Optimising remote health care delivery in Antarctica: a review of the current capabilities utilised in the British Antarctic Territory

ABSTRACT

Injury in Antarctica can have a significant impact when considering transfer timelines of several weeks. Medical support to the British Antarctic Territory (BAT) is provided by deployed healthcare professionals and the utilisation of “reach-back” with telemedicine. This is paired with robust training and familiarisation with a system of modularised deployed equipment.

This paper examines the current telemedicine strategy, infrastructure modularisation, and influence from military practice by the British Antarctic Survey Medical Unit (BASMU) for medical care at extreme reach. Current telemedicine practices and utilisation, as well as modular equipment capabilities across the BAT were reviewed to provide an outline of care delivery.

Requests varied from expert advice to remote supervision of clinical procedures. Integration of commercially available solutions enabled real-time display of patient physiology. The deployment of modular resources has improved equipment availability and greater standardisation between sites. The sending of case notes and digital x-rays has been generally sufficient but, when greater supervision was required, limited data transfer bandwidth was a challenge.

An ongoing review of deployed equipment capabilities may also enhance the ease with which remote support can be offered but an uplift in telemedicine capability will likely require infrastructure upgrades to maintain data transfer from 8000 miles away.

KEYWORDS:

• Antarctica
• telemedicine
• remote healthcare
• reach-back
• remote medicine

The operational risks of Antarctica

Any operation undertaken on the Antarctic continent poses a unique challenge. Any activity undertaken in Antarctica is subject to weather extremes with short-change windows, sub-zero temperatures and extremes of duration in light and dark hours. Furthermore, there exists variability in these environmental challenges across the various installations where these risks are then compounded by the challenges of potential need for evacuation from up to 8000 miles away.

In order to operate effectively, individuals require bespoke equipment and training, however, even with the greatest risk mitigation, there remains a need for a continuously deployed medical asset to support the deployed population.

Installations within the British Antarctic Territory

The British Antarctic Survey (BAS) operates from five installations within the British Antarctic Territory (BAT) based on both the Antarctic continent and the sub-Antarctic space (Figure 1) [1,2]. Each station (aside from the Halley VI and Signy Research Stations) operates throughout the summer and winter, with a large variation in population size according to the level of requirement [3]. The wintering teams for each installation are far smaller however may also represent the population at greatest risk due to adverse weather and low light.

Figure 1. The British Antarctic Territory [1].

The largest installation within the BAT is the Rothera Research Station, supporting over 160 summer personnel (excluding transiting deep field scientific teams) and ~20 during the Antarctic winter [4]. Rothera is an established scientific site with multiple teams both working at the installation and utilising it as a central hub when returning from deep field scientific sites or areas of interest. It is continuously operating with a busy maritime and aviation schedule – an additional risk for those living and working at the site when compared to the other installations accessed by ship only. Significant activity including the modernisation of infrastructure utilises heavy machinery vital for construction as well as blasting for movement of rock. When considered in isolation there are several safeguards in place to protect workers and those living at the station. If an incident was to occur, the casualty could not be immediately evacuated without a significant logistical challenge.

The smallest installation operated by BAS is Bird Island Research Station on South Georgia [5]. Bird Island hosts a summer population of approximately 10 people, falling to 4 in the winter. Not only is it a far smaller population when compared to Rothera, it is also far harder to access (via ship only and prone to periods of inaccessibility due to sea state and weather). Although Bird Island hosts fewer people, any incident that does occur on the island also poses a significant logistical challenge but with completely different risks and variables.

The challenge of the environment

Although all sites are similar in certain respects due to the nature of them being in the Antarctic and sub-Antarctic space, there are key differences that must be understood prior to any deployment.

Built on the floating Brunt Ice Shelf, Halley VI can experience temperatures ranging from −20°C during the summer to the extreme winter lows of −55°C [3]. Given the need to often work outside of the modules and when required, clear snow drifts from around the station, these temperatures place the population at greater risk of freezing cold injuries [6]. When this is combined with 105 days of darkness per year and the extreme reach of the Brunt Ice Shelf, any incident can have significant consequences. In addition to the risks of being on station, deep field sites are similarly subject to extreme weather effects but with limited communications and medical support at the most extremes of reach.

