Future neurohospitalist: teleneurohospitalist

Abstract

Despite the growing demand for emergency neurological evaluations and neurohospitalists, the supply of neurologists remains relatively fixed over time. Telemedicine is a unique tool that has the ability to put a medical specialist like a neurologist in 2 places in a relatively short period of time, expanding expertise in many rural and in some underserved urban facilities that would ordinarily be devoid of such expertise. Teleneurology is a branch of telemedicine that consults and practices through remote neurological evaluation. Telestroke is defined as remote stroke evaluation. The demand for timely neurological evaluation, especially acute stroke evaluation and treatment with intravenous recombinant tissue plasminogen activator (IV rtPA), continues to fuel the growth of neurohospitalists, telestroke, and teleneurology services. Remote, rural, or underserved urban emergency departments and hospitals which are unable to successfully recruit a neurologist or neurohospitalist to provide this service are uniquely suited to a teleneurology option. The number of private practices and academic centers providing telestroke services has grown significantly in the past decade with continued growth expected. We describe the benefits and drawbacks of teleneurology/telestroke, as well as other practical aspects for the teleneurohospitalist.

Keywords: clinical specialty; future neurology; hospitalist; neurohospitalist; telemedicine; teleneurology.

Figure 1.

Supply of graduating adult US neurology residency graduates from US and International Medical Schools (IMG) from 1989 to 2010. Adapted from Data from Annual Education Issues 1989-2010.

Figure 2.

Telestroke/telemedicine network concepts. A, Telemedicine robot from commercial vendor which is typically controlled via a computer base station which functions over high-speed Internet network. A laptop with Internet capability can also control and view the robot the same way. B, Image of a patient with a subarachnoid hemorrhage, with a right external ventricular drain. The imaging is seen remotely via mobile phone (iPhone) and Virtual Private Network (VPN) via cell phone carrier (AT&T in this case) to review imaging without a base station or a laptop.

Figure 3.

Example of Robotic telemedicine encounter of a 66-year-old female with a right MCA-M1 ischemic stroke, status postendovascular intra-arterial clot retrieval with suction device on postprocedure day #1, asked to give “2 thumbs-up” which shows left thumb having downward upper motor neuron drift.  Her formal National Institutes of Health Stroke scale (NIHSS) was a 4 (1 for left facial droop, and 1 for left arm downward drift) and 2 for hemibody sensory loss, including 1 point for extinction. She presented with an NIHSS of more than 7 and was globally aphasic (she was left handed) but had complete normalization on NIHSS by hospital day #2 (NIHSS = 0).

Figure 4.

Pupillometer images viewed from the telemedicine robot: normal pupil reactivity or “smile” (left image).  Right image shows “flat-line” or fixed-dilated (unreactive to manual inspection and pupillometer-derived neurological pupillary index, NPI shown as “-”which is nil) bilateral pupils (right is 4.38 mm and left is 5.23 mm) in a patient with massive ischemic stroke with uncal herniation who later was pronounced brain dead by formal American Academy of Neurology (AAN) criteria.