AcuteCare Telemedicine Blog


Stroke Mimics in the Emergency Setting

The role of the neurologist in treatment of acute stroke often focuses on the decision to use clot busting medication (tissue plasminogen activator; tPA), recommending care setting (e.g. ICU vs routine admission) based on patient deficits and prognosis, and of course, patient education in the midst of this emotionally charged experience. However, an often overlooked mandate for the neurologist is the proper recognition of stroke itself. Dr. J. Stephen Huff, Associate Professor of Neurology at the University of Virginia, provides a clear and comprehensive review of what are termed stroke “mimics” – disorders which may appear to be a stroke, but are not.

Stroke, broadly defined, is any prolonged disruption of focal neurologic function due to decreased blood flow from blood clotting in a specific region of brain. If that disruption is transient or intermittent it is typically referred to as a transient ischemic attack (TIA). If brain function is disrupted by a cause other than a blood clot, treatment with tPA may not only lack benefit but expose the patient to unnecessary harm. Recognition of “stroke syndromes” that result from specific artery involvement is the bread and butter of neurology. The abrupt onset of aphasia (language deficit) and right sided weakness almost certainly indicates a patient has blocked their left middle cerebral artery. Blocking this same artery on the right results in the classic presentation of left sided weakness and “neglect,” an inability to recognize one’s own physical deficits. In either case, the immediate administration of tPA can be life-saving.

Other disorders may cause brain dysfunction unrelated to a blood clot. This is the case in approximately 13-20% of patients presenting with presumed stroke. If the duration of symptoms is unclear, this number may even be as high as 30%. The most common mimic is seizure. Excessive electrical and chemical brain activity may result in focal weakness (Todd’s paralysis) and other deficits. If the seizure was not witnessed (especially in patients with previous stroke as the cause of seizures), excluding an acute stroke can be difficult. Focal neurologic injury from brain tumor, inflammation (e.g. multiple sclerosis), or even peripheral nerve palsy may be mistaken for stroke.

Stroke can be mimicked without direct injury to the brain. The most common mimic in this category is a complex migraine in which visual disturbance, weakness, numbness and even aphasia can occur. Hypoglycemia or, less often, hyperglycemia (low and high blood sugar) can cause general symptoms of lethargy or coma, but focal brain dysfunction (particularly weakness) often occurs and can outlast normalization of blood glucose. Finally, 30% of patients presenting with psychiatric causes of physical illness (i.e. conversion disorder) exhibit neurologic deficits, typically weakness.

Determining the cause of a patient’s deficits can sometimes be accomplished in an emergency setting through the use of CT imaging and appropriate diagnostic tests. Often the results of serial examinations, detailed history and, increasingly, advances in MR imaging can eventually lead to the correct diagnosis. However, certain diagnoses, notably migraine and conversion, are diagnoses of exclusion, so repeated events and extensive negative testing may be required for confirmation.

Among patients presenting with neurologic deficits, emergency department physicians correctly identify stroke before applying diagnostic studies in about 75% of cases. This means as many as 1 in 4 cases are incorrectly diagnosed. It is the role of stroke experts, like those of AcuteCare Telemedicine, to quickly and accurately determine the likely cause of neurologic deficits, the risks and benefits of multiple treatment options and convey a plan of action simply yet fully to the patient and loved ones. It is a difficult but rewarding task.



Big Med Goes Back To School

In his most recent article in The New Yorker, contributor Dr. Atul Gawande demonstrates the value of quality-focused innovation in providing excellent service. Dr. Gawande nods to the Cheesecake Factory’s success in nimbly updating its large and varied menu as a potential model for healthcare innovation. Initially, he takes Big Med (as he calls organized American medicine) to task because, in his words, “good ideas still take an appallingly long time to trickle down,” but in the latter half of the article he provides examples of how the industry is getting things right.

Gawande’s own mother’s knee replacement surgery serves as his first example; by utilizing standardized protocols and equipment, his mother and her hospital achieved top results at a low cost. He then points to an innovative new way of managing patient data in real time that is serving to improve care: In Tele-ICU, nurses and doctors collect patient care data remotely from ICU patients and give direct feedback to the caregivers at the bedside. Using standardized treatment plans, Tele-ICU actually improves the quality of care while simultaneously lowering the costs associated with the sickest and traditionally most costly patients in the hospital.

As providers of teleneurology services, AcuteCare Telemedicine (ACT) wholeheartedly agrees with Dr. Gawande’s observations. Improving the quality of care in emergency neurology requires a standardized, quality-driven approach. Simply put, something done frequently becomes something done well. Traditionally, most neurologists who take ER calls don’t get much experience treating acute stroke patients, and neurology training focuses on diagnosing the problem rather than emphasizing treatment options and paradigms. The nuances of tPA inclusion and exclusion and the decisions about other stroke treatment options mandate that the neurologist treating stroke emergencies be familiar with the most up-to-date practices. Who would you rather have piloting your medical care: the team that flies sporadically, or the one that flies every day?

 



Healthcare Reform and the Impact on Telemedicine

The recent announcement of the Supreme Court’s 5-4 ruling in favor of upholding the Patient Protection and Affordable Care Act (PPACA) has prompted widespread speculation among citizens of the US about the future of healthcare.  Notwithstanding the politics associated with the decision, the ruling carries significant impact for citizens in terms of access to preventive care and insurance coverage.

Telemedicine providers are heavily impacted by the ruling as well. The American Telemedicine Association (ATA) believes that it will positively impact the development of telemedicine, mHealth, and other remote technologies, citing 4 main reasons; the announcement reduces hesitation to invest in telemedicine technologies, protects existing investments in telemedicine, bolster’s telemedicine’s role in many healthcare programs, and strengthens telemedicine’s fundamental value proposition.

As healthcare enters its next era, telemedicine offers a model for streamlining care coordination and improving patient outcomes. In the period of time between healthcare reform being codified into law and the Supreme Court ruling to uphold it, there had been a great deal of uncertainty surrounding the healthcare industry implementing major changes in practice, as it would cause complications should the law be overturned, but the affirmation clears up many of the primary legal and cost concerns, opening the door for telemedicine to address logistical and financial pain points for both providers and patients.

Ultimately, telemedicine fits snugly into the PPACA. For ACO’s needing to include services unavailable in their area, a remote presence physician will be drastically most cost-effective than hiring a full time local MD. Telemedicine also helps alleviate costs for underinsured or completely uninsured patients as well as alleviating strain on the healthcare system caused by unnecessary emergency visits through improvements in preventive care. The court’s decision, while sparking some controversy on other fronts, is the latest step forward in the rapid evolution of telemedicine as a powerful solution for a multitude of healthcare issues facing Americans.



US Government Stands Behind Telemedicine

The USDA has announced its renewed support for the development of telemedicine programs in rural areas. The latest round of funding is part of the agency’s Distance Learning and Telemedicine Loan and Grant Program (DLT), designed specifically to “meet the educational and health care needs of rural America.” Through loans, grants and loan/grant combinations, advanced telecommunications technologies such as those utilized in the practice of telemedicine provide enhanced learning and health care opportunities for rural residents.

The agency has long stood behind telehealth initiatives, touting the abilities of telemedicine to increase citizen access to quality healthcare while simultaneously opening lines of communication to enhance educational for hospitals and schools in underserved areas. Practitioners in the field of telemedicine share in the ideology that where a patient chooses to live should not affect the quality of care they can access.

The upgraded equipment and professional development that will result from the grants will help extend telemedicine services to a larger network of rural dwellers. As telemedicine networks grow, the benefits will continue to grow, both in terms of both improved patient outcomes and reduced healthcare costs.