Jan 18 2012
By Sage P. Whitmore, M.D.
Vanderbilt University Medical Center: Emergency Medicine
I had plenty of time to contemplate all that I had seen during 12 hours of travel back home from a medical mission trip to Georgetown, Guyana. I had just spent three weeks working in the Accident & Emergency (A&E) department at Georgetown Public Hospital and using my training as an Emergency Medicine resident in the United States to help teach new ER doctors core material such as EKG reading, airway management, and the approach to shortness of breath and chest pain. I had not realized when I arrived how much of my time would be dedicated to sitting in the metaphorical trenches and caring directly for patients coming to the A&E. I was prepared for a foreign experience in a distant land, but instead I found myself right in my element.
The minute-to-minute practice of medicine was in Georgetown was very similar to what I was used to; see as many patients as possible, gather all the information you can, make a decision—often instinctual—to admit a patient or treat them at home. One important difference, however, is that in the United States it is easy to get caught up in which hospital has a trauma center, who has immediate cardiac catheterization capabilities, and how long it might take to get a specialized MRI or exotic blood test; these distinctions do not exist in Georgetown, and as a physician I got back to basics. In medical school what we really learn is how to interact with and assess a patient; how to sit, what to ask and how to listen, where to push and prod, how to translate the patient’s presentation into terms of anatomy and disease process, and how to offer comfort. These remain the most useful tools in a physician’s arsenal and are the foundation of all medical care no matter how many elaborate adjunctive capabilities you have at your disposal.
When a concerned mother presented her coughing infant for evaluation, rather than immediately ordering an expensive antibody test for respiratory viruses, I got to be a doctor. Does the patient look ill, or does she look like a normal baby who happens to be coughing? How long had she been sick, did she have a fever, did she have any prior medical problems? What do her lungs sound like? While I was thinking about the possibilities, I used the moment to reassure the mother how well her baby looked, and her look of relief reminded me why my job can be so gratifying. Ultimately the baby checked out fine, required no testing, and the decision to discharge her was as practical as it was scientific—her mother was reliable, lived nearby, and would return if the situation worsened. In this case, practicing medicine meant relieving anxiety and educating a family member, at the cost of merely a few minutes of focused attention and interaction.
One early morning, a young man was brought in by his family members for confusion and shortness of breath. Sitting in a wheelchair, he was having difficulty concentrating on my questions and panting as if he had just finished a marathon. Virtually any cause of confusion and shortness of breath can be diagnosed for the price of a couple CT scans, a blood gas analysis, full panel of labs, possibly a cardiology consult and stress test, maybe an ultrasound or MRI. If resources were unlimited, one could simply check all the boxes on an order sheet at home if so inclined. Instead, we started with the basics—looking and listening. This shortness of breath had not started suddenly. He had no pain. He was not blue from lack of oxygen. He looked very dehydrated. Despite his rapid rate of breathing, his lungs sounded clear and he was not sucking in at the ribs or working hard to breath through fluid or inflammation in the airways. In medical school we learned about “Kussmaul” respirations, a pattern of deep breathing meant to get rid of acids in the blood, usually from undiagnosed diabetes. We did have a glucose meter on hand, and it turned out his blood sugar was critically elevated, proving the diagnosis. The treatment is simple, and he improved over several hours with IV fluids and insulin. In this case, practicing medicine meant a thorough history and physical examination, and the cost of one glucose check and widely available basic medications.
In a blur of activity, orderlies whipped into the A&E with a woman found unconscious at home. She was limp, unresponsive, snoring and gurgling through her oral secretions. In this situation, protecting the patient’s airway with a breathing tube is essential to prevent secretions from draining into the lungs and getting infected. There is no fancy test required, but getting the tube in place can be difficult and can require specialized equipment. At my home institution, a cutting edge machine with a fiberoptic camera at the tip and a high definition screen can be used to look around the patient’s tongue and place the breathing tube through the vocal cords. In this A&E we had one basic device, and with it the resident was having difficulty passing the tube as the patient’s oxygen dropped lower and lower. Even in this extreme case, going back to the basics proved life saving. As we learn in our airway courses, what saves lives initially is not placing a breathing tube, but rather simply ventilating the patient with a bag and a facemask, by holding the jaw just so. Employing this technique brought the patient’s oxygen back up and gave us time to change the patient’s position, the size of the breathing tube, the height and angle of the bed, and optimize the conditions for the procedure. When the situation had calmed down, we took a slow, deliberate look for the vocal cords and passed the tube successfully.
I came away from these clinical scenarios with a new appreciation for basic medicine. In the era of whole body CT scans, unlimited lab analysis, and myriad medical gadgets, the fall back is always our own eyes, ears, and hands. Forming a therapeutic bond with a patient, asking the right questions, searching for the right clues, combining instinct and basic life support skills, and caring for patients with compassion are principals that know no borders.