Telemedicine in Practice

1. First episode of illness (5th July 2018)

1.1. Presenting history of first episode

A healthy 85 year-old man, a close relative of mine, went to fetch the newspaper at his garden gate, slipped and fell quite heavily on the drive-way, hitting the hard concrete with his buttock first and then fell backwards so that the back of his head, the occiput, hit the concrete but with less force.

He did not lose consciousness and could get up and walk into the house with the help of his wife and son. The buttock and back of the head were painful and there was no bleeding anywhere, but a lump about the size of a half-lemon appeared later that day at the occiput.

He was a bit giddy but could walk about on his own, swallow and eat food and drink fluids. Apparently there were no broken bones of the limbs or spine. There was no bleeding or discharge of any kind from the nose, ears or mouth.

1.2. Physical examination and clinical management

He is about 5 feet 2 inches and about 120 lbs. body weight, slightly obese with a protuberant belly. A nearby general practitioner who was called examined himand apparently saw nothing seriously wrong; he was given some palliative treatment.

1.3. Initial investigation

A plain X-ray of the skull was done same evening and the report showed no fracture; the outer table of the skull bone was intact at the occiput and elsewhere.

1.4. Past history

He has moderate grade 2 hypertensionof 160/100 which was controlled at 130/80 with anti-hypertensive drugs but no diabetes. He has coronary artery disease for which a drug eluting stent had been inserted in the left main anterior descending branch in 1999.He is under the care of a cardiologist who has given him anti-hypertensive drugs, coronary vasodilators and low dose aspirin. He is regularly followed up monthly by the cardiologist, the last visit being in June 2018.

He has benign prostatic hypertrophy but not too troublesome and need not undergo surgery.

He had heat-stroke with hyperthermia two years ago for which he was immediately hospitalized, treated and recovered.

2. Second episode of illness ( 15th July 2018)

2.1. Resumption of normal life after the fall

He resumed normal life and recovered fully after the fall on 5.7.2018; he is fit, being a footballer and sportsman when young; he has a good appetite, passes urine and stools normally, sleeps well, watches TV, potters around the house doing light repairs and gardening, Since about 2-3 years ago he is forgetful and easily moved to tears by any unpleasant event, which became worse after a heat stroke

2.2. Presenting history of second episode

On the afternoon of 15.7.2018 and 10 days after the fall, his daughter noticed that he could not hold his spoon while eating food, could not tie his longyi-, and could not walk. She phoned me at once and I learnt from her that he was fully alert, could understand her and could tell her what was wrong with him and that he was hungry or wanted a drink, etc. This second episode was surprising and perplexing because he had recovered fully after the fall and the plain X-ray had revealed no abnormalities. Anyhow, he needed urgent attention.But I could not go because at that time I was at the bedside of another relative of mine who had been admitted to YGH for a gastro-intestinal bleed due to Cancer stomach and was dying.

2.3. Telemedicine – remote clinical examination using Video/ICT

I then remembered to do what I had been urging other doctors to do under similar circumstances – to use the methods of Telemedicine.

I told his daughter, who was an intelligent lady although not a doctor or nurse, to ask the patient to do as I instructed her and take Videos of the patient doing as told to do. She followed my instructions and while the patient was doing as told to do, she took a Video of the patient’s responses with her cell-phone (made in Singapore called MI) and sent me the Video at once.

I saw by the Video I received from her that on being told to lift the left arm and grip her finger with his left hand, the patient could do so normally. But when he was told to lift his right arm, he could not do so; it was dangling down inertly by his side; and when told to grip her fingers with his right hand he could not grip. He could close his eyes tight and the mouth was not pulled to one side when he talked or when told to show his teeth and his tongue. When told to look at her fore-finger and follow it with his eyes when she moved the finger left and right, up and down, he could do so easily; there was no squint and no nystagmus;when told to walk, he could stand up and walk but did so dragging his right leg. He could drink water without gaggling. He could hear, talk and understand what he was told.

Obviously, he was suffering from right-sided hemiparesis but all the cranial nerves appeared to be intact – a stroke in evolution. Obviously he needed to be admitted to the hospital for a possible CT Scanand maybe an MRI.

