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On any given morning in the intensive care unit of Nemours/Alfred I. duPont Hospital for Children, about a dozen doctors and health care providers gather outside the open door of a patient's room.
The process, called "rounding," is the daily opportunity for doctors, nurses and specialists to discuss a patient's condition and care.
The problem is, the gathering "goes against any concept of social distancing" practices initiated in the wake of the coronavirus, said Dr. Nicholas Slamon, a critical care specialist at Nemours.
Still, these patients, many of whom are not hospitalized for COVID-19, desperately need care and attention. That's where technology comes in.
While many think of telemedicine as a downloadable phone app that allows patients to connect with an on-call doctor rather than brave the waiting room of an urgent care or schedule an in-person appointment, this practice has been employed inside Delaware hospitals to limit patient exposure amid the coronavirus pandemic.
It has meant calling upon already existing in-room cameras and speakers to talk to patients and their parents. It has involved setting up a conference room for residents – doctors early in their training – to join the briefing remotely. And it has meant standing the presenting doctor, nurse and potentially, a parent, in a 6-foot-by-6-foot triangle outside a patient's room each day to keep adequate distance between them.
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"It's putting together a bunch of technology that we've had available to us for years," said Dr. Patrick Barth, a pediatric ear, nose and throat specialist who helped create these new protocols as the enterprise medical director of telehealth specialty care. "Fortunately, it's resulted in physicians adopting it.
"This is going to alter medicine in general," Barth added, "and it's going to alter people's mindsets."
New circumstances, new options
The same can be said for family care doctors who, for some, have long offered telemedicine services as a supplement or replacement for an in-person appointment. And while a phone call or video chat can't replace some features of a physical exam, it has provided doctors, in a time of crisis, another option to offer care.
Take Dr. Jim Gill, who adopted telemedicine as an offering at Family Medicine at Greenhill about three years ago.
Despite implementing the new technology, both patients and fellow doctors were resistant to the new way of interacting, he said. In the last two years, Gill estimated that of the 1,200 appointments his office conducts each month, about 20 to 25 were telemedicine visits.
That was, until coronavirus hit.
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Now, his office does about 15 to 20 telemedicine calls and chats per day, according to Gill's estimations.
"Patients think it's great," he said. "Obviously the ones who are using it are the ones who want to use it. We keep hearing, 'It's great you started doing it,' but no, we've been using it for three years."
The telemedicine visits do pose challenges though, as some aspects of an exam can't be replicated through the phone. Some coughs will still need to be listened to through a stethoscope, for example.
Though federal officials have loosened the regulations around telemedicine and subsequent reimbursement by insurance companies, many family care doctors are holding their breath to see whether the payments actually come in.
"Our only true worry right now, and we have to put it in our back pocket, is what are these insurances going to do?" asked Dr. Kristine Diehl, a primary care physician at Delaware Family Care Associates on Silverside Road. "Are they going to leave us high and dry?"
And given that a doctor's order is required in Delaware to be tested for coronavirus, the demand for care is even more apparent.
"We're getting work done for people who need it desperately," said Diehl, who also serves on the Medical Society of Delaware's Public Health Subcommittee. "We may not be on the front lines, but we're in the trenches, trying to take the burden off the system and keep people from going to the emergency room ... so the volume of care can be dedicated to people who have coronavirus."
Changing doctor visits
Technology hasn't changed the fact that doctors still need to physically see patients, especially if they're hospitalized with a serious condition or there's a chance they may need to head to a hospital for more care.
Both Diehl and Gill are still seeing patients in person, though both of their family practice offices have taken added precautions to protect patients and staff.
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At Gill's office, well visits – or those without suspected contagious issues – are seen from 7 a.m. until 12:30 p.m. Then, the office closes for a deep cleaning before the "sick session" of patients from about 2:30 to 6:30 p.m., Gill said.
All the while, the waiting room is cleaned each hour, walls are wiped down, patients are escorted to rooms rather than sitting with others, and masks and gloves are requirements, Gill said. Telemedicine visits are also going on.
Some aspects are very similar to in-person visits, Diehl said, though audio glitches can lead to some lag in the conversation.
Otherwise, she's still asking patients the same questions she would in person and gauging their reactions: How long have you been sick? Can you describe your symptoms? What have you been exposed to?
In some cases, she's asking patients to take a deep breath and hold it.
"It's limited, but it's a way to evaluate their lungs," Diehl said, adding that nothing can really replace listening to someone's lungs directly.
Simply put, the entire process has been "very, very, very challenging," Gill said.
For most people, calling their primary care doctor is the first step when they get sick, so his office and others have felt the increased demand.
The good news? Gill's office has plenty of coronavirus tests, and the doctor is adamant about getting people tested who may be a carrier or who desperately want to be tested.
"One of the ways we really missed the boat and have gotten behind the curve ... is not testing," Gill said. "I'm not saying I'd test anybody but certainly ... do not ration tests."
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The future of medicine
As the coronavirus reshapes industries around the world, pushing services online, or even shuttering them completely, the pandemic is also altering medicine and what's yet to come.
Both Dr. Barth and Dr. Slamon wondered what will change inside Nemours once the restrictions lift and life begins its inevitable shift back to normal.
Admittedly, Slamon said, his gut feeling is people will go back to doing things the way they've always been done, if for no other reason than for the comfort of being able to after so much change.
But the alterations made to the hospital's delivery of care are worth talking about.
"Are we replacing what we did before with something better or worse?" Slamon asked of these changes. "It's definitely made us thoughtful about the way we're providing care when you have absolutely no restrictions."
For some fields like psychology, telemedicine has allowed health care providers a glimpse into the lives of their patients, said Meghan Walls, a child psychologist at Nemours.
"I have a depressed teenager I'm working with and I was able to see that she was laying in her bed at 10:30 in the morning," she said. "There's a lot of things we can do that's really useful at this time.
"Almost every behavioral health provider I know is doing telehealth right now," she said.
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It's also forced doctors to use technology already at their hospitals.
Take the Eko stethoscope, which has a detachable head or listening device that can be placed on a patient's chest and livestreamed to a specialist in another room, another building or another state.
This has allowed one care provider to gather information for numerous doctors and specialists with a single visit, rather than rotating many people through a patient's room.
In the era of COVID-19, that obviously has its perks, said Slamon.
It's allowed the hospital to simultaneously conserve personal protective equipment for doctors and nurses due to the number of times they need to enter and exit a room, while also allowing for breath and heart sounds to be recorded, thus limiting the amount of time a doctor needs to spend in a room with a potentially contagious patient.
Eko sees the opportunity. The company is giving health providers free and unlimited licenses of its software through June 1, according to the company's website.
"I think and hope that as we move forward, some things will stay and they will be adopted as a way we can do this more efficiently," Slamon said. "A lot of times, we've done wasteful care, and we can add some new pieces that may actually improve things in the long run."
Is there a story you feel needs to be told in the wake of the coronavirus pandemic? Contact investigative reporter Brittany Horn at (302) 324-2771 or bhorn@delawareonline.com. Follow her on Twitter at @brittanyhorn.
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