AcuteCare Telemedicine Blog

Dr. James Kiely Honored To Be Entrusted With Offering Guidance And Care

Dr. James M. Kiely characterizes his AcuteCare Telemedicine team as personable, professional, expert, engaged, and available.

“People feel they are buying hardware when they engage in telemedicine,” says the neurologist originally from Peoria, Ill., and raised in Naples, Fla. Dr. Kiely has been named one of America’s top doctors by U.S. News and World Report in recent years. “They think that (telemedicine) is just an app and they are gonna have this faceless, personless, characterless interaction. When you engage with AcuteCare Telemedicine you are engaging in a staffing solution,” Dr. Kiely adds. “You are gaining quality individuals to join your medical staff and your patients are going to be engaging with individuals with whom they can relate on a personal level who are invested in their care.”

Dr. Kiely’s own investment in medical care took flight after graduating with honors from the University of Florida. He still follows his beloved Gators. He received his M.D. from Emory University and Ph.D. from the Emory Department of Pharmacology. He completed his neurology residency at the University of Virginia and has been a partner of Atlanta Neurology since 2000.  In 2009, he became a founding member of AcuteCare Telemedcine.

It is the duality of the mind and brain that drew Dr. Kiely to neurology. “The idea that this was at once an organ and at the same time it is where we manifest ourselves,” the father of four says. “There is no disease that affects the brain without affecting who that person is,” he adds. “It affects their actual sense of self.”

AcuteCare Telemedicine was created, Dr. Kiely says, to guide and significantly impact the well-being of patients with a sudden catastrophic event who otherwise wouldn’t have swift access to vital expertise.

Dr. Kiely is pleased at telemedicine’s high level of patient and family acceptance. “To be able to come in and affect somebody in this way at the time of their most crucial need is undeniably a very personal experience for the patient and the physician,” he says. “Using technology you can still go to the bedside and look around the room. It really is a very personal encounter and I have yet to have a patient or family, when asked, say they’d rather not be treated this way.”

The doctor’s Irish Catholic descent drives him to go to work, do his job, and share his talent. He derives inspiration from patients and their caregivers. “Faced with life-changing, even life-ending circumstances they make difficult decisions and endure daily challenges I have never personally had to,” Dr. Kiely says. “It is an honor to be trusted with providing counsel and guidance.”

Examples of the life-saving impact of telemedicine come easily from Dr. Kiely. He tells of a call suggesting a patient was exhibiting stroke symptoms. The ER physician sought advice regarding treatment with tPA, the clotbusting stroke drug. But when Dr. Kiely went online, it turned out to be something else. “Once I ‘beamed in,’ spent time in the room with the patient and had a conversation with his wife, it became apparent that he needed an acute, urgent intervention for stopping seizure, not for treating a stroke,” he says. The patient was having subtle seizures that mimicked the appearance of a stroke.

Amid the technology that enables telemedicine, the concept revives a method of care from days gone by, when doctors actually made housecalls.

“Everything old is new again,” Dr. Kiely says. “It wasn’t until after World War II and an increase in specialists and hospitals, that patients were brought to the doctors. We’re still using doctors’ offices and hospitals as a setting for care, but it won’t be long before patients routinely see physicians in their offices and homes. You may keep a child home from school, and have the physician see the child there or at the school.”

When Dr. Kiely isn’t making long-distance housecalls, he enjoys exercising, movies and hanging out with family and his wife of 27 years. He misses having the time to relax with brewing and gardening.

Fishing is not among his off-hours hobbies, but is his analogy for his work at AcuteCare. He doesn’t need fishing, stating he gets enough hours of contemplation interspersed with minutes of intense action at work. “You are gonna go out there. You have no idea what your day may hold, but you know it’s gonna be worthwhile,” Dr. Kiely reflects, connecting hook and line, with his healthcare duties. “It’s gonna be exciting. You’re gonna make a difference. You’re gonna have some fun. There is nothing routine about it.”

Breaking the Rules

The Georgia Composite Medical Board recently voted against implementing a rule requiring that any patient must be seen by a physician before receiving care from nurses or PAs via telemedicine technologies, a requirement that realistically cannot be met in most non-telemedicine encounters. It was a small but important victory for practitioners and patients alike.

Prior to being voted down, the proposed rule was drawing widespread criticism from proponents of telemedicine, and for good reason. The motivation for suggesting the rule was to ensure that all mid-level providers caring for patients via telemedicine were being properly supervised by doctors who are more familiar with the technologies. Certainly, taking steps to guarantee the quality of care and safety of patients, especially when dealing with new tools and methods, is of utmost importance to everyone involved in the care process. However, the rule would have been damaging to the improved access to care that is a hallmark of telemedicine, placing an additional an unnecessary step between patients who need immediate attention and the care they require.

With the increasing shortage of physicians, not just in Georgia, but nationwide, telemedicine has opened avenues for the delivery of quality care to individuals living in rural and underserved locales where providers simply are not available. As more practitioners educate themselves on the virtues of telehealth, the reach of doctors, nurses, and other healthcare professionals will extend further than ever before.