2.4. Special investigations and clinical management

I told the daughter to go to a nearby private hospital and do a CT Scan before going to YGH which was some distance away. The CT Scan was done in about a half hour but there was no radiologist to read it but they gave her copies of the CT Scan film. Due to heavy traffic, they arrived after about one hour at the Emergency Department of the old YGH where I had phoned ahead. The Emergency doctor and Physician called for consult, examined the patient thoroughly, and confirmed the right sided hemiparesis with no cranial nerve involvement. But on looking at the CT scan film they found no evidence of intracranial hematoma, in the occipital region or elsewhere; no evidence of blood in the ventricular system. Instead they found a cerebral infarct in the left parietal lobe of the cerebral cortex region and also one old cerebral infarct in the right middle frontal lobe.

The Radiologist Report read the next day is as follows:

1. Small infarct is seen in at the right middle frontal lobe and left parietal lobe
2. Small post traumatic gliosis is seen at right orbital-frontal lobe
3. Frontal, temporal, parietal and occipital lobes are slightly small with compensatory mild enlargement of lateral ventricles. This represents a mild cerebral atrophy
4. There is no skull fracture, SDH or EDH
5. Slight mucosal thickening is seen at left at ethmoid sinus compatible with sinusitis

Nasopharynx, visualized upper portion of maxillary and sphenoid sinuses are normal. Orbital globe, optic nerve, extra-ocular muscles, retro-bulbar fat are normal. There is no mass effect or mid-line shift.Basal ganglia, thalamus and pituitary fossa are un-remarkable. Suprasellar cistern is normal.No abnormal calcification is noted. Cerebellum, cerebellar-pontine and brain stem are normal.

Impression: (1) Small infarct at right middle frontal lobe and left parietal lobe (2). Small post traumatic gliosis at right orbital-frontal lobe (3). Mild cerebral atrophy.

Meanwhile, the patient’s cardiologist who initially admitted the patient to the CCU then transferred him to the Neuromedical Ward where he was treated and fully recovered from the hemiparesis within a few days.

Further cardiovascular investigations showed trivial mitral regurgitation, no pulmonary hypertension, no thrombus, no pericardial effusion. He was discharged on 20th July, 2018and followed up as an OPD patient. A Carotid Doppler test was scheduled to be done later. However, his senile dementia worsened and he had to undergo psychiatric treatment after discharge from hospital.

So, the hemi-paresis which was thought to be due to slow oozing of blood intra-cranially secondary to head injury turned out to be caused by a co-incident cerebral thrombosis: a double pathology.

COMMENTS ON THE USE OF TELEMEDICINE

The reason for reporting this case is to illustrate the practical use and usefulness of telemedicine by the patient’s family using the ubiquitously available smart cell-phone (costing about Kyats 150,000). I believe this is the first case- report of such a use in Myanmar, but there must be many more instances of such a use which are not reported.If so, doctors are urged to share their experiences in the MJCMP or elsewhere so that others who learn of it will widen the practice of using the smart cell phone, almost ubiquitously available, for medical purposes also and not only for social and commercial purposes as they are doing now. On-line shopping for many items has been available in Myanmar for several years So, why not on-line medicine? I was told that certain enterprises have already set up call centers through which patients may access private practice doctors on line. We should know more about the type of services provided (i) provision of real time interactive services to patients and family (ii) storage and forwarding of medical data (iii) remote monitoring and the quality of such services. An appraisal should be made and published.

Of course there are ethical, financial, technical and other considerations special to medicine but they can be overcome, step by step. It is important to start – start with simple cases where the benefits are obvious and there is no alternative; then expand its use to cases where there are some obstacles which are removable and the benefits far outweigh the bother and difficulty of overcoming them.Proceed incrementally.

There have been previous reviews and articles advocating the use of Telemedicine or E-medicine in Myanmar, excerpts from which are given below:

1. Excerpt 1 from the ‘Myanmar Medical Journal’ ¹

“Another example of the use of Information Technology that will come to Myanmar sooner than later is the following: The Annals of Internal Medicine (Vol.162, No. 6, 21 April 2015) in the article on “The Return of the House Call” refers to ‘virtual house calls’ which are now being initiated by several health care organizations in the USA. “Fueled by new technological advances in the 21st century, house call is emerging chiefly to increase access to medical care. Point of care diagnostics, remote monitoring, and increasingly ubiquitous broadband technology, are enabling care to return to the home. At the same time, other forces, including aging populations, growing burden of chronic conditions, consumer empowerment and need for cost effective care are driving adoption. These virtual house calls meet the aims of providing health care that is safe, effective, patient-centered, timely, efficient andequitable.”

