Lying in an emergency-room bed at Mena Regional Health System on June 1, Iva Mae Sikes did her best to answer the questions asked by the male voice coming from the computer in front of her.

The entire left half of her body was paralyzed. The 89-year-old’s usually clear, direct speech was slurred and the muscles in the left side of her face slackened. She’d had a stroke, and the voice from the computer was a neurologist evaluating Sikes’ symptoms from 145 miles away in Little Rock.

Sikes is one of about 35 ruralhospital patients who’ve been reviewed from afar via videoconferencing technology as part of the Arkansas Stroke Assistance Through Virtual Emergency Support program, known as Arkansas SAVES.

The program started Nov. 1, with a one-year $6.1 million Medicaid contract with the Arkansas Department of Human Services.

It began as a partnership between the state Medicaid program, the Mena hospital, the University of Arkansas for Medical Sciences’ Center for Distance Health in Little Rock, Sparks Health System in Fort Smith, Booneville Community Hospital, Johnson Regional Medical Center and the Arkansas Department of Health.

Since it began, hospitals in McGehee, DeWitt, Helena-West Helena, Mountain Home, Batesville and Arkadelphia have also joined SAVES.

The program provides rural hospitals access to neurologists at UAMS and Sparks 24 hours a day, with the goal of quickly identifying the type of stroke suffered. Doctors then see if patients can be given a potentially lifesaving medicine that must be administered within three hours of a stroke to dissolve blood clots.

A stroke is a sudden loss of brain function caused by a blockage or rupture of a blood vessel in the brain. Nationwide, it’s the leading cause of serious long-term disability and the third-leading cause of death in the United States.

There are about 795,000 strokes in the country each year, according to the federal Centers for Disease Control and Prevention. Arkansas has the country’s third-highest rate of deaths from stroke.

In 2005, 58.6 of every 100,000 deaths among Arkansas adults were due to stroke, for a total of 1,847 stroke deaths. That’s compared with a national average of 46.6 of every 100,000 adult deaths, or 143,579 total stroke deaths, according to the latest CDC statistics.

Alabama had the highest rate, with stroke deaths making up 60.9 of every 100,000 adult deaths that year, followed by Tennessee with 60.7 of every 100,000.

Arkansas’ high rates of obesity, smoking, diabetes, high cholesterol and untreated high blood pressure all contribute to the state’s high stroke death rate, said Dr. Margaret Tremwel, neurologist at Sparks Regional Medical Center and director of the hospital’s Early Intervention and Treatment Program.

“In every treatable risk factor we exceed the national average,” she said. “We have a real problem here in Arkansas.”

Telemedicine that takes specialty care to rural hospitals and community education about the signs of stroke and importance of getting immediate medical care are key to reducing strokerelated deaths and disabilities, Tremwel said.

ACCESS

Sikes has lived in Mena, the county seat of Polk County on the western edge of the state, for about 60 years. She was alone in her house when she suddenly collapsed the morning of her stroke. It was 9 a.m. She knows because she counted off the chimes from the clock as she lay there.

She said she knew right away it was a stroke. Half of her body had suddenly gone numb, and she knew the signs.

“I just went down,” Sikes said. “I tried to find my left side, but I couldn’t find it.”

Sikes reached for the Lifeline medical-alert necklace she wears at all times and pushed the button for help. Her grandson was by her side in five minutes, and paramedics came moments later.

Sikes was transported to Mena Regional Health System about four miles from her home. There, Dr. David Ureckis, a team of nurses and medical personnel examined her and quickly confirmed she’d had a stroke. That’s when they activated the SAVES system.

Mena Regional was one of the first three hospitals to join the SAVES network, said Bob Ellzey, chief executive officer of the city-owned 65-bed community hospital.

Like most rural hospitals, Mena Regional doesn’t have the resources or patient volume to attract neurologists, Ellzey said.

“We have very good general physicians, but we don’t have a lot of specialists,” he said. “Nationwide, there is a shortage of physicians, and particularly in the rural areas, there’s a shortage of specialty physicians.”

Located in the midst of the Ouachita National Forest, Mena has a population of about 5,588. It’s about 85 miles to the nearest large hospital. That can be problematic for patients needing emergency specialty care, such as with a stroke, said Ureckis, who’s been an emergency-room physician in Mena for seven years.