Understanding the differences between these sites is key to understanding how they can be best supported. Focussing on the support to the deployed population, BAS utilises the support of its own medical unit, the British Antarctic Survey Medical Unit (BASMU) for a number of key processes [7].

Medical support to the British Antarctic Survey

BASMU is part of University Hospitals Plymouth NHS Trust which is a regional major trauma and tertiary referral centre covering the Southwest of England, UK. BASMU provides all medical support for Polar deployed BAS personnel as well as all medical logistic functions. The permanent clinical staff of BASMU are made up of Emergency Physicians and Emergency Nurses of whom all have a special interest in the delivery of remote and austere medicine.

Deployment of medical assets

To ensure continuous access to medical care at sites across the BAT, BASMU deploys healthcare professionals to support summer and winter operations. The larger installations of have a continuous physician presence whilst the smaller sites of Bird Island, Signy and Halley have been supported by both physicians and allied healthcare professionals (AHP) with remote support from BASMU UK directly.

Physicians appointed to any of the BASMU roles will have completed several years of post-graduate practice as well as having experience in Emergency Medicine. AHPs have been recruited with expedition or remote healthcare backgrounds. All deploying medical professionals undergo extensive training with a period of supervised practice in an Emergency Department as well as completion-specific tasks, observing presentations and procedures prior to deployment.

This training is orientated towards the management of critically unwell patients, as well as specific further training in dentistry, radiography, physiotherapy, hyperbaric medicine, as well as bespoke pre hospital training by specialist paramedics and physicians. This training period does not only focus on major trauma but includes the care of patients presenting with the wide variety of conditions that would be expected in any general adult population. Additionally, patients may need to be held for an extended period due to adverse environmental conditions or logistical constraints and consideration of this is included within the training program.

Medical personnel are also fully integrated into their respective summer or winter team to ensure optimal cohesion whilst deployed. All deploying personnel will undertake a period of pre-deployment training focussed on the daily operations on station as well as aspects of search and rescue training and mountaineering.

Pre-deployment screening

BASMU undertakes medical screening for all personnel to ensure medical fitness to deploy. The process requires a self-declaration form, then an initial medical screening by a family physician or general practitioner before review of this data by a senior BASMU physician to ensure fitness to deploy for the specified period. This is typically summer or “over-wintering” that will see a member of staff remain on station for 18 months through two summer seasons and the intervening winter.

When necessary, deploying personnel may be invited to interview with BASMU to review items declared in the submitted documentation. Additional information may also be requested from an individual’s named physician or specialist to ensure all measures can be taken to support a period of deployment. Although the aim is to deploy all people, there are instances where due to medical risk in conjunction with logistical and/or environmental challenges, deployment is not possible. Conditions that may suddenly incapacitate an individuals (for example, uncontrolled epilepsy) would likely be a barrier to deployment.

Personnel will also undergo dental assessment to ensure dental fitness to deploy.

Pre-deployment training

In addition to the training of medical personnel, BASMU also provide a level of medical training for all deployed personnel – regardless of role, position or destination.

Those deploying will be taught the basics of casualty assessment and care that will include the control of catastrophic haemorrhage, trauma primary survey, principles of bleeding control and limb splintage as well as the recognition of life-threating conditions, such as anaphylaxis and the management of cardiac arrest. The principle of this training is to not only equip all those deploying to care for or recognise acute illness in their colleagues but to empower them to support the deployed medical professional during an incident.

Of those deploying, certain members of the summer and winter teams will be selected for further training with the BASMU senior team to build upon the principles that they have already been taught whilst also enabling them to support with incidents off station or during a major incident situation.

Maintenance of deployed medical capabilities

All deployed medical equipment is maintained by BASMU with annual review of both the condition of the item and its role within the deployed setting. This is not limited to station surgeries but also the medical equipment required for air and/or maritime transfer, support to the deep field sites and for incidents on and off station.

