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What If Doctors Are Always Watching, but Never There?

the James Paget University Hospital
Confidential Enquiry
Child Deaths
National Health Service
Chris Parshuram
the Pediatric Early Warning System
Birmingham Children’s Hospital
McLaren Electronics
McLaren Applied
Formula One
Nature Scientific Reports
Cedars-Sinai Medical Center
Carnegie Mellon University
Condé Nast
Affiliate Partnerships

Neil SinghTo
Heather Duncan
Peter van Manen
Gillian Gresham
TED Talk
Torres Strait Islander
Min Kyung Lee
Luke Fildes
Heather Duncan’s

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In modern wards, to prevent infection and protect privacy, patients like Oliver, who might be contagious, are put in isolation rooms—out of sight—with their observation chart hooked on plastic rails beside the door.We first noticed something was wrong when his chart showed the dreaded “seagull sign.” When plotted on the same graph using the same scale, systolic blood pressure (marked on charts with a birdlike chevron) should, in healthy people, remain above the dot that signifies the pulse rate. I set out to discover ways that technology might help me work more safely in the community, which led to a new piece of equipment that was initially developed for the Formula One racing circuit, and which is currently being piloted in intensive care to see if it picks up early signs of decline in children.This new system, which continually monitors and collects patient data, has recently gone wireless. The more I read on the subject, the more I realized that remote patient monitoring could change medicine radically: hastening medical responses and improving health outcomes; remapping the zones of health care; but also perhaps transforming how doctors like me think, in ways we might not so readily welcome.Close observation of patients has been a universal duty of all doctors throughout time. What if, she wondered, patients could have their observations recorded not just when nurses found time to record them but continuously and automatically?In 2009, Duncan happened to meet Peter van Manen, who was then managing director of McLaren Electronics (now called McLaren Applied), originally founded to design custom engineering components for Formula One sports cars. Duncan named her team’s new automated system the Rapid (or Real-Time Adaptive Predictive Indicator of Deterioration) Index.Duncan’s team soon extended the use of their kit to patients in the pediatric cardiac wards, since heart disease is a common cause of rapid decline in children. When the measurements fall outside normal parameters, a warning appears immediately on a tablet or smartphone dashboard anywhere in the hospital, alerting staff.Over three years, Duncan’s group monitored more than 7 million minutes of data from 982 patients at Birmingham Children’s Hospital. “I am not sure that we are at the point of widespread implementation of Rapid index,” she said.Still, in Duncan’s vision, wireless monitoring throughout the patient journey might help kids like Oliver. In a 2012 TED Talk on his collaboration with Duncan, Peter van Manen said, “With wireless connectivity these days, there is no reason why patients, doctors, and nurses always have to be in the same place at the same time.” Duncan already has plans to expand the use of her kit outside the hospital.“I think that, in 10 years’ time, everybody will be wirelessly monitored, whether that’s at home, en route in between primary and secondary care, or in hospital,” Duncan says. Moreover, most participants found using the system reassuring, and gained insights into their own health and how to manage it.Wireless systems like Duncan’s could provide a second pair of eyes—in fact, hundreds of pairs of eyes—installed in the homes of patients who are sick, but not sick enough to be in the hospital. “If a midwife has a population of 40 women at home that she or he is monitoring,” Duncan says, “then they would still do video calls intermittently to touch base.”But while remote monitoring technologies will extend the frontiers of medicine into domestic, private spaces, will they also, paradoxically, push patients and health care workers further apart? In a system where costs are measured and metered, it’s unlikely that the time saved by using technology would be allocated to help care workers commune in invaluable but unprofitable ways, with their patients.In other words, remote patient monitoring may mean that doctors are always watching, but never there. But while the invention of the observation chart punted the doctor from the bedside to the foot of the bed, remote patient monitoring kicks us out of sight. Fildes deliberately omitted these items to focus the viewer on perhaps the most important things a doctor can offer at times of critical illness: the desire to be present, the ability to endure suffering along with patients and carers, and the courage to watch.I imagine how the painting would look if it were to capture 21st-century doctoring, if remote medicine becomes the norm. If her vision of patient monitoring comes to pass, the doctor in our hypothetical painting would be smiling at the sleeping child, having been summoned by remote monitors to administer medicines in time to save its life, now packing up their things into their bag, and ready to leave and face the dawn.Let us know what you think about this article.

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