Telemedicine in Extreme Conditions: Supporting the Martin Strel Amazon Swim Expedition

By Rifat Latifi, M.D., Mateja de Leonni Stanonik, M.D., Ph.D., Ronald C.
Merrell, M.D., and Ronald S. Weinstein, M.D.

Slovenian Martin Strel, the Guinness world record holder in ultra marathon swimming, recently set a new world record by swimming the entire Amazon River. Over a 66-day period beginning in Atalaya, Peru, he swam to the Atlantic Ocean at Belém, Brazil. This record-breaking swim was part of the Amazon Swim Expedition. This entire mission was supported by a comprehensive medical team, the Amazon Virtual Medical Team (AVMT), which provided medical support using telemedicine. The AVMT, a multinational volunteer group of specialists, physicians, and telemedicine experts, provided medical support 24/7 in some of the most remote, dangerous, and yet beautiful areas of the Amazon basin. The AVMT was directed by Dr. Rifat Latifi and expedition team physician, Dr. Mateja de Leonni Stanonik, who was aboard the boat during the entire expedition. The expedition provided a unique opportunity to promote telemedicine and e-health in over 17 communities in the Amazon basin.

The Amazon River is made up of over 1,100 tributaries, 17 of which are longer than 1,000 miles. These endless bodies of water span over eight South American countries: Brazil, Bolivia, Peru, Ecuador, Colombia, Venezuela, Guyana, and Suriname. The Amazon River starts high in the Andes Mountains and flows more than 4,000 miles (6,436 km) across the South American continent until it enters the Atlantic Ocean at Belém, Brazil. Ever since humans discovered this magnificent river with its vast, mysterious, remote, dangerous, and yet beautiful territories, the Amazon jungle and the river have been explored. The adventures have ended in new discoveries or tragically with death, yet humans have never stopped attempting to conquer the River and its unchartered tributaries. No one, however, has ever attempted to swim the entire river, until Martin Strel, the Guinness world record holder, tried and succeeded. This record was made possible primarily by Martin Strel’s determination, strength, and superhuman abilities to swim continuously day in and day out, through pain, bad weather, rain, danger, among heavy logs, trees, jungle debris, and numerous river animals, some dangerous and some just curious to see a man swimming among them.

For the first time, however, in addition to grueling preparation and training, Martin Strel had at his side advanced technology and tele-medicine support, and an entire team of virtual physicians of different specialties and expertise from around the world working together as members of the Amazon Virtual Medical Team (AVMT).

The AVMT was established to support the Amazon Swim Expedition (ASE) and was directed from the Arizona Telemedicine Program in Tucson, Arizona. The team consisted of an international panel of expert volunteers networked to provide consultations to the physician on board (Dr. Mateja de Leonni Stanonik) 24 hours per day for the duration of the endeavor. The telemedicine team consisted of surgeons, infectious and tropical disease experts, a dermatologist, an exercise physiologist, psychiatrists, a pathologist, and other experts in telemedicine.

The network was based upon live videoconferencing, store-and-forward technology, e-mail consultations, and telephone. The AVMT was responsible for creation of telemedicine protocols for consultation, and assembling, testing, training on the use of, and transporting the telemedicine equipment to Atalaya, Peru, the starting point of the expedition. All this was accomplished in a very short period (less than 4 months). The connectivity to the boat was provided using a low bandwidth satellite link, Broadband Global Area Network (BGAN) (London, UK) (Fig. 2). Equipment was either borrowed or donated for the expedition and consisted of the following: a Second Opinion real-time and store-and-forward software (Second Opinion Software, Torrance, CA); a portable field deployable telemedicine system (General Devices Rosetta Go-box, Richfield, NJ) (Fig. 3); and a vital signs monitor and defibrillator (Zoll, Chelmsford, MA), which is compatible with portable field deployable telemedicine systems and portable ultrasound machines (SonoSite, Bothell, WA). On the Brazilian part of the expedition, the boat was connected to high bandwidth Internet for “commercial” and advertising purposes of the expedition; however, this was not used for the telemedicine part of the project. Overall, the ASE was a high-tech laboratory floating in the Amazon River, following Martin Strel, while he swam an average of 50 miles a day, 10–12 hours a day, which was broadcast
directly through a World Wide Web-cast.

