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The Evaluation
carried out in July must be unfortunately confirmed at the end of August:
there are still troubles due essentially to "human factors" and after
the first moments of enthusiasm due to the new situation, the healthcare
management of the island is the same as it was before Telemedicine experiment
.
This "Timtem" seems to have been useful only in order to draw the "political
" attention on the island and to hold a "Congress", even though we hope
to be wrong.
The following image is emblematic of the local situation.
A very fragile small boat in the midst of a "calm" sea of intentions but
with no seamen and no rudder at all. The engine and the basic structure
are ready but there is no will of either making them work continuously
and of managing them. This had been claimed to be a local "Greek" management
(please see the Report on the Congress) but, not considering the external
political aspects, it can not be activated either by local operators and
reference local hospital: this is the current situation.
Some examples of healthcare emergencies happened in August could be reported
in detail in the methodology of management; we rather not do it and prefer
to report only a synthesis comment. Notwithstanding the "protocols" of
typologies of treatment (for example for 2 cases of gastro-duodenal haemorrhages
in stable patients, one particularly was a Jehovah's Witness) the laboratory,
telematic facilities and professional consultations at immediate disposal,
nothing has been done to use this potential both of diagnosis and treatment.
There was no will of evaluating the "potentials" of risk even though,
with no incidents at all, diagnosis and treatment in loco and modalities
of transport have been carried out on a "clinical-empirical" basis. In
a word, "the old method of making medicine" has prevailed over the "messages"
of modernity and acceptance of teleconsultation which TimTem had tried
to implant and develop in Tilos for at least 1 year.
We referred to "the potentials at risk" of every clinical case, but we
have to point out also some elements of "new risks", that is general risks,
which impend over this island and which probably could be or are already
present in remote areas with similar characteristics subject to investments
and tourist development.
The roads on the island have increased in number and have been enlarged
thus enhancing the speed: so doing, the number of car accidents due to
bad road-keeping could decrease, but there could be accidents and injuries
due to the "high speed". At the present moment, there are no elements
of prevention ,no road signalling and no kind of control.
The other problem which besets us is that with the development (for example
night clubs with no control at all) and the consequent "flow of money"
due to tourism, there could be episodes of violence and micro-crime (I
happened to see personally one of them) due to situations of serious alcoholism
(which indeed are very frequent) and drugs abuse which could affect the
young generations both resident and on holidays .The immediate attention
these negative factors of risks deserve to have, should be considered
as an action of prevention and protection of the general health of people
living on the islands and of tourists as well.
This analysis, which can be easily defined a "pitiless criticism", gives
anyway the opportunity to point out the "critical points" in the application
of Telemedicine in remote areas similar to Tilos; at the same time it
can show the best solution to be achieved in terms of application.
The "model" must not take into consideration either physicians and "resident"
paramedic personnel: should there be healthcare providers resident for
many years, they must be obliged to apply themselves to the practice of
"Telemedicine" as integral part of the usual "making medicine". This "model"
has to be applied easily above all for physicians and paramedic personnel
who are resident for short period, or work in shift or are simply assistant.
All of them, anyway, must be obliged to follow a period of specific "training"
on the spot, in order to become "actors" of this kind of didactic experience
supported by telematic instrumentation; they must be able to use totally
telemedicine facilities and instrumentation, above all in emergency, following
specific protocols, otherwise there could be medical and legal consequences
for them.
The regular use of Reference Hospitals for Telemedicine is far to be achieved;
rules and planning depend on Central Political and Administrative Institutions.
Which could be the solution to this "stalemate" situation for Tilos and
TimTem? The experience on the field has pointed out once again that theories
can easily fail even tough based on small planned steps (consider TimTem).
A part from the complete implementation of instrumentation and facilities
for a Telemediicne station, the only possible solution could be the presence
on the island for many months, it would be better for at least one year,
of mother tongue operators specifically trained and able to teach the
telematic use of instrumentation and methodological protocols. In a word,
the solution in theory is the temporary continuous presence of a "teaching
staff" on the island. This solution is likely to be necessary for many
other "remote areas".On the contrary, the solution of a wider territorial
range should be considered the "national" or "regional" institution "
of a real School aiming at the training of personnel able to use centrally
and completely Telemedicine instrumentation and methods.
As far as we are concerned (TimTem and Tilos Island) the local solution
(technicians on the island for a long period) can be achieved only if
there is the positive evolution of "TimTem" into "Archipelago", that is
the project submitted to the European Community.
We really hope this honest presentation of difficulties and negative results
can make all people willing to devote to telemedicine in remote areas
think about it carefully.
Enrico Cavina, MD, FACS Professor of Surgery
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