US military, 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 guidelines for remote locations. Expansion of the current military teleconsultation program capabilities to include video teleconsultation may improve the effectiveness of military medical toxicology teleconsultation.

Telemedicine and e-Health, 2006

This paper presents and discusses the U.S. Army telemedicine support systems currently available ... more This paper presents and discusses the U.S. Army telemedicine support systems currently available to our deployed forces in Southwest Asia. Organization and structure of the support system are discussed, along with some of the business rules and policies developed for its use. Some of the lessons learned are directly applicable to any type of large-scale telemedicine deployment, civilian or military.

Neurology, 2012

This study evaluated usage of the Army Knowledge Online (AKO) Telemedicine Consultation Program f... more This study evaluated usage of the Army Knowledge Online (AKO) Telemedicine Consultation Program for neurology and traumatic brain injury (TBI) cases in remote overseas areas with limited access to subspecialists. We performed a descriptive analysis of quantity of consults, response times, sites where consults originated, military branches that benefitted, anatomic locations of problems, and diagnoses. This was a retrospective analysis that searched electronic databases for neurology consults from October 2006 to December 2010 and TBI consults from March 2008 to December 2010. A total of 508 consults were received for neurology, and 131 consults involved TBI. For the most part, quantity of consults increased over the years. Meanwhile, response times decreased, with a mean response time of 8 hours, 14 minutes for neurology consults and 2 hours, 44 minutes for TBI consults. Most neurology consults originated in Iraq (67.59%) followed by Afghanistan (16.84%), whereas TBI consults mainly originated from Afghanistan (40.87%) followed by Iraq (33.91%). The most common consultant diagnoses were headaches, including migraines (52.1%), for neurology cases and mild TBI/concussion (52.3%) for TBI cases. In the majority of cases, consultants recommended in-theater management. After receipt of consultant's recommendation, 84 known neurology evacuations were facilitated, and 3 known neurology evacuations were prevented. E-mail-based neurology and TBI subspecialty teleconsultation is a viable method for overseas providers in remote locations to receive expert recommendations for a range of neurologic conditions. These recommendations can facilitate medically necessary patient evacuations or prevent evacuations for which on-site care is preferable.

Military Medicine, 2009

Global operations place large numbers of military and nonmilitary personnel in austere environmen... more Global operations place large numbers of military and nonmilitary personnel in austere environments. Aeromedical evacuation for cardiovascular issues is periodically required. The Army Knowledge Online (AKO) Telemedicine Consultation Program was initiated by the Office of the Surgeon General to electronically link deployed medical providers with subspecialty consultants to assist and guide triage and disposition. Electronic consultation triggered a text page to an on-call staff cardiologist at Brooke Army Medical Center. Cardiology teleconsultations for the first 3.5 years were analyzed. Two hundred seven cardiology teleconsults were managed, with an average response time of 4 hours 54 minutes. The three most prevalent reasons for teleconsultation were electrocardiographic abnormalities, chest pain syndromes, and syncope. Six evacuations were avoided; 29 evacuations were facilitated. An estimated $144,000 was saved, plus intangible benefits. Cardiology teleconsultation provides a valuable service to deployed providers, decreases medical evacuation costs, and facilitates transfer of patients to appropriate facilities.

Military Medicine, 2009

The user has requested enhancement of the downloaded file.

American Journal of Ophthalmology, 2011

Journal of surgical orthopaedic advances, 2011

Telemedicine is a recent development, designed to assist patients with limited physical access to... more Telemedicine is a recent development, designed to assist patients with limited physical access to expert subspecialty medical care. The United States Army has established a telemedicine program, consisting of e-mail consultations from deployed health care providers to subspecialty consultants. Orthopaedic surgery became a participating consultant group in July 2007. The goal of this study is to describe the Army's telemedicine orthopaedic program and to review its progress and achievements. All consults initiated from July 2007 through April 2009 were reviewed. A total of 208 consults were received by the telemedicine orthopaedic consultation program. Predominant regions of origin were Iraq, Navy Afloat, and Afghanistan. The Army accounted for the majority of consults. Prevalent musculoskeletal complaints were fracture, sprain, neuropathy, and tendon injury. Of the 74 fracture consultations, hand and wrist fractures were most common. Symptomatic treatment or casting/splinting we...