HOWARD YONAS, MD

THE TERRIBLE THINGS WE DO TO OURSELVES AND OTHERS FIRST NEUROSURGICAL TEXT 1540

HAD BEEN AT THE UNIVERSITY OF PITTSBURGH FOR OVER 25 YEARS.

I ARRIVED IN NEW MEXICO AS THE FIRST CHAIR OF THE NEW DEPARTMENT OF NEUROSURGERY IN 2005.

WE HAD A 12 BED NEURO/ICU AND WE WERE THE ONLY TRAUMA CENTER FOR THE STATE.

I SOON LEARNED THAT NEW MEXICANS HAD A FEW MEDICAL PROBLEMS THAT I WAS FAMILIAR WITH AND SOME THAT WERE NEW..

ALCOHOL ABUSE WAS NOT NEW

ALCOHOL WHILE BULL RIDING WAS NEW..

ALCOHOL WHILE RIDING ON THE HOOD OF A MOVING CAR WAS NEW.

AUTO ACCIDENTS AND GUN SHOT WOUNDS ARE OLD STUFF

BASEBALL BATS AND OTHER BLUNT OBJECTS FOR ABUSING RELATIVES WAS NEW TO ME ( OF COURSE USUALLY COMBINED WITH MORE ALOCHOL IN THE BLOOD THAN I THOUGHT WAS CONSISTENT WITH LIFE, LET ALONE SWINGING A BASEBALL BAT)

WHILE MANY PATIENTS DID REQUIRE NEUROSURGICAL ATTENTION MOST IN FACT DID NOT.

EMERGENCY ROOM PHYSICIANS WOULD HOWEVER, CALL FOR AIR TRANSPORT AUTOMATICALLY IF THEY WERE TOLD BY RADIOLOGY THAT THERE WAS “BLOOD IN THE HEAD” THAT WAS NOT IN A BLOOD VESSEL.

WHILE THOSE THAT NEEDED OUR CARE RECEIVED IT, THE MAJORITY OF PATIENTS THAT WERE FLOWN TO US HAD NO SIGNIFICANT PROBLEM (MANY WITH MISS INTERPRETED FILMS , READ BY DOCTORS IN INDIA)..

MY PROBLEM ON A DAILY BASIS WAS HOW TO GET THESE FOLKS HOME, WHICH OFTEN REQUIRED THAT I BOUGHT SOMEONE A BUS TICKET.

MINOR AND MODERATE HEAD TRAUMA IS VERY COMMON

THE WIDE AVAILABILITY OF CT SCANNING MEANT WE WERE NOW “SEEING SOMETHING” THAT WAS ALWAYS THERE IN PATIENTS WITH A SIGNIFICANT CONCUSSION.

NO RURAL NEW MEXICO DOCTORS HAD ANY TRAINING INVOLVING BLEEDING IN OR AROUND THE BRAIN..

IT BECAME CLEAR THAT THE NEUROSURGEON HAD TO SEE THE PATIENT’S FILMS AS PART OF AN INITIAL CONSULTATION.

NET MEDICAL (ALBUQURQUE BASED COMPANY ENGAGED INTRANSFERING IMAGES FROM HOSPITALS TO DOCTORS WHO COULD READ THEM) BECAME OUR EARLY PARTNER..

IMEDCON WAS A ROUTE FOR FILMS AT ONE CENTER TO BE SENT TO A NEUTRAL WEB SITE FOR REVIEW AND INTEGRATON INTO THE CONSULT.

BY ALLOWING THE CONSULTING NEUROSURGEON TO SEE THE FILMS THAT WERE THE BASIS FOR TRANSFER RESULTED IN BETTER READS (ANEURYSMS BECAME MISS READ BONE PROJECTIONS, ETC, ETC)

ALLOWED FOR A DISCUSSION OF OPTIONS. CLEARLY SOME PATIENTS NEEDED TO TRAVEL

BUT MANY MORE DID NOT….