“A lot of times there’s a limited amount that can be done,” he said.

THREE-HOUR WINDOW

At Mena Regional, emergency-room personnel ran lab tests and did a computed tomography, or CT, scan of Sikes’ brain. She was disoriented and afraid.

“It was scary,” she said. “I remember being questioned, but I didn’t remember what day it was.”

Dr. Salah Keyrouz, a neurologist and assistant professor at UAMS, was on call that morning for SAVES and was online within five minutes of getting the call. From Little Rock, he was able to review her CT scan and lab results and ask her questions.

Although she couldn’t see him, he could see her with a high-definition video screen that allowed him to zoom and inspect details like the dilation of her eyes and direction of her gaze.

He determined she was a candidate for tissue plasminogen activator. Known by its abbreviation, tPA, it’s a powerful “clot-busting drug” commonly used for acute-stroke patients. The SAVES program requires that it be administered within three hours of a stroke, in accordance with U.S. Food and Drug Administration recommendations.

“When you have a stroke, time is of the essence,” Ellzey said.

Sikes was given the medicine with just 12 minutes to spare.

About 85 percent of strokes are caused by blood clots that could be treated with tPA, Tremwel said. It’s a medicine that increases a patient’s chances of recovery within three months of a stroke from 30 percent to 50 percent.

But as a potent blood thinner, there are also concerns about potential side effects, Ureckis said. It can be harmful if the drug is given to the 15 percent of patients whose strokes are caused by a hemorrhage, or bleeding, in the brain because it makes the bleeding worse. That’s why a specialist is needed to examine the patient and determine the kind of stroke first.

The limited time frame can be a problem, especially for people living in rural areas, said Keyrouz, also director of the Arkansas SAVES telestroke program. Too often, stroke victims wait too long to seek care, either because they don’t know treatment is available or they think the problem will resolve itself, he said.

“The vast majority of strokes would be amenable to this treatment. The problem is people don’t get into the emergency room fast enough, and the emergency rooms don’t know what to do when a person gets there,” Tremwel said. “That’s where Arkansas SAVES comes in.”

Sparks Regional has had a relationship with the Mena hospital for several years. Before SAVES, Tremwel said, she provided consultation by phone. In some cases, patients were transported to the Fort Smith hospital by air ambulance, but that can waste precious time, she said.

Under SAVES, doctors and nurses in rural hospitals are trained in the standard steps used to evaluate patients for stroke endorsed by the National Institutes of Health. They work as a team with the on-call neurologist to evaluate patients and render the most appropriate care.

It’s made treating stroke patients from afar much more effective and efficient, Tremwel said.

“The quality of care we can provide - it’s like night and day,” she said.

‘A LITTLE MIRACLE’

When she came to after receiving the tPA, Sikes said she found herself surrounded by her grandchildren. She immediately felt better.

Carol Allen, a registered nurse and emergency-room director at Mena Regional, said Sikes showed tremendous improvement within 20 minutes of getting the medicine. She started flexing her toes, could smile and moved her eyes in all directions.

“It was quite an experience. I was grateful to live,” Sikes said.

Granddaughter Tyra Hobson, also of Mena, said she was ecstatic to see the sudden change. She pulled the blankets off of Sikes’ feet and asked her to wiggle her toes.

“I was like ‘Grandma!’ I was dancing all over,” Hobson said. “I was over there hugging on her and everything.”

Keyrouz said plans call for expanding the stroke network to hospitals around the state, with a goal of adding nine to 12 new hospitals a year.

The concept is already being used in other states and with other specialties in Arkansas. For example, the Antenatal and Neonatal Guidelines, Education and Learning System, at UAMS has linked specialists in neonatal intensive care with doctors in clinics and hospitals around the state since 2003.

Ellzey said such programs should be used nationwide to lower health-care costs, extend the reach of specialists and improve treatment available to patients in rural areas.

Hobson said she’s just glad to have her grandmother back to her old self. Sikes went through rehabilitation at Mena Regional. She has regained movement throughout her body and walks with the help of a walker.

She was released on June 17.

