Thoughts that may help!

Telemedicine Brings Specialists to Rural Hospitals

NH Business Magazine

Published Monday, October 20, 2014

by RACHEL M. COLLINS

Ronaldo Pelchat has lived in northern NH his entire life. It is where he’s raised a family, taught social studies for 30 years and become an integral part of the Lancaster community. It is here, too, where he learned he had Amyotrophic Lateral Sclerosis (ALS), also known as Lou Gehrig’s disease. Since that news four-and-a-half years ago, he has lost the ability to speak and walk because of the progressive, fatal neuromuscular disease. But thanks to great strides in telemedicine in NH, Pelchat continues to live at home with his family.

“It’s been quite advantageous to stay in my community because it’s less stress on me and my family, both financially and emotionally,” says Pelchat, 57, in an email interview made possible by the DynaVox Vmax+ speech generating device. “Plus the support and care we receive from family and community—for example church groups prepping and delivering meals regularly, volunteers helping with house work and home repairs—takes a great burden off my wife and me so she can concentrate on my need for constant care.”

Rather than make what has become a daylong journey back and forth to Dartmouth-Hitchcock Medical Center in Lebanon for consultations with his neurologist, Pelchat travels 15 minutes to Weeks Medical Center in Lancaster to teleconference. Telemedicine—supported by a local team of home care providers, visiting nurses, a speech therapist, a physical and occupational therapist, and pulmonology and nutrition specialists—allows Pelchat to help raise his grandchildren, spend time with wife Anita and stay in touch with colleagues.

“In New Hampshire and Vermont, because of the geographical challenges and the number of rural communities, there has been a strong interest in using these telehealth technologies,” says Sarah N. Pletcher, director of Dartmouth-Hitchcock’s Center for Telehealth. “Just in the last year or so, we have really seen a major growth in using these technologies.”

Telemedicine saves costs for patients in terms of transportation expenses and less missed work time to make appointments. Horvath says telemedicine provides quality care at lower cost to hospitals, which results in lower costs for patients who need specialty care. Reimbursement varies by state. In NH, insurance companies and Medicare pay telemedicine services the same as in-person care, although it is not covered
by Medicaid.

As King sees it, telemedicine not only “offers better care at the local level while keeping down the costs of specialist reimbursement treatments, but it is cost effective and, instead of jamming up the system, patients can be seen on their own terms.”

For Pelchat that certainly has made all the difference. “Being close to grandkids, friends and family allows for me to feel some sense of normalcy and maintain some pride in who I am when this disease strips the human dignity and normalcy away,” he says. “So staying local, and in my community, allows me to sort of be me, thus a healthy spirit is a healthy mind, even if the body ain’t.”

Ronaldo Pelchat would like to help others by sharing his journey with ALS. Visit his website at rpelch57.wix.com/alsdisease

Above: Ron Pelchat at Weeks Medical Center in Lancaster, NH, for a telehealth appointment with his D-H neurologist Jeffrey Cohen, MD, in Lebanon. Also pictured, Pelchat’s wife Anita and his pulmonologist Peggy Simon, MD.

Life on a Ventilator: One Former School Teacher’s Journey

Madeira Public Relations

Heather Grzelka, APR

Ronaldo Pelchat has been living with the support of a ventilator for more than a year and a half. The decision was difficult, but one he’s ultimately glad he made to enjoy more time with his family and loved ones. This candid interview with Pelchat explores his decision process and daily life with a tracheostomy.

For how long have you been living with your tracheostomy?

I've had my tracheostomy since December of 2013. I was sedated and had my feeding tube inserted at the same time. Sedation can be more risky for someone with ALS or any neuromuscular disease. Doing both at once is optimal when applicable.

Did the procedures cause you any discomfort?

There was no real soreness initially, nor the weeks following, in either location. Just some expected irritation. The tracheostomy tube is held in place by Velcro ties that connect behind the neck and look like a priest's collar. The ties can be changed easily daily or weekly.

The operation consists of inserting a tube about the size and shape of a slightly bent index finger, into the "V" of the neck and into the airway. The hole is about the size of a nickel. The tracheostomy tube fits tightly—think newly pierced ears.

What post-operative care is required?

Inserted into the tracheostomy tube is an inner tube called a cannula (think slightly bent little finger). This is removable (done by a caregiver, yup!) and changed once a week. The tracheostomy tube is initially changed the first week in the hospital or rehab facility, then once a month and if healing well, every three to six months. A medical professional will change the tracheostomy tube in their office or another medical location in case of complications.

Have you found the day-to-day maintenance to be difficult?

Changing the inner cannula is relatively easy. The tracheostomy tube is more complicated thus the need for a medical professional.

There is a learning curve and necessary rehabilitation time for both the patient and primary caregivers. The rehab facility will teach both. I spent a month in rehab at an outstanding facility in Salem, Massachusetts, called Spaulding North Shore Rehabilitation Center.

For anyone having a tracheostomy and/or feeding tube, I'd say this is a must. Go to a reputable rehab facility, spend the necessary time (don't rush it) and work out any glitches, and be sure you and your primary caregivers are fully trained in all facets of trach tube and feeding tube care.

What were your biggest concerns when making the decision to have this procedure?

It was very hard for my wife and I to contemplate; apprehension times ten! Would I die from the operation? Could I live on a vent? Was it worth doing? Would there be pain and suffering? Should I just die and make it easier on my wife? Was I being selfish, a coward, too afraid to die and putting an unbearable burden on my wife, the primary caregiver?

But now I love it. I don't have to struggle to breathe. I always get a quality breath. It feels really good. The rehab facility and pulmonologist will adjust the vent settings to the patient's needs and comfort. It's actually relaxing to know my breathing is automated. As long as the vent works, breathing is easy. BUT YOU DO NEED DEDICATED CAREGIVERS!

Tell us more about the need for a dedicated caregiver.

It’s important to have someone available 24/7 to identify problems and/or call 911. The most constant job is replacing the air hose when it falls off the tracheostomy tube. My mantra is, "If the trach hose falls off, just relax, and put it back on.”

You get used to it, and if it's off, the alarm sounds to alert the caregiver. You don't need someone always right next to you, but caregivers must be within earshot and well trained! That's why 24/7 care is a must.

What advice do you have for others considering this procedure?

My best advice is why die if you can live. Talk about the choice with people close to you. Evaluate your options and their reactions. Then once you have all the information and fully understand it, find quiet time and think. Make the best choice for your situation, but if fear is your only stumbling block, I'd encourage you, based on my experience, to say yes!