Hello, Khabrovites! Today I will tell you about two cases from the life of a teledoctor that were not included in the previous (already too long) post. In both cases, I had to become a telemedicine not because of my official duties, but out of necessity. All this happened a long time ago, I changed some of the details so as not to de-anonymize the patients. Both were my acquaintances in a difficult situation and we resorted to telemedicine with them, because we did not see any other way out at that moment.
The first case. Natasha, 25 years old, works as an au-pair in the American metropolis. No insurance, no money for a private doctor. There are no special complaints, he just notes a general decrease in working capacity, constant weakness, all this is slowly increasing over the course of months. Let's meet on Skype.
I start with the standard history taking. Here, a symptom checker would have helped us a lot, but then they were still in children's pants.
I ask how, when it all began, the alleged triggers, what makes the condition easier and what worsens it, whether circadian rhythms are traced, the connection with food intake, and so on. Now inspection: daylight is best for him. Clothes: sports bra and underpants. Please walk around the room, bend over, touch your socks. Sit close to the camera.
Hmm ... with this lighting, you can't really look into your mouth. It is necessary at least to sort out to which group of diseases this applies.
- Infection? Is there anyone around you with similar symptoms?
- Metabolism? How often do you go to the toilet? And in a small way?
- Neoplasm? How do you sleep at night? Are you sweating?
Please stand up so I can see you in full growth. Stop. Can you stand up straight? And closer to the light? Take the laptop to the window. Did you have that belly all the time? No, I didn't say I was fat. You are not fat at all, do not be offended, kid. Turn sideways, please.
That time, I never made a diagnosis. But I found the address of a community clinic where medical students receive free visits to the poor. I asked Natasha to draw the attention of doctors to the asymmetry of the abdomen. It was, as it were, depressed on the left side and slightly bulged or even slightly sagged on the right. It struck me as unusual. Anything that is unusual may be important for the diagnosis. At that moment I thought that it could be an enlargement of the liver. Although the whites of the eyes and palms of the girl were not yellow (if the color resolution did not deceive). If I were next to her, then it would not be difficult to determine the size of the liver with the help of fingers and a stethoscope. But there were thousands of kilometers between us.
Three days later, Natasha attended a reception. It turned out that she had a disease caused by ticks and affecting the central nervous system. The pathogen settled in the paravertebral nerve roots and caused their paresis. This is how the scheme of innervation of the human body looks like: a certain level of nerve pathways from the spinal cord corresponds to a certain musculocutaneous segment.
Her lesion occurred approximately at the level of the 9-11 thoracic segment (Th9-Th11).
Therefore, the abdominal muscles, to which the nerves from the affected roots departed, lost their tone and the abdomen "sagged" on one side. The treatment of this disease is not the most difficult, but it took months to recover. Everything is fine now.
The second case. Around the same time, another friend approached me, let it be Max, 32 years old. Max worked in the same financial structure for 16 hours a day and for some time now felt pain in the chest. He could not get to the polyclinic in any way due to eternal employment. In general, chest pain is such a symptom that if you are over twenty, you urgently need to put your feet in your hands - and see a doctor. Chest pain can mean anything, including very serious things.
We meet in skype, again taking anamnesis: how long has it hurt, when, what is the nature of the pain - stabbing, dull, aching. Where exactly does it hurt? Is there a connection with physical activity, time of day? Do you take cocaine? Alcohol? How much, how often? Does it hurt when you inhale? When bending the torso? In general, Max, given your age, weight and the nature of the complaints, it is unlikely that this makes itself felt in the heart. Rather, the cause of the pain lies in the musculoskeletal system. But I still need ECG results, blood for enzymes and a chest x-ray.
- Yes, I still fly home soon, vacation has long been needed.
Max flew to his homeland, where he was confirmed to have intercostal neuralgia and the absence of heart problems. He returned refreshed, with a firm decision to change something in his life. I found a new job, where the salary was slightly lower, but the workload was incomparably less. In addition, the new employer provided good medical insurance conditions.
- Now I know what to look for in the first place during the interview, - he wrote to me in WhatsApp: - This is medical insurance, not the size of the bonus!
Telemedicine is now a buzzword, and many companies are working to introduce technological devices that are designed to facilitate remote patient appointments. But you know what? Now I will express an idea, which in the geek community probably sounds seditious: high-tech medicine is not needed for the bulk of the population.
It is quite possible to provide good medicine for the majority cheap and cheerful, the 95% rule works here:
- In 95% of cases, a survey and examination are needed for the correct diagnosis. All. No complicated laboratory and instrumental diagnostics. Elementary - you only need your own eyes, ears, fingers, brain ... well, a flashlight and the simplest stethoscope.
- In 95% of cases (not necessarily the same as in the first paragraph), the disease is either self-imitated (goes away by itself, treat it or not) or proceeds according to a known algorithm.
It is thanks to this 95% that all kinds of complementary, traditional or, as it is also called, alternative medicine flourish. Her rituals are often complex and take a certain amount of time. During this time, the illness goes away on its own, following the natural course of events. But it is difficult for an ordinary person to distinguish sequence from causality, which means that "I tried it and I don't know how, but it helps."
But in "normal", that is, evidence-based medicine, unnecessary appointments are not welcome. For example, in Europe the ECE principle operates: “efficiency, expediency, economy”. That is, the treatment should not only make sense, achieve its goal, but also do it in a not too expensive way. That is why our people are so often indignant with European medicine: “I went there, but they shoved ibuprofen and sent me home, they didn't even have a urine test”. In their view, good medicine is a general analysis of blood, urine, fluorography and a dropper. Somewhere in the comments I was already written about the assistant professor (!), Who in any incomprehensible case prescribes a general blood test. It is not right. You always need a working hypothesis and tests to test it. And not vice versa. We treat not numbers, not milligrams or millimoles, but people. Because purely statistically:the more tests you order, the more chances that some of them will be outside the norm. The boundaries of the norms are based on the standard deviation and there are always such 5% in which everything is in order with health, but some laboratory parameter does not fit into the norm. This is again the 95% rule in action.
It means that if the salaries of simple local physicians are paid normally, the vast majority of medical needs can be covered.
High-tech (and very expensive) medicine is needed for serious injuries, cancer, and cardiovascular diseases. Cyclotrons, augmented reality, 3-D modeling, Da Vinci robot and individually selected monoclonal antibodies are already involved. But if a person is well treated at a basic level, then it may very well be that the disease will not reach the stage where all this is needed.
A specialist is not needed in 95% of cases. It is needed for those damned five percent, where everything can go completely, not at all according to plan. And to distinguish these same five from others. The devil is in the details as usual. There are states when it is better to listen to the lungs in a certain position of the body. Or you need to hold your breath while inhaling or exhaling. There is a technique when you put the stethoscope membrane on the edge. There are cases when I heard something in my heart and was immediately like this: “Let me listen to the cervical vessels again”. All these tasks are not for a telemetry kiosk. I heard a weakening of the tone and immediately knocked there - yeah, fluid in the pleural cavity. That is why the only really working format for telemedicine is “doctor-doctor”.
I was rightly corrected here, so I clarify: not the “doctor-doctor” format, but “doctor-medical worker”. On the other end of the line, along with the patient, of course, there may well be a nurse, a paramedic, even a 4th year student, any person who knows the technique of physical examination.
Telemedicine is never "my mother's therapist". At both ends of the wire there should be people in the subject, and another telemedicine gadget will not do the weather.
Thanks for reading, stay healthy, don't get sick!