Telemedicine Fright

  • Alexandra Epee-Bounya
    Address correspondence to Alexandra Epee-Bounya, MD, Division of General Pediatrics, Harvard Medical School, Boston Children's Hospital, 300 Longwood Ave, Boston, MA 02130
    Division of General Pediatrics, Harvard Medical School, Boston Children's Hospital, Boston, Mass
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      It was a busy urgent care session in the midst of the Omicron wave of the SARS CoV-2 pandemic. Cases were soaring, everyone knew someone who was symptomatic or was exposed. Parents everywhere were reeling from another positive result in the pool testing, from another child being sent home and yet another dire need for a coronavirus disease (COVID) test. I, the primary care pediatrician assigned to a Virtual Urgent Care session that morning, logged on the telemedicine platform, entering via the electronic medical record. My next patient was an 11-year-old girl. This patient—her first name was Celeste—was the eighth of the morning, and there were 5 more to go. The complaint listed by Celeste's name was a variation of what was listed by every patient's name: “COVID exposure, fever.” A quick glance—there was no time for anything longer than a quick glance—at the problem list revealed no past medical history, but Celeste had not been seen in the clinic for the past 2 years. I thought nothing of it, just another child lost to well-child follow-up during the pandemic.
      The virtual visit platform avatar chosen by the parent was odd, a drawing of a skull figure with bright colors, which made me uncomfortable because it felt out of place. I asked if the parent could turn their camera on, and the Dad answered with a flat “No.” Undeterred, I forged ahead and started asking the usual “COVID call questions”: when was she exposed? Is she vaccinated? Tell me about her symptoms. Celeste's Dad gave short answers, and I did not hear in his voice the usual worry I had come to hear in so many parents’ voices. There was only a lot of the frustration, which was also so common. “I really need you to turn on your camera, so I can make sure her breathing is ok,” I said. Dad did not answer but finally turned the camera on and his face filled the screen. He called: “Celeste, come, she needs to see you.” Celeste came into view. “How are you doing, Celeste?”, I asked. The child looked at the camera but did not answer. “I just want to make sure you are feeling ok. Is your breathing feeling normal?”, I tried again.
      And this is when it happened. No warning, no inkling this was coming. The Dad screamed at the top of his lungs, his voice threatening. “Answer her!”, he yelled. And because he stood up and moved toward his daughter, his movements reflecting his sudden anger, I felt certain he was going to hit her.
      Prior to the COVID-19 pandemic, telemedicine had been shown to effectively provide access to pediatric care with high family satisfaction rating scores, yet it was not routine in our clinic. Most of the pediatricians felt uncomfortable with this new care delivery platform. Not being able to examine patients—“I am going to miss something”—was the most common reason my colleagues and I cited when explaining our resistance. Yet, when the pandemic hit and confinement and social distancing became necessary, I embraced the opportunity to continue providing care while maintaining safety for both myself and my patients. And although some of the families still faced challenges accessing the telemedicine portal because of language barriers or poor internet connectivity, almost 2 years into the pandemic, I had started feeling like a seasoned telemedicine provider.
      This sense of expertise disappeared the second I heard Dad yell at Celeste and saw him move toward her menacingly. I felt as if I could see the future: his arm will swing, he will hit her and I will not be able to stop it through this screen. I felt so scared for her and somehow scared for myself, for how could I ever recover from failing my patient so badly? I cursed this electronic platform for being able to bring me so close to a patient, while simultaneously keep me so far I would not be able to protect her. If I had been in an actual exam room, I could have stood in front of Celeste, I could have called for help and my colleagues—the care team—would have rushed in. In these milliseconds, as I was seeing the future, I cursed at how alone a telemedicine provider is during those virtual visits. There is no care team, there is no nurse, and there is no social worker within ear shot. Everyone is a page or email away, and in an emergency situation, that feels like a world too far. And I remembered how little training I had received in delivering care virtually. Yes, there were learning sessions on how to access the platform, there was communication on how to streamline orders and expedite documentation, but there never was any guidance on what to do in the rare, yet possible, instances when the safety of the patient is at risk, in real time.
      The milliseconds stretched and finally I just reacted. I could feel my heart beat faster but I steeled my voice and, as calmly as I could, said: “Everything is ok, Dad. Don't get upset.” And that was enough. Nothing actually happened. Dad backed up, the tension dissipated as quickly as it came. The visit continued, including a couple of minutes I was able to spend with Celeste alone (when Dad went in another room to get the container of over the counter medicine he has been using). She confirmed she was safe. The future I had envisioned in those milliseconds never came true. I eventually closed the visit and made an urgent referral to the Social Work team to connect with this family. And yes, I ordered a COVID test.
      As more care delivery is occurring via telemedicine platforms, more has to be done to ensure medical providers receive appropriate trainings at all levels of medical education to allow for safe and holistic patient encounters.