People: Practicing medicine in the dark, on the edge

(originally posted 09/06/05)

Practicing Medicine in the Dark, on the Edge - from NY Times.

Practicing Medicine in the Dark, on the Edge
By PERRI KLASS, M.D.
Published: September 6, 2005

They're heroes, all of them, the doctors and nurses taking care of patients in the hurricane zone, the ones you read about in the newspapers, ventilating the intensive care unit patients by bag and mask when the generator fails, or binding up wounds by flashlight.

It's a very particular kind of heroism - doing what you were trained to do, but doing it under circumstances where you are pitting your standard professional skills against unimaginable disaster.

The doctors and nurses in those hospitals and clinics have been fighting the right and proper ancient battles of the medical profession - and in many places, fighting them under horrifically ancient conditions.

Some of the most important, most necessary medical specialties - performing life-and-death operations, providing life support for the desperately ill - are the very fields most handicapped by the loss of technology; in those battles, fought out on the edge of what is possible, you need every advantage.

Dr. Manish Jain, a third-year neurosurgery resident at Tulane, who spent the days after the hurricane at the Veterans Affairs Hospital in New Orleans, described taking care of intensive care unit patients on "drips" - intravenous hookups meant to deliver tremendously potent drugs at scrupulously measured rates, so that every detail of the patient's heart rate and blood pressure can be monitored and bring about an appropriate adjustment in dosage.

Without working monitors, he said, without the machines that dole out the drugs by the milligram, by the minute, they managed the drips by literally counting the drips of medication into the IV. "Everyone from respiratory therapists to nurses to pharmacists to physicians," he said, "we used our collective skills to ovecome the deficits."

Outside intensive care, doctors and nurses are struggling to provide very basic care: people are sick, people are hurt, people are scared, and they need care. Children need their chests listened to, their asthma treated, their skin infections managed with the proper antibiotics; they need the right fluids if they're dehydrated. And even that is hard to do properly without technology so basic that we don't even notice it till it's gone.

A couple of days after the hurricane hit, I talked with Dr. Cindy Sheets in the pediatric clinic at the University of South Alabama Children's and Women's Hospital in Mobile, where the hospital was running on generator power.

"You end up trusting more in your judgment," she said, "relying less on the backup tests you do sometimes for medicolegal reasons. Over time, you know, we all have a fair amount of experience to tell us what's going on."

But the truth is that the way we deliver care has come to depend extensively on technology, not just the imaging miracles of radiology and the subtleties of serology, but on the whole electronic network of communication and commerce that keeps our world turning.

So Dr. Sheets was busy seeing patients, worrying about the risk of heat exhaustion to the people without power in the hot city around her. She was listening to chests and looking in ears and examining children's bodies.

It wasn't the diagnostic technology that was most on her mind. She was worried about the pharmacies: Without power, she said, many of the bigger chain pharmacies could not dispense pills or print labels.

She and her colleagues were dispensing the powdered antibiotic samples they had on hand, and directing patients to the few open pharmacies which were willing to compound prescriptions and provide medications without their own technological supports.

Most of us know, when we train as doctors in this country, that along with our phenomenal professional arsenals - our diagnostic tests, our imaging machines, our life-support systems, our wonder drugs and even our not-quite-wonder drugs - comes a certain dependence on the complex web of technical support.

Even in the kind of relatively low-tech, relatively old-fashioned medicine I practice - primary care pediatrics - there's an inexorable tendency to move away from relying on your own medical skills and get the extra test.

When I was a resident, in the relatively low-tech 1980's, there were plenty of senior doctors to point out to us, with a little bit of regret, that the art of physical diagnosis, for so many years the great point of medical professional pride, was getting lost in the newer technologies.

Those doctors showed us, over and over, how much you could infer from the appearance of the patient, from what you could palpate, from carefully assessing the different pulses around the body, from listening - really listening - with a stethoscope. And they worried that those skills would be lost in an era when you could easily obtain unimaginably sophisticated images of the heart and its blood flow, when you could look to definitive diagnoses by technology that answered every question you had thought to ask, resolved every diagnostic ambiguity.

Some teachers made a special point of teaching cases where too much reliance on diagnostic tests had led to wrong treatment or overtreatment or missed diagnoses. It's still a teaching truism: "When all else fails, look at the patient."

And there is no question that the technology, while it makes it possible to look inside a patient, to quantify ever more obscure shadowy presences in a patient's bloodstream, also tends to change the way you do - or do not - look at your patient.

You trust your own eyes and ears a little less. You look for confirmation from machines before you act. You ask clinical questions partly because you know they can be answered and you want to "document" the answers.

So yes, for example, "pneumonia is a clinical diagnosis," as I punctiliously remind the residents and medical students. And, yes, this is supposed to mean that if you listen with your stethoscope and hear pneumonia in a child's chest, you treat it. But the truth is, I often end up checking the X-ray and letting that guide me.

Sometimes it's uncertainty: did I really hear what I thought I heard? Sometimes it's that medicolegal desire to check every box. Suppose the child gets sicker, could I really justify not having gotten an X-ray? And sometimes, I confess, it's just the awareness that the X-ray is possible, the X-ray is there, the X-ray is easy.

Dr. Marsha Raulerson, a pediatrician in rural Alabama, remembers vividly when Hurricane Ivan devastated the small town of Brewton. Practicing in a rural area, she said, she probably relies less on technology than many other doctors.

"I depend on my physical exam, not an X-ray," she said.

But she was terribly upset by the idea that she was truly and profoundly out of touch.

"I'm always with my cellphone, I'm always with my beeper," Dr. Raulerson said. "They wouldn't work, phone lines were down. My husband said I lost my mind; I was just frantic.

"I ended up the day after the storm going to the office just sitting there in the dark, wondering if people were going to find me. A few wandered in, children injured during the storm, but I was just worried that if they needed help they wouldn't be able to call or to get there, so I was sending out people to check on all my high-risk babies that were at home."

That was the biggest anxiety. Not that she would have trouble diagnosing an illness, even if she was armed only with her five senses, her stethoscope and her clinical experience, but the sense of being out of touch, unreachable, unavailable to someone in trouble.

It was the sense, I think, of wanting to use what you were trained to do, what you know, who you are, wanting to fight that battle, in which the stake of a single life matters so surpassingly, even in the setting of overwhelming disaster.

There are many kinds of heroism, and even many kinds of medical heroism. There is the true drama of what we actually call, in the hospital, "heroic" surgery - high stakes, high tech, life and death. And there is also the everyday one-on-one heroism of truly looking at the patient, listening to the patient, even when you're both in semi-darkness.