Materials and Methods

The AVMT was created to support the ASE for the first time in the history of swim expeditions. By using advanced technologies, a virtual medical team assembled to ensure telepresence 24/7 throughout the mission. By using a low bandwidth satellite connection, there was access to the boat at all times. At the end of each mission day, the swimmer’s condition was analyzed. He underwent detailed physical examinations twice a day, before and after the swim. This dynamic process ensured real-time medical management, and changes could be quickly implemented when needed. Furthermore, when we combined real-time access and store-and-forward telemedicine technology, we ensured that every element of the medical care was captured and analyzed as needed by the team of virtual specialists.

The second mission of the AVMT during this expedition was to introduce telemedicine to the region, and to the world. As the expedition traveled the Amazon River, we had a firsthand opportunity to meet with local Presidents of the regions, Governors of the states, and hospital leadership. They all embraced the telemedicine concept and promised full political and moral support. Various methods to introduce telemedicine were used, from demonstrating the equipment aboard the boat to both medical personnel and local leadership, giving formal presentations, and conducting direct discussions regarding the role and importance of telemedicine with the media. This often was done in the presence of political leadership, who were eager to learn more about the technology. We were able to introduce telemedicine to 17 communities during this journey. Contemporary techniques of disseminating information such as MP3 audio reports and YouTube video reports, in addition to written reports (Journal from the Jungle), were used very successfully.

Results

During the expedition, 337 teleconsultations were performed using various techniques. Daily calls between the team physician on board the boat and the medical director of the AVMT were performed using different communication techniques, mainly Skype or satellite phone. When the need for immediate consultation became apparent, such as severe cases of dehydration, conjunctivitis, a fungal mouth infection, and/or a burn, a telephone call was made followed by a video connection. Daily telemedicine rounds were followed by videoconference. If the situation called for a specialty, consult digital images of pertinent pathology such as a fungal infection were taken regularly and sent directly to members of the AVMT for their advice.

On two occasions, an ophthalmologist was consulted for conjunctivitis. Although telemedicine encounters, using the Rosetta Go-box and the Second Opinion software, were recorded and could be sent to the AVMT members as needed, this feature was not used as contact was made directly by e-mail or by telephony for immediate answers.

Despite possibilities of serious injuries, the most common issues were cases of dehydration and other related conditions. Many interventions were performed by the team physician during the expedition on team members and on people from local populations.

The health status of all crewmembers of the ASE was satisfactory at all times, except for the initial adaptation period associated with episodes of diarrhea, upper respiratory infections, and episodes of sunburn. There were few serious diseases or conditions. Dermatitis and a mild pneumonia were treated without any major difficulty.

There were also no serious injuries and no alligator or piranha bites to any of the members of the ASE, including Martin Strel. Episodes of dermatitis, mainly contact dermatitis from the wet suit, in the neck, groin, perineum, and popliteal fossae on Martin Strel were treated aggressively. Prophylaxis for tropical diseases such as malaria and immunization against yellow fever, typhoid fever, and hepatitis A and B, were enforced among all team members.

Prophylaxis for dengue consisted of rigorous insect repellant use.

High doses of vitamin C, mineral complexes, and glutamine were given empirically to the swimmer daily. Also, daily eye and skin care was applied to the swimmer. One member of the team was sent to the local hospital for a chest x-ray and treatment for asthma exacerbation. A team member was sent to a local hospital and treated for anaphylactic shock.

Discussion

Advances in telemedicine and telepresence have made it possible to have a presence in the most remote areas of the world, and to provide care in most situations, from basic medical problems, all the way to trauma and emergencies. This capability offers solutions to bring remote regions into a continuum with established medical facilities in the cities and the global medical community. Such benefits can be applied in the most extreme sports,7 but never before was this attempted in any extreme swimming sports expedition. The AVMT was offered an opportunity to utilize and promote telemedicine applications in very remote areas of the world that are extremely logistically difficult to access. The AVMT used the globalization of this sporting event and its media coverage as a reality that lent itself to the promotion of telemedicine, as a worthwhile cause.

Lessons Learned

Realization of projects such as the AVMT telemedicine expedition requires an enormous amount of resources, a large group of people, and plenty of time for preparation, including visits to various locations along the expedition route. Throughout the preparation process for the expedition and during the swim, the team was plagued by many difficulties and unexpected events that often put the telemedicine mission in serious jeopardy, but in the end we succeeded, due to incredible help from many people throughout the mission.

