VA Maryland Health Care System
Expanding Access to Surgical Services for Rural Veterans
Jay Harrison needed surgery for a lump on his head. This U.S. Coast Guard veteran and lifelong waterman from Tilghman Island, where he still lives, found a fast-growing lump at the top of his forehead, and despite all the jokes with his grandchildren about becoming a unicorn, it worried him. He also worried about lost wages since seeking care in Baltimore, a 93-mile, two or three-hour –long drive one-way, not counting the added drive time caused by the summer time Chesapeake Bay Bridge traffic, translated into missed work and wages. Watermen rise before dawn, leave the docks in their workboats before the rest of the world awakes to check the crab pots and oyster beds—so there’s no coming into work late after a doctor’s appointment. Traveling to the Cambridge VA Outpatient Clinic from Tilghman Island offered a better option.
Similarly, Steven Glen Dunlap, a U.S. Army veteran and Smith Island resident, needed surgery on his shoulder where a mass the size of a kiwi formed. In summer, the ferry between Smith Island and Crisfield runs twice daily, but only once in winter, and all his trips off the island need to be planned around the ferry schedule. “Otherwise, I’d be stuck on the other side when it was time to go home, and that would mean having to find someplace to stay,” he said. Multiple trips to and from the Baltimore VA Medical Center for examinations, diagnosis and treatments could easily leave him stranded in Crisfield.
Veterans like Harrison and Dunlap in rural areas can be at a disadvantage in accessing specialty medical care, but the VA Maryland Health Care System’s TeleMedicine program deploys technology to make a huge difference by eliminating the access issues. “TeleMedicine expands rural access to surgical services while maintaining continuity and familiarity for our veterans and their families,” said Dr. Martin Garcia-Bunuel, acting chief of staff for the VA Maryland Health Care System. “The potential barriers of distance, discomfort and inconvenience are reduced or eliminated by bringing this technology to our community based outpatient clinics on the Eastern Shore.”
TeleMedicine technology enables veterans to be examined closer to home at the VA outpatient clinics on the Eastern Shore, saving time and money by limiting their travel time to the Baltimore VA Medical Center only for the surgical procedure itself. “The TeleHealth/TeleMedicine technology is so useful. We are using it in a number of clinics. said Dr. Muhammad Ejaz, the lead physician at the Cambridge VA Outpatient Clinic. “When a Veteran needs to see a specialist, we submit the request for a consult, and for things that are visible, the examination can be done using the TeleMedicine /TeleSurgery technology. Sometimes a nurse helps by moving the patient into a certain position if the specialty doctor needs a different view,” he said, noting that the TeleMedicine technician is also present. Patients give their consent to be evaluated remotely using TeleMedicine technology.
The Veterans agree: “Everyone is used to FaceTime, so for me, it was no big deal, and it worked out well. It meant I only had to make a single trip to Baltimore and back because everything else, took place 23 minutes away at the Pocomoke City [VA] Outpatient Clinic,” Dunlap said.
“The TeleMedicine clinic is wonderful,” said Harrison. “I love it. I can get examined without having to drive all the way to Baltimore, except for the surgery itself,” he said, noting that it reduced the amount of time he spent on the road to access treatment and the amount of time he needed to be away from his job.
Dr. Preeti John, a staff surgeon at the Baltimore VA Medical Center, started using TeleMedicine technology in 2012 to examine veterans in the rural Eastern Shore in need of surgery on a trial basis and then beginning in 2016, gradually increased the numbers. To date, John has served about 60 patients using this technology. Patients with complicated wounds have a wound care nurse present during the TeleSurgery consult if the dressing needs to be replaced.
TeleMedicine technology is like using Skype, except the connection is secure. Just as in a regular clinic, the surgeon takes the patient’s history with the the patient’s electronic chart accessed on the computer, enabling the surgeon to review past medical history. The surgeon in Baltimore can examine a Veteran on the Eastern Shore or anywhere else where the TeleMedicine technology is available and via the screen and audio equipment, determine if surgery is a viable treatment plan for the condition at hand. The physical exam has four components: inspection, palpitation, percussion, auscultation.
“I work closely with the primary care team before and after the surgery,” said John.
“For the ‘remote’ physical exam, a high resolution camera is available in case we need to focus on a particular body part,” she said. “If a mass/swelling/growth or wound needs to be measured, the TeleMedicine technician can assist by holding the measuring tape,” John said.
Prior to a scheduled surgery in Baltimore, John examines patients in person before taking them into the operating room. “Patients have expressed a great deal of satisfaction with the process,” she said.
Presently, John uses TeleMedicine technology to assess referrals for possible surgical procedures, diagnose patients with surgical problems, follow-up with post-operative patients and examine wounds. ”Conducting follow-up exams using TeleMedicine technology eliminates the need for patients to return to Baltimore,” John said. “It is especially helpful when the primary care physician is able to remove sutures after I inspect a post-operative wound that has healed.”
For veterans on the Eastern Shore, TeleMedicine/TeleSurgery is a boon. “It’s great! It was helpful and saved me a lot of time and money,” Dunlap said.