Breathing....

I'm back to teaching.  It is, usually, a pleasant if challenging duty.  Somebody taught me, had patience (or not!) and helped me become a good doc.  So the payback is:  I teach.  This has both benefits and costs.

The benefit is that a good student is a joy to have - smart, inquisitive people always make me happy.  The cost is that even the best of students require time and effort, and sometimes I feel a bit short on both.  A bad student can ruin an entire month.  There's a jar on my windowsill labeled "Ashes of Problem Students."

My current student is a mix of Hermione Granger and Ron Weasley.  Brilliant, yet oddly hapless.  She has an impressive knowledge base and no idea on this earth what to do with it.  She's very concerned, to the point of correcting me in front of patients, that I may be making the wrong choices.  She is absolutely breathless with excitement when she thinks she has nailed some rare disease that I've failed to notice in a patient I've known for years.

Don't get me wrong.  There's a reason doctors get education credits for teaching.  Students are up-to-date on newer drugs.  Their memories are fresher and they know a lot about disease states in areas where progress has been made in the 25 years since I walked across the stage at med school graduation.  They are attentive because they are frightened.  They just have no idea how to use what they know.

So yesterday my student came gasping into my office and informed me that the patient she had just seen had his heart located on the RIGHT side of his body (it happens - I have one patient where this is true) and almost NO breath sounds! He told her he sometimes gets chest tightness!  He needs cardiology!  And a CT scan!  And just generally O M G!!!

"What is he here for exactly?" 

The patient came in for a chronic pain evaluation.  And to assess his depression - suicide is on his mind.  And, oh, by the way, he has a cold. 

Sigh.  I've known this guy for years.  His life is sad, his brain chemistry sadder, his depression generally not responsive to medication, and his monthly visits with me largely the entire extent of his social life.  As far as I know he has both a heart AND lungs and they function pretty well.

We go in together.  He is, as usual, happy to see me.  He is relaxed and not visibly having difficulty breathing. The light scent of alcohol in the room has escaped the student's notice, and I remind the patient that alcohol doesn't mix well with his meds.  I assess his one truly life-threatening illness and adjust his depression medications and get a promise from him that he won't hurt himself before his next appointment.  I ascertain that his chest tightness is fleeting - a few seconds now and then. Then I listen to his chest. 

He's thin, so every heart sound bounces around in his chest.  Since everybody's heart is right behind the breastbone, I can hear sounds equally right versus left, but the tip of his heart is clearly exactly where it belongs.  I teach the sheepish student how to evaluate such a patient.  Then I ask him to breathe.  I hear....nothing. 

Patients, when I ask them to breathe, very frequently start heaving their shoulders up an down, breathing with their mouths tightly closed.  This guy?  He just moved his shoulders.  I stopped, instructed him to open his mouth and taught him how I wanted him to breathe and hey presto!  Instant normal lungs.  

I think it was a watershed moment for this girl.  The sudden realization that what she knows doesn't matter in the least if she can't listen correctly was profoundly humbling.  She missed the things that could kill this man because she was distracted by her own inexperience.  It's a moment that, in the end, may re-define her. 

I was taught that the first thing I should do in any emergency is to take my OWN pulse.  Slow down, get a grip on the panic, and breathe.  How can I teach someone to breathe if I can't do it myself?

Those of us who practice medicine need humility.  We need to approach our patients not just with our heads, but with our hearts.  We need to keep a vast store of knowledge on tap, but be able to connect with people well enough to be able to spot the more subtle killers:  Alcohol abuse, depression, loneliness. We need to listen to the true hearts of our patients when they let us.  It is a profound privilege, and an honored responsibility, and it is utterly frightening.  Pray God every day that I don't miss the thing that matters.

DeeDee