The AVMT was created and served by volunteers, with limited designated funds. The telemedicine equipment was loaned to the team. The only possible mode of connectivity was satellite. Initially we thought we would have a large stationary satellite that was supposed to be donated by a local provider, while the satellite segment was donated by Intelsat (Washington, DC). This proved to be a daunting task. Intelsat donated satellite bandwidth, but we were not able to use it because of problems with an antenna provider in Peru and delay in bringing and clearing the necessary the equipment through customs in Peru and transporting them to the boat. First, the satellite dish was enormous, and not practical for being on the constantly moving boat, which was often at the mercy of the Amazon River. What was sorely needed was a mobile satellite that offered broad bandwidth.

We found this on a mobile satellite BGAN. While still quite expensive ($7.00 per megabyte data transferred), it was ideal for the expedition and ensured connectivity from the boat at all times. Preparations for expeditions such as the ASE require much time, resources, local contacts, adaptation to the local culture, and knowledge of the territory, traditions, and other cultural barriers. We lacked all of these. Staying on time and on schedule with the expedition was one of the most difficult tasks. There was a tendency for things to happen at a much slower pace than the one we are accustomed to in the developed world. Transportation of large amounts of expensive equipment is very difficult as well, and fraught with serious problems, from the weight of the equipment during flights on the small planes to the security of such equipment. We found that by involving the locals in the decision-making process and having their help with the project was very important and highly desirable. Yet, it tends to become complicated at times, and one has to be very careful throughout the process. One of the best methods to get local help was
to work with their governments, military, and other organizations that have both the infrastructure and the human capacity. Due to ongoing diplomatic efforts of the former President of Slovenia, Dr. Drnovsek, and the leaders in Peru and Brazil, and subsequently the navy and the army of both countries. Through collaborative efforts on many occasions, the entire expedition was helped by both militaries. Team members were brought to the boat even under the most severe and dangerous conditions. Working with local media is also another very important element that one should orchestrate with local leadership.

Despite many difficulties, there were no failures in this project. Every time we encountered a barrier in certain situations, we actually learned something new. We overcame many difficulties and we learned how to use different types of technology, different bandwidths, different cultural nuances, etc. Our achievements were many.

The most important one was the fact that Martin Strel made it to the finish line without any major injury or disease. Although Strel has swum many great rivers before, none compare to the mighty Amazon River. We had telepresence throughout the entire journey. The next most important aspect of the AVMT’s accomplishments was the introduction of telemedicine into regions that are so remote, not just physically but also developmentally. Also, we have created valuable contacts, forming a “human bridge” with these villages, towns, and cities and their medical and political leaders from Atalaya, Peru and Belém, Brazil. This achievement is simply priceless. The handshakes and the relationships that we created with the local people and the regions leaders are one of the most important achievements of this project. Certainly this represents a base for further development of telemedicine in this part of the world. The virtual connectivity that we had from the middle of the Amazon River, in the middle of nowhere,
is just part of the success; however, the human success was much greater than the technological successes we experienced.

Conclusions

The ASE was an incredible human adventure helped by telemedicine, its advanced technologies, and by the spirit of collaborations of many individuals, organizations, and institutions. Telemedicine added the much needed safety factor to the expedition, which brought success to this extraordinary human endeavor. In addition, the ASE, as a high-profile media event, provided a great, as well as a unique medium for promoting telemedicine programs in the Amazon region and the communities along this great river. The ASE brought telemedicine to the global spotlight, with hopes that in the future telemedicine might become utilized on a greater scale in developing countries and medically underserved regions around the world.

As such, telemedicine can lend itself to be extremely beneficial in rendering medical care to people in extreme conditions, or, simply to people living in remote and mountainous sites, and areas affected by natural or manmade catastrophes, or simply in territories that do not have access to modern medical care. We are in the process of developing programs that will follow up on the contacts we made during the expedition, and in establishing sustainable collaborative programs between various organizations and governments as well as individuals. Potentially, these programs will integrate the processes of establishing telemedicine and education/training programs for the healthcare providers in the Amazon region. On the basis of our experiences, we believe that telemedicine could be introduced to regions in need of services or at other high-profile sports and media events around the world. Such promotion, however, needs to be carefully orchestrated by the multidisciplinary team. The enterprise becomes very complex when dealing with many different interests of the partnering groups and individuals during the expeditions.

Acknowledgments

We would like to extend our deepest thanks to the members of the AVMT, the International Virtual e-Hospital Foundation, the Arizona Telemedicine Program, the Governments of Slovenia, Peru, and Brazil, and all other individuals who helped the ASE reach its full potential. Without your help and guidance, this project would not have been possible.