NORFOLK, VA-July 29, 2000- Dr. Gene Burke kept a critically ill patient from slipping into shock on Tuesday -- eight miles away from the man's bedside.
Burke, stationed at an electronic command center, couldn't touch the sick man's skin. He couldn't palpate the abdomen to check for swelling. But he could watch a crystal-clear image of the patient, filmed by a digital camera sensitive enough to zero in on the pupil of an eye.
The physician didn't like what he saw: ``This guy's really taken a turn for the worse.''
Burke, an intensive care specialist at Sentara Norfolk General Hospital, was using a new form of ``telemedicine'' that allows doctors to care for 20 patient in two intensive care units 24 hours a day. Sentara Healthcare is the first hospital system in the country to provide the service.
Typically, ICU patients at hospitals like Norfolk General see their regular doctors only during morning rounds, which last 10 to 30 minutes, Burke said. The growing number of patients who require critical care vastly outnumbers the nation's 5,500 or so intensive care specialists.
Trained nurses are always nearby, and they can page doctors for emergencies. But by monitoring the ICU around the clock -- even on weekends and at night when patients' regular doctors are asleep -- Sentara hopes to catch problems before they turn into crises, said Dr. Brian Rosenfeld, an intensive care physician who created the system.
In a clinical trial of more than 200 patients at a Baltimore-area hospital, Rosenfeld cut patient deaths by 60 percent and the rate of complications by 40 percent. The study, scheduled for publication in coming months in the journal Critical Care Medicine, found that costs dropped 30 percent.
That means the new service -- which costs from $800,000 to $1 million annually -- should pay for itself in about three years, even though the hospital probably will hire two or three more intensive care specialists, said Sentara's chief medical officer, Dr. Rodney Hochman.
``We're not going to have an empty ICU,'' Hochman said. ``We're not taking anything away. This isn't robotics. . . . There's no substitute for nurses at the bedside. This also puts doctors at the bedside.''
At least electronically.
The patient at Norfolk General had been hospitalized with a life-threatening infection.
From an office building just off Newtown Road, Burke and an ICU nurse tracked the young man's vital signs on three computer screens Suddenly, they noticed his heart rate spike.
Burke searched the computer for answers. At first, he suspected a problem with the patient's heart.
After analyzing the cardiac rhythm on the new computer software, Burke wondered if one of the man's medications -- designed to strengthen the heart muscle -- was working too well, making the heart race.
Burke, wearing a headset, spoke to clinicians at the hospital through a microphone connected directly to his computer's communications software.
``I agree he's vasodilated,'' Burke told them. He watched the man's room fill with a respiratory therapist, an ICU nurse and two residents, who could hear the doctor's words through a speaker but could not see his face. ``I just think the dobutamine in this fellow is driving his tachycardia.''
Burke paused, listening to his fellow clinicians. The patient had been admitted with white blood cell count of 200, far below the healthy level of 7,000. Now, Burke recognized the signs that an infection somewhere in the man's body was spreading to the bloodstream, pushing him into shock.
``He's septic as all get out,'' Burke told a resident at the man's bedside.
An intensive care nurse called the man's personal physician in his office. The drugs being administered to strengthen the man's heart seemed to be causing new problems, Burke said.
``He's on a bucket of levophed and they've got him on dobutamine, which isn't helping. I just propose that she (the resident) hold off the dobutamine.'' At the hospital, the resident felt the man's abdomen to locate the source of the infection.
Burke wasn't sure about the man's chances. ``Is the family around?'' Burke
asked her. ``How hard are we pushing?''
The attending physician agreed to change the medication and provide large
amounts of fluids.
Then, eyes locked on the computer screen, Burke watched as the man's vital signs edged back into a healthier zone. His dangerously low blood pressure was climbing. His heart rate was slowing from 170 beats per minute to 149 -- still about twice that of a healthy resting adult, but a big improvement. Although the patient still needed attention and further tests treatment seemed to be working.
The entire consultation had taken a few minutes. Normally, the exchange would have taken an hour, Burke said. And he might never have caught the real source of the patient's problem without the computer's help, he said.
``His pulse is slowing down,'' Burke said, talking to himself. ``God, I love this system.''
In September, when Sentara Hampton General Hospital's ICU goes on line, Burke and other doctors will be able to cover two hospitals at once an additional 16 patients, said registered nurse Sarah Darwin, director of Sentara Healthcare's ICU. In the future, the telemedicine service may be extended to rural hospitals 60 miles away with fewer resources, Hochman said.
Sentara does not have plans to enroll its other hospitals with IC-USA, the Baltimore-based company that Rosenfeld, a former professor at Johns Hopkins University School of Medicine, founded to market his telemedicine system. Burke signed on as medical director.
Intensive care specialists praised Sentara for agreeing to be IC-USA's first
``They're taking medicine in the right direction,'' said Dr. Tom Rainey, a former president of the Society of Critical Care Medicine who was as impressed with IC-USA that he agreed to join its scientific advisory panel ``It's a good hospital system that is looking for ways to improve care and improve value.''
The system could backfire only if hospitals try to substitute computers for
clinicians at the hospital, Rainey said.
For most hospitals, however, telemedicine could be a big help, said Dr. Barry Shapiro, interim CEO of the Society for Critical Care Medicine.
Fewer than a third of ICUs across the country have qualified intensive care specialists on hand, Shapiro said. But a study due to be published soon in The New England Journal of Medicine shows that care by full-time intensive care doctors -- like those provided by Sentara's program -- can save many lives.
Sentara may soon be a model for other hospitals, said Chris Stenzel, director of venture development for Kaiser Permanente, one of the country's large not-for-profit health maintenance organizations.
By allowing sick people to spend less time in the hospital, telemedicine reduces costs for patients and insurance companies -- a fact that may attract notice from health maintenance companies, Stenzel said.
``This is very innovative and very forward-thinking,'' said Stenzel, who expects other hospitals to follow Sentara's lead. ``It's a tremendous leap forward.''
But the technology is pretty familiar.
One of IC-USA's best innovations was harnessing existing technology and transforming it for a new purpose, Hochman said. Proven technology poses less risk of breaking down.
Yet IC-USA's software is improving all the time.
In coming months, the company will develop ``smart alarms'' that will sound when a computer spots a potential problem, Darwin said. Conventional alarms signal only when a patient needs life-saving attention.
Just as they do now, nurses will still be able to page a patient's personal physician if they're needed, she said. But doctors at the telemedicine command center, like Burke, may be able to make better and quicker decisions about patient care. Unlike doctors who are called at home -- especially if woken up from a deep sleep -- physicians at the command center will have access to a sick person's medical history, current vital signs, even their lab work and X-rays.
Doctors at the command center also will be connected directly to the hospital ICU's nursing station through a hot line, Burke said. And they can talk to nurses virtually face to face -- as in ``Star Trek'' and ``The Jetsons'' -- at computer terminals with video monitors.
``This is one of the few things to come along in the past five years that has a potential to really improve patient care,'' said Rainey, who's also director of the ICU at Suburban Hospital in Bethesda, Md. ``It's not completely proven That's why Sentara is so important. I hope . . . this lives up to its potential. I’ll be very disappointed for the critically ill if it doesn't.''
From the Virginian-Pilot by Liz Szabo