Mile 3079: Back to Basics

Above: "Hole in the walls" are some of the best places to eat. May I recommend the Oasis Cafe if you're ever on Key Biscayne, with its sophisticated year-round Christmas lights. But their Tilapia Filet & Rice is absolutely amazing.

ARE YOU THIRTY? - One of my patients.
Me: Ha, not yet!

I remember having a talk with one of my professors in Dominica about why med schools do two years of basic sciences. At that point in time, I thought that basic sciences education wasn't really worth my time. My naive self then was thinking, "How is the pathway of glycolysis going to really be used in a clinical setting? I'm not going to tell my patients about it."

Now looking back at things, without basic sciences, to me, learning the clinical sciences would be like learning things blind.

Basic science education has its hits and misses. It kinda sucks that with basic sciences information, practicality in real situations doesn't really come by until put together with clinical experiences. After Step 1, I probably could tell you a lot about what tests to run with a patient who comes in with concerns about breast cancer, but knowing that the the genes BRCA-1 and BRCA-2 are linked to that cancer won't tell me when to start yearly mammograms, what questions to ask from my patient to assess the situation, and how to reassure them.

Practicality can come in the form of algorithms (flowcharts which guide clinical thought). These are great when trying to organize one's thoughts take a proper, succinct history. Although for common conditions, they work well, but what if someone doesn't have a "textbook" case or condition? Here I see the benefits of basic science education, as the foundations of medicine can help clinicians to adapt to "new-found" cases. Because the processes within the human body are linked together, there has to be a way to explain non-textbook cases through the mechanisms learned in the basic sciences.

But that's not the only benefit... the human mind is one to learn more by links & context (I think I might have blogged about this before). So by knowing the mechanism as to how drugs work, how diseases appear, and the molecular background behind the human body can one make the puzzle pieces of medicine fit together a lot better. Integrating the basic & clinical sciences can contribute to better skills in diagnosis & treatment for our patients.

Although I still think of it as frustrating, taking time to memorize the glycolytic pathway in first semester is now something I am more appreciative of.

---

Today ended my 2 weeks at my current site in my family medicine rotation. On my last day, one family came in, displaced from another clinic that was closing down. One of the kids in the family was afraid of shots, so I offered some of my "insider tips" for surviving them, which made the patient smile. I could tell by the kid's expression that he/she was ready for immunizations when I left the room. When the family left, they all said, "We'll see you next time." And I said to myself, Damn, I won't be here next week. Here, I was about to start a strong foundation for a good relationship with this family. On the outside, I laughed, saying "I won't be here next week, but you'll see another student just like me." But on the inside, I had one of my first feelings of settling down; I started to feel how much I valued relationship bonding in medicine. I didn't want to move on.

Starting next week, I'll be moving on to a clinic run by a local homeless support group here in Miami. Four more weeks, and then the adventure will take me to what I think is the most critical rotation in my education...

Retrospective: Red No. 40

Above: Robert Moore, Director of Patient Simulation, Ross University School of Medicine - Bahamas campus demonstrates use of a patient simulator. (From Derek Caroll, BahamaIslandsInfo.com)

IN MY DAY,
WE CALLED HIM STAN.

2008. I remember during fourth semester in Dominica, I was ready to draw blood for a blood test on the patient. My proctor was watching me as I went for the median cubital vein for the draw, and I only pulled out air. He said, try again, and as this was my first shot at drawing blood, I mistakenly pushed the syringe in the wrong direction, pushing the air into the patient.

STOP! WHAT DID YOU DO!?
He shouted.

Back then, I didn't know. He told me I almost triggered an air embolus in a patient. Fortunately, I never harmed the patient. After a second try, I hit the median cubital vein, and I drew blood properly using the syringe method. Okay, I fibbed, it wasn't blood... more like a watery substance colored with loads of Red #40 food coloring.

----

If you didn't catch it by now, I was working on a full-blown human simulator.

I'll admit that it wasn't exactly like working on a real patient: the simulator couldn't give feedback (only through what our proctor interpreting as the patient), techniques that require fine hand skills (e.g. placement of IVs or drawing blood) could only be coarsely worked upon, and we always had a second chance if one of us did something wrong. In the case of the failed blood draw on my part, I was glad I did: an air embolus might have killed the patient.

However, it was different in years past. From a recent New York Times article by Pauline W. Chen, much of her clinical experiences on patients was done directly to real patients with that risk, and teams reviewed their cases on videotape. Now, patient simulators can be used for full clinical situations, putting away that risk that lies with working with patients needing critical care. It seems to be the answer to the ethical dilemma of if its acceptable to use patients as "airplanes or machines" (according to Dr. David M. Gaba from Stanford University School of Medicine) to test on.

With the simulators at Ross University in Dominica, we were able to work in teams of eight directly on a simulator with a professor as a proctor. And if a group of eight of us, for the first time, had issues with figuring what to do in such a critical situation, imagine us doing the same with a real patient. We'd definitely scare them, and not to mention put them at harm. The simulator room gave us a "safe zone" where we could try our best to develop a team dynamic so we could work efficiently towards the patient. Seconds count with the simulator, but fortunately running out of them doesn't mean life or death (in real terms, anyway).

The one thing I found initially annoying though was how easily the program running the patient could be manipulated. Sometimes our proctor would go right to the controlling computer and click a button, and all of a sudden the patient would be undergoing a deadly arrhythmia. However, I responded exactly as I would have with a real patients, with greater alertness toward the situation, and our team made the appropriate actions. This flexibility enhanced the realism and educational benefit of a simulator session, and in the end, I actually appreciated the switcheroo.

I really hope that simulator technology improves for the next generation of doctors, as I found it very valuable in my medical education. Thanks for the memories, Stan.

Sources: BahamaIslandsInfo.com & The New York Times