Thursday, March 24, 2011

Patients Lie

icu has 4 beds for all of Grenada
4 icu beds for 100,000 people
Grenada only has 4 monitors for the patients in the ICU
no one else on the wards has a bp/hr/rr monitor
there is no beep beep beep in any other part of the hospital
i didn't notice this until this week, the 7th time i went.

Dr. g was our instructor for the day
Cuban doc, came to Grenada because his dad is a surgeon here
you do school in Cuba for free, but you owe the govt 6 years of social service
then you can go wherever you want if you pass their test
came to Grenada 2 years ago knowing no english.

There were 3 patients in the ICU
one was the girl we had seen previously in peds, with muscular dystrophy
she was alert but in need of monitoring
the other was an older man with a subarachnoid hemorrhage, apparently unconscious
and another was a middle aged lady also with a cranial hemorrhage

before we saw the tube put in, we were to examine the man with a subarachnoid hemorrhage
as usual, no one in my group is quite awake, yet i am fully caffeinated by this point
so i take the lead to examine
one of the guys in my group says we cannot touch the patients in ICU because
his friend was there before and they weren't allowed
so i am puzzled as to how we can examine this patient without doing anything
i ask Dr. g - he says yes you can examine
so we try to communicate, he does not seem response
he makes some unintelligible muttering sounds
another fellow student suggest we do the Glasgow coma scale to assess this patient

the GCS is the scale used to asses and monitor levels of consciousness
you have 3 sections and get points for each section
conscious awake aware = 15 points
you asses visual stimuli response, verbal stimuli response and touch/pain stimuli response
if you are in a coma and completely nonresponsive, or even if you are dead
you still get 3 points for showing up

So we decide to do the GCS scale
he does not seem responsive to verbal stimuli - we ask him to blink if he hears us
it is just random, and he mutters
he gets 2 points for verbal
after some observation we decided his eyes don't really open to our voice
we think 1 point maybe
however, we need to test his response to painful stimuli
so i decide to poke the patient, but not hard
he moves his arm a bit when i touch
V says no, you really can't assess that
and that that is not a response to your stimuli because you didn't get his consent/understanding
i say we don't need that, but how are we supposed to assess this?
i am told by my colleagues that we don't need to really do it
its just a textbook thing
i say that is absurd, aren't we supposed to be monitoring this every hour?
what do you guys suggest?
they are nonresponsive
Dr. g then brings us over to see a nasogastric tube put in the middle aged lady
they needed to sedate her.

After, we go outside the ward
Dr. g asks us if we have any questions
i remember to always ask a question, i read this somewhere about rotations
so i ask how are we supposed to do the GCS scale and how important is it that we really do it?

Dr. g says
instead of answering
i will tell you a story:

I was given a page to examine a patient with coma
comes in, boy, 10yo, has IV line on each arm, fluids
given oxygen nasal, given nasogastric tube.

i examined the patient - respiration is normal, rr 20 bpm, hr 80bpm, bp 120/76
airway sounds normal, so does heart
something is not right he thinks, intuitively
i does his reflexes - none
i pinched the patient, no response to pain, no response to stimuli.

i calls the nurse over and say
"nurse this patient is dead, he died 5 minutes ago" shocked looks and gasps
"bring me the tools so that i may perform the autopsy"
suddenly the boy cries "no no, i am alive!"

Saturday, March 19, 2011

Reboot and Open Access

My guilty spiral of not posting, and then having things to post but not enough mental energy/time, seemed to be stalled in a perpetual procrastination spiral, but then I ran across a fellow med student blogger - Lex MD - and realized that I don't need to write paragraphs of detail about, well, studying without internet (it really works - thank you silly campus Bradford security restrictions!) in order to keep things going here - or at my other neglected blog with Global Pulse Journal (though I have been keeping up with the twitter account). So even with Step 1 slowly creeping towards me, I hope to have a little more of a social-net presence.

Speaking of journals, I've been loosely following the Open Access debate going on in the scientific journal community. It seems that one of the journals I published at supports the DC Principles for Free Access to Science, purporting to be a middle way between traditional publishers and open access advocates like the Public Library of Science and the NIH. An interesting debate - any thoughts out there in blog land about this?