Monday, June 30, 2008

Remote care by faxed flow chart

I arrive at work early on Monday to take care of some paperwork. A letter has been sitting on my desk for a week while I decide how to manage a cardiologist’s apparently simple request: to follow a patient’s hypertension after discharge from Edmonton.

After a left thalamic hemorrhage and a diagnosis of hypertensive cardiomyopathy (with an LVEF of 27%), the patient clearly needs frequent follow-up.

The cardiologist probably imagined me booking monthly clinic appointments, adjusting medications, and handing the patient a lab requisition each time. I guess he doesn’t have a map of the north in his clinic.

The patient is from a coastal community in Nunavut, 1100 km away with no road access. The cheapest return flight to Yellowknife, where I practice, costs over $1500. His community is intermittently served by a rotation of family physicians visiting for a week at a time; between physician visits, the nurse in charge runs the show.

I pick up my dictaphone and begin with the usual header: “Dear nurse in charge, I would be grateful for your help in following this patient who was referred to me by his Edmonton cardiologist for hypertension follow-up. Attached is a flow sheet that should be faxed to me every 2 weeks by your home care nurse. …”

After the dictation, I type up the flow chart. Every 2 weeks: blood pressure, heart rate, symptoms. Every 4 weeks: weight, creatinine, and potassium. Fax the form to my clinic and I will fax back necessary changes in medications. Call me with any concerns and book the patient to see the internist who visits his community every 6 months.

I add a postscript to my dictation: “I would like to see this patient when he comes down to Yellowknife for his next echocardiogram, which will be booked for the fall of this year.”
It will be a pleasure — even a luxury — to eventually meet the patient whose care I will be overseeing for the next several months, although I trust his community’s nursing team to contact me with any concerns in the meantime.

I must admit that I felt some trepidation the first time I managed a remote CHF patient by faxed flow sheet. But I have become accustomed to this model of care, and what is lost by the physician being off-site is often gained back by frequent nursing contact and the ability to find a patient easily in the small community.

Northern nurses are attuned to monitoring subtle clinical changes; perhaps because they will be the ones stuck managing pulmonary edema — alone — if the patient decompensates, with a medevac plane many hours away.

My favorite northern band, the Gumboots, wrote a song in honour of the average northern nurse: “…She’s an angel, she’s a surgeon, and she operates alone. Guided through the angioplasty by a doctor on the phone. …”

Poetic license and frontier hyperbole aside, I know my patient is in good hands.

It has taken me 45 minutes to organize his follow-up. Fortunately, I’m on salary. I wouldn’t know how to bill for a flow sheet anyway.

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