As my third year was winding down last month, I had the opportunity to do a two-week elective in anything I wanted. Supposedly it had to be medically-related, but given that some of my classmates were approved for two weeks of wakeboarding or a 3-hour first aid course*, spending two weeks in paramedicine made me look like an overachiever.
The elective was pretty incredible from a medical point of view. Among the dozens of calls we attended, we picked up a young lady whose ATV had gotten away from her, crushing her leg to the point where she might never walk again. We also treated a few patients who had fallen off ladders or nearly drowned, and a nailgun injury. As well, there was a variety of medical patients too complex for the rural hospitals who needed to be brought to the big city for super-specialized care.
There were things that I didn't anticipate. There were heart-wrenching moments, like talking to one of our patients, a young lady who had been poisioned by carbon monoxide...intentionally. Sadly, she was not the only suicide survivor that we saw during my two weeks. As well, we went to a few car accident scenes and I saw some things, tragic things, that I wish I hadn't.
One thing about the elective really surprised me. Those of you who have read this blog for a while might remember that I have shadowed flight paramedics in the past. Back then, it was fascinating for me to see what the paramedics did...treat and transport the sickest patients in the province. What surprised me is that this year, my time with the paramedics served as a stunning eye-opener, revealing to me how little I knew about not only paramedicine, but medicine in general back then.
In other words, until I had completed my third year of medical school, I had no comprehension of just how sick the patients were that we were transporting. Not only that, but I had no idea the elite level of training of the flight paramedics. Back then, I did not understand the skill demanded when handling ventilator settings for patients with severe lung disease, or the implications and specialization required in order to keep alive a patient with bacterial infection coursing through their entire body. I only now realized just how sick these patients were, having been involved in identifying and treating sick patients myself, and also that some of the drugs that the paramedics were trained to prescribe are typically only used by intensive care specialists.
It was exciting to be able to understand at a deeper level the diseases affecting our patients, and to be able to have a new level of conversation with the flight paramedics, actually discussing treatment options with them. To put it another way, before I had completed three years of medical school, I didn't even know what questions to ask.
Needless to say, my understanding of the complexity of the patients and the difficulty of their management gave me a new level of respect for the critical care flight paramedics.
Retrospect, for me, is a valuable, meaningful experience. In fact, one of the reasons I started this blog was so I could look back and see how far I've come; in a program that is years in length and where you rarely realize how much you have learned from day to day, sometimes looking back is the only time you'll realize how much you are learning. It was a huge privilege to be invited back to spend time with these highly-trained paramedics, and it was a great surprise to discover that without realizing it, I had signed up for two weeks of seeing how much I have learned. Glad the $45,000 I've spent so far on tuition seems to be paying for something!
*In defense of my classmates, they did have to write a 500-word essay relating their elective to medicine
Wednesday, August 19, 2009
The best part of spending two weeks with medevac? Not what you might think.
Thursday, April 16, 2009
First do no harm...unless you haven't gone to medical school
Albert was on the phone with his sister on a sunny afternoon last week, telling her about the trip they had gone on over the weekend and his wife's bingo winnings at the local senior's centre that week, when suddenly she interrupted. "Albert, don't be silly."
"What are you talking about?" he replied.
"Albert, I can't understand you, what's going on?" He was confused - he was speaking perfectly fine, as far as he could tell.
His wife walked into the room, and noticed that he was indeed slurring all his words, and rushed him to their naturopath. The naturopath saw his mouth drooping on one side, and told him he knew exactly what was going on. He promptly gave him a glass of water, into which she had mixed several spoonfuls of salt, and told him to drink up, and encouraged him to do this over the next several days. Why?
Because, as the wife explained to me, "Well, when the left side of the mouth droops, he has a deficiency of sodium. And when the right side droops, he is low in potassium, you see. When both droop, then he needs more calcium."
Sure enough, in about half an hour, his droop had resolved, and his speech returned to normal. So the naturopath was right, right?
Unfortunately, in this case, his naturopath was wrong. Because he'd had a heart attack in the past, and his heart muscle didn't contract the way it should anymore, giving salt to this patient was a bad decision. In fact, research shows that patients with heart failure have worsening of their symptoms when they have salt in their diet, and the most recent heart association guidelines recommend low-salt diets for these patients.
And why did he get better? It had nothing to do with chugging brine. He'd had a TIA, or a transient ischemic attack, exactly like a stroke except it's just that - transient. The brain is starved of oxygen for a short time because of low flow or a small clot blocking an artery, but then the flow is restored before brain tissue dies. Had this lasted long enough to kill the brain tissue, it would have been called a stroke; in his case, the symptoms - temporary paralysis of his facial nerve innervating the orbicularis oris muscle, causing a mouth droop on one side - went away about half an hour after he drank the salt water. Though it looked like the natural treatment worked, it in fact had nothing to do with his symptoms resolving.
