Still. As a newly-qualified doctor, I may have been
a little bit lacking in book-learning and no doubt I had the regrettable
tendency of youth to give scant respect to authority, but I’d been taught good
clinical skills, and once I had the responsibilities it turned out I had the Scottish
work ethic in spades.
A 24-hour receiving period might
involve admitting a dozen or twenty patients to the internal medicine or
surgical ward. As well as admissions,
there were routine duties in looking after a couple of hundred patients as the
sole doctor on duty in the hospital, and dealing with whatever emergency situations
cropped up. Oh, and Casualty to look
after. Much of this was in reality
unsupervised, although I did have the telephone number of a consultant, and if
things got really difficult I could call in someone a year or two more senior
than myself.
There were two saving graces to
this fragile arrangement. The first was that
I learned very quickly to pay attention to the nursing staff. The experienced staff-nurse who could drop
respectful hints about whether or not to admit an apparently minor head-injury,
without infringing the strict rules of the doctor/nurse hierarchy of those days. It was always worthwhile to read their body
language too, when making a decision. In
those days, decisions really were agonising, since one never had enough
knowledge and only a tiny amount of experience on which to base decision-making,
and there was rarely the kind of training and educational network which
clinicians these days rightly insist are absolutely essential for
trainees. Should I admit the patient or
allow them to go home? Discharge from
the clinic or come back in 6 weeks – hopefully to see someone else? How am I going to tell a 30-year old woman
that her husband has just died of a heart attack, when I currently have the
emotional maturity of a new kitten?
The second safety-net was to deploy
one’s powers of observation very carefully, and day-by-day to develop them
through constant practice. To examine
the patient, to go away and think about the overall picture, to strive for
perspective, to go back and try to calibrate what you saw and felt and heard
against how the patient’s condition was changing or even against some nascent
intuitive feeling that things were not as they seemed.
Clinical skills, then, firstly involved
reviewing the patient’s entire medical record, if one was available, followed
by taking a full medical history at the bedside, direct from the
individual. Every bodily system has a
series of questions which need answering, negatives being as important as
positives, and a particularly salient point in those days was that the medical
history was taken by the junior doctor, who then took responsibility for
communicating relevant facts and information to the rest of the clinical
team. That was a kind of ownership which
led directly to a deep sense of responsibility as well as providing a
foundation for good teamwork.
Following history taking, the
patient was examined minutely and systematically. Musculo-skeletal system, cardio-vascular system,
respiratory system, neurological systems including an examination of the cranial
nerves and looking through an ophthalmoscope at the retinal fundi. In those days we never ommitted a rectal
examination; to miss a palpable tumour
in the rectum or reproductive system would have been unforgiveable by oneself,
one’s colleagues and, worst of all, by one’s patient.
The clinical examination skills were
particularly interesting to me. To
practice obervational skills and become able to see things with
every-increasing clarity, to be alert to common or unusual abnormalities while
gaining an understanding of normal variations, these were aspects which
required constant attention.
Auscultation of the praecordium:
that means listening to the heart by placing the stethoscope-bell at a
series of prescribed positions on the patient’s chest, and listening intently
throughout the cardiac cycle for normal and abnormal sounds as the valves open
and close and blood jets from one heart-chamber to another or from the heart to
the aorta or pulmonary artery. The skill
of auscultation has a particular attraction for anyone with a deep interest in
music, for it demands an ability to hear events in detail, and to remember them
with such clarity that they can be thought about and re-examined in the mind
over and over again. In this way the
physician extracts the maximum possible information and relevant meaning from
observations which depend on the senses of vision, hearing and touch.
Even the sense of smell shouldn’t
be ignored; on one occasion I actually saved
a young woman’s life by sending a blood sample for plasma glucose estimation,
having been alerted by her peculiar smell to the fact that her unconsciousness
was not necessarily attributable to a drug overdose as everyone involved had
presumed, but to a metabolic disorder, which ultimately was shown to have been
caused by pituitary failure – Sheehan’s Syndrome. However this event may be viewed, it was
certainly a matter of a junior member of the clinical team being alert to the
actual reality as opposed to heeding what his more senior colleagues were
telling him! Once I’d taken an excited
telephone call from the laboratory about “the lowest blood glucose I’ve seen in
40 years!!”, it was a matter of finding a fat glass ampoule of concentrated
sugar, persuading it into a syringe, and waking the girl up within minutes of
its injection into a vein. Damn, lucky
for her I didn’t go to art school!
© Donnie Ross 2012
