Prof. Eilif Dahl, MD, MHA, PhD, Professor Dahls gate 50A, 0260 Oslo, Norway, tel: +47 959 21 759, fax: +47 22 56 31 12, e-mail: eilifdahl@hotmail.com

Key words: telemedical assistance service (TMAS), teledermatology, clinical photography, digital photo transmission, cruise ships

INTRODUCTION

Skin conditions are frequent concerns of seafarers [1]. Skin disorders ranged second and third of the most important groups of diseases in a large survey among Polish fishermen and seafarers, respectively [2]. Hence, it is hardly surprising that a substantial part of advice requests from ships to land based telemedical assistance services (TMAS) regards skin conditions [1].

Based on telemedical case logs, Lucas et al. [3] found that 10% (183/1844) of calls that required acute treatment were due to skin disorders and that ‘in some cases digital photographs helped in the diagnostics’.

In two world cruise studies, the most frequent reason for crew visits to the ships’ medical centers was skin conditions; they accounted for 29% and 27% of the crew consultations, respectively [4, 5]. Although none of these visits resulted in crew referrals to port dermatologists, such referrals are nevertheless so common that one large cruise corporation in 2010 decided to introduce teledermatology on the vessels [6]. Instead of referring a passenger or crew member to a dermatologist in a port of call, the ship’s doctor must first consult with the company’s contracted teledermatology service.

TELEDERMATOLOGY

Teledermatology is dermatologic care given to patients where and when it’s needed using telecommunication technologies to exchange medical information over a distance [7]. On land it is a well-established dermatology subspecialty and probably one of the most common applications of telemedicine and e-health. It is practiced on the basis of two concepts: store and forward and real time/live interactive teledermatology. Hybrid modes also exist (combining store and forward and real time applications). The store and forward method is most commonly used in teledermatology: It involves sending (forwarding) digital images associated with (anonymous) medical information to the data storage unit of a consulted specialist. It can be as easy as sending an e-mail with a digital image of a lesion to seek advice for a skin condition. Advantages of this method are that it does not demand the presence of both parties at the same time and does not usually require expensive equipment [7]. It can be useful for patient filtering and triage (i.e. referral based on the severity and character of their skin condition) and to limit unnecessary dermatology clinic referrals, as well as provide diagnoses, treatment suggestions and follow-up [8].

TELEDERMATOLOGY AT SEA

International commercial shipping comprises 55–65,000 ship with more than 1.2 million seafarers who at times may be in areas where telemedical services may be necessary, and it has been estimated that worldwide there are more than 120,000 telemedical consultations a year [9]. According to The Maritime Labour Convention (MLC) 2006, all coastal states must provide medical advice by radio or satellite communication to ships at sea, including specialist advice, available 24 h a day free of charge to all ships irrespective of the flag that they fly [10].

When TMAS is needed, the ship’s officer responsible for crew care aboard, usually the captain or the first mate/chief officer, will contact the TMAS doctor on call. For skin conditions the TMAS doctor will usually ask for photos in additional to a brief description of the lesion and a medical history. Most vessels now have a high quality digital camera, and even new-generation mobile devices (smart phones) can be used to take good enough photos to be transferred as attachments to encrypted e-mail [11].

In Norway, TMAS is run by the Norwegian Centre for Maritime Medicine, which is located at and part of Haukeland University Hospital in Bergen. It responds to requests for medical assistance from ships all over the world, regardless of flag state (contact information: www.ncmm.no, see Radio Medico/Medical Advice). If the TMAS doctor wants a second or expert opinion, he or she can use the university hospital’s resources and forward the information and photos received from the ship to any of its specialists on 24/7 call, including the dermatologist.

Urgent teledermatology consultations might be considered in cases with rapid onset, when there is a widespread rash, or the rash is on the face, hands or genitals, if there is fever, severe itching, pronounced pain, blisters or swelling, or when decisions regarding isolation or medical evacuation must be made. Less urgently TMAS can be contacted for dermatologic diagnosis, treatment suggestions and follow-up of progression and/or treatment effect. On merchant ships without a doctor, the options for dermatological therapies are rather limited on board [12, 13], but most skin lesions will heal with simple remedies.

RELEVANT TELEDERMATOLOGY DATA

Although good photos in skin cases say more than many words, additional written information may give better results. Hence, as much of the below data as possible should be forwarded in each case:

• Demographics: Identification number (passport, seafarer book, or company employee number), name, age, gender, occupation aboard and skin colour (race/ethnicity).
• History: Chief skin complaint or symptoms, time of onset and duration, aggravating and/or alleviating factors, known allergies, recent exposures and drugs/medication.
• Description: Type and number of lesions, size [mm], surface, shape, borders (sharp/diffuse), colour, distribution and location. Scratch marks? Table 1 gives some examples of dermatology definitions and terminology [14].
• Location and distribution: It is important to note whether lesions are single or multiple; particular body parts are affected (e.g. palms or soles, genitals, scalp, mucosal membranes); lesions are on sun-exposed or protected skin; and whether distribution is random or patterned, symmetric or asymmetric.