“She’s just tough. I knew she was going to make it one way or another,” Hobson said. “We just saw a little miracle here.”

Knowing stroke symptoms

Stroke is the third-leading cause of death in the United States and a leading cause of serious, long-term disability in adults. A 2007 survey found only 47 percent of Arkansas’ 2.15 million adults know the symptoms of stroke, according to the Arkansas Department of Health. Doctors advise calling 911 if a person shows any of these sudden signs of stroke:

· Numbness or weakness of the face, arm, or leg, especially on one side of the body

· Confusion, trouble speaking or understanding speech

· Trouble seeing in one or both eyes

· Trouble walking, dizziness, loss of balance or coordination

· Severe headache with no known cause

SOURCE: Arkansas Department of Health Arkansas Democrat-Gazette

Telemedicine is a rapidly developing application of clinical medicine where medical information is transferred via telephone, the Internet or other networks for the purpose of consulting, and sometimes remote medical procedures or examinations.

Telemedicine may be as simple as two health professionals discussing a case over the telephone, or as complex as using satellite technology and video-conferencing equipment to conduct a real-time consultation between medical specialists in two different countries. Telemedicine generally refers to the use of communications and information technologies for the delivery of clinical care.

Care at a distance (also called in absentia care), is an old practice which was often conducted via post; there has been a long and successful history of iin absentia health care, which - thanks to modern communication technology - has metamorphosed into what we know as modern telemedicine.

The terms e-health and telehealth are at times wrongly interchanged with telemedicine. Like the terms “medicine” and “health care”, telemedicine often refers only to the provision of clinical services while the term telehealth can refer to clinical and non-clinical services such as medical education, administration, and research. The term e-health is often, particularly in the UK and Europe, used as an umbrella term that includes telehealth, electronic medical records, and other components of health IT.

Telemedicine is practiced on the basis of two concepts: real time (synchronous) and store-and-forward and Home Health(asynchronous).

Real time telemedicine could be as simple as a telephone call or as complex as robotic surgery. It requires the presence of both parties at the same time and a communications link between them that allows a real-time interaction to take place. Video-conferencing equipment is one of the most common forms of technologies used in synchronous telemedicine. There are also peripheral devices which can be attached to computers or the video-conferencing equipment which can aid in an interactive examination. For instance, a tele-otoscope allows a remote physician to ’see’ inside a patient’s ear; a tele-stethoscope allows the consulting remote physician to hear the patient’s heartbeat. Medical specialties conducive to this kind of consultation include psychiatry, family practice, internal medicine, rehabilitation, cardiology, pediatrics, obstetrics, gynecology, neurology, speech-language pathology and pharmacy.

Store-and-forward telemedicine involves acquiring medical data (like medical images, biosignals etc) and then transmitting this data to a doctor or medical specialist at a convenient time for assessment offline. It does not require the presence of both parties at the same time. Dermatology (cf: teledermatology), radiology, and pathology are common specialties that are conducive to asynchronous telemedicine. A properly structured Medical Record preferably in electronic form should be a component of this transfer.

Home Health Telemedicine When a patient is in the hospital and he is placed under general observation after a surgery or other medical procedure, the hospital is usually losing a valuable bed and the patient would rather not be there as well. Home health allows the remote observation and care of a patient. Home health equipment consists of vital signs capture, video conferencing capabilities, and patient stats can be reviewed and alarms can be set from the hospital nurse’s station, depending on the specific home health device. Usually low bandwidth analog Plain Old Telephone System (POTS). Some newer systems do support higher bandwidth capabilities. Disease management, post-hospital care, assisted living, etc.

Telemedicine is most beneficial for populations living in isolated communities and remote regions and is currently being applied in virtually all medical domains. Specialties that use telemedicine often use a “tele-” prefix; for example, telemedicine as applied by radiologists is called Teleradiology. Similarly telemedicine as applied by cardiologists is termed as telecardiology, etc.

Telemedicine is also useful as a communication tool between a general practitioner and a specialist available at a remote location.