Engagement with Antarctic Medical Community

BASMU is fully engaged with multiple organisations committed to delivering healthcare on the Antarctic continent. The Joint Expert Group on Human Biology and Medicine (JEGHBM) is a joint group of the Council of Managers of National Antarctic Programmes (COMNAP) and the Scientific Committee on Antarctic Research (SCAR) [8]. BASMU is the UK representative for the executive JEGHBM committee which provides experience, information and data to support the development and advice on best practice for the provision of healthcare in support of the scientific research in Antarctica.

Remote support

To enhance the deployed medical capability at all stations, BASMU provides remote support available 24 hours a day. The remote support comes from the senior BASMU team with additional input from specialists or when necessary, logistical support and co-ordination from BAS to facilitate medical evacuation.

With increasing technological advances, the provision of remote support has gradually evolved into telemedical support allowing for the deployed personnel to “reach-back” to the UK for advice through a variety of means [9]. This concept has been influenced by methods utilised by the UK Armed Forces and deployed medical assets from various campaigns and operations over the preceding decades [10–13]. Key lessons for BASMU when considering operational impact have been rapid access to specialist opinion as was used for infectious diseases in Op TRENTON and the sending of digital radiographs as was initially developed during the Bosnia conflict [10,12].

The provision of telemedicine support

As with several aspects of care delivery on the Antarctic continent, the provision of telemedicine support is not exempt from the challenges of the environment. Adverse weather conditions can impact communications lines and impede data transfer. However, all these processes have been improved by technological advances and, to an extent, the impact of the COVID-19 pandemic created an increased need for support to remote working and video conferencing.

The evolution of reach-back in Antarctica

The practice of medicine on the Antarctic continent has been recognised as a unique challenge since the heroic age [14]. A deployed team with their own physician would be forced to operate in isolation with no opportunity for assistance or review of cases until returning home.

Thankfully, this is no longer the case as support from a senior BASMU physician can be obtained 24 hours a day. This ability to support decision-making is critical when considering the potential extraction/evacuation timeline. If compared to doctrine on medical support, the Antarctic equivalent of the operational patient care pathway can be days to weeks as opposed to minutes to hours [15,16].

The original form of reach-back through telephone from the continent to the BASMU office has increased with the use of email to the sending of digital radiographs, sharing with specialists for further advice and regular updates on those patients under serial review [12,13].

The current reach-back capability and its impact

The current BASMU reach-back capability is in some respects tiered dependant on the requirement of the deployed healthcare professional.

Training on the various methods of providing reach-back can enable the full use of the spectrum of support that is available to the installation surgeries or hospitals (scaled to resemble a Role 1 (R1) facility) [16].

Recent utilisation of reach-back in support of Antarctic operations

Although reach-back has provided early communication with respect to patients requiring evacuation, it has also been utilised to keep patients on station by providing bespoke telemedicine support [10,17]. Table 1 contains examples of recent utilisation.

Table 1. Examples of recent reach-back utilisation.

Dental inspection post traumatic injury	Remote support for manipulation of fracture/dislocation	Suspicious skin lesion review
Dental extraction	Hand examination for concern of traumatic tendon injury	Counselling for new diagnosis from specialist
Assessment of suspicious oral lesion	Wound closure advice	Review of spreading skin infection
Review of ECG trace	Review of plain film imaging	Review of spirometry trace
Review of audiogram result	Physiotherapy assessment with exercise guidance	Remote support for procedural sedation

Specialist dental advice

Due to a requirement to produce drinking water through reverse osmosis, installation drinking water is without fluoride. All wintering personnel are issued high fluoride products to compensate for the protracted period without fluorinated water to mitigate any potential issues with dentition.

Despite this mitigation and pre-deployment dental assessments, there are instances where those who deploy medically fit develop dental problems during the winter period. All deployed medical personnel will have completed a bespoke dental course as part of their pre-deployment training including training in the practice of taking dental radiographs, dental assessment and simple treatments.

