Fabiana Troxler spent a decade and a half in primary care nursing, but she wanted a little more from her work. In February, she made the leap to in-home, visiting nurse practitioner for geriatric patients. She joined Prospero Health in Charlotte to do so and gleefully set about her new career path.
“My heart was always with geriatrics,” she said.
About three weeks into that new career, it was March of 2020.
Like it did to most professionals, the coronavirus pandemic threw an entirely new paradigm at Troxler. It immediately limited her ability to drop in on patients and, as a result, stripped her of the hands-on, in-person components of her work that she finds the most fulfilling.
It also robbed her and her patients of that vital, intangible need to be in the same room with someone who cares about us. Overnight, across the medical world, virtual visits and telehealth went from being the future to being the right-now.
So how does that look from Troxler’s side?
“I think that there are definitely … more challenges,” she said. “You’re not given as many opportunities to be as objective. You’re not using your other senses. You can’t touch, you can’t look around, you can’t feel, and I think that that’s … to a certain extent more important than the actual medical care, the relationship and the bond that you form with a patient.”
As unwelcome as this sudden new paradigm might be, it does come at a fortuitous time in technological development. Troxler, after all, still has the ability to hear her patients over the phone and to see them over the GrandPads her patients have.
A GrandPad is a tablet designed specifically to be user friendly to seniors who might otherwise not feel comfortable with technology. Troxler says it’s been a game changer by allowing her and her patients to see each other in real time. They can show her a bruise or a swollen leg if they need to, and she can get a better read on their emotions and states of mind.
They can also just chat. Patients can fill her in on what else is going on in their lives and she might even let someone in her family say hello.
“She even had her daughter with her when I was on the pad the other day,” said Walker Holmes. “She introduced me to her daughter.”
At 73, Holmes is a patient at high risk from COVID-19. He has a Pacemaker, has problems with swelling in his legs, suffered a stroke and embolism in January, and has to cope with the specter of congestive heart failure. He was Troxler’s first patient with Prospero, and their relationship is exactly what Troxler meant when she said how important it is to have a bond with a patient. She calls him “a very special person” and he calls her “a good friend.”
He also calls her the best nurse he’s ever had.
“I got up last Saturday morning, and I couldn’t walk,” he said. “She walked me through what I can do, over the phone.”
But that’s far from the end of it.
“He had done a virtual visit with his cardiologist and the cardiologist had instructed him to go to the emergency room,” she said. “I said give me an hour.”
Troxler lives in Fort Mill, Holmes in Great Falls, about an hour’s drive.
“I walked in and his legs were swollen,” she said, “but he also hadn’t taken his medicine. He also had been drinking soda. He also had had catfish – stuff that you’re not supposed to do when you have heart failure.”
Troxler’s main treatment that day was “education, education, education,” she said. And it did keep Holmes out of the hospital and got him back to walking normally the next day.
She was happy to have the in-person visit – and the hug – but said there is little doubt that virtual medical care will be the norm as the world dukes it out with the coronavirus.
The tricky part, she said, will be the ability to build trust with new patients.
“Trust is hard to build,” she said. “They don’ t know me, they don’t know my intentions.”
And that, she said, is especially difficult to do over the phone. She does ask patients if they want her to come see them. Some, like Holmes, say yes a lot. Some say no because they’re worried about having any contact with people and are content with virtual visits, at least for now.
'You can't live in this world by yourself.' ~Walker Holmes
While Troxler said the GrandPads make her more comfortable, because she can at least get a visual read on patients, they don’t make her all the way comfortable. Her instincts as a healthcare provider have been honed in-person for years, after all.
But she said that going through this pandemic has taught her to approach her work in a new way.
“I have to be more inquisitive,” she said. “When I sit in front of a patient, I can get the nonverbal cues. Now I have to ask the right questions in the right way.”
And the promise of virtual visits could be telehealth’s ability to connect nurse practitioners like Troxler with more people like Walker Holmes – retired, often lonely, and living in rural areas, where healthcare is not around every corner.
She said this pandemic’s ability to stomp on paradigms might just prove that personalized healthcare programs, even if they’re to be a mix of virtual and in-person visits, are the answer for rural patients – especially elderly rural patients.
“They have less access to medical care,” she said. “They’re lonely, insecure … what happens? They freak out, they’re going to call 9-1-1. That’s not the place to be.”
She said that being able to reach people who’ve been geographically cut off from healthcare dovetails nicely with what draws her to medicine as an avocation.
“I think that’s what I love most about my job,” she said. “The fact that at the end of the day, I’m having a positive impact.”
Scott Morgan is the Upstate Multimedia Reporter for South Carolina Public Radio. Follow Scott on Twitter @ByScottMorgan.