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froglegz
05-02-2004, 13:12
during a chat with two physicians recently i was amazed to find them confiding that they felt today's purveyors of medicine are sorely lacking in diagnostic capabilities. their point was this.... pre-hospital, in-hospital wherever it is we have far too many machines that we rely on for medical care and the art of medicine has practically vanished in some areas. this discussion came about because we had just finished an acls class and as i do during the rhythm recognition class i tell the story of winkebach who identified and accurately described the 2nd degree heart block which bears his name. he did this in 1899 but eindhoven did not invent the ecg until 1903. his description was made on visual and auditory observation alone. it is amazing to me that one's diagnostic skills could be so sharp as to do this. today we require a diagnostic quality monitor and a paper print-out before we would even think to commit to a dx of this condition.

so here is my challenge for the group...... turn off your pulse ox, take the batteries out of your monitor, and don't even think of the x-ray or ct. let's dx pts with pneumonia, intracerebral bleed, cardiac arrhythmias, and anything else you can come up with... pull out all your tricks of the trade and take medicine back 50 years....... maybe we will all learn something

Surgicalcric
05-02-2004, 13:28
Very well put.

The Reaper
05-02-2004, 13:38
That is the way we have to teach SF medics due to the austerity of our operating environment.

Thanks, JM.

TR

Sacamuelas
05-02-2004, 15:35
Excellent post.

krader
05-02-2004, 22:36
We have a very new datascope in the back of our 1st out rig, and I always say to myself, "I gotta get away from these machines and do more stuff the old fashioned way." After reading that I think its time to start within the boundries that a given situation will allow. Thanks great post.


krader

DoctorDoom
05-03-2004, 07:39
x

shadowflyer
05-03-2004, 14:02
As a new medic in training I am being taught the "right" way to do things. We are being taught to not rely on the computers and machines. BP/Pulse/RR are all done by hand in our class as well as all Trauma and Non-Trauma Assesment. Assessing pupils, LS,HT,BP,RR, Pulse... we have been doing it over and over and over until we have it stone cold.


My-Medic in training 2 cents.

Jason

Maple Flag
05-03-2004, 15:25
The Winkeback story (which I had not heard of before now) sounds annecdotal unto itself, but it stands to reason that the onslaught of technology to help us can naturally lead to changing emphasis on skills (ie: spending more time learning how to work with the technology rather than with the patient).

Technology is great, so long as we do not lose the ability to operate without it.

Great post.

greg c
05-03-2004, 15:37
Counterpoint: The use of technology enables safer patient management.

In my training I have seen a few procedures go from "blind" to "guided." The two that first come to mind are the the use of ultrasound (US) guidance for thoracentesis and US guidance for central venous catheter placement. In the first case, US does not replace physical diagnostic techniques of pecussion of the thorax or auscultation of breath sounds, but simply ensures a margin of safety when needles are being placed into cavities that contain vital organs. In the second case, US guidance does not replace visualization of landmarks, or palpation of pulses, but again can help guide needles and help avoid accidental needlesticks to vital arteries.

The above said, I rarely use US guidance for central line placement- my comfort level with the procedure allows me to believe that it does not add much in the way of safety given that I have a significant number of that particular procedure under my belt, and an almost nil personal complication rate bears that out. But I see a lot of new guys and gals erroneously poking arteries and lungs and whatnot because they eschew the available technology and don't have the talent/experience to make it safe to do so.

On the flip side, I use ultrasound for nearly every thoracentesis I do. It makes it safer given that I cannot palpate or percuss the depth of a given effusion. And within effusions you may have areas of thick or thin layers, making one area for needlestick safe where an area not less then a few centimeters away might be dangerous.

I suppose is that at some point an operator gains a level of skill which may perhaps relegate technology to not be as necessary, but in the sometimes suboptimal situations that arise (obese patients, distorted anatomy, coagulopathies) judicious use of technology has been proven to reduce complications.

Some case studies:

What if your blunt trauma patient has a slowly increasing pneumothorax? Would your exam reveal this as well as a chest film before it got big enough to cause obvious dyspnea and decreased breath sounds? Or would you triage the patient as "ok" only to find him blue an hour later?

What if your patient had an abd wound that was slowly internally bleeding? Would your exam detect this as well a peritoneal lavage- or would you find him dead hours later?

What if your patient had whacked his head and had no neuro signs but a headache (and a subdural hematoma)? Would your initally normal exam make you feel better about his death a hours later?

I don't deny that the physical diagnosis is a powerful thing, but I can't fool myself into thinking that practicing without technology is a good thing either. Best combination is to do your thorough exam, make your best guess, then do the studies and see if you are right. If not, then figure out why you blew it, and do better next time.

Respectfully submitted.
-G

PS. I Googled Wenkebach because I had in my head a picture of the man leaning over a pulse with his head bowed in deep concentration but it appears that he used a sphygmograph to diagnose his now famous arrythmia. And he first diagnosed it via experiments with frogs.

Def: Sphymograph: instrument which, when applied over an artery, indicates graphically the movements or character of the pulse.

froglegz
05-03-2004, 19:26
very good points..... i did not mean to suggest that we actually throw everything away and practice blood-letting and the odd cranial burr hole medicine but the best approach must be somewhere in between using acute diagnostic skills complimented by the gadgets of the trade. i also wanted to emphasize that when many people are forced out-side the comfort zone the gadgets provide they simply become lost. it always just aggrivates me when i ask a medic how his patient is doing and he looks not at the patient but at the equipment. "it doesn't matter what the pulse ox says he looks like a smurf.... do something"

this is one of the reasons i think that sf medics are the best in the world. we train them to do without the gadgets. we train them to rely on their instincts and not on equipment they may not have access to. they are going into a setting where most of these gadgets are going to be denied to them. where they have to listen to their patients and get a good histories. then put all of that together and formulate the plan for your patient and follow through. when cool toys are available, of course, use them to confirm what you may already know or to learn what you only suspected but do not become dependent on the toys. it will lead to a dulling of the sharp skills needed to be a great medic.

and to all who read this remember i am just rambling and you are a some-what captive audience so full speed ahead.....

froglegz
05-03-2004, 19:33
and G.... about that frog thing.... it seems lots of early experiments were done with frogs... stop the madness.... let my people go!!! (modified version)

froglegz

greg c
05-03-2004, 23:27
We share a common philosophy- continually striving to become better versions of ourselves- but with patient care above all.

And sorry about the frog thing- I was a perpetrator myself back in the day.

Oh, and an interesting exercise is to do the Px first, and try to diagnose the pt's disease before you get to the Hx. I find myself doing a hell of a thorough exam.

Stay safe.
-G

DoctorDoom
05-04-2004, 00:53
x

greg c
05-04-2004, 09:34
Originally posted by DoctorDoom
Pulm/CC fellow... howdy greg c.

Glad to be here, thanks.

Re: your profile- *redheads* I love it!