But, because of this advice, his wife faithfully gave him several spoonfuls of salt every day, causing more and more water to build up in his blood vessels. And it wasn't long before his failing heart couldn't cope with this excess salt. He soon could walk shorter and shorter distances without having to stop for air, and would wake up gasping for breath in the middle of the night. His heart muscle's ability to pump blood, which had been measured right after his heart attack as still being still quite reasonable, couldn't cope with the extra water in his blood vessels and took a drastic turn for the worse.
I saw him when he came into the hospital with his wife, unable to breathe, but it was too late. Despite receiving massive amounts of diuretics, vasodilators, and being placed on a breathing machine, it was too little too late. A few weeks later his heart gave out completely, he died with his lungs full of water instead of air, with a look of panic on his face, gasping for oxygen, because of the misinformation the wife had been told naturopath.
It doesn't worry me that naturopaths provide a whole-person approach, and attempt to treat the cause of patients' ailments rather than the symptoms.
It does worry me when they cause harm to patients, and make their health worse.
Any doctor that prescribed salt to a patient with heart failure... not to mention miss the diagnosis of a stroke... could be sued, successfully, for malpractice.
It also worries me that out on the western coast of this country, in British Columbia, naturopaths have been given the right to prescribe medications,which not only seems to go against their entire profession's objective of treating things naturally, but is possibly dangerous given that they are quite simply not trained in this area.
But going back to the story...you know what the worst part is? Had he seen a physician earlier, this could have been avoided... but the wife didn't see it that way. She left the hospital, without her husband, thinking that traditional medical treatment had failed to save her husband, when in fact the damage had been done long before he got to the hospital. Hopefully, her stronger belief in natural therapy doesn't kill her too.
Sunday, January 13, 2008
How a doctor might tell you that "you are dying."
Which is worse... telling a patient directly "you are going to die," or having them leave your office having no idea because you tried to phrase it gently?
While I haven't yet been trained in breaking bad news to patients, the answer to this seems like it may be fairly obvious.
In an article published in the Journal of Clinical Oncology, author Scott Berry tackles this issue. Most interesting is a role-play situation in which physicians had to tell a patient they were dying; only one of eight oncologists used the word death. In the name of empathy and gentleness, perhaps the following statements veered too far into the realm of vague:
What the physicain said: Most people with this disease will have problems soon...Time could be very short—a few weeks to a few months. I think it is advisable to prepare for the worst and hope for the best.
What the physician meant: You are dying.
What the physicain said: Your time may be short.
What the physician meant: You are dying.
What the physicain said: If there were a hundred people in your situation, most of those people would have major problems within one month or so...let's consider that we are now at Labor Day. By the time we get to late September, early October, I would expect that you would be having major challenges or problems.
What the physician meant: You are dying.
What the physicain said: Certainly, it sounds like the disease is really threatening your life.
What the physician meant: You are dying.
Sunday, September 30, 2007
Getting used to palliative patients might take some time.
For our clinical skills classes, we spend most of our time on actors / standardized patients, who come into our clinical skills training rooms at the hospital and we learn how to do basic exams on them.
However, the odd time we'll go onto an actual hospital ward and get the opportunity to examine symptomatic patients.
Last semester we were at the hospital practicing our cardiac exams on a couple of hospitalized patients. My group was assigned a patient who was really friendly, and such a great sport - she didn't complain once about the four medical students percussing and auscultating her chest, tapping for a lung here, listening for a murmur there, asking her to sit up and lie down, even though it was obvious that due to her bad back the ordeal wasn't entirely pain-free for her.
Over the twenty or so minutes we spent at her bedside, she told us more and more about her condition, but she also talked her life - her job, her family, and the things she enjoyed doing before she ended up in the hospital. She wasn't too old, and she was pretty coherent. She seemed like a really nice lady, and I really enjoyed the chance to get to know her.
After our exam, we went to the nurse's station with our physician tutor, who called up the patient's lab tests and CT scans on the computer. We talked a bit more about the patient - she had a few other conditions that weren't related to our cardiac exam which we briefly talked over - and then were ready to move on to the next one, when the doctor said something that hit me like a truck.
"So that's Mrs. Walters. With all of that going on in her body, she doesn't have much longer to live."
I was shocked. I had just spent twenty minutes with this patient. She seemed to be functioning cognitively pretty well, and I figured she was in the hospital getting fixed! Never in a million years would I have thought she was about to die.
The seriousness of her situation started to set in, and from a medical perspective I realized that yeah, if I had been given this patient as a narrative case, I probably would have figured out that the prognosis was dismal. But because I met the patient as a person first, and didn't know all the details of her condition while I was talking to her, I hadn't really thought about what her prognosis was. Even while our tutor was going through the patient's chart, listing her conditions, the impending outcome of the sum of her conditions never hit me until the doctor put it into those words.
I suppose that now that I think of it, I might as well get ready for my clerkship year next year, when I will be meeting dozens of patients on a regular basis - some of them who don't have much longer to live. I've never really been in that situation before, and I think it's going to take some getting used to.
