During the coronavirus pandemic, telemedicine looks like the future of health care. Is it a future that we want?
The call came in to the emergency department at Alice Peck Day Memorial Hospital, a twenty-five-bed facility in Lebanon, New Hampshire, around 2 p.m. on a weekday in mid-March. Patient X had arrived by car, and, by the time he reached the hospital, the pain in his legs was so severe that he couldn’t move.
Jesse Webber, a paramedic, donned full personal protective equipment (P.P.E.) before going outside with a wheelchair. Since the onset of the pandemic, almost all sick people who entered the hospital’s E.R. were considered, whatever their symptoms, to be P.U.I.s—persons under investigation for covid-19.
The patient, a heavyset man in middle age, was lucid when Webber wheeled him into the emergency department’s negative-pressure room—a seven-by-eleven-foot windowless space fitted with a noisy exhaust fan that removes contaminated air. Once the man was inside, his mental state deteriorated rapidly. A team made up of Nancy Ferguson, a doctor, and two critical-care nurses, Kacie Boyle and Laura Williams, in full P.P.E., joined Webber and Patient X in the cramped room.
The patient was having difficulty breathing. “Very quickly, his respiratory rate dropped,” Webber later told me. He was “crumping,” as nurses say—not crashing, but failing fast. “His body essentially stopped breathing in front of us,” Webber said.
Ferguson ordered a rapid-sequence intubation, a procedure for swiftly connecting a patient to a ventilator. Ventilating a patient is a complex task that involves not just putting a breathing tube into the trachea but also inserting intravenous lines to deliver sedatives, so that the patient doesn’t fight the tube—known in hospitals as “bucking the vent.”
“As soon as I heard the doctor say that, I reached behind me and hit the emergency-telehealth button,” Webber recalled. Within seconds, the team at Alice Peck Day was connected, through a secure audiovisual link, to the tele-emergency hub at Dartmouth-Hitchcock Medical Center, an academic training institution with more than five thousand employees, affiliated with Dartmouth College’s Geisel School of Medicine. Sadie Smith, a nurse, and Victoria Martin, a doctor, were in the middle of twelve-hour shifts, sitting side by side at one of the hub’s four-screen workstations. The workstations are hardwired into the emergency department at Alice Peck Day, and also into those of ten other community hospitals across the region; the most distant is a hundred and eighty miles away.
Smith’s face popped up on the screen in the Alice Peck Day negative-pressure room. Smith is one of the most experienced tele-emergency nurses on the Dartmouth-Hitchcock staff, and she has an air of unflappable competence that would inspire calm in any crisis.
“How can we help?” she asked.
Smith and Martin had control of a high-resolution camera mounted on the wall of the negative-pressure room. They could zoom in on Patient X, watch his cardiac monitor, and talk to the doctor, nurses, and paramedic on the scene. Electronic-record-sharing allowed them to “chart on” the patient—to have real-time access to his vitals and his medications, just as though they were there. But, unlike the staff attending to him, who were working elbow to elbow in the negative-pressure room, straining to speak over the noise of the exhaust fan, the tele-hub team was unharried and safe from possible covid-19 exposure. The hub personnel could check records and arrange for transport to the medical center, on the other side of town, without the nurses having to leave the room, thereby avoiding the hospital’s P.P.E.-doffing procedure—a two-person, twenty-eight-step job—and the need to put on new P.P.E. on their return.
In the hub, Smith noticed that the hydration fluid the patient was receiving wasn’t compatible with the sedative that he was on; the Alice Peck Day nurses switched fluids. The doctors decided to insert a second I.V. line, using the intraosseous method, which infuses medicine directly into the patient’s bone marrow. Smith told me later that “really large patients are difficult, because it’s really hard to find I.V. access. So I suggested going through the humeral head”—the top of the arm bone. “I’m standing there, with my camera view, going, ‘Bring his arm over, lay it across his belly, then feel here, and right in the middle is where you want to go.’ ”
“Sadie kind of guided us in,” Webber said.
Finally, they got Patient X intubated, and “it turned out his expired CO2 was really quite high,” Smith told me. As the nurses used the ventilator to blow pressurized oxygen into his lungs, his CO2 level started to trend down. The crisis had passed.
Telemedicine and telehealth involve a myriad of remote-health-care technologies and services collectively known as “virtual care.” For years, virtual care played a minor role in the United States’ $3.6-trillion health-care industry; now, with the covid-19 pandemic, millions of people are discovering its benefits and its shortcomings for the first time. If virtual care is the future of health care, is it a future that we want?
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https://www.newyorker.com/magazine/2020/06/29/the-promise-and-the-peril-of-virtual-health-care
