Jamie, a 17-year-old gardener, is horrified as he looks down at the index finger on his left hand. Blood is oozing out and the tip is hanging off following an accident with a hedge-trimmer. A nurse stands next to him, holding his hand and pointing at his finger. She wonders aloud whether it can be saved. In the corner of the room, a doctor's face appears on a video screen and in a calm voice assures her the finger can be sewn together.
It's not a scene from a slasher movie, but a reality in present day Cornwall. In minor injuries units up and down the county, the use of imaging and video-conferencing equipment, allowing remote diagnosis, means a consultant's opinion is only a phone call away. Instead of waiting hours for treatment, patients are assessed and treated within minutes.
This hi-tech revolution in medical care has been seized on by managers at Cornwall Healthcare trust, who are playing a leading role in the development of telemedicine in Britain. Driven by the remoteness of the region and the need to curtail spiralling healthcare costs, their use of information technologies has allowed them to challenge traditional ways of delivering healthcare. By installing computers, they have given cottage hospitals under threat of closure a new lease of life as nurse-led units.
A further example of this willingness to embrace "e-health" is a plan later this year to extend the technology to 20 GP surgeries, giving patients with skin complaints a chance to link up with their dermatologist rather than spend an hour travelling to - and possibly waiting at - the county's one major acute hospital in Truro. This is already happening on the Isles of Scilly and island doctors are in regular contact with specialists on the mainland.
It was on Tresco, 28 miles off Land's End, that Jamie (not his real name) almost sawed off his finger as he struggled to cut a hedge. He was lifted on to a rowing boat and taken across the mile-long stretch of water to St Mary's - the largest of the islands - where he was taken to hospital.
Dee Hore, lead practioner for the minor injuries units, was on duty at the time. She recalls: "He had almost severed the top of his finger. I took him to the video-conferencing room and lifted up the flap and showed it to an A&E consultant based at Truro. I thought the top of the finger would have to come off . But the consultant said it could be stitched up. We managed to save his finger - and saved him a long trip in the helicopter."
Toby Dalton, one of two doctors covering the 2,500 residents on the five islands, sees the technology as a massive breakthrough that benefits patients and professionals alike. Patients are treated more quickly by health workers who no longer feel they are working in professional isolation. There is also an end to wasted helicopter journeys to the Royal Cornwall Hospital at Treliske, near Truro. These can cost as much as £8,000 for one trip.
"Living on an island, the transport costs are very high," says Dalton. "In the summer, the population goes up to 7,500. Having access to a consultant 24 hours a day via a television screen makes a huge difference to us. I find the equipment most useful with fractures.The coastline is very rugged, like the west of Scotland, and we get to see quite a few turned ankles and fractures. I can show a specialist a fracture and find out whether it needs manipulating. The equipment can also transmit high quality, digital X-rays and scans to consultants for opinion and diagnosis.
"If the specialist says the injury needs to be manipulated under a general anaesthetic, then the person can be flown to hospital. Otherwise I deal with the injury myself."
Patients with unexplained rashes and suspect moles have also benefited from the new technology, which has put an end to agonising waits for appointments. One call from Dalton to the dermatologist fixes times for a live link-up the same day between the patient, GP and consultant. In the past, islanders could wait as long as three months to see a dermatologist on one of their quarterly visits to the Scillies, or face a helicopter journey to a hospital on the mainland.
Managers at Cornwall Healthcare are mindful that it is not just patients on the Scillies who face long, and possibly uncomfortable, journeys for hospital treatment. The county, which is almost 100 miles long, has a poor public transport infrastructure. Indeed, some villages have a weekly bus service only. Faced with budget cuts, and aware of the danger of isolating patients, the trust has been installing imaging and video-conferencing equipment at 10 minor injury units. These give nurses and patients a link with A&E consultants at Treliske.
Hore explains: "Five years ago, the trust could no longer afford to pay for GP cover for minor injuries units and warned they faced closure. There was a huge outcry. The trust said that the only way forward was the use of video-conferencing equipment.
"This was introduced alongside a change management programme that developed the skills of nursing staff to diagnose and treat the majority of cases within the minor injury units. The video-conferencing units have proved enormously useful for enabling nursing staff to support each other, share information and for clinical supervision."
Cornwall's adoption of telemedicine is being used as a model of good practice by health workers elsewhere. Videoconferencing is to be used in Welsh minor injuries units and for dermatology consultations in the principality. Health managers in Wales are also considering use of the equipment for routine consultations across all specialties.
BT Health, which is behind the technology, believes telemedicine could be introduced nationally and for all kinds of conditions. Peter Dyke, the company's head of business and maketing, says many diagnoses can be made by working from only an image. "For example, pictures of the eye can tell you about diabetes, a widespread and serious condition in the UK today," says Dyke. "Essentially, all that is required is for the GP to have connection to NHSnet, the electronic network that runs across the NHS, and access to digital camera equipment. The image can then be taken and sent for expert diagnosis."
Alternatively, argues Dyke, a trained nurse could even visit an elderly patient's home to take the image to be sent on for diagnosis.
In Cornwall, the development of modern information technologies continues apace. Within the next few weeks, sonographers will be able to send digital pictures of ultrasound scans to Bristol, to be checked by specialists. This will save pregnant women, perhaps already distressed by a first diagnosis of foetal malformation, a 400-mile round trip to Bristol for a second opinion.
"This will make a huge difference to expectant mothers in Cornwall," says Andrew Forrest, deputy manager of Cornwall IT services, which is part of the Royal Cornwall Hospitals trust. "Doctors and nurses will be able to get advice online from Bristol, the specialist centre, saving patients and the trust time and money."
Another transformation promising to benefit patients is the installation of electronic health records. These will allow GPs, community hospitals and acute hospitals to have access to a patient's complete medical history, including details of X-rays and blood tests that might have been carried out elsewhere. Information about diabetics and cancer patients is already being held this way under a multi-million pound programme. Government cash has been earmarked for the project - one of two being piloted in Britain.
The health records project is being phased in over the next five years. Forrest believes this cautionary approach is vital to the successful implementation of e-health and telecare. "The future is very exciting," he says. "There are all sorts of possibilities on the horizon. We have the technology to install home monitors for elderly. This analyses medical data and raises alerts with clinicians. But this technology will only work with those patients who want it.
"However, we are entering a new era. Today's communications technologies are giving us a marvellous opportunity to improve healthcare for the most vulnerable people in the community."
How skin specialists became west country pioneers
The development of telemedicine at GP practices in Cornwall builds on the success of a pilot project under which remote diagnosis was used at three doctors' surgeries for assessing patients with skin complaints.
Using digital cameras and an electronic referral system, GPs sent pictures of skin conditions to one of the county's two consultant dermatologists in Truro. They determined that one in four patients did not need to see a specialist and could be treated by their family doctor.
The remaining patients were assessed, with urgent cases being seen within two weeks. Patients whose conditions were not urgent, but who needed to be treated soon, were guaranteed an appointment within six weeks.
"Teledermatology" was chosen to test the approach because dermatologists had a particularly heavy workload. In addition, elderly people - who make up a high proportion of caseloads in the specialism - had difficulties getting to and from the hospital
Family doctors, patients, and consultants were all found to be happy with the new system. A study of the project concluded: "Electronic solutions are a practical approach to solving management problems in areas which are widely dispersed and poorly provided with public transport. Preliminary data suggest that referral pressure on outpatient clinics may also be more easily controlled.
"Rapid advice appeared to be appreciated by primary care physicians and nurses and seemed to stimulate the learning process."
