I love working in the Emergency Department. If I am really being honest, I love BEING in the Emergency Department. I have been hanging out in emergency departments for most of my medical career and couldn’t imagine practicing medicine in any other environment. There is something about being in an ER that makes me feel like a real doctor.
However as my life has gotten more complicated (enter 1 husband, 3 kids, a full academic career and a hobby called FemInEM) the need to be IN an emergency department for 8-12 hours at time has become rather inconvenient. It has become harder and harder to ignore my cell phone for an entire clinical shift and expect that my “other stuff” will wait patiently for me until my shift is done. My husband and kids are also growing weary of me going to the hospital on various overnights, weekends and holidays because “that’s where the patients are.” I love my clinical shifts but missing my family for days on end just stinks. Nevertheless, I accept this as the journey of a full-time FemInEM and, besides, are there any other ways to practice emergency medicine?
Enter telemedicine. Telemedicine companies have been around for over 40 years. Most companies facilitate communication “direct to consumer” or “physician to another clinician” via a video or audio interface. Telemedicine companies are as varied as the patients they serve, with one source quoting over 450 telemedicine companies servicing over a million visitors last year. Telemedicine is currently being used by hospitals, specialists, home health agencies and private practice MDs. In 2011, the veterans health administration delivered over 300,000 remote consultations using telemedicine. Telemedicine is a significant and rapidly growing area of health care. Physicians generally evaluate a patient virtually, assessing the need for intervention or medication without a physical exam. The lack of physical exam, or diagnostic intervention, is what limits the scope of practice of many telemedicine interactions. While any specialty, in theory, can avail themselves for a telemedicine consult, unless there is a clinician on the receiving end, consultations are limited to history and visual physical diagnosis. This usually limits tele-emergency medicine to urgent care and consultation services.
A few months back, I received a call from Tim Peck, the CEO of a telemedicine start up: Call9. Call9 is a company that delivers tele-emergency medicine to nursing homes by combining tele-physician services with onsite medical care. This allows urgent and emergent medical interventions to be done at a nursing home or assisted living facility instead of an ED. Through a web-based application interface of an off-site board certified EM doctor with an on-site attendant (RN, LPN or tech). The emergency physician conducts an initial clinical assessment, then directs the onsite attendant to perform immediate diagnostics, including point of care lab testing, ultrasound, EKGs, telemetry and vital sign monitoring. This integrated virtual/hands-on solution allows patients to be treated within the facility instead of the ED. If the medical emergency cannot be addressed in the facility the patient is transported via EMS to the nearest hospital. However, the tele-physician continues caring for the patient and collecting data until the ambulance arrives.
At the time of our first call Tim was looking for summer medical students with active EMT licenses to pilot his idea. He explained that EMTs serve as the on-site medical providers for a Call9 consult and they would act as the the eyes, ears and hands of the ED physicians in charge on the call. I was happy to find him a few medical students, but once we started talking my mind went straight to the physician job description.
This is how I heard the job described:
- Work from home, no commute.
- Work during the day, evening or overnight, but if there are no patients, do what you want at home (sleep, eat, see your kids).
- Use point of care testing, ultrasound, EKG and X ray to diagnose and treat reversible emergency conditions in the patient’s familiar environment.
- Rapidly assess and treat hospital bound patients while they are waiting for EMS, likely shortening their necessary ED stay.
- Interact with nursing home patients and their families in a space with limited distractions, providing a better environment to have possibly lengthy conversations around sensitive topics like end of life and palliative care.
From my vantage point this tele-emergency medicine thing seemed perfect for so many people I knew. It seemed perfect for working parents who want to practice EM but also wanted to be at home for their kids. It seemed perfect for moms on maternity leave who can’t physically be in the hospital for 8 hours at a time but would love to take calls in between stints of nursing and caring for their newborn. It seemed perfect for a physically disabled EM physician who can’t walk around the ED anymore but has all his faculties intact and still wants to impact patient’s lives. It seemed perfect for the physician spouse of a deployed service person who is functionally a single parent despite being actually married.
Last week, a physician executive posted on my physician mom group of 32,000 women asking if anyone would like to “know more” about telemedicine. The response was overwhelming. In 2 days she had over 500 physicians from every corner of the country and virtually every specialty begging for more information on “seeing patients from home.” For whatever its worth, this type of medicine will fill a need for patients and, possibly for doctors.
Call9 is still in it’s start up phase. Over the 4 shifts I have worked with them I have gotten only couple of calls and never needed to send anyone to the ED. I have been able to successfully treat my patients in the nursing home or sent them for outpatient intervention. I have also used my downtime on call to hang with my family, work on FemInEM or just eat dinner. My experience, so far, has been better than I expected. I hope that as additional tele-emergency medicine companies are developed there will be more opportunities for my fellow FemInEMs (and MenInEMs).
I also don’t expect that tele-emergency medicine will strike a chord with all practicing EM docs. In fact, I think that most doctors practicing tele-emergency medicine will do it part time in conjunction with traditional ED shifts. But for over taxed working parents, mothers on maternity leave or physicians with physical disabilities, tele-emergency medicine may not just save lives, it may save careers.