Telemedicine via data glasses in CBRN protection suit—Evaluation of medical qualification and technical feasibility

Sarah Bovenkerk; Anna Mueller; Rolf Rossaint; Michael Czaplik; Andreas Follmann

doi:10.1371/journal.pone.0324558

Peer Review History

Original SubmissionNovember 23, 2024
23 Nov 2024 Author Response https://doi.org/10.1371/journal.pone.0324558.r001
18 Mar 2025 Decision Letter - Thiago Gonçalves dos Santos Martins, Editor PONE-D-24-49405Telemedicine via data glasses in CBRN protection suit – Evaluation of medical qualification and technical feasibilityPLOS ONE Dear Dr. Bovenkerk Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Please submit your revised manuscript by May 02 2025 11:59PM , If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. 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The PLOS ONE style templates can be found at https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf 2. We note that the grant information you provided in the ‘Funding Information’ and ‘Financial Disclosure’ sections do not match. When you resubmit, please ensure that you provide the correct grant numbers for the awards you received for your study in the ‘Funding Information’ section. 3. Thank you for stating the following financial disclosure: “Funded by Federal Office of Civil Protection and Disaster Assistance during the TeleSAN project (FKZ: 41201/45).” Please state what role the funders took in the study. If the funders had no role, please state: "The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript." If this statement is not correct you must amend it as needed. Please include this amended Role of Funder statement in your cover letter; we will change the online submission form on your behalf. 4. Thank you for stating the following in the Competing Interests section: “MC (CEO, co-founder) and RR (co-founder) are with Docs in Clouds TeleCare GmbH, a company developing telemedicine software. The other authors declare no conflicts of interest.” Please confirm that this does not alter your adherence to all PLOS ONE policies on sharing data and materials, by including the following statement: "This does not alter our adherence to PLOS ONE policies on sharing data and materials.” (as detailed online in our guide for authors http://journals.plos.org/plosone/s/competing-interests). If there are restrictions on sharing of data and/or materials, please state these. Please note that we cannot proceed with consideration of your article until this information has been declared. Please include your updated Competing Interests statement in your cover letter; we will change the online submission form on your behalf. 5. Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice. Additional Editor Comments : Dear Sarah, We are pleased to inform you that the review process for your manuscript, Telemedicine via data glasses in CBRN protection suit – Evaluation of medical qualification and technical feasibility , has been completed. The reviewers have provided their comments and suggestions, which are now available for your consideration. We kindly request that you review their feedback and submit your responses along with the revised version of your manuscript. Addressing these comments thoroughly will help strengthen your work and enhance its overall quality. Please submit your revisions by [Deadline Date]. If you require additional time or have any questions regarding the reviewers’ comments, do not hesitate to reach out. We appreciate your contributions and look forward to receiving your revised manuscript soon. Reviewer 1: Title: Telemedicine via data glasses in CBRN protection suit – Evaluation of medical qualification and technical feasibility Overall, this was a well written and very interesting study on possible applications of data glasses in an area of need. Syntax/Grammar -Recommend rephrasing lines 32 and 33 of the Results section of the abstract to improve clarity -Recommend rephrasing line 239 of page 11 (section 3.1) to improve clarity Abstract -Please spell out CBRN in the abstract for those who may not read the full manuscript -After stating “data glasses” in the abstract and title, consider adding in parentheses “smart glasses” which may be better understood in some countries. For example, data glasses (smart glasses) -You may also consider adding additional terms for protection suit (more commonly referred to as a hazmat suit in the US). Introduction -On page 4 line 73 could you please list a few examples of medications (such as pain meds or meds needed for blood pressure management or all meds?) -The last two sentences of the introduction on page 5 lines 100-102 would better be moved to the Results or Conclusion sections -It may be useful to include information (if available) about what currently happens in emergency situations when a physician is not present on site. For example, do patients simply not undergo any needed interventions and not receive any medications until appropriate staff is present? Are other forms of telemedicine such as telephones, smart phones or real-time messaging used that would fulfill the legal requirement? Methods -In section 2.1, it would be helpful if clarification on the first questionnaire could be given. Specifically, is this the same as the questionnaire given after the simulation and if not, what types of questions were on the questionnaire -Please specify in section 2.4 if both types of data glasses also give real-time audio to the telemedicine physician Results -Good Limitations -As participants were actively monitored and graded by an on-site observer and the telemedicine provider, it may be worth mentioning the Hawthorne effect as a possible bias Discussion -While it is notable from the technical difficulties that the data glasses were not a viable solution, it is worth noting that they allowed these medical procedures at all. If the alternative is patients not receiving any urgent/essential medical care then it could be said that the telemedicine solution is a success and that in addition to smart phones, any other telemedicine platform that fulfills the legal requirement whether it be radio (which may be more reliable in disaster situations) or synchronous text messaging would be far superior to the current model Tables/Figures -Good Reviewer 2: This is an original research. Methods were described in sufficient detail The conclusions are supported by the methods applied. Statistical analysis are coherent with the objectives/study design. The Authors made available data used in the study. [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Yes Reviewer #2: Yes ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: I Don't Know Reviewer #2: Yes ****** 3. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: Yes Reviewer #2: Yes ****** 4. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: Yes Reviewer #2: Yes ****** 5. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: Title: Telemedicine via data glasses in CBRN protection suit – Evaluation of medical qualification and technical feasibility Overall, this was a well written and very interesting study on possible applications of data glasses in an area of need. Syntax/Grammar -Recommend rephrasing lines 32 and 33 of the Results section of the abstract to improve clarity -Recommend rephrasing line 239 of page 11 (section 3.1) to improve clarity Abstract -Please spell out CBRN in the abstract for those who may not read the full manuscript -After stating “data glasses” in the abstract and title, consider adding in parentheses “smart glasses” which may be better understood in some countries. For example, data glasses (smart glasses) -You may also consider adding additional terms for protection suit (more commonly referred to as a hazmat suit in the US). Introduction -On page 4 line 73 could you please list a few examples of medications (such as pain meds or meds needed for blood pressure management or all meds?) -The last two sentences of the introduction on page 5 lines 100-102 would better be moved to the Results or Conclusion sections -It may be useful to include information (if available) about what currently happens in emergency situations when a physician is not present on site. For example, do patients simply not undergo any needed interventions and not receive any medications until appropriate staff is present? Are other forms of telemedicine such as telephones, smart phones or real-time messaging used that would fulfill the legal requirement? Methods -In section 2.1, it would be helpful if clarification on the first questionnaire could be given. Specifically, is this the same as the questionnaire given after the simulation and if not, what types of questions were on the questionnaire -Please specify in section 2.4 if both types of data glasses also give real-time audio to the telemedicine physician Results -Good Limitations -As participants were actively monitored and graded by an on-site observer and the telemedicine provider, it may be worth mentioning the Hawthorne effect as a possible bias Discussion -While it is notable from the technical difficulties that the data glasses were not a viable solution, it is worth noting that they allowed these medical procedures at all. If the alternative is patients not receiving any urgent/essential medical care then it could be said that the telemedicine solution is a success and that in addition to smart phones, any other telemedicine platform that fulfills the legal requirement whether it be radio (which may be more reliable in disaster situations) or synchronous text messaging would be far superior to the current model Tables/Figures -Good Reviewer #2: This is an original research. Methods were described in sufficient detail The conclusions are supported by the methods applied. Statistical analysis are coherent with the objectives/study design. The Authors made available data used in the study. ******** Attachments Attachment Submitted filename: PONE-D-24-49405.docx https://doi.org/10.1371/journal.pone.0324558.r002
Revision 1
4 Apr 2025 Author Response Response to Reviewers Dear Sir or Madam, thank you very much for taking the time to read my manuscript and for our comments and improvements. We have edited the manuscript accordingly and made the following changes: Financial disclosure The funding code of the study was incorrect. We request the following change in the submission portal. We have also added that the sponsor had no influence on the study with your proposal: “Funded by the Federal Office of Civil Protection and Disaster Assistance as part of the TeleSAN project (FKZ: 41201/425). The sponsor had no influence on the study design, the data collection and analysis, the decision to publish or the preparation of the manuscript.