A Thesis submitted to The University of Arizona College of Medicine - Phoenix in partial fulfillment of the requirements for the Degree of Doctor of Medicine.

The field of telehealth has developed rapidly in recent years. It provides medical support particularly to those who are living in remote areas and in emergency cases. Although developments in both technology and practice have been rapid, there are still many gaps in our knowledge with regard to the effective application of telehealth. This study investigated human colour perception in telehealth, specifically the colour red as one of the key symptoms when diagnosing different pathologies. The quality of medical images is safety critical when transmitting the symptoms of pathologies in telehealth, as distorted or degraded colours may result in errors. The study focused on the use of digital images in teleconsultation, particularly on images showing cellulitis (bacterial skin infection) and conjunctivitis (red eye) as case studies, as both of these pathologies involve the colour red in their diagnosis. The study proposed and tested the use of an image quality scale, which represented the level of image resolution; a red colour scale, which represented the intensity of redness in an image; and a confidence scale, which represented the levels of confidence that telehealth users had when judging the colour red. The research involved a series of experiments using hypothetico-deductive and formal hypothesis testing with two groups of participants, medical doctors and non-medical participants. The experiments were conducted in collaboration with the local National Health Service (NHS) Accident and Emergency (A&E) department at Aberdeen Royal Infirmary (ARI). Medical experts in ophthalmology and dermatology were also involved in selecting and verifying the relevant images. The study found that doctors and non-doctors were consistent in the majority of the experiments. The accuracy of the participants was demonstrably higher when using a colour scale with pictures, more so for the non-doctor group than the doctor group. It also found that the level of accuracy for both doctors and nondoctors was higher when using red colour scale of three divisions than when using a scale of five divisions. This result was supported by previous studies, which used telehealth for diagnosing extreme cases. The study also found that when the image quality was poor the participants had higher error rates and less consistency in their answers. The study found poor correlation between accuracy, confidence and time for both participant groups. The study found that most participants in both doctor and non-doctor groups had high confidence most of the time, whether the accuracy was high or low. It was also found that medical background or clinical experience had no effect on the accuracy level across the experiment sets. In some cases, doctors with no or little experience had higher accuracy than those with greater experience. This result may have significant implications for the feasibility of involving non-doctors in the management of telehealth systems, especially in tasks not requiring medical skills, such as colour classification. This has the potential to provide a considerable saving in resources and costs for healthcare providers. An auto-evaluation system was introduced, and proposed for further study, in order to improve the current telehealth diagnostic protocol and to avoid or prevent errors by making red colour classification more objective and accurate.

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This is a submission for a PhD by portfolio on the subject of managing health services support to military operations. It is based upon my prior published work supported by an ‘action research’ analysis of the application of this prior knowledge to my experiences from spending a year in the South of Afghanistan from October 2009 to November 2010. The submission is structured around three thematic areas; medical planning to support military operations, management of military medical operations and international military medical engagement with indigenous health sectors. The submission presents evidence for my contribution to original thinking in each of these thematic areas by means of a review of my published work, my application of these concepts in support of NATO operations in Afghanistan and evidence of the impact of these concepts in influencing other military organisations. The first theme area on medical planning to support military operations will be supported by 3 monographs. These will describe the context of medical support to military operations in the current security environment, the use of the ‘estimate’ process to develop a medical plan and the analytical process termed ‘the casualty estimate’. The second theme covers the management of military medical operations. This is the largest section and contains monographs on pre-hospital helicopter medical evacuation, aeromedical evacuation movement between hospitals, managing casualty flows, deployed hospital care, and quality assurance of the medical system. The final theme covers international military medical engagement with medical support systems for indigenous security forces and indigenous civilian health systems. The closing section of this submission reflects on my two tours in Afghanistan comparing my recent experiences with my views at the end of my first tour in 2006/07. My whole thesis provides evidence of my considerable personal learning from my experiences managing medical support to military operations. This section will highlight how I have tried to share this experience both personally and across multiple stakeholder organisations to ensure my observations can be converted into lessons learned.

Bakgrund: Regionalt Läkarstöd (RLS) har utformats för att säkra prehospital involvering från läkare. Dagens ambulanssjukvård ställer höga krav på att bedöma och triagera patienter till rätt vårdnivå. Till sin hjälp i sitt dagliga arbete med detta behöver sjuksköterskan en läkare som är väl insatt i verksamheten. Syfte: Att beskriva läkares erfarenhet av att fungera som rådgivare till sjuksköterskor inom ambulanssjukvården Metod: Kvalitativ intervjustudie med tio läkare som tjänstgör som RLS. Analysen genomfördes med en kvalitativ innehållsanalys. Resultat: Resultatet beskrivs med de fyra kategorierna Teamsammanhållning, Frustration, Bristande ansvarskänsla och Lyhördhet, som speglade läkarnas erfarenheter av att vara telefonstöd till sjuksköterskor. Ett latent huvudbudskap identifierades som Skör tillit. Att som en del i teamet finnas som stöd och rådgivare till sjuksköterskor i ambulanssjukvården upplevdes som positivt och funktionen ses som relevant och viktig. Det krävs en god teamsamverkan mellan professionerna för en patientsäker vård och för att uppnå det utkristalliserades tillit som en nyckelfaktor. Konklusion: En telefonbaserad bakjourslinje dit sjuksköterskor kan vända sig för råd och stöd är en relevant funktion för läkarna, där de känner sig som en del i det prehospitala teamet. I arbetet med bättre teamsamverkan inkluderande god kommunikation för säker vård, är gemensamma möten och övningar en viktig del för att ge professionerna en chans att mötas som personer och främja ökad förståelse för varandras kunskap och utforma gemensamma mål. / Background: Regional Medical support has been designed to ensure an involvement of doctors in the prehospital field. The current system for ambulance care raise high demands to ensure a correct patient assessment and triage to the right level of care, and for their assistance in this daily work, the nurse needs a doctor who is very knowledgeable in the organization. Purpose: To describe doctors’ experience of functioning as advisors for nurses working in the ambulance. Method: A qualitative research design was conducted including interviews with nine doctors serving as Regional Medical support. The content analysis was conducted according to a qualitative content analysis method.  Result: The analysis resulted in the four categories team spirit, frustration, lack of sense of responsibility and responsiveness, which mirrored the doctors’ experiences of acting as a phone support for specialist nurses on the ambulance. An underlying main message was identified as delicate trust. To be part of the team and act as a support and advisor for nurses working on the ambulance was perceived as positive, relevant and important. Good teamwork between the professions is required to guarantee patient safe care, and to obtain that, trust came through as a key factor. Conclusion: For the nurses to have an on call doctor that they can reach on the phone for support and advice was seen as a relevant system for the doctors, where they feel as a part of the prehospital team. In the continuous work for better teamwork, including good communication for safe care, it's important with common gatherings and training sessions to give the professions a chance to meet in person and gain a better understanding for each other’s roles, and enunciate common goals.

No description available.