The first interactive Telemedicine system, operating over standard telephone lines, for remotely diagnosing and treating patients requiring cardiac resuscitation (defibrillation) was developed and marketed by MedPhone Corporation in 1989. A year latter the company introduced a mobile cellular version, the MDphone. Twelve hospitals in the U.S. served as receiving and treatment centers. (See: Telecommunications, Concepts, Development, and Management, Second Edition, pages 280-282, W. John Blyth, Glencoe/McCgraw-Hill Company,1990)

Monitoring a patient at home using known devices like blood pressure monitors and transferring the information to a caregiver is a fast growing emerging service. These remote monitoring solutions have a focus on current high morbidity chronic diseases and are mainly deployed for the First World. In developing countries a new way of practicing telemedicine is emerging better known as Primary Remote Diagnostic Visits whereby a doctor uses devices to remotely examine and treat a patient. Consultations monitors an already diagnosed chronic disease, AND has the promise to diagnosing and managing the diseases a patient will typically visit a general practitioner for.

Examining the feasibility and effectiveness of doctor-patient interaction through videoconferencing, a study has shown that such virtual doctor visits are similar to face-to-face visits on most measures. 

“There is growing evidence that the use of videoconferencing in the medical environment is useful for a variety of acute and chronic issues.

Videoconferencing between a provider and patients allows for the evaluation of many issues that may not require an office visit and can be achieved in a shorter time,” says Dr. Ronald F. Dixon, an internist at Massachusetts General Hospital and the study’s senior author.

In America, telemedicine projects are being examined to evaluate their capacity to improve patient access to care and lower healthcare costs.

During the current study, the researchers randomised patients to one of two arms.

In the first arm, the patients completed a visit-either virtual or face-to-face-with a physician, and later completed a second visit via the other modality with another physician.

In the second arm of the study, the subjects had both visits face-to-face with two different physicians.

All of the doctors and patients involved completed evaluation questionnaires after each visit.

The researchers observed that the patients found virtual visits similar to face-to-face meetings on most measures, including time spent with the physician, ease of interaction and personal aspects of the interaction.

The doctors in the study were also found to score virtual visits similar to face-to-face visits on measures like history taking and medication dispensing.

Though the physicians appeared less satisfied on measures of clinical skill and overall satisfaction, the ratings they gave to virtual visits were still in the good to excellent range.

The diagnostic agreement between physicians was 84 percent between face-to-face and virtual visits; it was 80 percent between the two face-to-face visits.

“The tradition of medicine is to lay hands on the patients, which has always been considered paramount to patient care in the minds of physicians. However, these findings suggest that virtual visits could be a viable option in circumstances where patients need to be monitored routinely for chronic conditions like diabetes , hypertension, obesity or depression, and where self-management strategies are not working. Virtual visits may also be effective for triage of acute, non-urgent issues like back pain or respiratory infections,” says Dixon.

Based on their observations, the researchers came to the conclusion that both patients and physicians could benefit if virtual visits were used as an alternative method of accessing primary care.

The study has been reported in the Journal of Telemedicine and Telecare. (ANI)

Telemedicine can be implemented within stroke-care systems to help fill the gaps in coverage, according to two articles published online on May 7 in Stroke. A third article published in the same online edition revisits the definition and evaluation of transient ischemic attack.

J. Donald Easton, M.D., chair of the American Heart Association/American Stroke Association Stroke Council, and colleagues write that the definitions of transient ischemic attack, early stroke, and other vascular outcomes risks, as well as how to evaluate transient ischemic stroke have all undergone revision in the light of recent scientific research. Among their recommendations are for patients to undergo a brain scan within 24 hours of symptom onset, as well as routine noninvasive imaging of the cervicocephalic vessels.

Lee H. Schwamm, M.D., and Heinrich J. Audebert, M.D., co-chairs of the American Heart Association, and colleagues reviewed the existing evidence on the use of telemedicine by stroke-care systems in order to establish consensus recommendations on the use of telemedicine in primary prevention of stroke and general neurological assessment; emergency medical services notification and response; acute and subacute treatment of stroke; and secondary prevention and rehabilitation.

“Whenever local or on-site acute stroke expertise or resources are insufficient to provide around-the-clock coverage for a health care facility, telestroke systems should be deployed to supplement resources at participating sites,” Schwamm and Audebert write. “This should be done within the context of stroke systems of care model framework wherever possible.”