There have been instances where initial consultation and inspection has raised concerns for significant pathology that may either deteriorate to the point of needing intervention or, require immediate treatment (in the case of dental trauma, for example). Using digital radiographs, telephone consultation and digital images, specialist advice from dental and oral surgeons has been provided to the deployed medical teams in order to guide treatment or to determine if evacuation for specialist care is needed.

Specialist consultation with surgical and medical specialities

As with dental screening, all deployed personnel should be medically fit prior to leaving the UK for any of the BAS installations. It is however recognised that new pathologies do develop and conditions previously well-controlled deteriorate during time in the Polar regions. It is also recognised that any accident or incident on the continent that results in injury may also require further review or assessment beyond the scope of what may be undertaken in the installation facility.

An area of concern with respect to injury is that of hand trauma and its potential consequences. Although deployed clinicians can undertake an initial assessment, if there are concerns for injury to any deeper structures, review by hand specialists is paramount. Rather than immediately plan to evacuate any hand injury, video conferencing has been used to allow specialists from the field of plastic surgery to provide remote expert review. The ability for an experienced clinician to be able to see and assess the affected limb (albeit remotely) has enabled several deployed personnel to remain on the continent without immediate evacuation.

The utilisation of video conferencing has not been limited to the assessment of injuries. If there is concern for a new diagnosis or, flare of an existing condition, specialists have been able to consult with deployed individuals after initial assessment by the BASMU clinician. This has been vital in counselling for new diagnoses but also in supporting patients in managing their own disease whilst deployed. An additional effect of this is that the deployed clinician can also seek advice from the specialist to enable them to also support the individual in the duration of their deployment.

Supervision of procedures

In some instances, immediate intervention is required prior to the evacuation of any patient as part of a stabilisation and injury treatment phase.

The most common intervention has been the reduction and immobilisation of limb injuries prior to aeromedical evacuation. Although the station will have deployed personnel who have undergone advanced medical pre-deployment training, there will likely only be one physician deployed to the site. In this situation, there may be a requirement for the advance trained deployed personnel to perform the reduction of the fracture-dislocation and application of immobilisation whilst the physician undertakes sedation.

In order to support the deployed team, senior clinicians from BASMU have provided a layered form of reach-back support. This takes the form of initial telephone call to highlight the immediate need and clinical concern. The next phase will be to attach physiological monitoring which can be remotely viewed by the UK team and finally, video conferencing for the senior clinician to view the clinical area and provide direct support. This provides a number of risk mitigating factors such as additional support for physiological monitoring, direct advice/instruction for procedure completion, immediate closed-loop feedback for questioning and contemporaneous information sharing with the UK for guiding further treatment or evacuation.

Early clinical escalation and evacuation planning

Building on the impact of support provided by procedural supervision, contemporaneous information sharing via reach-back is critical for informing the logistical changes of BAS and international partners to guide evacuation planning.

The ability of deployed clinicians to identify and escalate concerns enables senior BASMU and BAS leaders to initiate the process of evacuation planning. It also permits the identification of patients who may not immediately require evacuation but are at risk of deteriorating. This ability to inform the UK, particularly if heading into the challenges of the winter seasons, enables accurate risk assessment and early intervention as required. This not only protects patients and maintains station operations; it also enables the deployed clinician to focus on providing optimal care whilst the logistical aspect is managed by the UK team in order to mitigate against any distractions.

Enhanced case discussion and clinical governance

With the progression of video conferencing technology during the pandemic, is has become possible for all deployed clinicians to dial into a regular clinical governance meeting in addition to the monthly reporting of case load.

Digital communication technology has enabled the secure sharing of digital radiographs, digital photography, bedside interventions, recorded physiological data and the sharing of case reports. This enables BASMU seniors to offer advice and guidance based on clinical presentations as well as supporting adherence to medico-legal frameworks (for example, image reporting) [18].

This also has a significant additional benefit in ensuring the welfare and wellbeing of those deployed. The period of deployment for BASMU clinicians is extensive and represents a protracted period of working in isolation. The regular virtual clinical governance meeting offers an additional opportunity for BASMU seniors to communicate with the deployed clinicians.

