Fran Pothecary, a Field Guide at Rothera Research Station, Adelaide Island, Antarctica begins by outlining her consultation with Gareth. FP: My recent physiotherapy consultation with Gareth was unusual in that it was conducted by phone call from Antarctica in September 2015, following email correspondence. Skype would have been ideal but the lack of bandwidth at Rothera Research Station precluded that! Rothera is a science research station on Adelaide Island in Antarctica, run by the British Antarctic Survey. I arrived at the Station in October 2014 on an 18 month over-wintering contract as a Field Guide. Rothera employs a doctor (a Senior House Doctor) and has fairly basic medical facilities, there is an X-ray machine but no access to ultrasound, MRI or CT imaging. Diagnosis was done without the benefit of these facilities but in consultation with the BAS Medical Unit based at Derriford Hospital, Plymouth.
I presented in November 2014 with rotator cuff pain in my right shoulder, which was most evident as ‘painful arc’ syndrome over the deltoid. My ROM was good except for internal rotation, which was about 50% less on my right shoulder than my left. I was prescribed analgesics, physio exercises and rest. However due to my job as a Field Guide (essentially a mix of mountaineering work and manual labour) it was difficult to achieve rest and whilst the pain abated for temporary periods any prolonged use – such as during weeklong “Winter Trips” and once the ‘summer’ science season started up again in October 2015 – the pain came back. Quite late on in the Antarctica winter it was decided that I was not fit to complete the second summer season of my contract and I was scheduled to return to the UK for further diagnosis and treatment. I was put in touch with Gareth via a climbing friend of mine back in Scotland. We exchanged emails and Gareth sent me two power point presentations describing the shoulder joint and problems associated with it – and one with a range of exercises to follow. Video clips of exercises being performed would have been the icing on the cake, but again lack of bandwidth meant that I couldn’t download or stream any such files.
Lastly I had a phone consultation with Gareth and was surprised how effective and comprehensive it was considering that we were 10,000 miles apart! By dint of detailed questioning – accompanied by me doing pantomime moves in my office at Rothera to ascertain the level of pain and movement – Gareth was able to confirm the likely diagnosis of tendinopathy and also the possibility of a tear in the supraspinatus. Successful consultations that like would appear to rely on the patient being able to accurately identify things like origin and type of pain and ROM – this isn’t always straightforward especially if pain tends to come and go, it can be harder to describe the ‘memory’ of pain than it’s actuality. This though is a problem that could pertain to anybody doing a face-to-face meeting. Overall it was a very positive experience and one I would recommend. Gareth’s knowledge and experience shone through and it was reassuring that he painted the same picture – and filled it out considerably – that had been suggested by the doctor at Rothera.
Gareth picks up the story...
Gareth, tell us what were the challenges of assessing Fran’s issues?
GJ: The greatest challenge was attempting to make a clear timeline of events and findings based on information from a variety of sources including Fran by email, the original contact from her friend and colleague in this country who supplied some clinical commentary, the clinical reports from the medic who had seen Fran in Antarctica and the Medics based back in the UK. I had to clinically reason and consider various hypothesise in terms of those that were more or less likely. Ultimately I knew that my opinion may form part of the decision as to whether she needed to return home. A comprehensive amount of subjective information was reviewed and compared to the responses Fran gave via telephone link. Minimal objective information was then required to arrive at a possible diagnosis.
Have you conducted many remote consultations before?
GJ: I have assessed and treated individuals in Mountain environments. This was somewhat different in that it was not life threatening but could have long term consequences for the individual and short term consequences for the survey team.
How did you have to adapt your approach to deal with the distance/communication challenges?
GJ: I had to adopt a mixed method clinical reasoning model which allowed me to consider all the information and judge it on relevance and probability. This allowed me to construct a range of suitable questions and suitable objective tests that may be useful to rule in or out a condition.
What’s your overall reflection on how the consultation went?
GJ: I was pleased with that consultation. Despite the distance and difficulties in communication a satisfactory outcome for Fran and the British Antarctic survey was reached. It further reinforces the importance of clinical reasoning models, knowledge of anatomy and pathophysiology.
What have you learned from the experience?
GJ: The experience has made me consider the effectiveness of such consultation and whether diagnostic and therapeutic algorithms would be useful for future use in such circumstances.