13 Oct, 10 | by BMJ Group
Some medical technologies creep up on you, some arrive with a bang. In internal medicine much of the change – electronic laboratory reporting, digital imaging – is gradualist and steered by other disciplines, and physicians are grateful if relatively passive users. On the other hand, telemedicine for stroke thrombolysis was a radical step for both my personal and professional life. In addition, it showed me how telemedicine could facilitate social networking of a nature totally different to that commonly imagined.
Up to the end of 2009, I and my two geriatrician colleagues had been on a one in three rota for thrombolysis for three years for our small university teaching hospital. Having developed a stroke service, an embryonic stroke unit, and a TIA clinic, it was increasingly difficult to neglect the lack of thrombolysis for those arriving in the hospital out of hours. However, the time and energy involved was quite considerable – travel to and from the hospital, the inevitable hanging around, and the time needed for those for whom thrombolysis was not eventually possible (about two out of every three calls). Soon we had the highest level of out-of hours call-out of any of the physicians in the hospital: although we had got to a respectable thrombolysis rate of 8%, given our commitments in geriatric medicine, general medicine and off-site rehabilitation, this could not be sustained.
My enterprising colleague who directed our stroke service had been impressed with the emerging literature on thrombolysis and demonstrations at international meetings. He decided to pull together interested stroke geriatricians in smaller local district hospitals to make a successful bid for an innovation grant from the Irish health service to hire a telemedicine system.
And so it was that I found myself somewhat apprehensively sitting in my study at home one Sunday afternoon this January, supervising our first remote thrombolysis on a woman in a hospital 55 miles away. The system, a mobile robot that looks straight out of 1950’s science fiction, has as its “face” a screen which projects the face of the remote operator. As I spoke to the woman and the team using my laptop and joystick, at a superficial level I was conscious that my gravitas was probably alleviated by the Airfix model of Concorde visible behind my shoulders!
However, there was an amazing sense of exultation and liberation at being able offer this service safely and effectively at a distance. I was able to talk to her, the team, scrutinize the observation charts, and review the CT brain slice by slice: indeed, I could readminister the standard stroke severity scale, using the screen and working with the medical registrar, and run through the consent with the patient and her family.
Since then, we have undertaken many more remote thrombolyses. The direct benefits are obvious: between six geriatricians and two neurologists, our thrombolysis rota has become a more comfortable one in seven, a fourth hospital has joined the group, 24/7 thrombolysis has become a reality for a large population of people, and by eliminating travel, the time taken for each episode has radically contracted.
But I have been even more affected by the sense of now belonging to a broader team of colleagues and advocates for better stroke care. The training together, the development of rotas, and the work on the database and quality control has brought together a group of us from different hospitals in a way that might never have happened otherwise. It has also allowed us to start looking at the wider spectrum of stroke care in the hospital network, from further development of our under-funded stroke units to more organised community care. A particular strength is the egalitarianism and non-hierarchical nature of the network – on a given night it can be a stroke physician in either the teaching hospital or the district hospital who provides the service for the whole network of the hospitals.
Even more potent is the excitement and sense of pride among a wide range of hospital staff in all the sites taking part in this new development. Stroke has been such a neglected area of care, and it is truly uplifting to see the positivity and welcome of the nursing and medical staff every time I log on for one of my sessions. In some way I feel part of a new and wider family which has discovered a new pathway to circumvent the indifference and passivity to stroke which has existed up to now. I also detect a shared sense of the importance of keeping coherence and continuity between hyperacute, acute, and rehabilitation care in each hospital.
Desmond O’Neill is a consultant physician in geriatric and stroke medicine, Dublin