Telemedicine will ultimately enter our vernacular and be known simply as ‘medicine.’ In the meantime, as our technology and methodology continue to evolve, we must be careful to steer clear of implementing laws such as the redundant rule proposed in Georgia to avoid setting precedents that will preclude telemedicine from playing its role in assisting our healthcare system reach new heights.

Check Your Head

In the wake of countless notable events including the deaths of several professional athletes in the past 5 years, new light has been shed on an epidemic which we are beginning to learn may be far more widespread than initially thought.

Researchers at Boston University recently published the largest study of chronic traumatic encephalopathy (CTE) to date. CTE, a progressive degenerative brain disease thought to stem from concussive trauma to the head, has been known to affect boxers since the 1920s, but only recently has gained notoriety as a serious concern for athletes of all ages across many sports. In these latest findings, 68 of 85 donated brains from deceased veterans and athletes with histories of head trauma showed visible evidence of the disease, including a staggering 34 of the 35 brains from former professional football players.


The greatest concerns sparked by our growing understanding of CTE’s causes and pathology are without a doubt related to the protection of younger children participating in sports and other activities where risk of injury to the brain is involved. The work of the BU researchers has led to drastically improved protective equipment and restructuring of rules and regulations to minimize the number and force of hits to the head, but it is nearly impossible to remove the potential for these injuries from sports at any level.

Thus, the best possible measures that can be taken are to prevent any repeat injury of the brain. Taking the lead, the NFL has instituted mandatory on-field concussion screening following hard hits. The NHL has also ordered that players with potential head injuries spend time in a ‘quiet room’ off the ice. Youth leagues are particularly concerned with preventing any participant who may have sustained an injury from getting back into the game and facing further danger.

Telemedicine offers the potential for significant further contribution to these efforts. With the help of technology, expert neurologists can always be on hand to examine potential head injuries, and monitor patients in the aftermath of an injury, aiding the recovery process. Thanks to telemedicine’s advances, logistics and associated costs are no longer obstacles to immediate and accurate concussion diagnosis and treatment.

The fight against CTE and other trauma-induced brain disease starts long before the first injury happens, but when it cannot be entirely prevented, telemedicine could play a role in ensuring fewer players incur more severe consequences later in life.

Stroke Treatment Gets a Boost

Fifty years ago, the only advice medical textbooks gave physicians for someone suffering with a stroke was to put him to bed and keep him comfortable, hoping that with time, the brain would heal as best it could. For 30 years, promising techniques preceded disappointing trials. First, heparin was going to be the savior, and for most of the 70s and 80s, it almost served as a standard, but better studies eventually showed that the treatment was not just worthless, but in reality dangerous, causing more brain hemorrhages than no treatment at all. Later, drugs that were intended to clear out “free radicals” were going to save the ischemic penumbra, part of viable brain tissue around a central core of dead cells, but all studies showed that either the medication didn’t get to the target, didn’t work, or could even be toxic to the brain.

In the mid 90s, tissue plasminogen activator (TPA), long used for heart attack victims to break up the clots inside arteries of the heart, was shown to be effective in doing the same in arteries of the brain. For the first time, physicians had something to offer patients that actually made a difference. About a third of patients who received TPA had better three month outcomes than those that did not. This success rate was quite good, but patients with severe strokes still did not respond as well because, in most cases, thrombi in the large arteries were not effectively dissolved.

Only in the last few years have studies been done to consider the effectiveness of a thrombectomy, the process of physically pulling out a thrombus inside an artery in the brain or neck, The early devices available to physicians are fairly good at the task, but a substantial number of patients continue to suffer from residual blockages of the arteries following the procedure.

A report of clinical trials using two new types of thrombectomy devices, called Solitaire and Trevo Retriever, show both of these new devices as being up to five times more effective than their predecessors in opening up arteries. Advances this drastic are rare in medicine, but physicians should be optimistic about the potential for these instruments in improving outcomes. Provided that patients can have access to skilled practitioners in time, within eight hours or sooner, the treatment of stroke may be about to enter a dramatic new phase.

Stroke is the most serious disabling condition in adults, resulting in hundreds of thousands of permanent injuries and deaths every year. This decade may witness the greatest advances in the history of stroke treatment. There are still further trials to run, but with these exciting new prospects, the importance of stroke neurologists like the doctors of ACT being present in every emergency room, either in person or by remote presence, cannot be overstated.

Botox – The Poison that Heals

Ounce for ounce, a molecule made by the bacterium Clostridium botulinum is the most potent neurotoxin on earth. A tiny amount ingested or introduced to the body through wounds has been enough to paralyze all the muscles in a human for more than long enough to allow suffocation from respiratory failure. The structure and biology of this large molecule, primarily made of protein, was deciphered just in the last century, but its ability to quickly and easily get into humans made it of great interest to scientists and physicians around the world.

