Thursday, December 16, 2010

Oh, the possibilities...

Once again I am in the unfamiliar waters of not having a solid answer at my fingertips.  So much in medicine is evidence based - we know that if we give you antibiotics (the right ones) you will be cured of your pneumonia.  We know that if we sew your wound closed within 6 hours (newer studies are saying 24 hours for clean wounds), your chance of infection is only about 5%.  These are facts as far as we're concerned.  No more debating to be done.  As students, we learn myriads of these facts and are armed with solid answers for a multitude of medical complaints.  And then comes clinical year and we realize that so much of actual medicine is far less certain than we were initially taught.  Does this wound need a two layer closure, or will just one do?  How many sutures does it need?  Is this viral, or bacterial?  Will chronic tonsillitis cause a child to have paroxysmal nausea with vomiting?  Is this patient septic?  Does an elevated carboxyhemoglobin explain all of these symptoms, or just a few?  Should this patient be admitted, or not?  Many of the questions that we have can only be answered after a lab has had a chance to run certain tests, which often take a day or two.  Thus we make treatment decisions based on probability, or more plainly put uncertainty.  This is medicine, take it or leave it.

I have spent much effort getting comfortable with this.  As a clinical student, it is my job to learn to operate in this world of incomplete certainty - "Mrs. Smith - you most likely have a viral bronchitis and will not need antibiotics for this condition.  Use symptomatic treatments like cough syrup and throat losenges.  If you're not better in a week, come back and see me and we'll see if we need to do something different."  In this case, the most likely diagnosis is a viral illness, but it could be bacterial.  We can't be certain without expensive and, sometimes, inaccurate tests.  This case is a simple one but they can be much more complex and serious such that if we don't have a grasp of operating in uncertainty then we may end up contributing to a patient's demise.

In the ER it comes down to a relatively simple problem - what could this be that might kill the patient?  If we can rule all of those out, but still don't find an answer to exactly what's causing the symptoms, then so be it.  We'll have them follow up with their primary care provider later.  But when I was working in internal medicine, we were the primary care providers.  Here's an example: "I went to the emergency room over the weekend because I was having a lot of trouble with pain in my legs - so bad I couldn't walk.  What do you think it is?"  In this case, the ER has ruled out the "Big Bads" - things like PE, cancer (sometimes), fractures, and the nasty bacterial infections.  But they didn't give the patient an answer - they were only able to treat the symptoms (make the patient functional again, which is always a win in my book), made sure it wasn't anything "serious" and let him go on his merry way.  But then in internal medicine we were expected to come up with the answer - this is our job, so I'm not complaining.  Yet the patient sits in the examining room and we, without certainty, begin the workup again (usually we don't get the results of all of the tests done in the ER).  So from an uncertain footing we begin and we do all the same stuff as the ER docs/PAs/NPs perhaps with the exception of x-rays at first (though, of course, repeating an x-ray after a week can show occult fractures - something to keep in mind).  We repeat the physical exam, trying to be perhaps more thorough than the previous provider, and hope to come up with some more clues.  Sometimes we get the answer from a test or a physical exam maneuver, but sometimes not.  In that case, we have to say something along the lines of, "This is most likely [you fill in the blank].  We'll treat you much as they did in the ER, but we'll try something new that will cure it if it is what we think it is."  Talk about uncertainty...

This is generally not how we are taught to practice medicine.  In classrooms, we are taught the typical prodromes and clinical pictures of disease - a patient comes in with chest pain when taking a deep breath and his EKG shows a deep S wave in lead I, a pathologic Q wave and a flipped T wave in lead III - what is it?  This would be a "classic" presentation of pulmonary embolus (PE) but truth be told, it is nearly never that clear cut.  One preceptor notes that in all his years of practice, he has never looked for that classic "S in lead I, Q and flipped T in lead III" pattern for PE.  Thus classroom learning, though undoubtedly beneficial, does not reflect real world situations as well as we would like.  In my recent (though short) experiences, I would have to say that probably 1/5 or even 1/4 of the patients I have seen have not had "classic" symptoms of the conditions with which they end up being diagnosed.  Though this is not news to anyone, I think it highlights the value of clinical experience - both before PA school and our clinical year.  In some ways, I believe this year is my true medical education because I not only learn the facts of disease but I learn the uncertainty of medicine as well.

Perhaps if we designed a new curriculum to address uncertainty a bit better, we would all be better off.  Of course, whoever can figure out how to do that will be a millionaire and won't ever have to work again.  Where would be the fun in that?

