AcuteCare Telemedicine Blog

Telemedicine in the Wake of Natural Disaster

As October 2012 came to a close, the arrival of Hurricane Sandy served as a haunting reminder that we can never underestimate the destructive and disruptive power of nature. The “superstorm” wreaked havoc on some of the most populous areas in the United States, not just causing billions in physical damage, but severely testing our infrastructure and its vital role in our society.

Considering the major implications that storms or other disaster events on this scale have for the healthcare industry, the days leading up to, during, and following Sandy were a demanding exercise in preparation, planning, and execution. The storm left countless citizens in need of medical attention, and threatened the adequate treatment of those already receiving care.

As one major resource put under the stresses of a disaster-level storm, hospitals and other healthcare facilities quickly became incapacitated by overcrowding, understaffing, a broken supply chain, and in select cases, power failures that crippled essential equipment. A small contingency of Mobile ERs were dispatched across the region, but a lack of pure manpower hindered the effectiveness of the efforts. Despite their mobility, the interrupted transportation systems within the affected communities prevented many from reaching the help they sorely needed.

Telehealth is an ideal candidate for addressing the challenges of these kinds of circumstances. The infrastructure of telemedicine is capable of delivering expert direction and attentive care to victims of natural disasters. The question of manpower becomes a negligible issue, as doctors and other respondents can call in from anywhere, and thanks to ever increasing internet access, the reach of the care administration is not limited by the victims’ location.

If emergency management agencies and telecommunications service providers are willing to work hand in hand with healthcare professionals, we now have the tools and knowledge to ensure that in future disaster scenarios, people can always have the support they need.

The Personal Side of Acute Stroke Intervention

Mr. Rigby was found unresponsive, gazing to the right and unable to move his left side. Just moments ago, his nurse had seen the 91 year old awake in his hospital bed preparing himself for discharge from the hospital. Though the hospital lacked a neurologist, it had invested in telemedicine services. Immediate assessment of his acute neurological deficits would determine whether treatment with tissue plasminogen activator (tPA), a clot-busting medication, or even thrombectomy (direct mechanical extraction of the clot) was appropriate. If performed within a very short time window, tPA or thrombectomy would open arteries and prevent progressive death of brain cells. However, it could also lead to hemorrhage, bleeding into the brain that could be devastating and even life-threatening. Thus, the teleneurologist was charged with not simply recognizing Mr. Rigby’s stroke symptoms, but also those factors which make the risk greater than the benefit.

As the AcuteCare Telemedicine physician on call, I was at the bedside within minutes via remote presence technology. The evidence; left hemiparesis, left visual field loss and inability to speak, made it clear; Mr. Rigby had sustained a large right hemisphere stroke. A large artery, the MCA, was blocked by clot. His nurse knew the exact time of symptom onset. Without treatment he may have survived, but it was likely he would not walk or talk. He met every inclusion criteria for tPA. Unfortunately, Mr. Rigby was not a good candidate. He had undergone a surgical procedure just the day before, his anticoagulation had been restarted that day and his platelets were very low. At the age of 91 years with these risk factors, the likelihood of serious hemorrhage was too great. As I informed the family members that had filled the hospital hallways, a look of desperation filled their eyes. His daughter stated, “This man is worth-saving.” Remembering my Hippocratic Oath, my immediate response in this case was, “I am certain he’s worth saving, but nobody is worth harming.”

Then I remembered this “case” was her father. I asked her to tell me more about Mr. Rigby. A picture of a family patriarch emerged. He was still vigorous, taking walks daily. He was driving. Indeed, he still routinely played 9 holes of golf. But what she told me next illustrated the shortcoming of using population-based inclusion and exclusion criteria as the sole determinant of risk-benefit for an individual. Mr. Rigby was the caretaker of his 89 year old disabled and blind wife. Without the ability to walk and speak not only Mr. Rigby would suffer. I made an immediate call to the Marcus Stroke Center at Grady Memorial Hospital in Atlanta. The Marcus Center stroke physician agreed the criteria for invasive intervention suggested a high risk, but Mr. Rigby would be given a chance because the potential for benefit was irrefutable. Within a few hours the clot was extracted. Mr. Rigby had an opened artery with full reperfusion. His symptoms improved with only residual left arm weakness. Though speaking slowly, his good humor was immediately apparent. A family had their patriarch back.

Telemedicine: Modern Breakthrough or Timeless Concept?

Telemedicine is the practice of medicine at a distance; interaction that occurs remotely with the physician removed from direct contact with either the patient or other physicians. Telemedicine can include all phases of the physician-patient relationship, from evaluation (including pathology) to diagnosis and treatment. Although  recent breakthroughs in telecommunications technologies have accelerated the advancement of telemedicine, the desire to seek medical counsel regardless of the proximity of the healthcare provider is a common thread throughout medical history. The mechanism has changed, but medicine has long worked to remove the barriers of distance and time.

As early as the Middle Ages, “telepathology” was employed in the form of sending urine samples over distance to physicians for analysis. Prescriptions were carried over miles to patients before the advent of postal services. With the postal service came written letters describing symptoms to physicians, who would reply with diagnoses and treatment plans. These are all examples distinctly foreshadowing the emails and blog centered care that is now gaining a foothold.

Eventually, a milestone was reached when the telegraph allowed transmission of x-ray images. By the late 1800’s, telephony allowed direct 2-way communication between physicians. Still, a physical connection was required, and physicians at sea or without telephone access were at a loss. The radio broke that barrier by the 1920’s, and by the middle of the century, television technology brought real time images into the equation.

Near the end of the last century the most rapid, indeed explosive, growth of telemedicine utilization resulted from the symbiosis of computer technology, wireless communication networks and the internet. The ease of access to telemedicine that modern communication technology provides has broadened the scope of services. “Telehealth,” the utilization of remote presence to monitor health conditions, rather than responding to acute emergencies, is essentially commonplace. Moreover, well-care and health education have benefitted as well.

Today, we do not think twice about calling patients or colleagues on a phone, logging onto a computer for laboratory results, or reviewing radiology images on a TV screen. Soon, electronic health records (EHR’s) will be the norm. There are even technologies on the horizon which will become a partner with the doctor in establishing a diagnosis. The question for our future is when does new remote presence technology become standard of care? Inevitably, we will lose the “tele” and acknowledge that we are completely free of distance as an obstacle to patient care.