December 1, 2021

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What If Doctors Are Always Watching, but Never There?

This new system, which continually monitors and collects patient data, has recently gone wireless. It is being tested on patients in a hospital in Birmingham, England, but it and similar remote systems might be used in patients’ homes in the future. 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. For millennia, medical practitioners used their senses to assess a patient’s condition. Even now, we doctors are trained to recognize the hard-candy breath of sick diabetics, the glass bottle clonking sound of an obstructed bowel, and the cold, clammy feel of skin when a patient’s circulation is shutting down. But the systematic recording of numerical observations is a surprisingly recent phenomenon.

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In the late 1800s, instruments were designed to measure a standardized set of health indicators. These are the four main vital signs: heart rate, respiratory rate, temperature, and blood pressure. It was just before the turn of the last century that these vital signs, also known as observations, were first documented systematically. By World War I they were used routinely. Studies of these charts revealed that people basically never died when these vital signs were normal; hearts don’t stop out of the blue. But for the better part of a century, the art of interpreting these so-called obs charts was, to the untrained, as mysterious as reading tea leaves.

Then, in 1997, a team based at the James Paget University Hospital, in Norfolk, England, developed an early warning system with which a nurse could quickly turn vital signs into a score. If the score surpassed a threshold, it was a signal to call for a doctor’s assistance. Such systems were steadily rolled out for adult patients, but it was not clear if they would work in children, whose physiological responses to illness are different from those of adults.

Heather Duncan knew about about early warning systems for adult patients in 2000, when she was working in South Africa as a general practitioner with a keen interest in children’s health. Ordinarily, observations taken in a hospital aren’t connected to earlier ones made in primary care clinics. But Duncan tried to link these two datasets—from the community and the hospital—to create a more meaningful, continuous story of what was happening to patients. She took the trouble to scrutinize the records of her sickest children, plotting their vital signs from the time they were first recorded in primary care to their discharge or death in the hospital. “I noticed children were having cardiac arrests or intensive care admissions, and that actually there were missed opportunities where we should have acted further,” she remembers.

Her nagging feeling that more could be done for such children was later corroborated by the UK’s Confidential Enquiry into Child Deaths, which found that more than a quarter of children in National Health Service hospitals were dying of avoidable causes. In 2003, Duncan completed a fellowship in critical care at Toronto’s Hospital for Sick Children, where—together with Chris Parshuram, a pediatric intensive care doctor—she developed the Pediatric Early Warning System, or PEWS, a bedside scoring system designed for sick children.

Duncan now works as a consulting pediatric intensivist in Birmingham Children’s Hospital. I caught up with her on Zoom last October. Duncan was working from home, wrapped up against the English autumn in an oversized, cream fleece, her hair pulled back into a loose bun, and wearing blue-rimmed specs that matched her eyes. She speaks with a genteel South African accent and has a calming manner, surely an asset working in such a stressful specialty. Her hospital had adopted the PEWS score in 2008 and seen a drop in the number of children dying after suffering a cardiac arrest—from 12 in 2005 to no deaths in 2010.