Dr. Jacob Skiwski
Children’s Health Center of Columbus
TelEmergency network provides vital link to rural hospitals during times of trauma
by Janis Quinn

The term "TelEmergency" doesn't get much response from Lisa and James Brewer of Richton. Their son, T. J., was the victim of an accidental gunshot wound to the chest on New Year 's Day 2008. His was the kind of injury most don't survive.

All the Brewers knew on that awful day was that someone was talking by video to nurse practitioner Joyce ("Dr. Joyce," as the Brewers call her) Martin and guiding her in the first steps toward saving their boy's life.

In spite of losing 34 units of blood and "dying" three times, their son is back on the football team at Richton. His 14-year-old fighting spirit got the jumpstart it needed from Martin at the Perry County Hospital, where she consulted with emergency medicine doctors here at the University of Mississippi Medical Center to intubate and stabilize him. The TelEmergency network is comprised of 15 rural hospitals and UMMC.

Martin's work with the ER docs was just the beginning of the Brewer's family odyssey into the grisly world of severe trauma and its aftermath.

Flown to Forrest General Hospital in Hattiesburg on UMMC's emergency helicopter service, AirCare, T. J. received emergency open heart surgery to stop the bleeding by cardiovascular surgeon Dr. James Kot.

From Hattiesburg he came to UMMC, where he spent 10 days.

"We weren't given much hope of him surviving at all," Lisa Brewer said. "And they said if he lived, he would probably lose his right arm."

The bullet from the rifle had bounced around after it had entered the left chest and had come out the right side. It damaged the major vessel controlling the arm's blood supply.

The Brewers also were warned that he might have brain damage because no one knew how long his brain had been without oxygen during the times he coded.

"It just wasn't time to go," his parents said.

Dr. Kristi Henderson, director of the training program for nurse practitioners in TelEmergency, says T. J. benefited because every step in the system worked.

"Everyone did the right thing," said Henderson, who also is director of the ED's RapidTrack and business development.

Henderson said most people with these kinds of injuries rarely survive.

"It's a typical hunting-type accident and they are usually in rural areas too far away from an emergency department to stabilize them quickly enough to prevent death."

T. J. and his brother, Jacob, were on their property for a family outing. They beat their parents to the lake by just minutes.

"We heard the shot, but we thought it was the firecrackers we bought that explode in the water," James Brewer said. James had given T. J. the rifle for Christmas, and he had been hunting with his dad many times.

"T. J. was very calm when we got there," his mother said. On their way to meet the ambulance, however, the situation changed, and Lisa Brewer heard words no mother can bear.

"T. J. was saying goodbye to us. He said, 'I know I'm dying and want you and Daddy and Jacob to know I love you all.'"

The Brewers said they had the prayers of entire communities and the hands of experts at every turn.

TelEmergency is one of the components in a system of care that extends the skill of UMMC to communities throughout the state. And although the technology to provide that access is impressive, the system is more about outreach and giving people access to care they might not have in rural areas.

And TelEmergency, conceived by Dr. Robert Galli, professor of emergency medicine, and Henderson, has provided the basis for other disciplines - radiology, neurology and psychiatry - to provide care electronically to sites remote from the Medical Center.

Galli monitoring Telemedicine Sytem
It could broadly be defined as "telehealth."

In TelEmergency, board-certified emergency medicine physicians in the UMMC emergency department are connected through a video network with nurse practitioners in rural hospitals that cannot afford to staff their emergency departments with emergency medicine doctors. UMMC trains every nurse practitioner who works with the program. Martin, the nurse practitioner in Richton, has been with the program since its beginnings.

"No one in the United States does what we're doing," Galli said.

Officials from South Dakota consulted with Galli to start their program, but they rely on family physicians in remote sites, he said. "Our package is unique: our program and our nurse practitioner training."

A grant from the Bower Foundation provided start-up funds for equipment, and since the program started, TelEmergency has seen 180,000 patients in other hospitals.

Dr. Alexander Auchus, chairman of the Department of Neurology, uses the TelEmergency network to consult on stroke treatment.

"Stroke is the major emergency of neurology," he noted. "And time is brain," he said, referring to the mantra of stroke specialists who know that quickly diagnosing and treating a stroke saves debilitating loss of brain tissue.

Auchus says since October 2010, UMMC has been functioning as a comprehensive stroke center and received designation as such last month from the Institutions of Higher Learning board. This designation requires a dedicated research effort with ongoing clinical trials, specialist providers with additional certification in stroke neurology and neuroradiology, fellowship training in these subspecialties and patient care with community outreach efforts.

"That's how Telestroke fits in," Auchus said.

If a hospital in a rural area has a stroke patient, the team there needs to know quickly what kind of stroke it is.

"We can consult either by phone or by video to help them determine if the patient is a candidate for thrombolytic drugs," Auchus said. Thrombolysis is the use of clot-destroying drugs in strokes caused by blocked arteries.

"Some patients still have to come here even after thrombolysis, because they may need a catheter-based procedure to manually remove the clot," Auchus said. "We see this as a way to provide an additional level of expertise for Mississippians."

The UMMC Department of Psychiatry links to sites in the Mississippi Delta with a grant from the Delta Health Alliance. There are few resources except for the state-run mental health centers in the Delta.

UMMC psychiatry faculty members see and treat all manner of mental health issues, both adult and child. But according to psychiatry chair Dr. Grayson Norquist, they maximize the technology with video teaching.

"One of our clinical psychologists teaches motivational interviewing, an evidence-based proven method of dealing with alcohol and drug-abuse problems, to mental health professionals all across the Delta," Norquist said. "They don't have to give up several hours to come to Jackson, and we can monitor and teach as they do the treatment themselves."

There also are video connections from the Mississippi State Hospital to the mental health centers so the hospital can communicate with local mental health-care providers about a patient about to be discharged.

"It's a big network, and the opportunities are huge," Norquist said.

He is concerned about recent figures that indicate, on average, a person with a mental illness has a lifespan diminished by 25 years.

"Just think of the social capital we're losing and what we could to do to help people with these illnesses."

Like TelEmergency and TeleStroke, TelePsychiatry is not funded by Medicaid, and many Mississippians depend on Medicaid for their health care. Funding is the next big issue in telehealth.

"We get funding through grants, then when funding runs out, we have to figure out a way to be sustainable," Norquist says. "The data show that early intervention through telehealth can save money and improve lives. We just have to convince insurers."