BOTH SUBDURALS…. WHO NEEDS A PLANE RIDE?? 80% 10%

PRESBYTERIAN HOSPITAL RECEIVED 2/3 OF MAJOR NEUROLOGICAL PROBLEMS BUT THEY LACKED NEUROSURGICAL COVERAGE MORE THAN 2 DAYS/MONTH.

THEIR ER DOCTORS AND HOSPITALISTS HAD NO TRAINING AND WERE FEARFUL OF BEING RESPONSIBLE FOR ANY PATIENT WITH B.I.D. ( BLOOD IN DER).

UNMH HAS LIMITED BED CAPACITY AND IS RESPONSIBLE FOR PROVIDING CARE TO THE ENTIRE STATE OF NEW MEXICO.

THE FIX WAS TWO FOLD: BY BEING ABLE TO REVIEW FILMS OF PRES.

PATIENTS WERE ABLE TO PROVIDE BETTER GUIDANCE.

BY PROVIDING EDUCATION TO ER DOCS AND HOSPITALISTS, THEY WERE ABLE TO INCREASE THEIR COMFORT LEVEL CARING FOR NON TRULY EMERGENT NEUROLOGICAL PROBLEMS

BETTER CARE FOR PATIENTS. BETTER COMMUNICATION BETWEEN

CONSULTING AND CONSULTED PHYSICIANS.

BETTER USE OF VITAL BED RESOURCES BECAUSE PRES. AGREED TO PAY FOR THIS

ENHANCED CONSULTATIVE SERVICE, EVEN UNM PHYSICIANS WERE MORE WILLING TO WORK WITH PRES PHYSICIANS AT ALL HOURS OF DAY AND NIGHT…

GALLUP INDIAN HOSPITAL HAD AN UNCOMMONLY HIGH INCIDENCE OF HEAD TRAUMA (USUALLY INVOLVING ETOH AND A VARIETY OF BLUNT OBJECTS..

THEY TRADITIONALLY SENT ALL THESE PATIENTS TO ANY OTHER HOSPITAL THAT WOULD ACCEPT THEIR PATIENT.

MANY PATIENTS WHO NEEDED SURGICAL INTERVENTION COMMONLY WERE TRANSFERRED 2-3 TIMES PRIOR TO REACHING A NEUROSURGICAL CENTER.

IHS FUNDED THE IMPLEMENTATION OF TELE RADIOLOGY DIRECT TO UNMH NEUROSURGERY.

IMAGE INTEGRATION INTO CONSULTATION RESULTED IN MUCH BETTER CONSULTS… PATIENTS THAT NEEDED NEUROSURGICAL CARE

CAME DIRECTLY TO UNMH WHERE WE WERE PREPARED FOR THE PATIENT

PATIENTS THAT COULD BE EQUALLY WELL CARED FOR AT GALLUP STAYED AT GALLUP

REDUCED TRANSFERS BY OVER 40% SAVED IHS MILLIONS OF DOLLARS BY

AVOIDING UNNECESSARY TRANSPORTS (AT 40,000 DOLLARS PER TRANSPORT)..

BENEFIT OF TELE NEUROSURGERY EVOLVING… CLEARLY HAVING IMAGES IMPROVES DECISION

MAKING WOULD BEING ABLE TO SEE AND TALK WITH THE

PATIENT, FAMILY AND ER STAFF HELP WITH DECISION MAKING

DOES IT INCREASE ACCEPTANCE OF REMOTE DECISION MAKING BY BOTH CONSULTING AND TREATING PHYSICIANS??

400 BC. HIPPOCRATIES REFERRED TO APOPLEXY AS A SUDDEN LOSS OF FUNCTION.

STROKE PERHAPS DUE TO THE HAND

OF GOD INTERVENING.

1700 AD. BELIEVED DUE TO A HORMONAL IMBALLANCE.

UNTIL MID 1800’S CAUSE WAS NOT WELL DEFINED AND MOST OFTEN TREATED BY BLOOD LETTING.

