Practice Makes Perfect
Jeff Wonoprabowo -- Earlier this quarter I had a pretty busy afternoon. And for a while it was stressful, too. It all started when a 51-year-old man came into the hospital complaining about shortness of breath. On the way in he began to feel some chest pain. I stood by his side as he struggled to breathe and complained about mid-sternal chest pain. Two of my classmates began to auscultate the patient. I looked back at the monitor and read his vitals. He was hypotensive and his pulse was approximately 180.
The interview was over quickly. The ER doc asked what we wanted to do and my classmate suggested a beta blocker. I picked up the book to look up dosing but couldn't find it. It was the first time I had ever opened this particular book and it was frustrating not being able to find a simple drug. And it wasn't in the index, either.
The patient showed no improvement. Another classmate suggested adenosine. I found that dosage: 6 mg, intravenously. No change. I suggested we try a second dose, this time 12 mg. The book was turning out to be of some use.
The man's blood pressure started to increase and his heart rate lowered slightly. Positive signs. But it didn't last very long. Soon his blood pressure dropped again. My classmates and I looked at each other. I opened the pharmacology book again and flipped through the pages. It said that we could give another dose of adenosine. We gave him .76L normal saline instead.
The patient started complaining about trouble breathing. The doctor suggested we give him oxygen. Why didn't we think of that? My classmate fitted a non-rebreather mask over the patient's mouth and nose. But his vitals still weren't looking very good. We tried another drug to no effect.
Finally the doctor suggested electric cardioversion. He adjusted the settings on the defibrillator and moved aside. I picked up the paddles, completely unsure of what to do with them. He told me where to place them and told me to press both buttons simultaneously after everyone was clear.
I called for everyone to be clear and pressed the buttons. The man's vitals began to stabilize and the tracings indicated a return to normal sinus rhythm. The doctor told us we did a good job. Relieved to be done, we walked out and walked to a different room where other classmates had been sitting and watching us on a large flat-screen monitor. We removed our lapel microphones and took a seat.
It was an interesting day in Pharmacology Lab. The patient was a robot, anatomically correct and featuring pulses, breath sounds, heart sounds, and pupillary reflexes. Everything was simulated. And as we discussed the case, I couldn't help but think about the poster up on the wall. It had a quote by Aristotle: "We are what we repeatedly do. Excellence, then, is not an act but a habit."
I thought it quite fitting to see that quote in the university's medical simulation lab -- where students and residents can practice, practice, and practice some more. At least we get to "repeatedly do" on simulated patients before trying our hand at real ones.
January 21, 2009 | Permalink
Interesting point although I think medical students from third world countries can beat that. Medical students, at least in some medical schools in thirld world countries, practice on real live patients and if they did what you did with your robot patient, they would have had already killed someone.
Posted by: rj | Jan 22, 2009 12:16:47 AM
I really hope that no medical student is treating a patient like this -- especially at our level of training. We are barely halfway through our second year. If third world medical students are given free range in a clinical setting like this... with a real patient... at only their second year of med school.. well I will not only be disturbed and frightened, but impressed as well!
Posted by: Jeff W | Jan 22, 2009 12:51:17 AM
Im from Mexico, and what RJ wrote is not completely true, we do get to treat patients form third year on but most of the time we are observed by residents or attendings
Posted by: may | Jan 22, 2009 9:04:20 AM
RJ, i don't know where are you from, but I must say that your observation is wrong, it is true that in Chile we train with real patient, but we never take care of vital matters or problem unless you are a resident (and under a Doctor supervision).
Posted by: Psykel | Jan 23, 2009 4:10:48 AM
I am in agreement with Psykel and May. I study in Cuba and we only come in contact with patients from third year and when we are given the opportunity to do a procedure (paracentesis) or anything else apart from practicing physical exams, we are closely supervised, always by an attending and/or resident.
Posted by: Laurie | Jan 23, 2009 7:15:43 PM
I appologize for my point being unclear. It is true that generally though not always, residents are there to supervise the students. However, what I wanted to point out was their approach to the management of the patient is horrible. Treating a patient without a working diagnosis is just plain irresponsible. At the top of my head I could think of 12 differentials that could fit the case of the patient and thats hardly exhaustive and each one of them has a different management. All I'm saying was, if the author was in a third world country and did what he did to a real patient, he would have killed someone.
Posted by: rj | Jan 25, 2009 7:21:33 AM
Actually, we did have a working diagnosis. Maybe we didn't get to it as fast as a third year. Or even as fast as a second year would at the end of the school year.
Regardless, I left out details and the correct diagnosis because many in my class have not done this particular lab and I don't want to rob them of the joy of learning by giving the answer away.
And I understand your point -- that the "management of the patient is horrible." But maybe you misunderstand the point of a Pharmacology Lab Simulation.
Posted by: Jeff W | Jan 25, 2009 11:43:20 AM
Good job Jeff. While I agree that the management of this patient likely was not optimal... you are a second year student and there to LEARN. We did lots of simulations (mostly in 3rd year) and now that I am a senior resident, I am so glad I did. It is nice to experience the consequences of your actions on a mannequin without having to kill somebody to learn it. I remember some of my lessons on the simulator very well and it has helped me save patient's lives!
