“I had to do it – I had no other choice,
you’ve got to listen to the inside voice.
A bullet train will get you there fast,
but it won’t guarantee a long last.
Sometimes it takes a little bit of courage and doubt,
to push your boundaries out beyond your imagining.

While you were out there, chewing on fat for probable cause – I let go.
While you were out there, weighing odds – I was imploding the mirage.”
– “Imploding the Mirage” – The Killers (2020)

Things have been rough for the last few months in our small rural centre. In addition to managing the backlog of primary care after a pandemic shutdown, a combination of decompensated chronic disease and freak events led to a rush of critically ill patients. Starting with getting called away from an overdue pap smear to place an urgently needed central line, and a few weeks later ending with me flying out on a helicopter with an intubated patient, this summer reminded me why rural general practice is both exhilarating and absolutely terrifying.

Through all of this, I have had the pleasure of locally establishing and extensively testing the new Real-Time Virtual Support Pathways that have been founded during this crisis. In addition to the fantastic local medical team, I am deeply grateful to have been able to lean on my remote colleagues through RUDi & ROSe. A special thanks go to Dr. Adam Thomas (@adamdavidthomas), who assisted me with a hat trick of critical care cases in July.

These scenarios have helped me rapidly move from mulling the theoretical benefits of these services to experiencing the real utility and potential for physician-facing virtual supports. In doing so, I have been forced to reflect on the boundaries and limitations of this new province-wide virtual emergency department.

Reliance on an Internet connection

The first and most obvious limitation to these virtual supports is the reliance on a reliable broadband internet connection – something that many areas in the province and country still do not enjoy. With the proliferation of 4G cell towers and government programs to improve internet access, I was initially confident that this would prove to be a rare issue in rural emergency departments in 2020.

Then in the early hours of my first weekend on-call last month, I received a text message indicating that our community would lose essentially all communication capability for an unknown amount of time due to an impending local tower failure. This was rather vexing, especially as I realized that a patient on the ward was deteriorating and could need critical care interventions during that timeframe.

I received a text message indicating that our community would lose essentially all communication capability for an unknown amount of time due to an impending local tower failure.

I had just enough up-time to get briefed by @adamdavidthomas on the things I would need to consider should things go sideways, and alert the Patient Transfer Network about our patient and communications predicament. Luckily, everything went smoothly, but I had become painfully aware of the need for improvements in the broadband infrastructure in our province to support patient care and the promise of projects like SpaceX’s Starlink for our site in particular.

The Complexities of Personal Connections

The next issue that became apparent is one that I have also mentioned previously – the quality and character of the connections between local physicians, established referral centres and specialists, and these new supports. As a generalist, it is nice to be able to get advice on challenging and vague clinical scenarios that push the depth of your knowledge from multiple sources.

But when the advice one gets conflicts with your own reading of the situation, or when specialist colleagues disagree on the “correct” course of management, and more importantly, the need for transfer, frictions can quickly arise. In the worst case, these interactions can make already complicated patient presentations more difficult to manage, and potentially damage relationships between sites and individual clinicians.

But when the advice one gets conflicts with your own reading of the situation, or when specialist colleagues disagree on the “correct” course of management… frictions can quickly arise.

Though this remains a somewhat charged issue, progress is being made to manage it. From my experience, having all involved clinicians on the same PTN call solves a lot of problems. Work is being done both from the top and locally to integrate the Real-Time Virtual Supports into our existing referral/advice call patterns to streamline the interactions between our local staff and remote support, minimizing friction.

There is a respect and awareness from the physicians working with RUDi and ROSe (and other virtual programs) that their advice is just that. Ultimately, the decision and responsibility for the patient lies with the local physician and their knowledge of their particular context and resources.

Reliance on skilled rural practitioners

This brings us to the final limitation, and strength, of virtual care – the reliance on skilled, local, and broadly trained medical personnel. Despite the documented limitations and much forecasted death of the physical examination, virtual acute care cannot at this time replace a competent hand (and ultrasound probe) on the belly of a patient with abdominal pain.

Quality medical training, experience and knowledge of local patients and context provide the background to inform the “inside voice” that leads to the activation of said supports. Though I could ping @adamdavidthomas through ROSe for help with vent settings, he could not directly help me with the physical act of intubation or other critical procedures. For that, one must rely on their own training and the support of local colleagues.

Despite the documented limitations and much forecasted death of the physical examination, virtual acute care cannot at this time replace a skilled hand

I once had a specialist colleague at a conference (remember those?) lament that virtual care supports will result in the “dumbing down” of rural clinicians, and I am convinced they were wrong in this assessment. In my experience, these resources instead support and expand the already broad skill set of generalist physicians, enhancing rural patient care and ultimately improving outcomes. Though it comes with unique challenges and limitations, it is deeply gratifying to work with and constantly learn from a provincial emergency medicine team, and know you are providing the best care you possibly can with the local resources you have.

For a long time, the promise of virtual care support has hung in the air – something always a year or two away. COVID rushed these programs into existence, and it remains to be seen if they will indeed be long lasting. I hope that courageous front-line rural teams across the province push these virtual supports to their most extreme boundaries and implode their mirage-like promise into a solid foundation for enhanced remote acute care services into the future.

What kinds of cases have you used virtual support for in the last few months? What challenges or barriers have you encountered utilizing these new tools? How have you managed these issues? How could the integration of real-time virtual support into clinical practice be streamlined at your site?

Disclaimer: The views and opinions expressed in this blog post are those of the authors and do not necessarily reflect the official policy or position of the BC Emergency Medicine Network.