Sunday, December 12, 2010

"Lost to follow-up"

This phrase is one that is often used in scientific literature to describe members of a longitudinal experiment who cannot be contacted after a certain period of time following the initiation of the research project.  They have been lost as far as the researchers are concerned.

I have titled this post as such because this phrase keeps running through my mind as I consider some of the patients I have seen and treated in the ER.  A vast majority have been treated and discharged, some have been treated and admitted only to be discharged a day or two later by their hospitalists.  I don't consider these patients "lost to follow-up" because there is, essentially, no follow-up required.  We have provided definitive care either in our ER or within our hospital system and these patients leave my care in stable condition.  However, I carry the cases of a select few patients who did not receive definitive care while I was rotating through the ER.  Over my month-long clerkship, there were just a few patients who were so ill as to warrant admission, but who did not receive a cure while within our system.  These few are lost to follow-up for me, and it occurs to me that I am somewhat saddened by the fact that I couldn't have a hand in "fixing" them - making them free of their illness as I was able to with so many others.

This is part of being a student - involved in a certain population for a while, then off to the next rotation and everyone you had previously cared for is lost to follow-up.  

Wednesday, December 8, 2010

The worst day

Putting this one into words may be a little bit difficult.  My aim is to convey a couple of ideas and I need to do it while preserving plenty of anonymity.  On top of this restriction, it's a bit of an emotional issue - so please bear with me as I stumble through this topic.

A number of days ago, we had a remarkably sick patient come through the ER.  Not knowing how sick this person was, I was initially a little unimpressed by the presenting illness - nothing seemed too amiss.  As I presented to my Attending and proposed a workup and treatment plan, I was educated in just how to treat someone with these co-occurring symptoms.  Through this process I realized how ill our patient was (or had the potential to become) and thereafter kept a keener eye on how things progressed.  I was humbled by the experience of having initially assumed our patient was not sick when in fact the opposite was true. 

This brings to mind another point: we have had drilled into us the idea that we need to be able to differentiate sick from not-sick.  Sometimes this is referred to as a doorway assessment or a ten-foot assessment.  One of our instructors would show us pictures of patients and quiz us: "Sick or not-sick?" he would say...  Sometimes it was obvious, others not so much.  Admittedly it was difficult to tell especially for a new student.  I still have a ways to go, naturally.  But it's an important skill and this case illustrates that well.

At any rate, this patient was definitely sick and my doorway assessment was inaccurate.  Our patient became a bit more ill in our department so we got an admission to the hospital set up.  The patient got worse and ended up in the ICU (intensive care unit).

This is where the main point of this post comes in.  One aspect of emergency medicine that is incredibly rewarding is the fact that we often take care of people on their worst day.  Something has brought them to see us that is worse than any other illness or event in their life - something like a heart attack, brain attack, or major accident.  We have the opportunity to make a horrendous event just a little less miserable, sometimes make it resolve altogether.  What a great thing to be able to do.

On this particular day, our patient's worst day, I had the opportunity participate in the care that made it a little bit better.  We helped a family cope with difficult times and cared for a patient who, without good treatment, faced a terrible prognosis.  This is a part of the honor of practicing medicine.

Condensed down into a pithy saying: a patient's worst day brings the opportunity for us to have our best day.  I just hope that, with time and more training, I will be able to fulfill my end of the deal.

Wednesday, December 1, 2010

There'll be days like this....

As we all set about our medical careers we understand that there are going to be certain days that stick in our memories for a lifetime.  There will be days when the events that unfold make an impression upon us - days from which we learn volumes yet feel as if we have fallen flat on our faces.  These days are difficult to bear, but strike so well at our weaknesses that they are essential to becoming proficient medical providers.  Today was such a day for me.

Without going into too much detail, we had a number of pretty sick folks come through the ER today.  As a student, I was unfortunately a bit hamstrung in what I could do to help in these cases - the bustle of activity surrounding me included skills that I do not possess and skills that are not easily acquired in just a month of emergency medicine.  This experience was intensely frustrating in some ways and incredibly valuable in others - frustrating because the skills are ones that I need to know to practice medicine well, yet valuable in that essentially I was allowed to be a fly on the wall observing some talented providers work together to provide good medical care.  In my case, the frustration overshadows the value a bit.

But to make good use of the time I spent in the ER today, it is my job to see to it that the value is evident in the end.  Our clinical experiences will be what we make them to be, not more and not less.  With this in mind, I can let the memories of the events that unfolded today sink in and stay with me so that when I am in practice and begin taking care of patients as sick as those that I saw today, I will at least understand the sequence of the things that need to occur.

As it turns out, I don't think I have a choice about whether or not the events that transpired will stick with me - some things we don't tend to forget.