Pondering “Telestroke” While Covering A Telestroke Service

This week is one of my on-call weeks for Duke University’s telestroke network. When I first came to Duke just over one year ago, I was very familiar with the telestroke concept and had attended a number of meetings discussing what went into developing a telestroke network, but with my transition to a new hospital system, I then had the opportunity to start treating patients virtually who might otherwise not have access to a neurologist when this access was the most time-sensitive – during an acute stroke.

The word “telestroke” may be a bit misleading at first, because the evaluation is actually performed via video stream rather than by telephone (although a phone call usually starts the process). A telestroke network is typically comprised of a central hub hospital (tertiary care center with specialists available), and what are known as its spoke hospitals. The neurologist performing telestroke consultations is frequently employed by the hub hospital (in my example, this would be Duke University Medical Center), and the spokes call for telestroke assistance from the neurologist when a patient is acutely experiencing signs and symptoms that may are concerning for stroke at that spoke hospital. There are also non-hospital companies that provide telestroke consultation services, and neurologists are hired by the company to cover the acute stroke needs of its customer hospitals, rather than the neurologist specifically being employed by a hub hospital.

This is how I appear when “beamed in” on a telestroke robot. I can examine a stroke patient from many miles away, and can even “walk” around the room, or move into the hallway to find the emergency medicine provider to have a discussion about the plan.

Typically, telestroke works something like this in my world. I receive a page from one of our hospital spoke sites, and it is expected that I call the hospital that is paging me in less than five minutes. I then speak by phone with (the majority of the time) a physician, physician assistant, or nurse practitioner in the emergency department at that hospital about a patient who is suspected of having a stroke. We discuss when the patient was last known to be without the stroke symptoms (“last known well time”), as this is an important factor in deciding whether the patient may be eligible for IV t-PA, the “clot-busting” medication that can be given within the first three to four and a half hours after stroke symptoms begin. We also discuss whether the patient is taking any medications, the blood pressure, and many other factors that may influence our decision to give or to withhold t-PA. I then am able to look at the patient’s head CT scan on my computer screen. It is necessary to perform the CT scan in order to rule out bleeding in the brain, since 15-20% of strokes are hemorrhagic. We don’t want to give a medicine like t-PA to someone who is bleeding because it could worsen the bleeding without benefitting the patient. Then, I get to “beam in” to the robot or computer in the patient’s room to start examining the patient from miles away.

Telestroke is a revolutionary concept. A game-changer. Rural areas may not have neurologists in the area to see patients at hospitals, or may not have the capacity to have them available 24 hours a day. This places a neurologist at the bedside, and in a situation where “time is brain,” we are able to not only treat more patients with t-PA, but can also partner with emergency medicine providers to give the drug as soon as possible. Clinical trials have shown us that with earlier administration of t-PA comes a greater likelihood of being independent three months after an ischemic stroke. The odds of returning to independence are greater when t-PA is given 90 minutes after a stroke starts than when given three hours after a stroke starts.

We are also able to identify patients who may be candidates for mechanical thrombectomy, a procedure in which a catheter can be inserted at the groin and threaded to the site of the clot in the brain, with physical removal of the clot. If a patient is believed to benefit from this procedure, we can work with the emergency department at the spoke hospital on transferring the patient as quickly as possible to a hospital where this procedure can be performed.

Sometimes I examine a patient expecting to see a stroke, and after a few minutes of evaluating the patient realize that the patient is in the midst of a seizure. Seizures can mimic strokes. So can migraines. So can a lot of things. It’s another way that bedside neurologist collaboration with emergency medicine providers can be beneficial.

Other times, a patient may be having a stroke, but is not a candidate for t-PA or for a mechanical thrombectomy. Perhaps the patient’s stroke began a day ago and changes consistent with stroke are already evident on the CT scan. Perhaps the patient had a history of a brain hemorrhage in the past and the risk with t-PA is considered too great. During those instances, at least a neurologist has evaluated the patient, and everyone can move on with managing the patient’s care without wondering if something more could have been done had a neurologist been at the hospital.

There are challenges that accompany telestroke evaluations for physicians. A physician must be licensed in each state in which he or she is providing telestroke consultation. In my case, our hospitals are only in two states. In other situations, though, I know physicians who have to keep 10 or 15 state licenses current, which have to be renewed every 1-2 years. Since medical licensing is performed at the state level, there is not a federal license a physician can acquire allowing him or her to practice in all 50 states. Physicians also have to apply for “hospital privileges” at each hospital in which they are performing telestroke consultations, and this can be very time-consuming to reapply every 1-2 years.

There is also the challenge of not being able to physically touch the patient. For example, testing for sensation differences between the right and left sides has to be performed by someone physically present. However, I have found great partnerships with nurses and other physicians who are at the patient’s bedside, and this fosters a spirit of teamwork.

Telestroke is only one application of “telemedicine,” or providing medical care via video conferencing at the bedside. Telepsychiatry places psychiatry providers with patients who need them, and telecritical care allow providers trained in critical care medicine to weigh in on critically ill patients in areas without these experts available. These are only a few of the many possible applications of telemedicine.

While the robots are pretty cool, hospitals who choose not to purchase them or who cannot afford to purchase them can purchase a computer on a cart that can be wheeled into the patient’s room, and the telestroke consultation still goes smoothly. Some companies, such as Vigilias, are working with hospitals to bring telemedicine to rural areas and keep costs at a minimum by using a full-size SmartPhone-based system. The technology continues to develop at an impressive speed, and many innovative people are working towards more efficient ways to provide medical care to more people.