Doctor Samuel Campbell talks about the complexities of providing the best telemedicine support possible to clients in remote locations.
Dr. Samuel Campbell has been with PRAXES since 1997 and has seen the growth of the telemedicine industry firsthand. He trained in South Africa and worked there for three years before moving to Canada to practice in the far north around the British Columbia and Alaska border for five years. After specializing in emergency medicine in Vancouver, Campbell moved to Halifax where he still resides. In addition to working with PRAXES, he is Professor of Emergency Medicine at Dalhousie University and Chief of the Department of Emergency Medicine at the Charles V Keating Emergency and Trauma Centre at the Queen Elizabeth II Health Services Centre. Campbell also works as a provincial trauma team leader and on-line medical control physician for Nova Scotia Ground Ambulance, LifeFlight, the Community Emergency Care Centre program and the extended paramedic program and the Nova Scotia Regional Poison Centre. He answered a few questions for us on the complex challenges of providing the best telemedicine support possible.
You have such a diverse background and extensive experience in medicine. How do you apply your specialties and knowledge to your work providing telemedicine care with PRAXES?
I am extremely fortunate in working with some of the best minds in emergency medicine and critical thinking in the world, including my colleagues at PRAXES. Our association with the Academic Centre allows us, in addition to being the generalists required of us by emergency medicine, to have special areas of interest, and each of us is able to learn from the special knowledge of our colleagues. If time permits, modern communication systems allow us to consult with each other in really complicated or unusual cases to make the best and most patient-centred decision. My own research interests include medical support of remote healthcare providers, the emergency management of infectious and respiratory disease, continuous quality improvement and emergency airway management.
Telemedicine has evolved to become a viable option for healthcare. What are some of the challenges you face when providing telemedicine support?
The concept of remote support of people with emergencies extends many of the complexities that exist in contemporary emergency medical care. In John Ross’ earlier blog about being an emergency physician, he mentions the ‘undifferentiated’ nature of the emergency medicine patient. While TV shows might suggest that patients who present for emergency care are actively seizing, have blood squirting out of a wound or are profoundly unconscious after a drug overdose, these cases represent a very small proportion of what we do. Far more cases present a puzzle both from a diagnostic and a treatment perspective, and the ability to avoid being seduced by what seems an easy diagnosis, but is actually an atypical presentation of something worse – is very important. Perhaps only in primary care, is the cause of the patient’s concern, or any potential solution to their problem, as ill-defined. In emergency medicine, the need to decide what to do in a short frame of time is added to this complexity. In many cases, decisions will need to be made without all of the information that would be ideal to inform what is actually going on. Depending on how sick the patient is, a diagnosis might be less important than a specific action, referred to as ‘empiric therapy’ (therapy based on experience and on the basis of a clinical educated guess), which estimates what is most likely to kill the patient and treating it as if it is that, while you wait for the situation to become more clear.
There are many factors involved when making a medical decision from a distance such as the environment and the other individuals working with your patient. How do these elements affect your work?
After 20 years of delivering remote emergency advice in many different settings, to providers from lay patients alone at sea to emergency specialists in modern hospitals, I continue to receive calls that are very different from any I have had before, with new and unusual circumstances and challenges. I continue to make decisions I have never made before, adapting knowledge from a hundred other scenarios, usually in partnership with the caller, who, as the person on scene, really knows the most about what can and can’t be done. It is a thrilling, exciting and very rewarding job, and as our ability to communicate remotely continues to expand, the possible options for managing each case expand with it. Whenever I have been away for a holiday, I am excited to get back to work and receive my first call.
In the second of a two-part post, PRAXES Dr. Samuel Campbell further examines the challenging variables of delivering high-quality telemedicine and the complex differences between treating a patient in person versus remotely.
What are some of the overall challenges the medical industry faces when treating a patient in an emergency situation?
In this era of resource limitations and long waits for emergency care, any decision regarding how you manage one patient has to take into account the impact that the action will have on other patients or on the system trying to carry the load. Furthermore, medical intervention and testing is not always benign and unnecessary tests can lead to false results that further muddy the situation, delaying diagnosis and correct treatment while leading to unnecessary treatment and/or more invasive testing. It has been estimated that over a third of the money spent on healthcare in North America adds no value to patient care, and the emergency department is as guilty as the rest of the system in this regard.
Are there specific variables you must give special consideration when treating a patient remotely?
When it comes to supporting the emergency care of someone remotely, via telephone, videoconference or even by text, so many more variables complicate decision making. When the patient is away from organized care, there are the usual emergency medicine questions regarding diagnoses but contextual elements specific to the case also need to be considered, such as:
- Where is the patient and how far are they from a better health care location?
- How much more likely are the most dangerous possible diagnoses than the more benign ones?
- Who is there to take care of the patient and what is their training?
- What facilities and medications do they have available?
- Are there other people nearby with medications that we can borrow while waiting for transport to arrive?
- What are the medical risks of moving them/or of leaving them where they are?
- Would others be endangered if we had to get them out of there? If so, by how much?
- What is the risk of misdiagnosis in this particular patient? For example, is a ‘wait and see’ strategy made more risky by sacrificing transport time just waiting?
- What are the risks of empiric therapy and is it available?
- Am I about to spend a huge amount of money transporting a patient for the wrong reason?
What are some of the key differences between treating a patient in a hospital setting versus treating a patient remotely via telemedicine?
A decision made while working with a patient remotely may appropriately differ significantly from one which would be made if the patient was in front of you in a hospital setting. You might over-treat with antibiotics in a patient with only a small probability of a bacterial infection, or you may leave a patient with chest pain out at sea, even if you are worried he might be having a heart attack, if the risk to him and his rescuers are clearly higher than the risk of poor outcome from his heart.
To complicate things further is the need to address cognitive biases that all of us are prone to, and which can be amplified in the uncertainty illustrated above. For example, we tend to believe what we want to believe which might be the most convenient diagnosis. We persist with our first impressions, noticing things that support them as a conclusion less than things that refute them. We might inherit the impressions of others, and make different decisions if scenarios are presented to us in different ways. We make different decisions if we are tired, angry, impatient or depressed, and may attribute clinical findings to certain personal characteristics that have nothing to do with the question at hand. An example of how we might address a bias is asking ourselves if we are ordering a medevac only because we don’t have the cognitive energy to really evaluate the risks of leaving the patient where he is. Or are we considering a recent case experience that was totally unlike the current one but which went badly because you decided to delay a medevac. There is also possibility of making a decision because we feel more comfortable with just doing something (potential errors of commission) than with doing nothing (potential error of omission). Providing remote medical direction is both challenging and stimulating. The sense that we are providing some comfort and help to those to whom the ‘usual’ medical system cannot reach is a significant factor that keeps us engaged.