Posted by: Em | Jan 27, 2009 4:00:50 PM
I am a doctor trained in Dominican Republic, and I agree in the fact that we come in contact with patients in our third year of medical school, but most of the time we don't have a say in how the patient gets treated. Those desitions are left for residents and attendings.
I think that it's a great apportunity the one you have to use a medical simulation lab and learn from this types of experiences. I wish my university had had one of those. I would have learned a lot more that I know.
Posted by: Ana | Jan 28, 2009 10:18:14 AM
wow. i wish my school had simulated patients like that for us to practice on! i'm also from a third world country (although the government would say otherwise, but that's besides the point) and we don't have the luxury of robots in my med school. like the other guys who have commented earlier, i have early patient contact but because we have to "practice" on actual patients, we don't get a say in the management and we don't have any room to make mistakes and pump drugs or defibrillate a model like you do.
i shudder at the thought that when i graduate in about 18 months, i'd be thrown right into the field without being fully actively involved in the management of a patient, even on a fake one.
anyway, i am glad that students in other countries get to practice and make mistakes on simulated patients before going out and managing real ones. you're very privileged to have such facilities in your school, jeff!
Posted by: jc | Jan 28, 2009 5:53:35 PM
Another student in a "Developing country", Colombia this time.
The thing most foreign students in develping countries are forgetting is that most of us don't spend 4th years in medschool as in the USA, but 6... so we do start to see patients in 3rd year but we don't go farther than taking clinical histories, performing physical examn, and maybe suggesting differentials, labs and diagnosis in non-critically ill patients in rounds.
The difference is that at the end of our careers (6th year) we have been in contact with patients on a daily basis for about 3 years, plus one final year of Internship PRIOR to receiving the MD title, so in the 5th year and Internship we might get a little bit of trust from residents and attendings to do and decide somethings in our own, but we are ALWAYS closely supervised by any of them.
It's funny but I lived the situation Jeff describes, but with a real patient in my 3rd year, he was critically ill and needed cardioversion as well, but as soon as the patient came in, the attending and senior resident started taking care of him while another resident came to us, and placed us meters away from them so we couldn't hear their management plans but still could get to see the patient, he started to ask us all kinds of questions putting pressure on us like "come on, u need to decide quick, what if any of you were the only doctor in this room"...
We had the "adrenaline rush" and started saying all kinds of diagnosis, managements, etc etc, we kinda felt the pressure but we knew we weren't gonna kill anybody...
After the patient was stabilized, the attending explained us everything and asked us about what we suggested in the exercise with the resident and corrected us.
Maybe in developing countries we don't have fancy robots but we do have more ways to learn the medicine without being irresponsible or having to fear for somebody's life, which I guess it's also how many of the attendings in the USA learnt medicine 20 or 30 years ago when there weren't any robots.
Greetins from Colombia!
Posted by: Diego Nova | Jan 28, 2009 8:22:33 PM
Hallo to you all. Learning and practising medicine in the third world is fantastically fulfilling. With longer periods spent in clinical training, we start by watching with explanatory commentaries, then we do with consultant observation and then we take off on our own. In my country Kenya, we don't even have the simulators to use, but we are better off.Anyway, every setting has its own way of doing things.
Thanx to you all.
Posted by: valerian | Jan 29, 2009 1:24:01 PM
Might have been an experience in itself. I uphold the thought on the poster. In this case the patient responded, but i feel apart from the routine of habit we also need to have empathy.
Posted by: Govindan | Feb 2, 2009 12:09:35 AM
51-year-old male, presenting with shortness of air and chest pain? The differential for this is quite large. A thorough history and exam is first on the list of 'to do's.'
As a 1st year medical school applicant, medical scribe, and recent graduate, I feel fortunate to know several treatment options for a patient presenting with the aforementioned vital signs. Working in the ED for several years has given me a nice advantage. With somebody who is tachycardic and hypotensive, there are several things that come to mind immediately: 1.) Is the patient febrile? (Sepsis?) 2.) What are their oxygen saturations? (hypoxia?) 3.) Are their lungs clear and is their airway patent?
The first treatment option that I'd initiate is an IV fluid bolus. This would help with blood pressure. If this failed, I'd potentially consider pressors? I'm a little concerned with the classmate suggestion of a beta-blocker on a patient that's hypotensive? Equally, I'm concerned at the suggestion of Adenocard when we don't know if this person is having SVT. Let's order an EKG first and put the patient on a cardiac monitor. If he's in a dysrhythmia such as SVT consider 6mg of Adenosine IV push. Only after 12-18mg of Adenosine and failure of chemical conversion would I suggest electric cardioversion.
All of this being said, I'm impressed at the simulation opportunities that your school provides. Practice makes perfect and Jeff's quote from Aristotle reminds me of this one: -"The value of experience is not in seeing much, but in seeing wise”-- Dr. William Osler.
Posted by: Aaron | Feb 13, 2009 10:48:26 PM
Thanks for your comments. Actually, a lot of the questions you brought up were answered during the simulation. We did have access to the simulated EKG, temperature, CVP, etc.
I was just trying to communicate some of the things that were going on... not necessarily the details. Mainly because I was one of the first groups to go to this cardiac lab and I didn't want the rest of the class to read about the details beforehand. It kind of ruins the simulation if you know the exact problems....
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