Thursday, August 07, 2008

Medicine still amazes me...and still lets me down

As I learn all the physiology, pathology and pharmacology that medical school has to offer, sometimes there are unique things I see during my medical training that really, really impress me.

Whether it's the capabilities of a 3D reconstruction of a CT scan of a bone or the heart, or watching a patient's debilitating tremor disappear instantly at the press of a button activating a microelectrode in their brain, or re-starting the still heart of a dead person inside the chest of someone else, I occasionally find myself with my jaw on the floor when I learn things that medical practitioners are able to do and see that, only a few years ago, were an impossibility.

Then again, judging by something that happened earlier this month, perhaps I'm just easily impressed.

The doctor I'm working with was called from his office to go see Catherine, a pregnant woman in the hospital. She is early in her third trimester, but started having contractions. Of course, he explained, calls like this come right at the end of the lunch shift to provide the maximum inconvenience to him and the patients waiting in his office. He also explained that disruptions to the office like this are a part of the reason many other family practitioners don't do obstetrics anymore.

We're taught that a lot of information from a patient can be gained from the first part of the physical exam - from "five feet away," or the first glance of the patient at the foot of the bed. This patient was a great example of this. We had barely entered her room, and right away, we knew that Cathy was not doing well.

More than anything, Cathy was incredibly anxious, and for good reason. On the drive over, the doctor had explained to me that Cathy had never been pregnant, and it had been her dream to have a child. She and her husband Dale had been trying for years. No reason for her and her husband's infertility could be found, and finally, after several tries of drug-assisted and then subsequently in-vitro fertilization attempts at a high financial and emotional expense, this woman was now pregnant. And at 41 years old, Cathy knew just as well as we did that if something went wrong with this pregnancy, there likely wouldn't be another chance.

The doctor did a quick exam, and was convinced that the cervix had not begun to dilate. The baby's heart was still beating normally, and monitoring of the uterine muscle contractions revealed uterine muscle activity, but it wasn't clear if this was due to actual contractions or more minor uterine irritability.

Just a few years ago, Cathy would likely be admitted for observation, at a cost of a couple thousand dollars a day. She might not end up being in labour, and might not end up delivering for weeks... meaning a long, expensive stay in the hospital, with an expensive air ambulance transfer to a big-city hospital, with little benefit. On the other hand, she could be sent home, then suddenly go into full-blown labour, and deliver a premature infant away from the hospital after being sent home. How do you spell "lawsuit" again?

I was surprised to hear that this dilemma is not faced nearly as often thanks to an expensive but convenient lab test looking for
fetal fibronectin. This protein, made by the fetus, is found in the mother's cervical secretions only if the mother is likely to deliver within the next four weeks. By taking this swab, and getting the results from the lab a mere twenty minutes later, we were able to conclude with resonable certainty (the lab test is correct 15 out of 16 times, according to the packaging) that Cathy was not going to have a premature delivery, and that she could safely go home.

Despite the things I learn that amaze me, large or small, there still times that I am disappointed by the failures of modern medicine. So many diseases cannot be cured, and many can barely have symptomatic relief.

Earlier this week, I had to look into the eyes of a 83-year-old woman in a wheelchair who was begging me to fix her legs. She could no longer walk, and she desperately wanted to be able to. After she had left, my supervising doctor told me that she lost the use of her limbs because of a progressive neurodegenerative disease for which there is no cure, and she often forgets that this happened years ago because of her long-standing dementia. She has two diseases that, despite all of the advances in medicine these days, it still seems as though we can't do much more for her, and the millions with similar conditions, than apply a band-aid.

I'm told that throughout my medical career the advances in medical technology are expected to be staggering. Who knows what clinical decisions will be made much easier because of medical advances, or which devestating diseases will soon become relics of the past. Waiting to hear what the future will bring, and the chance to put these discoveries into action to change peoples' lives, is yet another exciting part of living a life of medicine.


Tyler and Leah said...

Keep up the good insights - hope third year is an amazing one!

incidental findings said...

Sometimes, there is no cure, right? Chin up, Vitum. Part of being a good doctor is knowing the limitations of the profession.