BASIC CLINICAL PHOTOGRAPHY

Proper description of skin lesions is difficult for officers without much medical training, but good photos can compensate for imprecise descriptions. Below are instructions for high quality clinical photos, following guidelines from Alaska Federal Health Care Access Network [15] and University of Miami Telehealth [16]:

• General: There should be at least one regional + one close-up + one tangential view of the lesions; all well-lit and clear — in true colour and sharp focus. If palms are involved, show dorsal hands; if palms are involved, check soles; and if it is a facial lesion, take photos of full face as well as left and right sides of the face.
• Subject: The lesion should take up most of the frame and remove items that distract from the lesion. For the right perspective, keep the camera parallel to the lesion surface. For shadows, to visualise raised lesions, use lighting from the side (elevated papules versus flat macules; Table 1). Care should be taken to get the colours of the lesions right; to reproduce the true shades of red is particularly challenging. Take photos both with and without flash to see which gives the best image. Provide enough information to determine the size of the lesion. For scale, add a ruler to the photo.
• Background: Choose a solid colour background, and avoid white, black or textured backgrounds. Avoid reflective surfaces.
• Focus: Use ‘Macro’ for all close-ups (5–70 cm/2″–28″). Zoom can allow a closer image without being close to the lesion. But zoom magnifies camera movement, so only use it when it is really necessary. Steady the camera to avoid blur from camera movement: use a tripod, or if standing brace your elbows against your body, and if sitting place your elbows on a table and use your arms as a tripod. Gently squeeze the shutter to focus and then take the photo.

TELEDERMATOLOGY ON CRUISE VESSELS

Although national TMAS are available for free to all ships, at least one cruise corporation has contracted a commercial, highly specialised teledermatology service ashore, considering it one component of its efforts to improve health care services for ship employees and passengers [6]. Ship’s doctors occasionally need to consult with dermatologists, but it is often difficult to access dermatologists for face-to-face visits during a cruise. Specialised teledermatology allows them to transmit dermatology images and information from ships across the fleet to dermatologists for remote consultation, “to receive expert medical opinion in a timely manner without the time, logistical issues and costs associated with seeking care ashore” [6]. It is particularly useful for patient filtering and triage (i.e. referral based on the severity and character of their skin condition) and to limit unnecessary dermatology clinic referrals. Furthermore, it provides diagnosis or differential diagnoses and recommendations for management and follow-up. When the contracted teledermatology service is familiar with the fleet’s standardised formulary, recommendations can be made based on the remedies that are available on the ships. Based on findings over time, the ships’ formulary can then be adjusted to cover the actual therapeutic needs of the fleet. For the cruise vessels’ medical staff the teledermatology service is an opportunity for continuous education which may benefit skin patients aboard in the future [16].

To qualify for using the contracted teledermatology service, the ship’s doctor or nurse must register and complete an internet training program, comprising short (5–7 min) videos on common dermatoses, teledermatology terminology, dermatologic photography, camera operation, store-and-forward photography technique, and how to enter a consult request with the teledermatology company [6, 16].

The teledermatology service involves a ship’s physician or nurse taking digital photographs of areas of concern on the patient’s skin. These images are combined with medical history and other relevant information that are entered into a special web-based software system that uploads the case to a secure server. A consulting dermatologist reviews the case and makes his or her recommendation for a course of care to be implemented by the ship’s physician. In urgent cases the ship will receive a report within 24 h while non-urgent or routine cases are evaluated within 72 h. Still, the accuracy of the response depends on the quality of the input received. Teledermatology consult replies therefore start with: “Based on the history and images provided, my impression is as follows...” [16].

CONCLUSIONS

TMAS, including specialist advice, is available 24 h a day free of charge to all ships. Acute skin disorders account for a significant part of urgent TMAS consultations. Skin lesions may be difficult to describe for seafarers without much medical training — and even for medical personnel on cruise ships, but good photographs can compensate for imprecise descriptions. By following simple guidelines useful photograph can be taken by a digital camera or smart phone and be transmitted by e-mail to an on-line physician who can then consult with a dermatologist if necessary. This takes us another step toward the MLC 2006 goal of ‘providing seafarers with health protection and medical care as comparable as possible to that which is generally available to workers ashore’ [10]. Highly specialised teledermatology services are commercially available for cruise ships with doctors aboard.