“ Compensating interests We request the following change in the submission portal: “MC (CEO, co-founder) and RR (co-founder) are with Docs in Clouds TeleCare GmbH, a company that develops telemedicine software. This does not change our adherence to PLOS ONE policies on sharing data and materials. The other authors declare no conflicts of interest.” Formatting The formatting of the manuscript has been changed according to the PLOS ONE style guide. Abstract The word CBRN was written out to make it easier to understand for readers who only read the abstract. The terms “hazmat suits” and “smart glasses” have been added to make it easier to understand in international context. According to reviewer 2, we have changed two sentences in the abstract for better understanding. Introduction Drug therapies in emergency situations are severely restricted by non-medical emergency personnel. Two substances were listed as examples. In the last section of the introduction, the current situation regarding the administration of medication by EMT-P and other non-medical emergency personnel in Germany was explained. Reviewer 1 has noted that the last sentences of the introduction should be better moved to the conclusion. Due to the submissions guidelines of PLOS Onne, who would like a preview of the results in the introduction, it was decided not to postpone the two sentences. Methods Thank you for your comments on the methodology section. A detailed description of the questionnaires has been included to improve the presentation of the study design. As described, the study participants were selected in equal proportions according to their qualifications. In addition, the information that both data glasses transmitted the sound in real time was added to the “Telemedicine” section. The patient was monitored on site with the help of a surveillance monitor. The practical performance of vital sign measurements was not part of the study investigation, as all participants were appropriately trained. Limitations Due to the study design, a Hawthorne effect could not be ruled out with certainty. This aspect was included in the limitations. We have added the reference [17] for this purpose. Discussion According to Figure 5, the HMT-1 does not show poor audio quality, so it is not necessary to add a headset at this point. A headset could be used as a supplement for other glasses; this has been added accordingly in the text referring to Reviewer 2. Reviewer 2 commented on whether additional medical equipment would be useful for telemedicine. As medical devices have to be cleaned or disposed of at great expense after use in contaminated areas, additional material is avoided wherever possible. In addition, a conceptual attempt is made to decontaminate the patient as quickly as possible. We have therefore dispensed with further equipment in the study and have not included this point in the paper. If you have any additional comments or requests for changes, please let us know. The following point was included in the discussion: Despite the technical difficulties, it should not be ignored that the smart glasses have made life-saving measures possible in the first place, which would not be possible without telemedicine. References The references has been checked. Since reference [4] is no longer available, it was replaced by a reference with the same content. A corresponding reference to the Hawthorne effect was added. Tracking changes of the references is unfortunately not possible, so the changes in the references have been highlighted accordingly. Attachments Attachment Submitted filename: Response to Reviewers.docx https://doi.org/10.1371/journal.pone.0324558.r003
27 Apr 2025 Decision Letter - Thiago Gonçalves dos Santos Martins, Editor Telemedicine via data glasses in CBRN protection suit – Evaluation of medical qualification and technical feasibility PONE-D-24-49405R1 Dear Dr. Bovenkerk, We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements. Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication. An invoice will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager® and clicking the ‘Update My Information' link at the top of the page. If you have any questions relating to publication charges, please contact our Author Billing department directly at authorbilling@plos.org. If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. Kind regards, Thiago Gonçalves dos Santos Martins Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: https://doi.org/10.1371/journal.pone.0324558.r004
Formally Accepted
Acceptance Letter - Thiago Gonçalves dos Santos Martins, Editor PONE-D-24-49405R1 PLOS ONE Dear Dr. Bovenkerk, I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now being handed over to our production team. At this stage, our production department will prepare your paper for publication. This includes ensuring the following: * All references, tables, and figures are properly cited * All relevant supporting information is included in the manuscript submission, * There are no issues that prevent the paper from being properly typeset You will receive further instructions from the production team, including instructions on how to review your proof when it is ready. Please keep in mind that we are working through a large volume of accepted articles, so please give us a few days to review your paper and let you know the next and final steps. Lastly, if your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. If we can help with anything else, please email us at customercare@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Dr. Thiago Gonçalves dos Santos Martins Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0324558.r005

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