Robyn Carr IPC & Associates (Thursday, 1.00pm, Works Infrastructure Room)

1. Swinfen Charitable Trust
Telemedicine at its best
www.swinfencharitabletrust.org

2. Swinfen Charitable Trust

UK-registered charity

founded in 1998 by Lord and Lady
Swinfen

aim: assisting poor, sick and disabled
people in the developing world, also
doctors in remote / isolated areas.

method: telemedicine (e-referrals)

3. Telemedicine
• real time telemedicine (e.g.
videoconferencing) works well in the
right circumstances – but is
expensive
• telemedicine can also be done using
relatively simple and cheap
techniques
– web
– email

4. 1 Referrer logs
into the server Process
& submits case
history
Automatic email notification sent to system operator
2 Operator reads
case and decides
which specialist(s) is
most appropriate
Automatic email notification sent to specialist(s)
3 Specialist logs into server
reads case history, and
provides a response
Automatic email notification sent to referrer
4 Referrer logs into server
and reads the response
from specialist

5. E-referral network
►low-cost telemedicine system – digital camera
pictures and email
►spinal injuries hospital in Bangladesh, 1999
►referrals to international specialists
coordinated by the charity,
Swinfen Charitable Trust
Centre for the Rehabilitation of the
Paralysed, Bangladesh

6. Email system
►specialists and staff work on a volunteer
basis
►from July 1999 until 2002 emails handled
manually
3
►AutoRouter Referring 1 2 Specialist
developed doctor
etc
by COH Swinfen
Charitable Trust
Panel of
specialists

7. Web messaging system
►from August 2008
►email for notifications (non-
confidential information)
►log in to secure server for patient data

8. Case from PNG
• Dr Michael Parsa, writing from a remote area in Papua
New Guinea...
• I was recently out at a remote village and saw a 4 month
old girl who appears to have congenital glaucoma. She
has bilateral cloudy, oedematous corneas, this is really
all I am basing my diagnosis on. She has a 4 year old
sister who was also "born blind." This 4 year old has
what appears to be a cataract on one side, but her eyes
just rove around and she does not appear to be able to
see anything from either eye.
• Will medicine alone be curative for this patient or will she
need surgery? How soon must the surgery be done?

9. Ophthalmologist's opinion
►If the eyes are also larger than normal, that is the so called
'ox eye' or buphthalmos, then the diagnosis is confirmed.
For congenital glaucoma, they are photophobic, very
watery, with cloudy corneas, and large eyes. The
treatment is 100% surgical. Before surgery can be
organised, I would suggest using betaxalol 0.5% once a
day (twice if no complications). She should be seen as
soon as possible in a paediatric eye facility, such as
Princess Margaret Hospital for Children in Perth, with a
view to surgery as soon as possible.
►Let me know if I can help. I am happy to manage her at the
above hospital in Perth.

10. Case from PNG
EL is a 2 month old male, who presented on 18th August with
cough, SOB and stridor. Examination revealed no fever, resp rate
44, both inspiratory and expiratory noises - stridor and wheeze, no
crepitations. CXR showed an opacity in the right upper zone. FBC
showed Hb 8.9 (MCV 80.6), WCC 9.7 (no differential done),
platelets 470. We treated with IV crystapen for pneumonia, and the
cough has settled. The resp rate has stayed about the same
(normal). The stridor is softer now, but still present. Repeat CXR
six days later showed no change in the right upper zone. This could
be R upper lobe collapse, but I am wondering about other causes.
Any suggestions?
Images received

11. Responses

two paediatric intensivists

one paediatric radiologist
Referrer:
Thanks, all, for the responses. I have seen the child today,
after discharging the child 5 days ago. Gaining weight. Still
has some noise on inspiration and expiration, but no distress
and no recession, RR 32, chest clear apart from transmitted
sounds. Will continue to follow, perhaps monthly, but doing
well for now.

12. Case from Afghanistan
• "patient complains about ulcer
(location face) . Has got it for 14
years already, sometimes bleeding,
no secretion, ulcer not painful but
itchy ..."
Fayzabad
Hospital
13-July-2006. Fayzabad Hospital,
Badakhshan, Afghanistan

13. Dermatologist's opinion
►... the most likely diagnosis is ulcerated
nodulocystic basal cell carcinoma. The proximity
to the eyelid is of concern (biopsy to confirm), and
if possible, the patient should be treated by an
experienced plastic, dermatologic or oculoplastic
surgeon to reduce the likelihood of eyelid
retraction post excision of the tumour
►(referrer subsequently put in touch with
IK Foundation in Pakistan)

14. Global e-referral network
(numbers of hospitals at Feb 2008)
Swinfen Charitable Trust
1 1
1
2
39 4 1
3 9 10 5
1 3
2
5 11 4 1
1 1 21 1
2 3
2 5
1
1 4 1 1
currently 242 hospitals
in 35 countries 1
Afghanistan, East Timor, Kenya, 1 Nepal, 10 Solomon Islands, 5 Tristan da Cunha (UK), 1
5 2
Albania, 1 Ethiopia, 4 Kuwait, 3 Pakistan, 9 Somalia, 1 Uganda, 2
Bangladesh, Gambia, 5 Lithuania, 1 Papua New Guinea, 3 Sri Lanka, 4 USA (Sri Lanka), 1
5
Bolivia, 1 Ghana, 1 Madagascar, 1 Philippines, 1 St Helena (UK), 1 Uzbekistan, 2

15. SCT cases

16. SCT cases

17. SCT experience

useful in a very wide range of cases,
e.g. neurology

not suitable for emergencies

web-messaging is superior to plain
email

doctors are poor at taking clinical
photos

18. Network activity

for the last ten years we have received
about 20 referrals/month ...

19. A paradox of altruism

it is often difficult to obtain a second
opinion in developing countries

telemedical networks offer a free and
often rapid service

why isn't demand growing rapidly?

20. "Satellite" systems

copy SCT systems are being
operated by other organisations
Organisation Region Language
MSF Africa English
MSF Africa French
MSF Africa Spanish
Funderma Bolivia Spanish
KEDAS Africa English
University of Africa English
Virginia

22. Medical Director of Patan
Hospital, Nepal
"It is hard to think of how it could be better.
There are a good number of consultants in a
range of specialties. The system is so easy to
use, and our librarian [Macha] has well learned
it. The answers come back (a) Fast (b) 80-90%
with some useful information (c) Repeatedly if
we keep asking follow-up questions. The
Kathmandu community is excited about it ..."

23. Summary

the Swinfen Charitable Trust network
has dealt with >2937 cases over the
last twelve years

the experience shows that low-cost
telemedicine is
– feasible
– clinically useful*
– cost-effective

24. How can you help the SCT?
• A Specialist? Come on board and offer your expert
advice.
• Donations ? All funds raised will help to provide
equipment, develop hospital links and training to access
the referral system and the maintenance of the
infrastructure.
www.swinfencharitabletrust.org