Got Spoons? Great, let’s make a splint

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Student shares invaluable insight on telemedicine.

Induced demand is a phenomenon in economics that states that as the supply of an object increases, more of it is consumed. This is most evident in city planning; if you build a new road, more people will drive on it because it is there. Studies have shown that metro areas that invest in building more roads did not fare better with congestion than metro areas that did not.[1] The concept of induced demand has also been explained in healthcare in 1959, when Roemer found a positive correlation between the amount of hospital beds and the number of inpatient hospitalization rates. He stated: “in an insured population, a hospital bed built is a filled bed.”[2]

In the emergency room, solely increasing the amount of beds does not decrease wait time, boarding hours or left without being seen rates.[3] To combat increased wasteful costs and patient complications due to over-hospitalization, the number of hospitals and hospital beds have decreased since 1975 from 7,156 to 5,564 and 1,465,828 to 897,961 respectively.[4,5] If this decline was to continue, telemedicine will become a more prevalent way of triaging and treating patients.

Social distancing protocols due to COVID-19 has shifted medical students to online learning. One of my classes is the Breckenridge Wilderness and Environmental Medicine elective offered through the Wilderness Medical Society and Sidney Kimmel Medical College.[6] In addition to learning about various topics in Wilderness Medicine — from dive medicine to disaster preparedness and Incident Command System — the instructors integrated telemedicine into the curriculum. We had scenarios over Zoom where one person acted as the physician and another as a patient. This taught us not only the importance of improved history taking, but also to adapt to the circumstances and be resourceful with a limited physical exam. We could not auscultate the lungs, heart or abdomen; however, we performed almost all the other parts of a physical exam as long as we walked the patient through doing it.

In one scenario, I cared for a patient who dislocated her ankle and was hesitant to go to the emergency room because of fear of Coronavirus. History taking was similar to what I have practiced during medical school. However, when it came to the physical exam, I had to teach her to do a neurovascular exam on her right foot and describe why I wanted her to wiggle her toes and feel for her dosalis pedis pulse. When my field of view was limited to the camera angle, I asked her to move the camera to allow me to see what she was doing. Describing the physical exam in a colloquial way not only helped improve the patient’s health literacy, but also reassured my communication and teaching skills.

After performing the physical exam, I had to initially help stabilize her ankle so she could go to the hospital for further treatment. She could not put any weight on her foot, so I instructed her on making a posterior ankle splint with everyday objects she had at her house. My first instinct was asking if she had an ace bandage along with three wooden spoons or some other flat and rigid objects. The spoons were to anchor the bandage on the medial, lateral, and posterior sides of the leg. To help describe what to do, I turned my camera so she could see my leg and demonstrated on myself. This exercise helped improve my confidence in procedural skills, because it requires someone to know procedures well before improvising and teaching with less than ideal materials.

This scenario not only introduced me to telemedicine, but also underscored the overlap between wilderness medicine, both which requires resourcefulness, innovation and critical thinking. Both have obstacles. One challenge with telemedicine is that although it helps improve access to those who live far away from physicians or in more rural areas, those are the same places that have decreased access to fast internet. This would cause freezing and possible disconnections while trying to get the history or teaching a patient to get through the physical exam. Similarly, history and physicals can be limited in wilderness medicine when caring for a patient in an austere environment where care may be disrupted due to changes in the scene safety.

My biggest challenge from this telemedicine scenario was interpreting the patient’s body making it harder to build a strong connection with them; however, research has shown that the main things that increased a patient’s trust in a provider were how they viewed the provider’s competence and transparency.

Three commonalities improved a provider’s competence according to the patient participants were: diagnostics and physical exams done during the telehealth appointment, the provider’s attitude towards a patient’s situation and qualms, and the patient feeling dependent on the provider for care.[7] Additionally, the distancing effect of telemedicine creates a less threatening environment for the patients and ultimately helped imbue the physician’s advice and treatment with more respect than in face to face situations.[8] With this in mind, I intend to focus my future telemedicine encounters on these components to help build trust with the patient.

Online learning has the advantage of teaching telemedicine through interactive scenarios – without which I would not have learned of the importance of telemedicine, especially during the pandemic.

Telemedicine has become a necessary extension of emergency medicine and will likely continue to grow in undergraduate and graduate medical education. You have the ability to reach out to patients who would otherwise not seek care or have access to appropriate medical facilities. It is an innovative method to deliver appropriate medical care while also empowering the patients to get creative by having them facilitate their own exam and care. To provide outreach and adapt to meet the needs of our patients is the crux of being an emergency medicine physician and online learning with telemedicine will help prepare for this future.

References

  1. Speck, Jeff (2012). “Walkable City: How Downtown Can Save America, One Step at a Time” New York: North Point Press.
  2. Shain, M; Roemer, MI (April 1959). “Hospital costs relate to the supply of beds”. Modern Hospital. 92 (4): 71–3
  3. Mumma et al. (2014). “Effects of Emergency Department Expansion of Emergency Department Patient Flow.” Acad Emerg Med. 2014 May; 21(5): 504–509.
  4. “Fast Facts on U.S. Hospitals, 2020: AHA.” American Hospital Association, aha.org/statistics/fast-facts-us-hospitals
  5. American Hospital Association Annual Survey. AHA Annual Survey Database. https://www.aha.org/
  6. Rudner, Josh and Phillips, Lara. “Breckenridge Wilderness and Environmental Medicine Elective”. www.Breckwild.org
  7. Van Velsen, Lex et al. (2016). “Trust in telemedicine portals for rehabilitation care: an exploratory focus group study with patients and healthcare professionals.” BMC Medical Informatics and Decision Making. 16 (11)
  8. Miller, Edward A. (2003) “The technical and interpersonal aspects of telemedicine: effects on doctor–patient communication.” Journal of Telemedicine and Telecare, 9(1), 1–7

 

ABOUT THE AUTHOR

Dr. Umashankar is a graduate of Sidney Kimmel Medical College at Thomas Jefferson University and is an incoming PGY1 in emergency medicine at Ochsner medical center, a 767 bed acute care hospital just outside of New Orleans.

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