ISCHEMIC STROKE IS WHEN AN ARTERY IS BLOCKED USUALLY DUE TO A BLOOD CLOT MIGRATING TO A BRAIN ARTERY. DESPITE BLOCKAGE OF A FEEDING ARTERY THERE

ARE A NUMBER OF COLLATERAL ROUTES FOR BLOOD SUPPLY SO THAT SURVIVAL OF A BRAIN REGION IS DEPENDENT ON QUANTITY OF REMAINING SUPPLY..

IF REDUCED BUT NOT ABSENT THE WINDOW FOR SERVIVAL CAN BE HOURS IF REPERFUSION IS ESTABLISHED IN A TIMELY MANNER..

FLOW VALUES < 9 CC/100GMS/MIN FOR MCA

TERRITORY:

- IRREVERSIBLE ISCHEMIA (CORE)

HEMORRHAGIC WITH REPERFUSION.

- HERNIATION IF INVOLVES MOST OF

MCA.

HOUR 2 HOUR 24

HOUR 48

FAILED REPERFUSION

FIRLIK, STROKE, 1998

SUCCESSFUL REPERFUSION

HOUR 4 HOUR 24

HOUR 48

FIRLIK, STROKE, 1998

THERE ARE A FEW BASIC PRINCIPLES

A LOST NERVE CELL IS FOR EVER.

TIME IS BRAIN- MEANING THAT WITHOUT ADEQUATE BLOOD SUPPLY BRAIN CELLS START TO DIE AT A RAPID RATE

tPA GOOD FOR SMALL CLOTS, NOT SO GOOD FOR BIG CLOTS BLOCKING MAJOR ARTERIES.

IF LESS THAN 4.5 HOURS OF ONSET OF SYMPTOMS, TPA IMPROVES OUTCOME SOMEWHAT…..

IF GIVEN LATER OR TO POOR CANDIDATE CAN INCREASE BLEEDING RISK.

SOONER THE BETTER

Brought to angiography. Stent retriever and suction used to remove clot in a single pass in NEED TO TREAT 4 PATIENTS TO HAVE A MAJOR BENEFIT..

IF A STROKE SPECIALIST IS AVAILABLE, tPA IS GIVEN TO 15-20+ % OF STROKE PATIENTS BUT WITHOUT EXPERTISE, MUCH SMALLER NUMBER. <1% OF CANDIDATES IN NEW MEXICO

QUESTION IS HOW TO GET STROKE

SPECIALIST IN EMERGENCY ROOMS WHEN AND WHERE PATIENTS NEED CARE..

EXPERT IN CENTER CAN USE TELEMEDICINE TO SEE, EXAMINE AND TALK WITH THE PATIENT. MUST ALSO SEE CT SCAN TO RULE OUT BLEEDING OR TOO LARGE A STROKE.

ACCESS GRANT BY CMS TO UNM DEPARTMENT OF NEUROSURGERY

WILL PROVIDE TELEMEDICINE SERVICES FOR ACUTE NEUROLOGICAL AND NEUROSURGICAL DECISION MAKING GOAL IS TO PROVIDE BEST OF CARE AND HELP KEEP PATIENTS IN LOCAL HOSPITALS

ACCESS AWARD FOR $15.2 TO DEVELOP A STATEWIDE SYSTEM OF TELE NEURO EMERGENT CONSULTATION USING TELE RADIOLOGY AND AUDIO AND VISUAL CONSULTATIONS.

GRANT PAYS FOR CMS PATIENTS (2/3) BUT NEEDED SEPARATE BILLING PROCEDURE FOR OTHER 1/3 OF PATIENTS.

CREATED A CLOUD BASED TECHNOLOGY (COULD BE ANSWERED FROM ANYWHERE ON EARTH)

LOW COST FOR ACQUISITION CHARGE ONLY FOR USE…

NO SUBSCRIPTION FEES, ON CALL FEES ETC

ACTIVE EDUCATIONAL PROGRAM FOR CARE OF STROKE AND NEUROTRAUMA… TWO SUPURB NURSES….

