Inside Dr. Landon's Brain
When the American public and the medical community think of telemedicine I have found that it appears that the Star Trek tricorder must be right around the corner (and it is!, http://www.scripps.edu/news/press/103197.html ) held by a robot with an impish personality and vague human fallibility, with an even more fallible human ready to check the findings against an infallible data base.
In terms of what is available
today, it is usually no better than the technology we can grasp - the telephone.
Although smarter phones are coming, the "Mr. Watson -- come here -- I want to
see you." of Alexander Graham Bell is usually sufficient. I talk daily to residents
who have graduated and left for small towns who are confronted with a sick child
or worried family that they fear their own experience will not help. Our teaching
program relies on them being able to communicate the history of a disease process
and the physical exam vocabulary of the specialist.
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The Problem With Telemedicine
The biggest problem with any form of telemedicine
is trying to get enough information through existing bandwidth. trying
to "pull" most images and information through POTS (the technical term
for plain old telephone service) is liking trying to suck an elephant through
a straw.
If you have ever had the misfortune to go out
to dinner with a doctor I can tell you that shoptalk usually revolves around
pus and diseased organs vividly described. Followed by complaints about
the food. As if anyone could eat after hearing about this grand tumor growing
out of a patient's eye. But we do actively discuss our cases seeking the
opinions and experience of our peers. When this fails and more information
is needed, a fax machine usually suffices to transfer complex medical records
or lab results. In true Victorian era medicine Xray and pathological findings
are described, as the quality of the images is insufficient to transmit
by fax.
Images
from http://www.andriestek.com/
Perhaps it is here, in image transfer, that telemedicine will eventually prove of use. Store and forward - obtaining an image electronically, storing the incredibly large amount of information, and forwarding it to a true expert will be of tremendous assistance in expert reading of cancer slides or Xrays. Raytheon provides free reading software but not the compression software to store the digital images http://www.emed.com. The miracle of software, while developed for "Godzilla", have helped us to reinterpret the electronic images in three dimensional ways and, again, making them available for store and forward.
Show Me The Money
In the same fashion that Ronald Reagan brought Russia to its knees with the threat and expense of high tech “Star Wars” the expense of a telemedicine station has prevented its rapid expansion. Winter floods consumed the University of Minnesota’s telemedicine equipment and they are in no rush to replace it. Americans want only the best in MRI scanners, artificial organs, and advanced medical treatments but all this comes at a cost. While applying business principles to medicine has led to a slew of Congressional bills to protect the consumer for the health maintenance organizations, low costs mean business survival. Technology must be economical and cost saving. Oklahoma State University hit the nail on the head in their needs assessment: What do you NEED to do ... that you cannot do ... because time and/or distance is a barrier? If your answer is nothing, you probably have no need for a Telemedicine/TeleHealth application… In some cases, you may rationally decide not to spend any money at all. http://www.telemed.okstate.edu/Webpages/Planning/homepage.html
High Tech or High Touch
We utilize our equipment for teaching purposes.
Through our associations with UCLA, USC, California State University Schools
of Nursing, local junior colleges, and medical students from other states
we teach the care of children with special health care needs. It is often
the most basic skills they learn, including looking in the ear of a child.
I cannot count the number of ear drums about to be treated as infected
that were really ear canals. Akin to a rodeo event, the fascination of
seeing an ear drum magnified eight inches holds the attention of most small
children and tired residents.
These images are taken of a normal eardrum on
the left and an eardrum with a hole on the right.
Give me a computer that only doubles my work and I'll be happy
Our own patient centered work
has revolved around the development of patient data bases, maintaining
confidentiality of records, and looking for patterns of illness that may
reflect the effects of ethnic background, social status, and parenting
patterns. We are proud participants in the most advanced clinical immunization
tracking registry in the United States. I hope that Jim Norris, project
director, will be able to comment in the future about the interface between
software and twenty patients waiting impatiently in line to register in
a system that cannot be integrated Of even greater import is/was/will be
the technophobia or morbid fear of keyboards. Thanks to the courageous
work of a young man with muscular dystrophy it became clear to our nurses
and receptionists that irrational fears are just that Dixon comes to our
clinic by motorized wheelchair after attending junior college. For him,
and other young adults with chronic diseases, the keyboard is their third
eye to the world, their inner strength magnified one hundred fold Once
this non medical person was taught patiently by a receptionist (who learned
more in the process of teaching him) that Hib and HepB were two different
immunizations Through active participation in the registry our immunization
rates have increased and it has helped prepare our staff for the more technological
world ahead.
Our own data base participation
has ranged from the RAND Corporation/UCLA (asthma and parenting), the University
of Minnesota (asthma and parenting), the Center For Disease Control (child
abuse and parenting - a higher death rate in our county than all the childhood
cancers put together), to UCLA/Harbor/Stanford ("Ventura Diabetes" - a
form of adult onset diabetes found in alarming rare in Hispanic children
in Ventura County) All the data was collected on this incredible medium
- it can store data with no degradation for literally thousands of years
but is erasable and can be written on both sides1 Paper - and then it was
transferred to electronic files to be sent - by ground transportation!
Sure telemedicine is here. The electronic medical record is right around
the corner. Right! I must admit the use of statistical packages for data
interpretation did reveal some unexpected conclusions but also consumed
the better part of two years while one of our research associates pursued
a holy war searching for mysterious last X statistic… but finally to be
published in the e-pages of Pediatrics. Dr. Lucey had to reassure our colleague
that moving beyond the printed page was the future. An editorial did appear
in the July issue of Pediatrics to appease rumors and fears that have arisen
from Pediatrics new and modern approach to dissemination of the scientific
literature.
Brains Turning To Tofu
Many of my residents claim their brains are turning
to tofu, something that biomedical engineers at NASA's Ames Research Center
are taking advantage of. I was always impressed with neurosurgery until I
find that an inadvertent extra second of suction meant the loss of fifth grade.
As it turns out tofu is the ideal way to test “smart sensors” for surgery
through brain tissue. The varying textures are an excellent learning laboratory
on their way to finding the differences between tumors, nervous system tissue,
and blood vessels. Guided with tiny cameras precision surgery is on the way. 
http://www.computermotion.com/zeus.htm
