Thursday, 25 October 2012
The Parthian Look
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