Shared understanding of deployed capabilities

A focus of the senior clinical team over the past three seasons has been to simplify this equipment to allow for enhanced training in the UK prior to deployment. The migration to a standardised, modular equipment approach has also supported reach-back capability – through an exact knowledge of exactly what equipment is available for utilisation given any scenario. It is through equipment modularisation that BASMU has been able to further mitigate risk on station.

Mitigating risk through modularisation

Previous designs for immediate casualty care have varied across the BAT. Given the unique features of each location, equipment for the provision of immediate aid, pre-hospital care and resuscitation/stabilisation has evolved over several seasons. This gradual refinement has been based upon previous incident, accident or event – reactive as opposed to proactive – in determining what equipment should be held at readiness.

With immense variability between equipment by which to provide immediate or first aid and resuscitation, the ability to provide accurate reach-back advice can be limited given that the senior clinician may also be working remotely and unable to pull up a list of current equipment at the installation asking for assistance. In line with optimising the reach-back capability, the decision was made to modularise key equipment capabilities based upon the experiences of the UK Armed Forces on operations and exercise [19,20].

Module design and construction

The process for the design and construction of the deployed equipment modules was based on multiple information sources. The basis for the design was taken from the experience of the UK Armed Forces during recent operations and applied to the known risks of operating within the Antarctic environment [17,19–22].

The deployed equipment capabilities were largely based on three assets. The immediate aid pouch (IAP) was built to support the immediate first aid of a single casualty, the field medical box (FMB) was built to provide immediate first aid to a larger party and the BASMU grab-bag was built to provide immediate care to a casualty with traumatic injuries or acute medical crisis. In order to provide effective care to a multitude of possible scenarios, the Immediate Casualty Care Equipment (ICCE) pack was developed to support operations.

Scope of use and risk mitigation

The ICCE pack would need to be modular and have capability to provide immediate casualty care for traumatic injuries or immediate medical aid based upon the risks that were likely to be encountered at any installation.

When considering additional measures by which risk could further be mitigated, the equipment contained within the ICCE pack would need to be commercially available. This decision was based on multiple factors such as how readily available replacement items would be, the shelf life for any consumable and the expected delay before arrival at any installation and items could be purchased in bulk to enable the construction of ICCE pack’s training modules.

In order to determine the finalised list of contents and key treatment capabilities, multiple plan-do-study-act cycles were undertaken to drive continuous improvement and, establish a foundation for future modifications [23].

Scale

After multiple PDSA cycles, it was agreed that the ICCE pack would be utilised in the treatment of one significantly injured or critically unwell patient for a period of up to 48 hours. It was also agreed that the ICCE pack could treat up to five moderately injured patients for the same period.

The scale of one to five casualties was based upon the size of a field party or those undertaking winter expeditions. The duration for providing care for a period of up to 48 hours was also based on the same group but with acknowledgement of the variability of the Antarctic weather. If persisting adverse weather prevented immediate withdrawal from any location, the 48-hour treatment capability window would enable resuscitation/treatment to continue whilst plans for rescue were drawn up by search and rescue teams based at the specific installation.

Equipment selection and design

Items were selected on the basis of being able to survive the conditions of Antarctica. On example of this was the change from Entonox to Methoxyflurane. As Entonox can laminate at −6°C increasing the risk of delivering a hypoxic mixture, methoxyflurane was placed into the analgesic modules due to its usability down to −20°C [24,25].

Core modules within the ICCE pack

The front pocket of the ICCE pack contains the catastrophic haemorrhage pouch or “big C” (<C>) pouch for the management of significant traumatic injury. As the ICCE pack was designed to also treat medical casualties, a small portable automated external defibrillator with pads is carried with the <C> pouch.

The larger central pocket is subdivided with pouches containing equipment for the treatment of specific aspects of the primary survey – those being airway, breathing, circulation, disability and exposure. An additional drugs pouch with equipment to draw up medications is carried.

Additional modules within the ICCE pack based on location

Although the drive behind the design of the ICCE pack was for a standardised modular treatment system, there was an additional module designed to meet the requirements for the MCA. This additional module was placed into the central pocket for those ICCE packs deployed on the research vessels as part of the ICCE pack integration.

