An apology from a telemedicine physician


In the emergency room, the stress is palpable. The hairs on your neck rise up as you enter the resuscitation bay where the next unconscious patient has just arrived. You can almost feel death as it circulates through the air, like a vulture in the sky. The air tastes sterile, and you hear the crash cart and ultrasound being rolled over to the patient’s bed.

The patient was fine 20 minutes ago, a healthy middle-aged woman who collapsed at home while preparing dinner with her husband. He now stands in the corner, face flushed and dampened by tears. You avoid making eye contact with him at first, until that empty feeling in your stomach recedes. Meanwhile, you examine the patient as the trauma team is preparing to intubate. Her eyes are disfigured, locked in opposite-facing directions like a broken doll. When you lift her arms, it feels as if all life were drained from them as they rest limp in your hands. After her neck is twisted backward and a rigid tube forced into her airway, she is shuttled off for a CT scan. But you already know what to expect. It’s a horrible stroke. The situation is devastating. You begin to counsel the husband about what you might see in her brain, and what you can do about it. And that there may be a way to save her.

Later that night when I’ve retreated to my home and sat down to dinner, I’m interrupted by the pager. A remote hospital’s emergency room is reaching out for help. An older man is suddenly paralyzed on the right side of his body and he is unable to speak. I walk over to my desk, unfold my notebook computer, and log in. On the other end of the line, in the emergency room, a nurse escorts a 5-foot mobile computer into the patient’s room. My face appears before the nurse on an 8-inch iPad screen. On my end, as I sit down on my living room sofa, I can see the patient’s sister is sitting in the chair next to the gurney. Her head is folded softly into her hands. I cannot hear the muffled sound of her crying. I cannot sense the weight of the air that fills the patient’s room. I select the icon for the “left” arrow and rotate the computer’s camera inch by inch until the patient comes into view. It is horribly slow. My chin rests in my free hand as I let out a short sigh, clicking my way across the patient’s room. I zoom in on him and watch as the nurse is measuring his blood pressure. In the midst of this “emergency,” I can’t help but feel reminded of The Sims. His life-threatening situation has been reduced to a shoddy video game.

I correct my posture and speak into the microphone, like I used to during my Xbox days in high school. There is no response. I toggle the volume icon and adjust the microphone settings. The woman in the chair looks up and the nurse faces me. Or at least my face on the mobile monitor. “Hello. My name is Dr. Siegler. I’m a neurology consultant from Philadelphia. May I get your name?”

The woman in the chair responds with her name. “Mia.”

“And to the nurse in the room,” I say, “May I get your name?”

“Alex,” she says.

“Nice to meet you,” I reply, perfunctorily. “Mia, can you tell me what happened?” And so my line of questioning begins. I listen carefully to Mia’s story. But I can’t help but notice the smell of my dog’s peanut butter chew toy or the pumpkin spice candle burning at my living room table. My neighbor and his daughter are playing in our shared backyard space, and I hear them laughing.

“Alex, would you be able to help me examine the patient?” I ask. She complies. “Let’s start with how attentive he is …” And so on.

Alex does an excellent job as we navigate through a routine assessment for stroke. Meanwhile, I check off boxes on the computer interface: “vital signs reviewed,” “lethargic”, “non-verbal,” “weakness present,” and “risks and benefits of treatment discussed.” This limited assessment is hardly acceptable by my own standards, but it’s the best we can do for now.

Despite the crudeness of these clinical encounters, I am optimistic that electronic consultations are helpful to patients. And we seem to be making a difference in their lives. But, as telestroke providers, we’re only as useful as the help we receive on the other end. While I’m relaxing comfortably on my living room sofa, ignoring scented candles and puppy sounds, the nurse is at the vanguard. Where I know I’m supposed to be. And no audio recording of patient’s gratitude is going to fix the emptiness I’m left with once I close the consult window.

I recognize the need to have a digital doctor on call, the value of an e-specialist. And there is a lot that telemedicine providers can offer over the phone. Telestroke is here to stay, and it should continue to improve. But rest assured, no iPad will replace a personal encounter.

James E. Siegler is a neurologist and is an editorial board member, resident and fellow section, Neurology.

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