Learnings from Tele Medicine

A few patients that a physician came across in this “lockdown season” over Tele links, and the experiences are being shared for reflections.

Late 30s lady, presented from a remote South Asia country location with a swelling in the right thumb, over the MPJ. Pain and swelling have been there for about 4 to 6 weeks, with worsening pain and swelling over the preceding week. Since there was no health care professional locally who could examine, all the consultation was over WhatsApp video calls. The joint appeared swollen and red, with self-elicited severe tenderness.  Patient was initiated on Amoxycillin with Clavulanic acid, and NSAIDS.

A complete blood done showed High Leucocyte count with predominant polymorphs and a high ESR. Antibiotics were continued, but soon there was an abscess that formed at the site that burst and a non-healing ulcer and sinus was seen. ESR continued to be high and 8 weeks into the illness, an X-ray done showed an osteomyelitis of the metacarpal bone with damage to the joint! Getting a culture, swab for TB or Gene expert was impossible! The only way was to start on a trial of ATT in view of the chronic osteomyelitis, and non-healing sinus. There was a supportive Strongly positive Mantoux!

The challenge was not over – the ongoing issue was one of acceptance of the illness and availability of ATT, where TB management is centralized by state! The pre-existing relationship of the physician with the family took care of the acceptance issue! The black-market pharmaceuticals provided the drugs, till the family could find a Mission Hospital who was sympathetic to a distance-based diagnosis done through WhatsApp. And over next 6 months, the ulcer, sinus healed, and the patient is on the way to recovery!

An 80-year-old lady who was asymptomatic, came on a zoom call to check her reports that she had got for a routine screening following a febrile illness 2 weeks prior. She had some feeling of exhaustion that she attributed to a short febrile illness. A quick history and observation over Zoom were unremarkable. Review of the reports showed 12% Monocytes, a high ESR in 100s range and a A/G reversal. Though asymptomatic, in view the high mononuclear cells, ESR and Globulins, a serum electrophoresis was asked for, which came positive for M band. Reviewing history again, her children informed that she has frequency of micturition and recurrent intermittent stools. She was asked to go to a tertiary center for further evaluation, and evaluation reveled a tumor in the pelvis with bone marrow infiltration, biopsy proved as NHL.

An 85-year-old male, came on a zoom call, to talk about his throat discomfort. A known patient with severe Cor-pulmonale on regular treatment, complained about some hoarseness of voice, and reflux symptoms. With comorbidities and age, they were reluctant to go to the hospital. A quick evaluation over zoom was not of much help. A suggestion was given to visit an ENT surgeon, but the COVID19 context did not make it possible, for the ENT visit. A Chest Xray and routine investigations were done which was normal.  At a review after 2 weeks of GERD and symptomatic management, patient felt better and wanted to wait for another 2 to 3 weeks more before a hospital visit. A subsequent review was somehow was not comfortable for the treating physician, and so an ENT checkup was insisted upon. An ENT evaluation revealed a growth in the tonsillar fossa and that later turned out to be an NHL!

A 65-year-old lady, who came on a zoom call, as part of a nurse supported home visit, complained about non healing ulcers in legs. There were multiple liner and serpiginous ulcers n both feet and ankles. A quick facilitated examination done along with the nurse, for peripheral pulses, varicose veins and other common problems did not reveal much. Understanding that the ulcers were chronic, patient was asked about the comorbidities. She rattled off a list of drugs – Anti diabetics, anti-hypertensives, and cardiac drugs. In the middle of this rattling off the list a drug stood out “Azuran”. It looked as if someone had started her on immunosuppressants! Further probing revealed that she was admitted in a tertiary hospital 5 times over the previous three years but did not have any documents of the same! After giving instructions for regular dressings and then asking for medical records, the consultation was closed. Subsequent sharing of the medical records showed that, patient had been diagnosed as “Sweet Syndrome” and she had been on intermittent follow up and management from a tertiary institution!

A few learnings from these consultations

Tele Medicine is best done in the context of a pre-existing relationship and or faith in the system, institution or the care provider. The care provider must have the ability to pick up subtle signs, symptoms and or findings and follow up with the same.  The limitations of tele consultation must be understood, and referral should be planned as soon as possible. Tele Medicine for a chronic illness is better provided by the physicians who were treating earlier.