“Hello? Can you hear me?”
Tightly holding the phone, I heard only an old man’s distant yelling and the shattering of dishes being thrown against the wall. Quickly shifting gears from my expectation for a diabetes follow-up call, I pieced together that being trapped in self-isolation for too long had caused my patient Edward with dementia to become dangerously agitated and delirious.
Another louder crash later, Edward’s wife uttered quietly, “Help me, doctor.”
National and state regulators have worked hard to support telemedicine in recent weeks to minimize exposure to COVID-19. Telemedicine has long been touted as the medicine of the future — both closing the equity gap and improving access. After all, who would not want to get their doctor’s visit taken care of in the comfort of their own home?
Unfortunately, with over 90% of our clinic appointments transitioning to telemedicine, it is increasingly clear with cases like Edward’s that telemedicine is not always an appropriate level of care.
Hierarchical levels of medical care exist for patients with differing levels of need. Clinic appointments are designed for stable patients because a clinic simply doesn’t have resources necessary for interventions like intravenous fluids or medications. These would require going to the emergency department (ED) for evaluation and possible hospitalization. On this spectrum, telemedicine ideally should be reserved for the lowest level of care — the healthiest subset of stable patients who would normally be seen in clinics.
As a primary care physician-in-training who works both in the clinic and in the hospital, part of my job is to distinguish appropriate levels of care. Right now, I feel more powerless than ever to do so — patients like Edward who are elderly and sick may require hospital-level care, but they often can no longer receive it. Even if beds were available, elderly coronavirus-negative individuals with multiple medical issues are at high risk of dying from COVID-19 in the ED or hospital. As hospitals continue to be overwhelmed, patients like Edward are inappropriately displaced to clinics that are not equipped to handle their decompensating medical problems.
As I thought through Edward’s case, I decided I could not in good conscience call 911, as I would under normal circumstances, to send him to the ED. This could ultimately become a death sentence. Struggling to pick the lesser of two evils, I settled on prescribing sedative medications to help Edward’s wife control his agitation while trapped within their home — all without ever laying eyes on this patient, who could not afford a video-capable phone.
Telemedicine will undoubtedly play an important future role, but we need to talk about how we plan to manage thousands of patients like Edward. When this pandemic peaks, our health system needs to continue to care for very sick patients who do not have coronavirus. One solution may be to dedicate entire hospitals to coronavirus-negative patients and providers who would be screened prior to entrance. These hospitals would be safe havens for elderly and sick patients who require hospital-level care without the additional risk of contracting coronavirus. While this is just one idea, our nation needs to begin this public discourse to prevent even more unnecessary deaths as a consequence of this pandemic.
Until we come up with a broader solution for patients like this, listening to the echoes of those screams might be the only physical exam I can offer.
Author’s note: All names and identifying information have been changed to protect patient privacy.
Image credit: crack by Dean Hochman is licensed under CC BY 2.0.
Resident Physician Contributing Writer
Boston University Medical Center
Rohit Abraham is a PGY-1 resident in combined Family Medicine & Psychiatry. He is training as a Copello Fellow in health advocacy through Doctors For America. His interests include health policy and care delivery innovations for integrating primary care and behavioral health for urban underserved populations, with an intersectional focus on substance use disorders.
