28 July 2008

Telemedicine: the future is now

I was tending to a young man who had accidentally given himself a wrist and hand laceration. It was a classic mechanism -- he had jumped up to climb a fence, and the sharp, rigid wire at the top had pierced his wrist somewhat proximal to the wrist crease. The patient, surprised by the unexpected pain, dropped back down, and the wire tore upwards through the wrist and palm of the hand.

He was a tough kid. Never a whine or a complaint escaped his lips. I did a careful functional exam of the hand, and a careful irrigation and exploration of the wound. To my delight, he had no functional deficit, implying that he had not damaged any of the important nerves or tendons that run through that area, and the exploration showed no apparent damage to the tendons that I could see (they were clearly exposed). But the flexor retinaculum of the wrist, also known as the transverse carpal ligament, was clearly transected.

I had seen this before -- many times. As I mentioned previously, I had strongly considered going into plastic surgery, and still have an interest in complex hand injuries. This injury that he had given himself was basically the exact same thing that I had done (well, witnessed and assisted) quite a few times in the operating room, under the guise of an open carpal ligament release, for carpal tunnel syndrome. This laceration ran little more laterally, up onto the thenar eminence, with the muscle belly of the opponens pollicis clearly visible but uninjured, but otherwise might have been mistaken for a surgical incision for the above-referenced surgery. *

I was pretty sure that this was a clinically insignificant injury. He had basically replicated what a hand surgeon would do therapeutically: he didn't need a carpal release, but it wasn't going to hurt him. As a general practice I like to run it past a specialist whenever a tendon or ligament is violated. Unfortunately, I happened to be working this evening at one of our rural, outlying injuries and we did not have a hand surgeon on call.

I managed to get the hand surgeon from the regional center on the phone. I happened to know him from previous professional interactions, so, fortunately, he did not think I was Dr HuckFead. I was able to give a clear description of my functional exam, but he was having a little trouble visualizing the path of the incision and the nature of the ligamentous injury. Alert readers may recall my joy at my recent acquisition of an iPhone. One of the first things I had noticed was the high quality of images taken with its 2 MP onboard camera.

So I took a quick pic of the wound and emailed it to the surgeon. (After some consideration, I decided not to post it -- I still struggle with the ethics of blogging about patients, even with fictionalized details, but I think posting pics without consent is clearly a distinct issue.) After our discussion, and review of the images, the surgeon was quite comfortable with my management of the case, and with his blessing I went ahead and repaired the wound. The surgeon, though under no obligation to do so, graciously agreed to see this nice young man in follow-up, in case there was any need for surgical exploration or revision. (I so love helpful consultants.)

I have read extensively about the promise of telemedicine. It's always described as the "next big thing," in the same sort of way that the Segway will transform the way we plan our cities, and in the future we'll all have personal jet packs. Which is to say that while I love gadgets, I'm not exactly convinced that telemedicine will actually much change medical practice in the main. But for certain specific applications and in certain circumstances, it can be damn useful. I feel like I just got a little glimpse into the future of medicine. Kinda cool.

* Fun fact: traumatic injuries are often quite neat. I remember a guy who got stabbed in the femoral artery with a kitchen knife by a vengeful girlfriend, and required an emergency trip to the OR. The vascular surgeon later commented that the artery had been transected cleaner than he had ever been able to accomplish in the operating room with razor-sharp scalpels. And the many, many box cutter injuries I have seen have been remarkably clean. I don't know what it is about the rapidity and depth of these rapid, sharp injuries, but they can in many cases be perfectly clean. Similarly, in this case, the wound could have been surgical it was so perfectly incised. Weird.


  1. Nice! Glad the young man only got the retinaculum and didn't skewer the nerve. Good use of the phone/camera.

  2. Hmm...trauma cuts aren't as deliberately made as surgical ones. Could that be why they are cleaner? Because they are made more rapidly and with less thought than a surgical incision?

  3. Telemedicine is the mainstay of outpost work consulting in the Arctic...I've saved many a $20 000 medivac using the simple words "check your email" to the doc on call in major center 4h away by plane.

    Plus not having the self doubt at your analysis always makes for a better sleep when you get home at night! :)

  4. This reminds me of the Over The Edge System Administration class I took from David Blank-Edelman at a big IT conference a few years ago. The theme was technical improvisation and one of the challenges in class was to think of all the ways you could use a digital camera to solve IT problems.

    It's hard to underestimate how eliminating the time and monetary cost of film really enable casual utilitarian photography. It's a small technical evolution but it's great to see something so simple help people.

    Speaking of the Segway, you should check out Make Magazine's interview with Dean Kamen (issue #4, sadly not online.) The thought that went into the problem to be solved is at least as interesting as the engineering that made it happen. Further, the Segway is a simpler version of his more ambitious project of revolutionizing the wheelchair.

    The spoiler: moving around isn't as big of a problem as having to do everything from a sitting position. From the perspective of the person in the chair, nothing is at the right height or within reach and there's a huge interpersonal status problem when you cannot make level eye contact with others.

    It's folly to expect technology to solve all our problems, but all it takes is a little innovation to get some amazing results - in hindsight it looks so obvious but in reality, it's not.

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