Such innovative use of advances in information technology could become one of the means of providing easier and wider access to certain types of medical care in Myanmar also. In Myanmar home visits by family doctors is still done in small towns, but in big cities the familydoctor and home visits have all but disappeared. Nowadays in Myanmar, even roadside frog sellers brandish smart phones. Busy workers and the aged in the upper socioeconomic stratum of city dwellers in Myanmar and even some ordinary folks as well as those in outlying physically inaccessible places may want to use virtual house calls and be willing to pay for it.

Health planners, the health care industry and medical educators in Myanmar may need to be alert to the potential offered by these innovations in technology. Medical educators, especially those offering continuing medical education (CME), should be aware that it may soon be possible to provide individual medical care directly by electronic means for certain types of common diseases and illnesses, and may have to teach students and practicing doctors the ability to do so effectively and efficiently.”

2. Excerpt 2 from ‘Letter of Intent to the Myanmar Academy of Medical Science’²

“Telemedicine is needed for patients who does not have easy access to health care due to lack of doctors, distance from services or lack of transportation, medical or social conditions or in emergency cases. In developing countries, telemedicine is applicable for primary health care, consultation with specialists, medical emergencies and disaster relief, access to specialized database, provision of medical and health care information services, training, public health monitoring, , ensuring evidence based decision making process and etc.The case for adopting these technologies has been evident for over a decade. However, it has taken a crisis in the health sector in many countries to move e-Health from the periphery to the center of strategic health planning. Several country experiences has revealed that, successful introduction of telemedicine services require more than just the delivery of the right hardware to the users .It is far more important in each case to formulate the relevant national e-health policy and strategies aligned closely to the country’s socio-economic, cultural and geographical terrain situation of the country.

It is recommended to conduct studies to investigate the effective use of tele-medicine in Health Care Management System in Myanmar.

Pilot Study of Tele-radiology and Tele-medicine in Mon State

Expected Outcome

1. The applicability of Tele-radiology and tele-consultation between the township hospitals and tertiary specialist hospital in Mon State will be known
2. The constraints and solutions of applying tele-radiology and tele-consultation in technical and logistic aspects will be explored
3. Ways to facilitate the performance ability of medical doctors and specialists in tele-radiology and telemedicine could be recommended
4. Thereby, a large scale comprehensive trial to find out an effective and applicable telemedicine channel among township hospitals and specialist hospitals will be planned

Conclusion

Knowledgeable, experienced, and well intentioned individual medical doctors have repeatedly advocated the introduction of Telemedicine into the health care system of Myanmar, as supplement to current measures being taken to achieve Universal Health Care.The WHO has long advocated Telemedicine in developing countries3.If the concerned national level health authority(s) are convinced that such advocacy is correct, acceptable and will improve national health,then they should at least make a policy statement saying that Telemedicine is acceptable as a supplementary mode of delivering health care in Myanmar and that it will be promoted This, I believe, will unleash many activities by private individuals, institutions and organizations as well as by public institutions, organizations and departments at state, division and township levels to make telemedicine available to patients, families and the general public. Clinicians and public health specialists can begin to draw up algorithms for uniform and ready use by medical practitioners who will be eventually delivering Telemedicine; IT specialists can gather information about current access and use of smart phones for social and commercial purposes by patients, families and health care-takers at various levels in communities. Instead of waiting for grandiose schemes for use of applications such as X-rays and ECG at point of care to become possible, let us begin small and simple with what we already have NOW as I have shown in my case report.

Let us now begin setting national policy, drawing up national level, institutional level, and grass root level plans of action for the introduction and utilization of Telemedicine in health care in Myanmar.

References

1. Aung Than Batu. Telemedicine in Myanmar. Myanmar Medical Journal, March 2016; vol. 58, No. 1;p 56-63.
2. Kan Tun. Letter of Intent to Myanmar Academy of Medical Science, 30.10.2017. Personal Communication.
3. World Health Organization. 2010. Telemedicine and Developments in Member States. Report on the Second Global Survey on e-Health. Global Observatory for e-Health – volume 2.