The future strategy for remote support and training

As previously discussed, the provision of remote support, training and modularised equipment represents a multi-year development programme to optimise the delivery of remote healthcare to Antarctica. Throughout this programme there are certain themes and lines of development that are felt to be critical in development of a world leading service.

ICCE pack re-design

The grab bag was selected as the first capability selected for review due to its role existing between the described capabilities of the IAP and FMB.

Both the IAP and FMB modularisation will represent the formation of a tiered approach to deployed casualty care or incident management depending on the location and severity of injury. Aspects of the three may well become interchangeable (such as the FMB carrying a <C> module like that of the ICCE pack) or the scale of the ICCE pack may require uplift to be suitable for a protracted deep field deployment.

With any change to these capabilities, there will also exist a need to review the pre-deployment training and the familiarity with which the deployed population has with the medical capabilities available across the BAT.

Augmented reality technologies

In parallel with the improvement of modular equipment, there is also a desire to optimise the reach-back capability within the BAT. Having made optimal use of video conferencing and telemedicine, there is now a consideration for the utilisation of augmented reality technologies.

The ability to visualise real-time physiological monitoring and video conferencing is regarded as a migration towards the application of augmented reality to permit senior BASMU clinicians to review multiple data inputs with video input. There is a drive to enhance the support from seniors within the UK utilising technologies that artificially reduce the distance from which any advice is given, simulating a working environment more akin to that of a UK Emergency Department rather than video conferencing from thousands of miles away. Table 2 contains examples of where augmented reality technologies may enhance current reach-back practices.

Table 2. Examples of the role of Augmented Reality (AR) technology reach-back.

Current Use	Limitation	Enhancement by AR
Video assessment of traumatic injury	Single camera, quality dependent on data transfer/resolution	Immersive, multi-angle assessment as seen by examiner
Real-time monitoring during procedural sedation	Single input to screen dependent on feed selected	Multiple data sources relayed at once for real-time awareness of patient and physiology
Digital data transfer of images/recordings	Time delay for time to review from sending	Real-time review of digital feeds or through AR viewer at same time as local practitioner

Optimising Antarctic telecommunications

The communications capability of the BAT has permitted rapid escalation of critically unwell patients and supported effective dialogue during complex logistical evacuations.

With increasing demands on bandwidth, there exists a need for increasing infrastructure in order to prevent loss of data transfer. Bandwidth optimisation on station is possible by limiting number of users on a network however outside of the station, all data is sent by satellite link. The issue is then related to the capability of the equipment taken into the deep field.

Any uplift or increase must not be to the detriment of the Antarctic continent. Similarly, the deeper into the continent at which science is undertaken, the greater the need for effective reach-back to ensure risk mitigation – this may again require uplift in infrastructure and its lasting impact be considered. Deep field camps and operations will likely continue to be reliant on satellite data link, with inherent far latitude challenges, for the foreseeable future. As is also evidence from the existing literature, novel developments must enhance care rather than simply demonstrate functionality in a remote environment [26].

Learning from military practice

The inspiration for a number of the change and optimisation programmes as part of the multi-year BASMU projects have been driven by lessons learnt from the UK Armed Forces [^{10,11,19,20]27}. Certainly, from a medical perspective, there has also been active engagement between the civilian Emergency Physicians of BASMU and the Emergency Physicians of the Tri-Service Emergency Medicine Cadre with a proportion of established posts within BASMU occupied by Military Physicians [17].

This synergistic relationship is mutually beneficial in terms of identifying areas for improvement in care of cold casualties, provision of pre-hospital care in cold environments and the potential impact of cold on the deployed population.

Author contributions

All authors developed the scope for this review as well as critically reviewing all drafts of the manuscript, edited and approved the final draft for submission.

Acknowledgments

The authors wish to express their thanks for the support of the British Antarctic Survey Medical Unit for their support in the writing of this article.

Disclosure statement

No potential conflict of interest was reported by the author(s).