NEEDED DOCS 24/7– TECHNOLOGY SOLVED BUT PHYSICIANS FOR CONSULTATION NOW LIMITING NEUROSURGERY AT UNM

NEUROLOGY NEEDED TO GO OUT OF STATE (BLUE SKY- 10 NEUROLOGISTS IN DENVER)

SUCCESS REQUIRES HANDS ON WITH

EACH HOSPITAL AND COMMUNITY OF MD’S

… IN 18 MONTHS HAVE 12 OF 35 RURAL HOSPITALS ON LINE.. 10 MORE SOON 1200 CONSULTS (90% NEUROLOGY, 10%

NEUROSURGERY)

ER DOCTORS IN RURAL HOSPITALS BECAME ADDICTED….. THEY ARE NOT ALONE.

WE ARE THERE AS BACK UP SUPPORTING LOCAL

DECISIONS… ALLOWING THEM TO KEEP PATIENTS THEY ARE COMFORTABLE TO KEEP.. INCLUDES MINOR TO TERMINAL PROBLEMS..

▪ CONVERTED 80% TRANSFER RATE TO 80% KEEP .

▪ IMPROVED tPA USE FROM < 1% TO 19% IN PATIENTS THAT PRESENT WITH DIAGNOSIS OF ISCHEMIC INFARCTIONS.

▪ SAVED OVER $20 MILLION IN AIR PLANE RIDES AND KEPT OVER $12 MILLION IN RURAL HOSPITALS

▪ HOSPITAL ADMINISTRATORS THINK IMPROVING CARE IS GOOD BUT SAVING THEM MONEY IS GREAT…

FIRST 100 NEUROSURGICAL CONSULTS

70 PATIENTS THAT HAD PROBLEMS THAT ER DOCTOR THOUGHT COULD MANAGE AT A LOCAL HOSPITAL BUT NEEDED A NEUROSURGEON TO AGREE..

15 PATIENTS HAD TRANSFERRED FOR PROBLEMS THAT WARRANTED EVALUATION BY NEUROSURGERY AT UNM. 13/15 UNDERWENT SURGERY 85 PATIENTS STAYED AT LOCAL HOSPITAL NONE REQUIRED EMERGENT LATER TRANSFERS. WITHOUT ABILITY TO SEE THE PATIENT AND TALK WITH FAMILY WE HAD TRANSFERRED 50% WHILE WITH TELEMEDICINE NUMBER DOWN TO 15%

VALUE PROPOSITION PROVIDES SUPPORT FOR CONCLUSION THAT HOSPITALS AND COMPANIES WIN BY ABSORBING RELATIVELY MINOR COST OF CONSULTATION.

IS NO CHARGE CODE FOR TELE NEURO CONSULTATION..

LOOKING TO GOVERNMENT TO CREATE A CHARGE CODE THAT IS APPROPRIATE FOR SERVICE – IT IS NOT AN OFFICE VISIT..

JUST A BEGINNING, A SUNRISE, OF USING TECHNOLOGY TO IMPROVE PATIENT CARE- IN ALL CLINICAL AREAS…. ACUTE, SUBACUTE AND CHRONIC CARE…

40 HEAD TRAUMA, MINOR SAH OR STABLE SMALL CONTUSIONS, REPEAT CT AND DISCHARGED..

30- SPINE INJURIES USUALLY OVER READ BY AUSTRIALIAN RADIOLOGIST

10- TUMORS (1/2 NEEDED TRANSFER FOR INTERVENTION, ½ NEEDED ANTICONVULSANTS, STEROIDS AND A CLINIC VISIT)

5- MASSIVE BRAIN STEM OR HEMISPHERIC HEMORRHAGES WHERE NO INTERVENTION INDICATED- AVOIDED PLANE RIDE TO SEE ME IN PERSON SO I COULD SAY THE SAME THING…

15-MISSELANEOUS- CAVERNOMAS, SHUNT DYSFUNCTION, ETC