COVID-19 has shown us new ways of doing things that are sometimes better than the old ways. The reality is that you can take the emergency physician out of the ED

THEY say that nothing improves insight like a diversity of personal experience. That has certainly been the case for me in my move from hospital-based emergency medicine to emergency telemedicine. I started well before COVID-19 struck, but the unfolding of the pandemic and its impact on the delivery of health care have only served to sharpen the insights I have gained. Looking back over decades in hospital emergency departments (EDs), I now have a sense of “outside, looking in”.

My move from public hospitals had two main motivations. First, I was looking for a more rewarding and less frustrating workplace. Second, and perhaps more importantly, I was starting to see overloaded EDs providing not only time-based but also process-based care. This wasn’t driven by generational change or any lack of training or motivation by my colleagues, it was the overwhelming influence of unsophisticated institutional risk management and blunt performance measures.

It became clear that many institutions were working to manage the service provider’s risk more than the patient’s risk.

I had always believed that EDs had a real and important role in accepting all-comers, in plugging the gaps in access for other health and social services. I have since understood that EDs are neither the best nor safest places for all health concerns, and that the acceptance of the “deputising” role for gaps in other services is a real threat to the core acute role for time-dependent and life-threatening conditions. My colleagues intuitively understood this, and it was a source of real moral injury. There is a serious dissonance between trying to be all things to all people but being unable to do individual care well.

I found a way of transferring my hospital emergency medicine skills out of the ED.

I love my specialty – the constant variety, the cognitive challenge, the need to communicate rapidly and effectively with new unknown patients, the range of issues from the womb to the grave, the requirement for rapid risk assessment and problem solving, the constant prioritisation. I was happy to leave behind the competitive hierarchy of the hospital, the fear that paralysed pragmatic decision making, and the emphasis on testing and procedures over explanation and reassurance. Overtesting and overtreatment cause real harm (and here), but the unrelenting pressure to move patients through the system, combined with fear of being crucified for “missing something” led to a production line of tests and referrals.

It became clear to me: this was not good patient care.

I now work across a computer screen, but can offer help to people from Kalgoorlie to Orbost, from babyhood to advanced age. I can reach into people’s homes, into their aged care residence or their remote nurse-run clinic – all in one session. I can provide the explanation and reassurance, when appropriate, which solve patients’ acute concerns and save them leaving home. I can refer or recommend further assessment, but reassure them about urgency. Most of all, I can use assessment and problem-solving skills gained from the ED without the drawbacks of ED – the long waits, the unnecessary tests, the noise and disorientation, the fear.

Taking calls from people who would otherwise have called an ambulance or gone to the ED, I have learned some important lessons.

I now know that many people call 000 because they don’t know where else to get help in a hurry. I know that advice lines that are based on risk-averse algorithms can be net exporters to EDs. I know that, by the time we have a good discussion, the sharp end of the presentation might be abating, and the person already feels better. I know that I would rather initially “see” a child in the comfort of their home, through a screen, than screaming and tired after a long wait in the ED. I know that I can assess a lot about a person through their voice over the telephone: their cheerfulness, the volume and quality of their voice, their breathing.

Emergency telemedicine is a relatively new practice, especially outside the hospital. People have legitimate questions, most of which I now feel comfortable answering. Most questions relate to how confident I can be without “seeing” the patients, especially for audio-only calls. The fact is, most of the money was always in the history, and still is. When I feel the need for some physical examination, I can enlist a parent, or an on-site nurse to do the manoeuvres for me. Where there isn’t enough information to reassure me, I can refer.

The ability to avoid late-night or weekend ED transfers of the frail elderly from their residential aged care facility (RACF) beds has been a real boon. I can assess, explain, reassure, treat or defer transfer – all saving these patients a cold hungry night in ED that can cause disorientation and injury. Not only am I helping the patients and RACF staff, but I am also saving additional load for overstretched ambulances and EDs.

As our services reach out to more rural and remote locations, backing up other clinicians, I hear concerns that the provision of telemedicine could theoretically stand in the way of those locations recruiting on-site medical staff.

It seems to me that, if the factors have been present for successful recruitment, telemedicine would not be needed. It’s also important to consider that the most satisfied clinicians have chosen their workplace for the positive aspects, not because they have limited choices. The choice for emergency physicians to do some telemedicine outside their currently overloaded hospital workplaces can only add to longevity in the specialty, an issue of current concern.