Over time after its discovery, physicians came to understand that there could actually be medicinal qualities to this poison. One such interesting properties of botulinum toxin was its mechanism to weaken muscles by being taken up by the nerve endings attached to those muscles. This shuts down the nerve endings and their communication with muscles which keeps the muscles from contracting. When exposure is due to a bacterial infection, the toxin is widely distributed, coming into contact with nerves throughout the body, including those of the chest and diaphragm, resulting in breathing paralysis.

But what would happen if a tiny amount of the toxin was isolated and injected right at a site of a muscle in doses that were too small to have any effect elsewhere? Using a small dose would preclude weakness developing throughout the body and produce effects just locally. In fact, this is exactly what happened; an ophthalmologist who was a previously involved with the Army project injected eye muscles of children with crossed eyes (strabismus), weakening the muscles that were pulling too far and straightening out the gaze. The results were very good with few or no side effects.

Ultimately, many other indications came along, all based on the theory that relaxation of muscles can have a desired effect. By far the most publicized application of Botox in particular has been for the treatment of wrinkles – popularized as a fountain of youth in a bottle. Shortly after, it was discovered that patients with chronic headaches, including migraine, who received Botox for wrinkle treatment in the foreign were alleviated, incurring fewer headaches.

The mechanism of action regarding headaches is unknown. Some scientists suggest that the relief results from the interaction of Botox with sensory nerves as well as its known effect on motor nerves. There is evidence of this, but it remains a mystery how it works. Studies clearly show that it does not get into the brain or spinal cord and so does not affect pain centers there. The muscle relaxation itself probably doesn’t play a huge role, though there are sensory receptors within muscle fibers that may be influenced.

The story of this poison that heals is truly fascinating and represents one of the most important medical advances in the last two decades. The future could be even more interesting, as it may be possible to use the properties of some parts of the botulinum toxin to bring other molecules into nerves and have effects on them. This may have implications in trying to restore function and vitality to weakened nerves from many diseases. But for now, millions of people have found that Botox is at least worth a shot.

Read a more detailed history and perspective on Botox here.

RLS in Four Easy Questions

Restless Leg Syndrome (RLS) is an often undiagnosed or misdiagnosed, yet relatively common, sensorimotor disorder, with a prevalence rate of 7.2% in the United States and Western Europe (a prevalence rate as high as 29% has also been reported). The effect of RLS on one’s quality of life can be significant. Furthermore, RLS can be a harbinger of other disease processes and therefore prompt and accurate diagnosis is essential.

Diagnosis of RLS is based on four clinical findings; an often indescribable sensation in the legs (or arms) causing an urge to move, an increase in symptoms with rest, symptom relief with movement, and symptom worsening at night. It is more prevalent in women than men (2:1) and although RLS can be genetic, the etiology in many cases is unknown. Research has suggested that the cause of RLS may be due to the brain’s inability to correctly utilize dopamine and or iron. Although causative effects are not clear, RLS is often seen in patients with chronic disorders such as diabetes mellitus, uremia, autoimmune disorders, thyroid disease and iron deficiency. Thorough laboratory evaluation in adult patients, especially with recent symptom onset should be pursued. In particular, ferritin levels should be checked in all men and post-menopausal women as iron deficiency is present in about 20% of those with RLS. Iron deficiency in this population can be the result of occult bleeding, which can be a sign of an underlying malignancy, such as colon cancer.

In 2005, the Restless Legs Syndrome Prevalence and Impact General Population study was published in the Archives of Internal Medicine. Of the 416 study participants found to have a clinical diagnosis consistent with RLS, 81% had discussed their symptoms with a primary care physician and 74% of these received a diagnosis. However, RLS was actually the second least common diagnosis comprising only 6.2% of all diagnoses. The most common diagnosis was “poor circulation” comprising 18.3% of the diagnoses. Other diagnoses in descending percentages included arthritis, back/spinal injury, varicose veins, depression/anxiety, and nerve entrapment. Although these may have been accurate, “secondary” diagnoses, in approximately 94% of patients, the diagnosis of RLS was not made. Unfortunately, the treatment of most of the above conditions would not effectively alleviate symptoms of RLS and in some cases may exacerbate them. (ie antidepressants).

Given reported prevalence rates, RLS it is not a rare disorder. The potential negative impact upon the lives of those with RLS has been found to be as high as in those with diabetes and clinical depression. Because the symptoms of RLS are more prevalent in the evenings, it can have a significant impact upon sleep onset and sleep maintenance. This in turn can lead to complaints of insomnia, daytime sleepiness and fatigue, cognitive dysfunction and poor daytime performance, all of which tend to lower quality of life. If not diagnosed and treated effectively, the cumulative impact of untreated RLS may lead to an increased economic burden due to work absenteeism and increased health care utilization.

Once RLS is diagnosed, there are several effective treatment options available, including behavior modification, discontinuation of offending agents, and medications such as dopamine agonists, gabapentin enacarbil, and iron supplementation.

To diagnose RLS is quick, easy, and done without the cost of diagnostic studies or procedures. Hopefully, increased healthcare provider and patient awareness will lead to fewer undiagnosed or misdiagnosed cases of RLS. It takes only four easy questions to diagnose a patient with RLS; a seemingly but not so benign disorder.