There are opportunities to practice emergency telemedicine via base hospitals, as outreach to their networks, and via dedicated private companies. Once registered with the service, it can be accessed by private individuals, institutions such as RACFs, and via a wide range of other pathways.

The feedback I get from telemedicine patients tells me that it’s not just satisfying for me, it’s good for them. From the ED “bunker”, it’s easy to assume that the ED is the answer to every acute problem – if only there were enough EDs, enough doctors, enough nurses, enough support staff, enough beds.

COVID-19 has shown us new ways of doing things that are sometimes better than the old ways. The reality is that you can take the emergency physician out of the ED.

Dr Sue Ieraci is a specialist emergency physician who has worked for 35 years in public hospitals and now works in telemedicine.



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9 thoughts on “Telemedicine: you can take the emergency physician out of the ED

  1. Helen E says:

    Sue, I love the phrase “risk-averse algorithms can be net exporters to EDs”. It certainly feels that way at the ED coalface and our nurses refer to 13-HEALTH as 13-GO-TO-HOSPITAL

  2. Dr Marielle ruigrok says:

    I think emergency telemedicine has a significant role and I agree this would create longevity in the profession if one day a week we could work from home providing emergency care. Doing what we trained to do without all the stress of managing the real ED which has become the department of available medicine and insuring that the inpatient teams have all the tests done first. I do think that listening, good advice and reassurance is the essence of medicine and agree that assistance from family and other health professionals can provide some of the examination aspects. I also see this as a way see this as a way to follow up those did not waits, missed investigation results and with good patient feedback checking in to see if their treatment had the desired effects in order to mitigate further harm. I would be interested in talking to you about how this can be part of the public health practice

  3. Sue Ieraci says:

    HI, Peter. My service covers the acute, episodic overlap between emergency medicine and general practice, as well as supporting acute stabilisation and resuscitation in remote areas, risk-assessment and support for other clinicians, but no ongoing or preventive care, which I understand to be the cornerstones of general practice/family medicine.

  4. Dr. Peter Stephenson says:

    sounds like you have become a GP. 🙂

  5. Sue Ieraci says:

    Thanks for those who have commented. The service I work for employs specialists, almost all of whom also work in hospital EDs, and has a very strong quality and audit system. We use video as well as audio, and interface with some nurse- or paramedic-run services, so there are many ways of doing an examination by proxy.

    Rob is right to say that there is overlap between emergency medicine and the more urgent scope of general practice. Emergency Telemedicine offers only acute services, not ongoing care, family medicine or preventive care. Of course, those who have ready access to their GP at the time that the need occurs don’t use the service.

    The other advantage of having emergency physicians doing acute telemedicine is the concurrent critical care scope of practice, so there it the capacity to support and stabilise the critically ill in remote areas as well as the acute concern in urban ones.

  6. Susan Ieraci says:

    Thanks for your comments, Vicki. The change has been energising!

  7. Anonymous says:

    be careful what you wish for.
    I have seen too many patients who have been underinvestigated, mismanaged and ending up in worse shape in an emergency department because they were not physically examined due to telemedicine.
    I’ve also seen far too may patients being directed to attend emergency departments by telemedicine practitioners because they cannot be physically examined, whereas a normal medical consultation could have prevented an unnecessary 6 hour wait in an emergency department.

  8. Rob says:

    It is interesting in that there has always been a tension between the ED functions of seeing the most urgent and life-threatening conditions (“Emergency Medicine proper”), and the social safety net for so many others (so-called “available medicine”). Access to urgent care has increasingly been more difficult due to bed shortages, staff shortages, and lack of alternative care for low-urgency conditions. Now we have a system of care developing which triages those with urgent conditions to ED, and non-urgent to telemedicine. It does seem incongruous to me that Emergency Physicians are staffing BOTH. Is their no other specialty that manages low urgency conditions in a comprehensive way? Oh yeah…. general…

  9. A/Professor Vicki Kotsirilos AM says:

    Wonderful article Sue!

    A positive way to embrace the benefits of telehealth to help reduce hospital attendances if not required!

    Well done & all the best for the next stage of your career.

    With kindness, Vicki

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